Sunday, July 26, 2015

Food for thought/Graders of the Lost Art

Graders of the Lost Art It is time to stand up and fight for our patients and the profession!

 Dr. Kris Held, July 18, 2015     
Our profession is on suicide watch. We enable what destroys us. We are addicts, victims, and enablers at once in a never-ending cycle of addiction and abuse. We are addicted to money that comes from third party payers, government and private healthcare insurers, who destroy the relationships with our patients and annihilate our autonomy to practice medicine. We are victims of what I call Battered Physician Syndrome. We must break free and get clean. Physicians, we must heal ourselves.
The abuse began just over 100 years ago with the establishment the federal income tax and creation of the Internal Revenue Service. The IRS is now the Executive Branch’s “Enforcer”, usurping powers, targeting individuals, and making law.
The addiction started in 1935 when The Social Security Act became law law. Compulsory health insurance was not a part, largely because of efforts of the American Medical Association. “The AMA based its opposition on the belief that the programs would eventually lead to government intervention into the practice of medicine.”
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.
In politically correct terms, the Law “evolved.” In reality, the practice of medicine in the United States has been fundamentally transformed. Our profession, the heart and the art of medicine, commandeered and lost.
So, here we are, living under the paradoxically named Affordable Care Act. President Obama just signed another law that massively increases government control of doctors, patients, and the practice of medicine, H.R.2, known as the “Doc Fix”, proving once again, a government pledge is fleeting and begs the question, are present day politicians well-intentioned statesmen subject to an inevitable slippery slope or are they self-promoting gamesmen, who must be bought and must not be trusted?
Most Americans did not and still do not want Obamacare. Under Obamacare and the Doc Fix, the Secretary of Health and Human Services, a non-doctor, partisan bureaucrat, is granted unprecedented power and unlimited money to control the practice of medicine. The Executive Branch and its IRS continue to rewrite the law and enforce it selectively, with a wink and a nod from the Department of Justice, while Congress perseverates and punts to the Supreme Court, which rewrites more, and there is no recourse.
A totalitarian ruling class that espouses an “ends justify the means” philosophy wove strategically crafted tricks through these healthcare laws and laced them with talking point tales, that are disseminated by the media. This pervasive philosophy and style extend to the Supreme Court where two major challenges to Obamacare took place. Government won both.
Amidst the storms of Constitutional chaos, unchecking and unbalancing, pruning the three branches, and systemic lawlessness, it is no surprise that the Doc Fix was passed under false pretense as well. Touted as the “fix” for the flawed Sustainable Growth Rate system by which government pays physicians, the so-called Doc Fix actually replaces the SGR with a far worse system. Instead of patients paying individual physicians, the Doc Fix law creates Alternative Payment Models where government pays payment entities on a capitated basis in a lump sum on an annual basis. The entity then doles out pay to doctors, after siphoning off their share in a perverse model where less money paid out to care for patients means more money retained to profit the APM entity.
And worse, as of 2019, in just 3 and half years, physicians will be subject to MIPs -Merit Based Incentive Plans. We will literally be graded in grade school fashion by government appointees and assigned a “Composite Performance Score” from 0 to 100 depending on how well we comply with the Secretary’s rubric. Our grade will then be publically displayed on the Physician Compare Internet Website of HHS. Based on our score, the Secretary will assign each of us a payment adjustment factor which will be positive, 0, or negative; hence, we will be rewarded or penalized by the Secretary for how well we follow her marching orders. There’s even a curve, points for showing improvement, and extra credit. The AMA, our state medical societies, and specialty societies supported this law. Did they even read it, or did they intentionally mislead us?
We must understand MIPS- “The Secretary shall establish an eligible professional Merit-based Incentive payment System.”
“Eligible professionals?” That’s the new term for “providers”, a large group that includes everyone from a doctor, PA, and nurse to a midwife, speech pathologist, and social worker.
Who’s the all-powerful Secretary of Health and Human Services?
Sylvia Matthews Burwell- who is not a physician, but a partisan politician, who after receiving degrees from Harvard in government and Oxford in philosophy, politics, and economics, served as a White House Aid during the Clinton administration and then as Clinton’s deputy chief of staff. She was Director of the Office of Management and Budget before Obama appointed her Secretary,
Research her for yourselves.
She is the government appointee who controls American medicine.
She is the grader of our lost art.
Our grade will be based on our scores in 4 Performance Categories: Quality, Resource Use, Clinical Improvement Activities, and Meaningful Use of Certified Electronic Health Records.
1. Quality comprises 30%.
January 1,2016 the Secretary will post her plan for quality measure development, including how private payers can be incorporated . May 2016, a final plan will be posted on the CMS website.
What constitutes quality to government? Government factors in “resource allocation” when it assesses quality. Patients’ and doctors’ perspectives of quality outcomes are vastly different from the government’s. Early examples of this discrepancy are the 2009 United States Preventive Services Task Force (USPSTF) recommendations that changed the accepted standard of care for screening mammography for breast cancer and screening PSA’s for prostate cancer. The task force was willing to screen fewer women, decrease the diagnosis rate, delay diagnoses, and lose lives to save money. The public outcry was huge and threatened passage of the ACA, so a sentence was added to the law to specifically disregard only the 2009 mammography recommendations. Men didn’t fare so well politically, and with less PSA screening we are now seeing decreased diagnoses of intermediate and high risk prostate cancer and will no doubt see increased presentation of high risk prostate cancer in later stages in younger men in the near future.
Is increased morbidity and mortality best quality medicine?
Is the physician who receives the highest score from the government doing what is best for the individual patient?
The potential ramifications of politically expedient medicine cannot be underestimated.
2. Resource Use comprises 30% of our grade
Measurement of our resource use is the government tally of every service we provide, every operation we perform, every medication we inject, and every prescription we write, including cost of drugs under part D. Outliers will be penalized-even if we’re the best at what we do for the patients and our patients do better. If our resource utilization is too high, we’ll get a low grade.
3. Clinical Improvement Activities comprises 15%.
We must do at least 6 types of activities.
To score well, the Secretary wants us to provide after hour advice, participate in a data registry, use remote monitoring or telehealth, use shared decision making and checklists, participate in an alternative payment model, and this is a biggie- she will score us on maintaining certification.
Maintenance of Certification (MOC) is used by government to control physicians. The Secretary may contract with entities to assist her in specifying clinical improvement activities, criteria for activities, and determining whether an Eligible Professional meets criteria. The Doc Fix allocates $90M to these guiding entities between 2015 and 2017. Who are these entities? Entities like the Institute of Medicine, ABIM, and National Quality Forum, headed by Dr. Christine Cassell, who is the former ABIM chief.
So, the same people who get $90M to tell the Secretary what constitutes MOC for our Clinical Improvement Score are the same people who make money from testing and certifying us. This is a shocking conflict of interest, as well as a massive waste of resources.
Worse is how the Institute of Medicine is using MOC to forward their agendas by requiring physicians engage in their pet MOC activities, even if their agenda items are counter to individual physician’s deeply held beliefs.
The IOM plays an important role in Obamacare decision-making and hopes their 2014 report on end of life care “will further shape the national conversation on dying in America.” The Committee seeks major reorientation and restructuring of Medicare and Medicaid including changing financial incentives and offering “positive alternatives for the end of life”. They say they want to maximize independence and “Quality of Life” over living longer. Obamacare bureaucrats will be the judges of what constitutes “Quality of Life.” Providing palliative services instead of providing life-prolonging services to the Medicare/Medicaid population will save money.
We are evolving from providing cure-oriented care to emphasizing palliative care and cost.
The authors of this publication recommend that to advance this agenda, it should be made part of physicians’ MOC requirements.
Physicians are being extorted financially and ethically to fulfill Maintenance of Certification requirements established by central planners.
4. Meaningful Use of Certified EHR- This counts 25%.
To be “meaningful users,” physicians must allow full disclosure of confidential patient information to the government in interoperable Electronic Health Records. Beginning July 1st, 2016, the Secretary can then sell this data on Medicare patients to Qualified Data Entities. Soon this will include Medicaid, SCHIP, and private insurance patients as well. Authorized users of this data who will have full access to patients’ private medical records are: a provider of services, a supplier, an employer, a health insurance issuer, a medical society or hospital association, or any entity that is approved by the Secretary, as determined by the Secretary.
This violates the Hippocratic Oath and defiles the patient-physician relationship. That the government gathers and sells this personal data is unethical. That physicians are willing to turn over confidential patient information to get paid more is a disgrace.
On a personal note, 3 years ago, I was hospitalized following cancer surgery and over the course of events discovered an EHR error had occurred in the recovery room whereby my data had been scanned to another patient’s EHR, and his medications showed up as mine. Had I not been a surgeon, the EHR error would have gone unnoticed with potentially grave complications.
EHR’s have been launched but have not been adequately tested and are not ready for prime time.
That we receive a higher score for doing what is untested and potentially harmful is perverse and flat wrong.
Physicians with the highest performance scores will get up to a 9.9% bonus while the lowest scorers will get a 9% penalty. Thus, MIPs will result in a 19% pay disparity among physicians based on who complies with the government rubric best, even if scoring the highest to get paid the most violates our code of ethics or harms the patient.
There is a budget neutrality requirement for MIPs, and here’s the clincher, “the Secretary shall ensure that the aggregate increase in pay from the adjustment factors shall be equal to $500M per year 2019-2024. This averages $910.75 per physician that bills Medicare. What a huge and expensive undertaking for $900. This is a losing proposition.
What if no physicians meet the Secretary’s performance standards? The Doc Fix has a fix for that too: “…the negative adjustment factors shall apply and the budget neutrality requirement shall not apply for such a year.” Translation: if none of us do what the Secretary says, we’ll all get a 9% reduction in pay, and HHS will keep the $500M that year.
SGR will soon be a speck on the rear view mirror as the Doc Fix hits us head on. Can you imagine our predecessors going along with this?
Why did our medical societies and physician Congressmen support this?
I found out about the Composite Performance Score by reading and dissecting H.R.2 for myself. The law completely hands our autonomy to practice medicine over to the Secretary. The Doc Fox grants her the power to determine whose National Provider Identifier is valid. She then requires a valid NPI be present on prescriptions in order to be covered. Thus, she can selectively destroy a physician’s ability to treat patients.
This is my line in the sand, my breaking point. What is yours?
I refuse to be graded and publically humiliated for how well I do a politician’s bidding, which may be in direct violation of my code of ethics and potentially harmful to my patients. I will not be morally complicit. I will not enable this. I will not be humiliated or threatened into doing this. Will you?
I offer a 12-point plan to help doctors break free, reclaim our patients and profession, and stay clean from third party domination.
1. Honor the Hippocratic Oath.
As physicians, we share a bond, having endured a rite of passage known to rare few. Our lifelong investments of time, money, heart, mind, and soul have resulted in us acquiring precious skills, knowledge, and experience necessary to treat patients. No one else can do what we do. They sell only the promise of our service. This is why they seek to compel and control us.
We alone have submitted and sold ourselves out to those who do not have the best interest of our patients or profession at heart, those who cannot be trusted, and career politicians who are influenced by special interest in pursuit of power, money, and winning the next election. Career politicians say one thing to get elected and do another once back in office.
I am talking about politicians from both parties. There is rare exception.
These politicians plead for our money and support to stop what’s happening, but they do not stop this. Their actions and inaction serve to entrench the very law they promised to repeal. They string us along saying “when we take the House back, we’ll repeal Obamacare.” “Wait, we mean when we take the Senate back…” “We mean when the Supreme Court rules… “Oops, when the Supreme Court rules this time…” “Um when we take back the White House…” It’s a farce.
Healthcare is a three trillion dollar a year proposition. Even the best-intentioned assimilate into the DC culture and acquiesce to hospitals, pharma, insurance, IT, unions, special interest du jour…anyone who brings more to the cartel table than we, mere individual physicians, do. I was on Capitol Hill the day the Doc Fix passed the House and was told we were the first practicing doctors who had come to several of the Congressmen’s offices, while they had been visited regularly by members of the AMA, hospital lobby, IT and so on. They will not fix this for us. They have proven that. We must fix this ourselves.
The Hippocratic Oath is critical to the survival of our patients and profession. Obamacare architects like ethicist Dr. Ezekiel Emanuel believe our Oath is outmoded and a new generation of physicians that do not embrace it must be cultivated. Medical schools, beholden to government and its money stream, are producing doctors according to government design. We must take back the education of our next generation of physicians. We must protect the Hippocratic Oath and preserve it.
2. We must Resist.
It is counterintuitive for us to resist or dissent. We are by nature healers and compliers.
No longer can we do things automatically just because we’re told.
We must judiciously examine each new requirement, rule, and regulation.
Do not comply, unless what we are being told to do is scientifically proven, fully transparent, verified and moral.
Ask yourself: Does this serve the patient first? Is this best use of resources?
If not, do not do it.
Kiss goodbye APM’s, MIPs, MU, ICD10… all the lettered and numbered bureaucratic schemes forced on us.
Admit they do not reflect precision scientific data from which meaningful clinical data can be derived and do not serve the best interests of the patients.
Admit you’re only doing it for the carrot and to avoid the stick.
MOC- don’t do it. But, if you feel you must recertify, choose the National Board of Physicians and Surgeons alternative, a second certifying body set up by Dr. Teirstein, who sets the example for what we must all do-push back and problem solve.
Do not submit because you think there’s no alternative- create one, be the alternative.
3. Don’t Trust and Do Verify
We are authority respecting, authority trusting, compliant, pleasers to a fault. This must change. The politicians have proven they and their laws are not to be trusted. Do not trust them.
Regard the government takeover of medicine as a highly contagious potentially lethal disease, a threat to public health. Have a high index of suspicion for worst-case scenario.
Read every new law, rule, and regulation critically, just like you do before prescribing a new medication or doing a new procedure. Evaluate your resources like you do journal articles. Remember biostatistics? Use them. Watch the Federal Register and CMS for new rules and requests for public comment. Create and serve on watch groups of physicians that coordinate this ongoing defense effort. Dedicate your time and resources.
4. No excuses/ No Fear
We can no longer be “too busy, too tired, fed up, trapped, or afraid…” We can’t just hang on until we early retire or career change.
Most of all I hear “I’m afraid”. “I’m afraid of losing my patients, my income, my livelihood…”
Recall the first time we encountered our cadavers or operated on our first patients. Fear did not deter us. It motivated us and made us better. Fear is trapping us in a professional and ethical death spiral now.
We are suffering from Battered Physician Syndrome-a pattern of signs and symptoms such as fear and the inability to escape, appearing in doctors who are physically and mentally abused over an extended period of time by demands and constraints of their profession or dominant individuals and groups seeking to malign and control them.
Physician morale is low. Physician suicide rate is up. Most physicians discourage family and friends from going into medicine.
Will doctors stay in this abusive relationship? We must end this cycle before it ends us. It’s time to take responsibility and break up.
5. Do Not Be Bullied
Over the years, we have gone from willingly working with to being completely dependent on 3rd party for our patients and our pay. At first we did it as a favor or convenience for our patients. We got on plans so patients would have a choice, the opportunity to see us-without having to exchange money and without having to acknowledge cost.  Wow, that has backfired. Our patients have become the insurance companies’ patients.
Shortly after the rollout of, I discovered Aetna and BC/BS listed me as a provider on their Obamacare exchange plans without my consent or notification. I regard this as false advertising to patients and a false claims type misrepresentation to HHS. It took over a year and completely severing ties until AETNA finally took my name off. BC/BS extorts me to this day, saying if I won’t see their exchange patients, I can’t see any of “their patients” I asked for this in writing and was told, “You have our verbal response.” They will not put this in writing. When I “got off “ United, they sent letters to my patients saying, because I am no longer a provider it might cost them more to see me. What if it actually costs the patients less to see me?
We must stand up to these companies that sell our services without our consent. They’ve evolved from providing insurance to protect people from financial crisis in the face of catastrophic medical problems to effectively practicing medicine without a license and abusing us. They redistribute the money the feds take in and ration the care they are charged with delivering to increase their bottom line. They bully us into enabling this inverted system.
President Obama himself denigrates and demonizes us. Recall when he said doctors will take out tonsils if we’re short on cash, that surgeons immediately get paid 30,40,50 thousand dollars to cut off a foot, when in reality, the surgeon is paid in the hundreds of dollars, and worst of all, remember when he said, ”We’ll let doctors know, and your mom know, that maybe you’re better off not having the surgery but taking the painkiller.” Rebuke him and report the facts. We must stand up for ourselves, if we hope to stand up for our patients.
Hospitals bully us too. Stop selling our practices and going to work for them. The artificially inflated Chargemaster bills, sham peer reviews, MOC requirements for staff privileges, over-regulation, and cyclical nonsense protocols harm us, as does hospitals hiring us for one salary, then offering an absurdly low salary when the contract comes up for renewal- after we’ve sold them our practices
The AMA now gets the majority of its revenue from Washington, $80-100M/year to maintain CPT billing and coding. Correspondingly, the AMA is threatened with losing this massive revenue source by the feds in an ongoing extortion for support scenario. Thus, the AMA has evolved into an active player in the DC cartel. Even the AMA code of ethics is now described as a living document, evolving hand in hand with the fundamental transformation of medicine. The AMA and our State and specialty societies tell us how to comply and implement with not even a whisper of an alternative.
And Each Other- we are our own worst enemies.
Here’s an excerpt from a classic EHR generated letter I recently received from a colleague.
“Dear Kristin: This is an update on Mr. John Doe. The following is a summary of my findings on 6/9/2015…Patient of Dr. Held for years, but now she is not taking his insurance. Send to Dr. X for care of glaucoma. Refer to Dr. X…Thank you again for allowing me to assist in the care of Mr. John Doe. Sincerely, Electronically signed.
I have cared for this patient and his wife for 18 years. They have my cell number. They have my trust. And now, they have a new doctor. It’s that easy. Ouch, it hurts.
Stop putting insurers before the patient-physician relationship. Send patients back to their established doctors, and if you don’t, please, don’t send the thoughtless EHR generated letter.
6. Don’t Play the Game
Government and politicians play games nonstop. Stop playing their games. We are barraged with threatening emails: “Get ready for ICD10, because it’s coming whether you like it or not.” Non-adopters will not be able to bill 3rd party for patient services as of October 1, 2015. No one has paused to check potential ramifications of this for patients if there is massive physician non-adoption of ICD10. Patients will have insurance, but suddenly as of October 1st, no doctors.
Instead of repealing the ICD10 and EHR mandates, politicians sold out to hospitals and IT. To appease us, they just passed a “Delay of Game” card, whereby ICD10 will be implemented, but the consequences will be delayed. Wait, what happens after 6 months?
This is nothing more than a stay of execution, a tube of KY jelly before the terminal prostate exam.
Politicians try to pass new laws to protect us from bad laws they just passed, such as “protecting physicians from being sued for abiding by government guidelines and mandates”-which begs the corollary question: “Will we be sued if we don’t follow government guidelines and mandates?” Or worse, will we be fined, jailed, and stripped of our licenses?
We need fewer laws, not more. Stop playing.
Gaming the system is not a solution either. To colleagues currently working with third party on our measuring, reporting, and grading- what the heck are you doing? Saying, “It’s better if we play with them than to let them do it for us” is a flawed argument. It’s like saying, “I’ll use my own recipe for my poison soup, because it will taste better going down.” The only way not to lose is not to play.
Two years ago at the government relations session of the ASCRS, our liaison/lobbyist actually had a power point slide saying: “If you can’t beat’em, join ‘em.” She told us we were to blame for our surgical fees going down, because we reported such short operating times, intimating that we should have just lied. Wait, if we’ll gameplay and lie to get paid, when will the lying stop? Is there anything we won’t do? Quit this most dangerous game.
7. Get Informed, Inform others, Be Transparent
Many doctors don’t even know what they get paid for what they do. We just keep working to the limit, presuming someone cares enough to pay us fairly, or that some genius, angelic economist actuarial has crunched numbers that work in everyone’s best interest. Sorry pals, no one does.
Fact is, the government preys on our charity, our trust of authority, and does what it takes to get their rules passed, including duping, bribing, penalizing, and grading us. They are banking on “the stupidity, naiveté, and cowardice of the American doctor.”
We must know what we are paid by third party, decide for ourselves what constitutes a fair-market price, and then post it clearly for patients to see.
Know what your expenses are. Know what your revenue is. Research what third party plans you are on. Make a detailed spreadsheet. What does each plan pay you for each service you provide? What are the maximum, minimum, and mean fees? What is the Medicare allowable? What percentage of your income does each payer account for? What percentage of your patient volume does each payer account for? Create your own personal fee schedule. Make it as affordable as you possibly can. Implement it, post it, and continually refine it.
Educate your patients about insurance and the total real cost of their premiums, deductibles, and cost-sharing, which are rising while their benefits are being restricted and denied. Show them your fee schedule and point out potential savings by opting out of Obamacare plans, choosing instead to seek direct patient care, supplement with a healthcare sharing medical plan, a catastrophic plan, and an HSA or FSA. Show them you can save them money, and they can keep the money they don’t use, and they can keep you.
8. Wean and Clean from 3rd party.
Get out your insurance payer spreadsheet. One by one, eliminate the insurance company that pays you the least and treats you and your patients the worst. Pause. Let things recalibrate and then eliminate the next. Continue the process.
I’ve been weaning from 3rd party for the past five years beginning with opting out of Medicaid, switching from participating to nonparticipating with Medicare, and terminating my agreements with United, AETNA, and other undesirable companies. October 1st, 2015 is my all clean date.
Join me or set yours.
If you’re on Medicaid, get off. Provide true charity yourself at lowest possible cost or free. Dr. Alieta Eck has a superb model for this in her Zarephath Health Center.
Opt out of Medicare. AAPS has excellent informational videos on how to do so. It starts with downloading a form. Start the process now.
If you can’t opt out yet, go to non-participating status. It makes you more accountable and makes patients see what things cost.
Our numbers are critical.
Of the 16,598 ophthalmologists in patient care in the US, only 30 have opted out. I will be #31. If just 29 more ophthalmologists will opt out, the number of ophthalmologists opting out of Medicare will have doubled. This is newsworthy.
Join me.
A mass opt out October 1st would be momentous, revolutionary.
9. Connect, Communicate, Cerebrate
Connect with patients and colleagues. Educate one another about what is happening to patients, practices, and the healthcare law. We are a team- recruit team members and strengthen team bonds. We will only survive if our patients stand with us.
Communicate- via email, blogs like SERMO, associations like AAPS, and UPSA. Don’t be arrogant. If you don’t want to be on an email chain, just press DELETE. Don’t castigate everyone else on the thread. But better yet, get educated, and engage. We need to keep one another bolstered up against the constant demands and demoraliztion. Communicate with staff, reassure them, and engage their support.
Cerebrate- through civil discourse and open exchange of ideas and information, we will be better equipped to fight our bullies and oppressors, think outside the box, and create solutions. Learn from other models. Refine them. Build on them.
10. Cut the Deal, Cut the Cost, Cut the strings, Call them out
Cut deals-personally go to our hospitals, surgery centers, and all vendors, and drive the hardest bargains we can on goods and services.
Cut the costs-then pass the savings on to the patients and undercut third party, replete with its built in waste, inefficiency, and redundancy, which we will have trimmed.
Cut the strings-once we’ve simplified things, start cutting strings with unnecessary vendors. Take things in house. When we are finally third party free we won’t be losing 7-10% off the top to billing/coding companies and so on.
Call them out!
Call out our oppressors-the AMA and ABIM for their conflicts of interest, our State and Specialty societies for endorsing bills they haven’t read and taking stances that don’t represent the majority of their members.
Call out individuals like Emanuel, Cassell, Gruber who profit from exploiting us.
Call out our elected officials for not reading laws they pass, for not keeping their word, and for selling us out to special interest.
Call out the media- educate them about realities in the trenches and call them out for disseminating talking point half-truths. Call out the media for not reporting harmful effects of the ACA .
11. Create an Alternate Universe
Create a practice model to be there and be prepared for patients when the system fails them. Create a world where we can practice patient-centered, state of the art medicine, unencumbered by the nonsense and waste of 3rd party, mandated healthcare, at a far lower cost to the patients.
Each individual specialty, community, practice, and model will be uniquely different.
Provide the best at a fraction of the cost with privacy and dignity. Dr. Keith Smith, founder of Surgery Center of Oklahoma is a visionary and modern day hero in this regard, and his center is a model to be emulated.
Purchase patients’ meds wholesale and pass on the savings like Dr. Josh Umbehr, Founder of Atlas MD, does. Offer other services in the office making things more convenient and less costly than using their insurance companies.
My patients post op eyedrops were costing some over $200. I bought generic drops online at cost, and the patients can buy the antibiotic drops from me for $4.00 a bottle. In Texas it is legal to dispense from your office.
Write your Medicare opt out letter now. Write a letter to your patients explaining why you’re opting out and why they should join you in an alternate universe.
Cut waste and get a line of credit in preparation for a year or more transition period.
Take a big risk. Build a new practice model. Go on offense.
Join and support physician groups who will fight with us.
No, the Graders of the Lost Art will not grade me. They will not destroy my colleagues’ lives with burnout, depression, and suicide. They will not regulate, restrict, or rule my patients and me. No nonsensical ICD10 for me. So, October 1st, 2015, I will not be able to file claims with 3rd party. Tough love is tough. This will be hard and hurtful, but I will be clean.
I have faith. I have great role models and resources, many of whom are speakers at this summit. I’m collaborating with a group of top-notch physicians who will be there with fair, transparent fees and access to excellent care in our Alternate Universe.
We must incur risk if we hope to preserve Hippocratic medicine and make the profession of medicine become something our children and grandchildren want to go into. Only we can break the abusive cycle.
12. Finally, we must Maintain Constant Vigilance
As we celebrate our freedom, our reconciliation with our patients, and our code of ethics, we must remain forever vigilant, build and maintain a strong defense, and participate in a constant action plan for the survival of Hippocratic medicine in the US. We must take our turns on watch. Do what each does best- whether it’s being the one that reads the laws, or investigates the graders, or speaks, writes, educates, negotiates, or leads.
We need platoons of physician guardians, united, working to secure the freedom to treat our patients, to stay clean.
Physicians, it’s time, heal ourselves.

Saturday, July 25, 2015

peds BOARD now offering to do your own experimentation on patients-just like 1938 in Europe?

Please take note of this "Offer to Create your own QI project", highlighted in Red below.  The goal is to make EVERY patient a research subject solely for the "personal Gain" of MOC compliance for every physician. And WHO is to say the changes will be for the better, especially when anyone can create the plan which suits THEM most, or if patients will suffer costs, complications and perhaps even increased doctor visits (and money into their pockets) to compensate them for the extra costs they incur to do this stuff?
This is the IMPORTANT message your readers must screen their physicians-are they making them guinea pigs for personal profit???

I can also provide published reports in journals of these experiments without oversight review, should you have interest. 
Finally, remember THESE are CHILDREN used as subjects!
This only demonstrates that MOC and certification can be anything the corporation decides it should be-with little study or forethought-they are reacting to the opposition with license to ignore Nuremberg and Helsinki safety protocols.

Date: Fri, 24 Jul 2015 14:59:34 -0400
Subject: ABP to Pilot Completely Different Type of MOC Assessment

Dear Diplomate, 

With this month's blog I share with you the outcome of the ABP's Future of Testing Conference, which was the culmination of an extensive review of our MOC examination process. Please read my latest blog to learn how we will pilot a completely different type of MOC examination (MOC Part 3) that is also designed to catalyze learning. 

I would also like to emphasize the message from my last blog. We understand the difficulty that some diplomates have had in finding a QI activity that is relevant to their practice needs. The solution is to "Create Your Own QI Project."  The videodescribes a very straightforward process whereby you and others in your QI team (including up to 10 diplomates) receive Part 4 QI credit for any QI project you create relevant to your own work. You will need to answer seven standard QI questions, upload a run chart (or control chart), and attest to meaningful participation of the other members of your team seeking credit.  

The ABP is grateful for all the constructive feedback we have received and remains committed to its mission and its own quality improvement efforts.  

I wish all of you a pleasant summer. 


David G. Nichols, MD, MBA 
President and CEO 
American Board of Pediatrics

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Wednesday, July 22, 2015

Now here is an answer to the whole ABMS extortion racket! Tell them to shove their programs where the sun don't shine!

" I successfully completed the original certification process and the subsequent recertification process, but enough is enough. The ABU has strayed far beyond its original mandate to ensure excellence in urologic training and has added yet another onerous burden onto the backs of practicing urologists.

The 2002 Physician Charter, which served as the foundation of MOC, is a flawed and disingenuous document that has one surreptitious purpose: to give specialty boards more power and control over their diplomates. How dare the ABU question my demonstrated commitment to lifelong learning! How dare the ABU attempt to lecture me on professionalism and ethics! How dare the ABU place the “benefit of the public” above the welfare of its diplomates! The “public” doesn’t pay the ABU’s expenses."

Sunday, June 28, 2015

Call to action for YOUR "bucketlist" from Medscape

Because you need to sign in and many wont:
Be a Hero for the Medical Profession
It's hard to be a doctor in today's healthcare environment. But instead of feeling defeated, many doctors are finding creative ways to defend their profession.
Paul Kempen, MD, an anesthesiologist at Weirton Medical Center, West Virginia, is one of them. Together with several other physicians, he spearheaded "Change Board Recertification," a national movement of physicians committed to reforming the board recertification process. Because physicians are "natural lifelong learners," continuing medical education (CME) and peer-reviewed journal articles should be sufficient to advance their knowledge, he says.
Grant Simons, MD, director of cardiac electrophysiology at Englewood Hospital and Medical Center, Englewood, New Jersey, feels that employed physicians will need some form of labor union dedicated to advocacy. "I want to play a role in the formation of an organized labor entity for doctors, so we'll have a better negotiating position when dividing up bundled payments. I want to be the George Meany for physicians."
(Shown) Abraham Verghese, MD, physician-author, Professor for the Theory and Practice of Medicine at Stanford University Medical School.

Thursday, June 18, 2015

Latest communication with the JACR editor regarding MOC Establishes clear support of MOC by these editors!

Dear Dr. Kempen -

Thank you for your continued interest in COI as it relates to a May 2015 publication in the journal by Dr. Guiberteau.

As I wrote you earlier today, the journal will soon publish an erratum noting the failure to disclose. However, in your email to me earlier today, I found several misconceptions in the following paragraph, which, for the record, I wish to correct:

"In conclusion, I regret the need to go through the Publisher regarding the COI, but remind you that my clear attempts to point out this intentional deception by the ABR and Dr Guiberteau were unsuccessful via direct communications with you.  The disclosure at the bottom of the publication clearly provides upon very superficial review enough information to demand ABR associations from that author, who gives his Email as at that board-ABR. I am also sure your journal approached these authors directly through the ABR/ABMS to provide a counter point view-just how they would otherwise become involved would otherwise deserve specific mention in your upcoming statement/publication."

1. You said I was non-responsive. However, I answered your initial email almost immediately. Following your second email, a day elapsed, during which I expended some effort researching this issue, before I wrote a response.  If this is being non-responsive, the fault lies more with your expectations than with my actions.
2. I found no justification for your charge that Dr. Guiberteau intentionally tried to deceive readers, nor can I understand why he might want to do so. Do you have some special power that enables you to discern intent?
3. You are incorrect that I approached Dr.s Guiberteau and Becker through the ABR or ABMS. I wished  to publish Dr. Jha's interesting take on the Board and believed readers would benefit from the conventional view. I know both Dr. Guiberteau and Becker, and they seemed the best options to provide the counter-perspective. I recruited their response directly with the authors.
4. There is the implication in what you wrote that Elsevier forced my hand in responding to your email. Incorrect again. The journal is owned by the ACR, not Elsevier. By contract, I have he responsibility for all editorial actions.
5. While I agree with you that it should have been easy for a knowledgeable person to spot Dr. Guiberteau's failure to disclose, I take issue with your implication that we turned a blind eye. It has not been part of the JACR staff routine (nor mine) to review COI disclosures. Perhaps we need to take another look at this issue. In this case, as in most others, it is wrong-headed to attribute to conspiracy what is better explained by simple human error.

Again, I appreciate your interest in JACR and trust that this email concludes the matter.

Bruce J. Hillman, MD
Editor-in-Chief, JACR

In response: 
Dear Dr Hillman:
1) Nowhere in that paragraph do I even see the words "non-responsive".  On The 25th you simply stated "Unfortunately, I found it to filled with unsupported assertions and accusatory language to consider it appropriate for publication. "  
While the message of the letter appeared unwanted by you,  I asked (to absolve any real issues)  what you would like referenced and I would be happy to provide such. I also indicated that the truth is not kind to those who obfuscate and there have been significant problems with these boards. You simply further stated "By no means did I intend to impugn your expertise in this area, which quite clearly is extensive. However, my initial editorial decision stands."
I followed that you had no interest in further pursuit in any information I might add  on the issues propagated upon physicians by the ABMS and ABIM through the other 23 affiliates including Radiology

2) This is not my first Rodeo with the boards, which espouse great amounts of corporate agenda as simple business practice. I am exposing this sort of lack of ethical declaration because it is WIDESPREAD and found only with the ABMS Boards who somehow feel they are magically without conflicts in selling their useless products in an extortive manner and without disclosure.  I did send you this link (  where you could read:
"For example, in two back-to-back articles in the Journal of the American Board of Family Medicine (JABFM), 24,25 one author who contributed to both papers failed to consistently declare conflicts, while another, James C. Puffer, is also executive editor of the journal. Despite the statement, “Conflicts of interest: none declared,”24 Puffer earns more than $600,000 per year as chief editor of JABFP and president and chief executive officer of the ABFM, according to IRS documents. ABMS funds journal supplements promoting its proprietary products, BC and MOC programs,26,27 spending as much as $50,000 per issue. See, for example, the 66-page Fall 2013 supplement to the Journal of Continuing Education in the Health Professions. Recently, the National Quality Forum (NQF), with a long history of American Board of Internal Medicine (ABIM) leadership interactions and personnel exchanges, has been involved in questionable conflicts of interest, leading to congressional investigation and strong allegations of misconduct by an NQF official and inadequate policy to prevent conflicts.28,29"

Dr Puffer is also CEO of the ABFP, Chief editor of the JABFP, senior author of the article espousing the benefits of certification, earns over $600,000 a year and yet has "no COI to declare". Does this amaze you too? See:
24. Schulte BM, Mannino DM, Royal KD, Brown SL, Peterson LE, Puffer JC. Community size and organization of practice predict family physician recertification success. J Am Board Fam Med 2014:27:383-390.  
It is freely available on the web at: because this journal is the property of that ABFP CORPORATION.

3) Normally one might consider Dr Jha's article is quite balanced on it's own. I certainly did. However because of the close link of income from MOC for both the boards and associated national societies which support YOUR journal and so many other close associations, there is apparently a continued need by these societies and their editorial staff to support the corporate structure of these corporations and always find opportunity to pair their viewpoint whenever a contrary view is expressed. These boards have in my opinion outlived any usefulness. 
The fact that  YOU knew both of the authors personally, would seem to support that you knew they were executive board members-which is why YOU asked them to protect the ABR ABMS interests in the face of this balanced, yet corporate embarrassing document from Dr. Jha.  As such, you are your journal's highest representative and ignored the obvious.  Jumping to number 

5) As you Knew these individual and obviously sought them out as representatives of the Corporations they serve, perhaps your choice was "two eyes open" rather than "I take issue with your implication that we turned a blind eye." Certainly you none the less read and approved this statement: "While the opinions offered in this article are the expression of the authors, the document was reviewed and is supported by the Board of Trustees of the American Board of Radiology." As well as recognize this as an ABR corporate email account?

As for Point #4, I refer to the example of Dr Puffer above and clearly recognize that editors and editorial staffs will still have collaboration with the Board Corporate interests. Not all publishers will, like Elsevier, even uphold these important interests regarding the international accepted COI standards. I recognize that would your journal have been directly published without oversight by a professional and acclaimed publisher like Elsevier, we would not be communicating at this point.

In conclusion, I am more than willing to write again an acceptable article or letter for your journal on these important issues, however feel a lack of interest for such on your behalf would require a written request at this time. 
Yes, I do have significant insight I could share with your readership and will be happy to work with you, should you send to me your request.
This is a very important topic of great interest to your readership. 

Thanks again for your time,


Paul Kempen, MD, PhD

Tuesday, June 16, 2015

Regarding the ABR and point counterpoint article and frank ABR support by the College

Here is the 500 word submission:
The recent Point-counterpoint articles on Maintenance of Certification (MOC) provide valuable information, especially both sides conceding that inadequate documentation of the value or validity of MOC exists. (1,2) This extends to the Board Certification ritual itself. Certification arose decades ago, before the multiple levels of regulatory control and capture evolved to provide effective oversight, making this process superfluous in 2015. (3) Several other matters of importance were inadequately stressed:
1) If MOC truly had universal value, it would be apparent and demanded by physicians. The “Boards” have had decades, repeatedly attempting to prove “certification matters” and have failed in spite of repeatedly publishing biased papers “supporting” their position and openly admitted it. (4)
2)MOC can be easily tested by taking 100 physicians each from Australia, England and Singapore and subjecting them to MOC, insuring that they get copies of the test questions they FAIL and requiring them to assess the validity of the questions on an international scale of truth. This is something that US physicians should have been afforded for decades, if learning and improvement were real issues for the ABMS. Cohort them to 100 non-MOC physicians and independently evaluate them by THEIR national standards. This test will never be done, because the boards have no interest in proving the lack of value-although with over $400 million in gross receipts each year and free access to this “product”, they clearly have ample ability to do so.
3) Everyone must realize that the counterpoint article and the referenced “Gallop poll” both are corporate products of the ABIM and extremely biased, if not specifically authored with corporate oversight. A quick PubMEd search shows over 20 such redundant and at times plagiaristic publications of proMOC articles by the authors in this past decade. The Gallop pole was funded, designed and marketed by ABIM. (5) “In addition to sampling error, question wording and practical difficulties in conducting surveys can introduce error or bias in the findings of opinion polls.” was acknowledged and question construction/methods specifically facilitate ABIM desired (biased) conclusions:
a) There is obvious transformation of high opinion rates that doctors should be evaluated by MOC: The fact that multiple other methods of evaluation exist is purposely disregarded and obfuscated there.
b) While 2/3 of opinions suggest demand for certification (implied ABMS) and indicate patients would change if doctor was not certified-only 1/3 of patients actually checked. This reflects discordance in realities.
c) The public can want anything that they do not finance. Everyone wants complete healthcare coverage for NO copay and preferably no premium. This is a very similar reality regarding this certification issue, while missing the reality that MOC takes doctors from patients at great cost and NO proven benefits:
The ABIM is the mother of Choosing Wisely-demanding proof of testing value in medical care-yet the hypocrisy of supporting THEIR brand of useless testing without proof of validity or value, screams of self-serving Regulatory Capture agenda. Regulatory oversight must be introduced upon “The Boards” -doctors already have multiple layers!
1) Guiberteau MJ, Becker GJ. Counterpoint: maintenance of certification: focus on physician concerns. J Am Coll Radiol. 2015 May;12(5):434-7.
2) Jha S: Point: twin dogmas of maintenance of certification. J Am Coll Radiol. 2015 May;12(5):430-3. doi: 10.1016/j.jacr.2014.10.011.
3) Kempen PM: Maintenance of Certification (MOC), Maintenance of Licensure (MOL), and Continuing Medical Education (CME):the Regulatory Capture of Medicine. Journal of American Physicians and Surgeons 2012;17:72-5.
4) Kempen PM: Maintenance of Certification -important and to whom? Journal of Community Hospital Internal Medicine Perspectives, Issue 1, 2013 Pages 1-4
5) The Gallup Organization. Awareness of and attitudes toward board-certification of physicians. Available at: Accessed June 11, 2015.

And here is the reply after the rejection was firm:
Thank you for your prompt reply. I do wish to point out to you that Dr. Milton J. Guiberteau, MD, assumed presidency of the American Board of Radiology effective July 1, 2014, as is indicated in the attached announcement (see: This may be common knowledge to you and many but not all of your readers, which thus would demand declaration of COI. It should not be left to assume everyone would recognize his email address as indicative of being the president or employee of the ABR-which he is and this explains his repetitive publishing of PRO MOC articles over the past decade.
As the Journal of the American College of Radiology is an Elsevier publishing Journal and Elsevier publishing states a commitment to
insuring highest ethical standards and eliminating COI in publications. The publisher's own Webpage states (at “The most obvious COI are financial relationships such as: direct: employment…” and states a “duty” of publisher and authors is to declare all real “and potential” conflicts.
The recent article reporting, I wish to point out that this would be a definite conflict of interest and that the disclosure I read at the bottom was as follows and did NOT indicate that Dr Guiberteau is the president of the ABR at the time of submission- a very definite conflict of interests:
"While the opinions offered in this article are the expression of the authors, the document was reviewed and is supported by the Board
of Trustees of the American Board of Radiology.
Milton J. Guiberteau, MD, is from the Baylor College of Medicine, Houston, Texas. Gary J. Becker, MD, is from the American
Board of Medical Specialties, Tucson, Arizona.
Milton J. Guiberteau, MD: Baylor College of Medicine, One Baylor Plaza, MS 360, Texas Medical Center, Houston, TX 77030;
Was there any purposeful intention to obfuscate this suppressed COI, and will you be issuing a clarification to this effect? Clearly, there is a great deal of active support of the various boards by specialty Journals, including the ABR. I would be happy to address to you a letter for publication regarding this COI declaration failure, should this be useful.
Please see the attached notice and my recent article regarding this very issue published in another Elsevier publishing Journal depicting very possibly exactly the same circumstances.