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 1^st, 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 3^rd 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 Healthcare.gov, 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 3^rd 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 1^st, 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 3^rd 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 1^st, 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 1^st 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 3^rd 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.

Pray.

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 1^st, 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.