Saturday, December 19, 2009

Letter to my fellow Physicians

The annual Medicare pay cut, based on the seriously flawed SGR (sustainable growth rate) formula has been a topic of great discussion every year. This year it was part of the discussion of the new health care bill. While most Americans are against a Medicare pay cut for physicians, one prominent House Democrat would prefer to let the Medicare cuts happen. "I'm inclined to do nothing," Rep. Pete Stark, D-Calif., told Congress Daily in December of last year.
"My colleagues, my staff say, 'Oh, dear, the doctors would all drop Medicare.' I don't believe it. I don't believe that doctors are willing to give up half their income."

Well, Mr.Stark, the doctors are going to drop Medicare and more third party payers - and here is the step-to-step plan on how to do it.

Simple Action Plan

We have been working more and more for less and less. We are being suffocated by ever increasing regulations, which usually turn out just to be new tricks to pay us less (e.g P4P). Many primary care colleagues are at the edge of viability of their practices. The demand for physicians is said to go up, some even talk about a "physician shortage", yet, in contrast to the most basic economical rules, our reimbursements continue to go down. We have lost 60-70% of our earning power since the 80's, a unique situation without precedent.

Patients perceive us as "rich", the media portrays us as making a most comfortable living in the top 5% of incomes.

The media also prefer to report on errors and scandals, on our weaknesses and failures rather than medical success.

For politicians we are part of the problem, not part of the solution. We have no friends in politics, since physicians only amount to 1% of voters. Americans in general consider us "rich" and "too expensive" and one congressman mentioned that "all health care problems would be solved if we could just get the doctors to be satisfied with 75,000 a year".

Insurances earn by not paying us or by delaying payments. They have successfully applied salami tactics for 20 years to reduce reimbursements.

The organisation that is meant to represent us, the AMA, has long bought into the status quo, has surrendered in every important issue and keeps busy tweaking minutia. The "solutions" the AMA offers are anemic and pathetic, and they lack the guts to confront the root problems.

We have no friends and we have no allies.

Nobody will help us. If we want change, we will have to do it ourselves. We have to remember that we are the ones with the knowledge, the skills and the expertise! We do not need anyone to diagnose and to treat. Those who have pushed themselves into the patient-physician relationship do not know medicine, and they are only able to harass us, because we have signed contracts allowing them to do so. Without us, they are nothing!

We have to remember that we have signed the contracts that allow them to withhold, deny, restrict, control, demand pre-authorization, delay and defraud us. We can cancel these contracts. And, with the coming "shortage of physicians" there is no better time. We have to remove the control of medicine from the third party payers. And we have to do it ourselves. Fortunately, this is not hard and may even be not just rewarding, but fun.

Here is a simple action plan. The actions complement each other, each strengthens the other. The plan is flexible, you can start wherever you want and you can go as far as you want. Going just a little step is good for you, going far helps your colleagues as well. the more physicians participate, the larger the impact on health care overall will be.

After putting our personal finances in order, we take a close look at our practice and see which third party payers (and yes, that incluides Medicaid and Medicare) are loosing propositions. We gradually, deliberately, smartly drop third party payers based on an economic analysis of our practices. This shrinks the networks of HMOs and reduces their power and market appeal. At the same time we unite into large groups working under one tax ID to bill together and negotiate together ("group practice without walls"). This increases our numbers and direct negotiation power with the remaining HMOs until we drop them too. At the same time we educate our patients about alternatives to HMOs, so that they favor more attractive options of insurance coverage, such as HSA, HRA, cooperatives, individual tax deductible health plans etc. We offer cash services at a very competitive price. We can do this since we would greatly benefit if we received the same amount of money in cash right from the patients - rather than from an HMO that pay us only after a lot of administration hoops, shenanigans, withholds and months of delay. "Carecredit" and other options may make it appealing to the patient. The more patients drop HMOs, the weaker they get. And finally, we talk to our colleagues about these issues to come to common concepts and understandings, to unite us. One of the possible ways to do this is sermo, the physician-only online community founded in Cambridge in 2006.

This is the plan:

1. Get your personal finances in order first

Consider a fee-only financial advisor. Fee-only advisers are paid by the hour and consequently have less of a conflict of interest than advisers who live on commission. Go over your personal finances, make a long term plan and a mid-range plan. Determine how much income you need as a minimum, what kind of drop of income you can afford while you drop HMOs, and for how long. Initially your income may decrease when you drop the low paying plans, although it does not have to.
Secondly, talk to your partner to get his or her agreement. While dropping HMOs may reduce your income initially, this is temporary and it will to a greatly improved quality of life in the long run. It is essential to have the support of your partner during this time.
Consider postponing larger purchases that put you in debt such as a new car, new home etc. Don't fall for the myth that "doctors are rich and can afford luxury". Living above your means will chain you to the third party payers. Limit your luxury purchases and spend wisely in general. Limit your monthly payments (new car, renovation of condo or house etc).

2. Streamline your practice finances

Sit down with your office manager, your accountant and/or your billing service. Write a business plan! The business plan should include your mission is and your financial goals. Write into the plan what you want to earn on a monthly and yearly basis. Look at your overhead. Based on your planned revenue and your overhead you can now calculate what you have to collect, what you have to earn for each visit and what you have to earn for your most common services. Note those figures. This is a standard business process that astonishingly is not done by many physicians.

Now make a spreadsheet with the ten most common procedures or services in your field. List what each third party payer reimburses you for these services. Calculate which payers will allow you to reach your business goal and which payers do not! Plan to drop the payers that do not allow you to reach your business goal! This is a crucial step.

You may also calculate what each third party payer contributes to your overall collections to help you with the decision about which payer to keep and which ones not to keep. Calculate the average payment for each visit from each payer. Consider the number of patients from each payer. Calculate the accounts receivable for each payer - as a fraction of the charges after 30 days and after 60 days. That informs you about their delays and denials, about the hassle and sleaze factor. Decide which third party payer makes no sense economically and also which payer gives you the most hassle.

3. Drop third party payers that threaten your financial viability

A colleague wrote the following: "I started with the lowest paying HMOs. It is a 2 year process. First I stop taking any new patients from that HMO. Then 1 year prior to dropping them, I will send out a letter to the patients with that insurance informing them that I will be dropping that insurance the following Jan. I send out this letter with the labs that I send to them prior to their physicals. They come in for their physical and they have the opportunity to ask me why I am dropping their plan. I inform them. I tell them which plans I will be taking and that they can still see me if they have out of network benefits. I would say that most patients change insurance or continue out of network with me."

Send certified return receipt cancellation letters to those third party payers that drag your practice down. It is likely not feasible to drop all third party payers at the same time. Start small, gain experiences, then drop more. Remember that you are not "abandoning patients", you are merely becoming an "out of network physician". You are supporting HSAs and high deductible insurances. You are moving your practice towards "consumer directed health care" or towards "cash medicine" or towards concierge medicine". Promote HSAs coupled with high deductible health plans (also called catastrophic coverage) to your patients by several means, such as those described in Neil Baum's book. We will talk about this more later.

The following two books are extraordinary useful and well written: "Think Business" by Owen Dahl, $69, a kind of mini-MBA for physicians written by a veteran of medical management, and "Marketing your medical practice" by Neil Baum, $89, a fantastic book by a successful urologist in private practice. And of course there is "Medical Economics" magazine....

Legal disclaimer: Do not coordinate this purely economical plan with your colleagues, since this might be misconstrued as a "conspiracy". In the past acting as a group to flex our muscle or to influence prices was deemed illegal for physicians, since it might "worsen patient access to health care" or "might increase prices" - something that actually never happened. This was ruled "illegal", since obviously the consumer is a higher priority than physician income or influence. This is a hidden compliment and an acknowledgment of our power.

Therefore do not write emails or letter about this using any other terms than "purely economical reasons" and "supporting consumer driven health care" and use only verbal communication in private places. And understand that this is NOT done to fix prices in any way, but to move the health care system to "consumer driven" - a system that offers maximum transparency, and uses market forces to deliver cost effective, affordable, high quality medicine to everybody. Consumer should call the shots and not the insurance, and therefore consumers should holds and control the money and not the insurances. That is why we are moving away from insurances, to empower consumers.
And we are obviously doing this based on purely economical thinking. We "think business", something that we have learned from just those HMOs - remember?

Should anyone threaten, bring up or even hint at us doing something "illegal" or "conspiring", go to the media and show how this person or entity wants to cheat the consumer and wants to prevent the consumer from being in charge! Consumer driven health care is the ultimate democratic health care system and should be supported by everybody! Nobody will dare object to our move in that direction!

Stop taking new patients 2 years prior to dropping the plan because it is often the case that many other doctors are dropping the same plan. You may have a rush of new HMO patients because the panel of that insurance is drying up. It is harder dropping an HMO which is 30% of your practice than 15%.

Inform the patients a year in advance because many insurance plans require the employee or employer to sign up for the following year 6 months or more before the end of the year.

4. Join or create a "Group Practice Without Walls"

This is the solution when you are faced with one or two dominating HMOs in your area holding 40 plus percent market share, which makes it very hard to cancel their contracts. This is a good solution for colleagues who prefer to have someone else handle the business aspects of medicine and for those who prefer to be employed.

Group Practice Without Walls means the physician continues to practice in his/her own facility, yet is part of a group, just not under one roof. The group does marketing, billing and collections, sometimes, but by now means necessary, also staffing and management. All members have the same tax ID. This way a large number of apparently independently practicing physicians can represent themselves as one group, buy and negotiate as one group, with the obvious advantage of using your larger numbers. The laughter of HMOs about you will become a lot softer.

I have seen this work very well in South Florida, by a group of ObGyns, who prefer not to be named.

Joining this group gives an ObGyn reimbursements of about twice Medicare/Medicaid. For example: global fee for prenatal care, delivery and postpartum care yields $1538 from Medicaid, and group members receive about $3000. Same amount of work, probably even a lot less for a Non-Medicaid patient. Much better payment for group members. Members of the group work in their own private offices, with their own staff, own equipment and rooms, own clinical guidelines and decisions, own budget, own finances, own everything. Except: they bill together and negotiate together under one tax ID. They pay 5% of collections for billing. Codes are entered in the practice computer in the same way you enter information for a clearinghouse. Members pay an entrance fee of 25-50,000 for admission to the group and would have to pay an equal fee in case they left.

The group management will negotiate with the remaining HMOs and routinely fire the lowest paying third party payer. Expect reimbursements of 150 to 200% Medicare. These groups can be set up so that your practice is an LLC within the LLC of the mega group. Billing goes through one single entity, you can pool labs and technical services such as Xray, mammography, ultrasound, bone density, but also cosmetic services, such as botox, epilation, vein therapy etc

How do you set it up? You first spread the word among the best doctors and the key players in the area offering to join you. Then you retain an attorney experienced with formation of such as group. this is expensive, but worth it in the end. You must stand up to anti-trust scrutiny. Your ultimate goal is to attract enough doctors to reach enough critical to have negotiating power, but not as many to violate anti-trust laws. Consider staying under 50% of physicians in your specialty in the area. This may take several years, but is well worth it.

5. Get support from your patients

The transition towards consumer driven health care (and away from HMOs and third party payers) will be much easier with patient support. There is a profound lack of knowledge about consumer driven health care, high deductible insurance plans (HDHP) and Health Savings Accounts (HSA). Once we help our patients understand these issues, they will help us in the transition to more economic and more responsible care!

Learn: buy a HSA/HDHP for your own employees and your family. Browse the most educational and easiest to understand websites on HSAs. Summarize the info into a one half page note. Post this in your office, hand out leaflets to your patients, leave them in your waiting room, post it on your website, in your monthly newsletter, email it to friends and colleagues, drop in mailboxes of other docs in your hospital. Ask your hospital HR to offer them, give a talk at the hospital and at the local chamber of commerce. Write a blog. Create a Google Alert on "HSA". Read and lay out Regina Herzlinger's book "Who killed health care" in your waiting room.

Teach: Educate your patients that they might save 30-40% of coverage costs, that HSAs are funded with pre-tax dollars, that they own those dollars, that they roll over to the next year and may collect interest! Even Medicare has Medical Savings Accounts available during the current enrollment. A huge benefit -it eliminates the need for MediGap coverage. HSAs teach the patient accountability and are the only solution to ever increasing health care costs.

Act: Offer cash services for your patients with HSAs! Patients need to know what to do with their HSAs!! Post a list of prices for your 10-20 most common services. You could even post a comparison list with the prices of a local plumber, electrician etc for comparison - an eye-opener!

Direct patients to the cheaper HDHP providers that actually save money. Traditional HMOs may price these plans so that they become less attractive. Tell your patients that every bank can administer a HSA.

Links: AMA brochure...
US Treasury Dept...

Consumers for Health Care Choices is a national membership organization, chaired by a former president of the American Medical Association. /Greg Scanlen,, tel:301-606-7364

Politicians, blissfully unaware of true details of healthcare, may claim that consumers actually do not know enough about and are "not smart enough" and not "educated enough" and "too weak" or "need protection" from all the other players in health care - and that of course, the "government knows best" and has only the best intentions and the best advice for consumers.

"Hi, I am from the government and I am here to help you"

A well designed HSA can save 30-40% on total coverage costs, including the HSA contribution. Further, this contribution is not lost, but owned by the individual, is rolled over into the next year and may collect interest. For the 80+% of us who are basically healthy, HSAs are a great deal. For those that are chronically ill, it is a wash. Employers like HSAs because they save money for the employer. HSAs have proven to decrease costs. Taking all risk away from the patient leads to overuse of resources because it is a lot easier to spend the insurer's money than your own money.

The vast majority of transactions can occur with a debit or credit card at point of sale, no need to file a claim.
Currently, pre-tax HSA dollars can be spent according to IRS section 213(d) which defines healthcare broadly as anything therapeutic, including "alternative medicine" or chiropractic care, while cosmetic surgery is not an "allowable expense"

The opposition to HSAs takes several forms:
1. Only the well-off can afford them
2. People with HSAs will see them as just another investment scheme, and will avoid needed medical care (including essential screening) to "save" this retirement money.
3. We have 4 or 5 generations of consumers / patients in the US who don't have a clue how much their insurance / Medicare is really paying, and will be shocked back to the old ways when they get their bills.
4. Unless they are combined with a cash-for-care schedule of lower payments (less hassle, less paperwork, lower charge) there is not much advantage to having an HSA.
HSAs would actually work great in a "health care cooperative", where physicians AND their patients unite and truly work together to combat their common enemy, disease.
Big opposition will come from HMOs, since they have the most to loose. Pharma is lobbying for a "carve out" of drug costs from the HSA dollars. If patients know the actual cost of drugs, they will prefer generics and "Direct to consumer advertising" will tank.

Unfortunately, most physicians are not offering cash services. We all should post a list of our services for cash payers - independent to the fact if we take HMOs and or Medicare / Medicaid etc. Just good business sense. You inform the patient, you give them an option and you get them thinking in the right, this is what it costs....with all the ramifications, such as why is my insurance so expensive or so cheap, could I afford this on my own without insurance? and so on

Educate your patients about alternatives to insurance, mention HSAs and high deductible plans. The AMA has a leaflet on this.

Patients often think that we receive all the money they pay to their insurance. They assume we make millions. It often is an eye-opener that we receive about the same amount the HMOs keep for their administration (withholding and denying) and they are often very surprised to find out how little we get paid for services. It is incredible effective to create a list comparing our services point by point with with that of a electrician and plumber - and you will find that they come out ahead. This creates sympathy from the patients and the willingness to drop HMOs

6. Get support from your colleagues

Previously we had recommended to put your own finances in order to be able to survive for a while with less income, then approach your practice from a business point of view: first establish how much you want to earn, calculate what each payer has to pay for your most common services and then drop those HMOs that do not meet your business needs. When Jack Welsh was CEO of GE her routinely dropped the two least profitable lines of business. Do the same with third party payers. This is plain economic thinking, and obviously not a plan to boycott third party payers. Start or join a group practice without walls. Encourage patients to enroll in HDHP / HSAs instead of conventional HMOs. This saves our patients money, allows them to accrue savings tax free, while paving the road for cash practice for us.

The last component is to spread the word to as many physicians as possible! Encourage your colleagues to join Sermo, to join our discussion. This way we can learn form each other how to save the health care system. Let them participate and contribute to our discussions. Keep talking about health care reform, stay in touch, write a blog, read about the issue, email a summary of the plan to friends and colleagues, drop a flyer in mailboxes of your colleagues at the hospital. Just invite them to Sermo, the rest will follow!

Follow the plan for yourself and it will be very helpful. Tell your colleagues about it, spread the word and the effect will multiply

Sunday, December 6, 2009

Letter from 240,000 physicians to Senator Reid opposing the legislation as currently written

240,000 doctors from 19 organizations have sent this letter to Senator Reid stating they "oppose the legislation as currently written." This is a letter that provides an appropriate answer and not the too-soft-to-be-effective approach of the AMA. Needless to say that the AMA does not represent me! And as far as I know, the AMA does NOT represent the majority of physicians!

Here is a copy of a letter by Dr. Palmisano to Senator Reid. I support the opinion expressed in this letter, it represents my feelings very accurately.

Start of letter of Dr. Palmisano:

Lots of different opinions exist and if one takes this collection of doctors plus the Coalition of State and Specialty Societies led by MAG plus the Coalition to Protect Patients' Rights, one has a large number of physicians opposing the current legislation as written. So when Washington, DC says trust the doctors and doctors favor the reform as written, remind them of the "rest of the story."

Imagine a simple bill of about 20 pages containing individual ownership of health insurance policies, tax credits to help those who buy their own insurance rather than being job-locked, proven medical liability reform, the right to privately contract for patients and physicians without penalty, convert current Medicaid to a voucher system and give those patients the same rights as senators and representatives, namely the right to pick insurance from an array of choices and periodically change the policy if needed. Encourage medical saving accounts rather than putting up barriers or trying to eliminate them. Address pre-existing conditions via purchasing exchanges. And yes, allow people to buy health insurance across state lines to ensure real competition.

Wow! That is a plan that will keep doctors in practice, give the patients control of their destiny, and not bankrupt America. If the plans in the House and Senate pass, the system will collapse and in the end the doctors will be blamed for the failure. Count on it.
Meanwhile, here is the letter that went to Senator Reid on behalf of 240,000 doctors.

December 1, 2009

The Honorable Harry Reid
Majority Leader
United States Senate
Washington, D.C. 20510

Dear Leader Reid:

On behalf of the over 240,000 surgeons and anesthesiologists we represent and the millions of surgical patients we treat each year, the undersigned 19 organizations strongly support the need for national health care reform and share the Senate’s commitment to make affordable quality health care more accessible to all Americans. As you know, we have been working diligently and in good faith with the Senate during the past year and have provided input at various stages in the process of drafting the Senate’s health care reform bill. To this end, we have reviewed the
Patient Protection and Affordable Care Act of 2009.

As you may recall, on November 4 our coalition sent you a letter outlining a number of serious concerns that needed to be addressed to ensure that any final health
care reform package would be built on a solid foundation in the best interest of our patients. Since those concerns have not been adequately addressed, as detailed below, we must oppose the legislation as currently written.

We oppose:

• Establishment and proposed implementation of an Independent Medicare Advisory Board whose recommendations could become law without congressional action;

• Mandatory participation in a seriously flawed Physician Quality Reporting Initiative (PQRI) program with penalties for non-participation;

• Budget-neutral bonus payments to primary care physicians and rural general surgeons;

• Creation of a budget-neutral value-based payment modifier which CMS does not have the capability to implement and places the provision on an unrealistic and unachievable timeline;

• Requirement that physicians pay an application fee to cover a background check for participation in Medicare despite already being obligated to meet considerable
requirements of training, licensure, and board certification;

• Relying solely on the limited recommendations of the United States Preventive Services Task Force (USPSTF) in determining a minimum coverage standard for
preventive services and associated cost-sharing protections;

• The so-called “non-discrimination in health care” provision that would create patient confusion over greatly differing levels of education, skills and training among health care professionals while inappropriately interjecting civil rights concepts into state scope of practice laws;

• The absence of a permanent fix to Medicare’s broken physician payment system and any meaningful proven medical liability reforms; and

• The last-minute addition of the excise tax on elective cosmetic medical procedures. This tax discriminates against women and the middle class. Experience at the state level has demonstrated that it is a failed policy which will not result in the projected revenue. Furthermore, this provision is arbitrary, difficult to administer, unfairly puts the physician in the role of tax collector, and raises
serious patient confidentiality issues.

This bill goes a long way towards realizing the goal of expanding health insurance coverage and takes important steps to improve quality and explore innovative systems for health care delivery. Despite serious concerns, there are several provisions in the Patient Protection and Affordable Care Act of 2009 that the surgical community supports, strongly believes are in the best interest of the surgical patients, and should be maintained in any final package. Specifically these include: health insurance market reforms, including the elimination of coverage denials based on preexisting medical conditions and guaranteed availability and renewability of health insurance coverage; strengthening patient access to emergency and trauma care by ensuring the survival of trauma centers, developing regionalized systems of care to optimize patient outcomes, and improving emergency care for children; welldesigned
clinical comparative effectiveness research, conducted through an independent institute and not used for determining medical necessity or making coverage and payment decisions or recommendations; and the exclusion of ultrasound from the increase in the utilization rate for calculating the payment for imaging services.

Further, while redistribution of unused residency positions to general surgery is a positive step in addressing the predicted shortage in the surgical workforce, we
believe that the Senate should look more broadly at the issue of limits on residency positions for all specialties that work in the surgical setting that are also facing severe workforce problems.

Finally, we are pleased that you have accepted our suggestion and removed language which would reduce payments to physicians who are found to have the highest
utilization of resources - without regard to the acuity of the patient’s physical condition or the complexity of the care being provided. We thank you for making this important change.

While we must oppose the Patient Protection and Affordable Care Act as currently written, the surgical coalition is committed to the passage of meaningful and comprehensive health care reform that is in the best interest of our patients. We are committed to working with you to make critical changes that are vital to ensuring that this legislation is based on sound policy, and that it will have a long-term positive impact on patient access to safe and effective high-quality
surgical care.


American Academy of Facial Plastic and Reconstructive Surgery
American Academy of Otolaryngology-Head and Neck Surgery
American Association of Neurological Surgeons
American Association of Orthopaedic Surgeons
American College of Obstetricians and Gynecologists
American College of Osteopathic Surgeons
American College of Surgeons
American Osteopathic Academy of Orthopedics
American Society of Anesthesiologists
American Society of Breast Surgeons
American Society of Cataract and Refractive Surgery
American Society of Colon and Rectal Surgeons
American Society for Metabolic & Bariatric Surgery
American Society of Plastic Surgeons
American Urological Association
Congress of Neurological Surgeons
Society for Vascular Surgery
Society of American Gastrointestinal and Endoscopic Surgeons
Society of Gynecologic Oncologists
cc: United States Senate

Stay well,

Donald J. Palmisano, MD, JD
Intrepid Resources® / The Medical Risk Manager Company
5000 West Esplanade Ave., #432
Metairie, Louisiana USA 70006
504-455-5895 office
504-455-9392 fax
312-560-0180 cell

This DJP Update goes to 2156 leaders in Medicine representing all of
the State Medical Associations and over 100 Specialty Societies plus
some other friends.

You can share it with your friends and colleagues and it has the potential to reach
800,000 physicians.

Tuesday, September 8, 2009

The AMA does not represent physicians

We physicians should declare that the AMA does NOT speak for us – and that they have the spine of a jellyfish....

The AMA recently had a historic chance of opening their mouths very wide and getting their intentions known. They had the attention of the president and the media and the pundits – and for a brief moment everybody on the health care reform stage was waiting to see what "the doctors" think about Obama’s important reform project. If you negotiate with someone like the US president, you do not open the conversation by saying "We basically agree with you". In that instant, you have lost, you are dead, you are in his pocket and only a side note in the health care debate.

And the AMA blew it, they blew it so magnificently and so terribly that I cannot find words for it. It was horrible....

Here is what they should have said:

”Dear Mr President:
before we even begin to talk about reform,


1. MALPRACTICE REFORM – and we want it our way, for example with health courts or with “Patient’s comp”, an institution analog to Workman’s comp. This will be much more fair than the present lottery system. It will encourage systems reform, it will curb defensive medicine. And that will save the country and the health care system a bold 100-200 billion a year - just what you want.

2. we want GUARANTEED BALANCE BILLING – for all patients, anywhere, all the time. Just like the dentists. Because that is the only way to ensure our financial survival. Then your government can decide to pay peanuts for our work, and we will still be able to find a way to survive.

3. and then, still before we take a look at your bill, we demand COLLECTIVE
BARGAINING for physicians. This seems to run in counter of the previous demand, but it is for all those physicians that agree to accept whatever an insurance company or government decides to pay us for our work. It is the only way they can hold up against the massive pressure of these usually very large and very powerful entities that have been lowering payments to us consistently over the past 20 years.

WE WANT THIS, because WE ARE health care. We are the people who do the work, we are the people who have the knowledge, the skills and the experience. Nobody else has.

When you have allowed us to write the above three points into the bill, we will consider the rest of the bill. And don’t even try to insinuate that we do not have the best interest of patients in mind, that would be despicable rhetoric – we have work for them all day long, it is our dedication, our choice, our profession to have their best interest in mind!

And if you and your party do not agree to this we will say louder than you can imagine that we are opposed to your plans, and we will not cooperate, in no way. We will continue to trumpet this into the world, no matter what happens. And we are not only the heart and core of health care, we talk to patients, to everybody, every day, all day long”

Now, that would have been a message! Not a meek rearranging of priorities of the points in Obama’s reform list.

I am not blind enough to think that these demands will go through. But you have to bring them up, you have to shout them out, you have to stand up for your concerns and your needs! Only then can you pester the other side with "well, you did not agree to 1 nor to 2 nor to 3 now you have to....."

The AMA does not even know the 101 of negotiating. What the AMA did was to lower their heads and demurely convey "oh, our demands will not go anywhere anyway, we may just throw the towel right away". Predictably the president filed the AMA away as “done deal, they are on my side”. Check.

We should be- and we are - selfless and always place patients first when in the office. But in politics we also have a few needs of our own. Representing those needs requires more than the AMA can see, can muster, can wrap their minds and their inner strength around and definitely more than what they can do.

The AMA missed, again, a historic opportunity to represent the interests of physicians. If they represent anything at all, it is certainly not physicians…..

AMA, if you have NO GUTS - and NO STREET SMARTS - then you should at least have the decency not to pretend to "represent" physicians.

Go home, AMA! You are not representing me!

Tuesday, September 1, 2009

The Physician' s Appeal

The Physicians' Appeal, written by the The Sermo Team - of

To the American People,

We, the physicians of this country want to reform health care and improve the quality and access to care for our patients while reducing costs. True health care reform will only succeed if:

1. Unnecessary tests and procedures are reduced through tort and malpractice reform

2. Doctors are allowed to spend more time with their patients and less time on paperwork by streamlining billing and making pricing more transparent (create an alternative to CPT codes)

3. Medical decisions are made by physicians and their patients, not insurance company administrators

4. Adequate supply of qualified physicians is assured by revising the methods used to calculate reimbursements.

We invite policy makers to work directly with the men and women who are on the frontlines of health care each and every day caring for the citizens of this country.

We pledge to be partners in true health care reform, improving the health care delivery system in this country while honoring the Hippocratic oath that we all have taken.

Respectfully Yours,

America's Physicians.

A Few Words to Our Patients

This is a letter that I recently received from Dr. Cameron Schaeffer, pediatric urologist in Lexington, Kentucky. It stands out due to its clarity and creativity. I very much agree with him!

Begin quote:

We, the undersigned physicians of this community, are concerned that expansion of the role of the Government in our nation’s health care system will significantly harm our nation, our profession, and our ability to care for you. We fear that we are on a path well-traveled by other nations and with a destination so predictable that the journey need not be repeated. Despite its faults, America still has the best health care system in the world as evidence by the hundreds of thousands of people who flock to this country every year for training and care; for critics to claim otherwise for political gain and without scrutiny is unconscionable.

We adhere to the following:

Privacy: Third party involvement in the doctor patient relationship is a fundamental violation of patient privacy and our Hippocratic Oath. Personal health information of the most sensitive nature already resides in the vast databases of insurance companies and governmental agencies. A centerpiece of proposed Government health care reform is the expansion of these databases, which are NEVER secure. We do not want your most personal secrets to leave our offices without your explicit permission.

Freedom: This Nation and its economy were founded on the right of independent parties to contract freely for goods and services in a competitive market, and this includes doctors and patients. Free markets lower costs and improve services. Goods and services are exchanged based on price, and prices for health-related services should be negotiated in advance of illness by insurance companies on behalf of their clients or by patients contracting directly with doctors and hospitals. Government price schedules have no market basis and often do not adequately cover physician costs, which is why many doctors do not accept Medicare and Medicaid. For markets to function properly, people must understand what they are exchanging. Our health care system woefully lacks transparency in price, cost, reimbursement, and quality of the services provided at every level. Reforms should empower all parties in the health care economy to contract freely, intelligently, transparently, and in good faith. Your freedom to determine what happens to your body must not be abridged.

Cost: The costs of Medicare and Medicaid are already staggering and unsustainable, and the Congressional Budget Office has stated that additional programs will incur more debt. Our debts, mostly carried by foreign countries, must be paid by our children or by devaluing the dollar. This course threatens our economy and our future as a Nation. Our health care system is based on, and our tax laws promote, third party payment schemes which are inherently inflationary because the patient and his doctor are incentivized to consume. Until we are incentivized to shop wisely as individual consumers caring for our own bodies, the problem will continue. As long as third parties, i.e. the Government an insurance companies, are paying the bills, they are incentivized to limit and to ration care.

Insurance Reform: We need fundamental insurance reform in this country. We can start by making health insurance about insuring risk of serious injury or illness, not a prepayment scheme for every sniffle. We have auto insurance for accidents, not oil changes. New private risk pools for individuals and not-for-profit insurance companies would enhance competition, i.e. improve services and lower costs. If insurance companies are required to accept all applicants, including those with preexisting conditions, they will create larger risk pools to manage the risk. The Government should not be allowed to “compete” because it is impossible to compete against an entity that prints money, does not have to collect premiums, does not have wellness programs, and does not pay taxes. Patients should be allowed to purchase health insurance across state lines like everything else that is sold in this country, and it should be tax-deductible. They should buy it as individuals for life, like life insurance, which makes it guaranteed, portable, and not subject to preexisting conditions. Freed of the need to provide health insurance for employees, employers will pay higher wages to stay competitive in the labor marketplace. Insurance companies need to improve transparency in physician contracts and quit playing reimbursement games with doctors.

Caring for the Uninsured: The Government cannot make uninsured patients disappear by passing laws. They are a societal problem. To ask providers to shoulder most of the cost of caring for the uninsured is unfair. The Government should allow providers to deduct the cost of caring for the uninsured from their taxes, like any other act of charity. Rather than create new programs for the uninsured, the Government should create a mechanism to allow immediate enrollment of the uninsured in Medicaid at the point of service. The insurance status and personal financial liability of these patients can be evaluated retroactively by Medicaid.

Malpractice Reform: The cost of medical liability insurance for physicians is high, and the cost of defensive medicine is real and enormous. Ultimately, these costs are paid by all of us. The utter absence of any discussion of malpractice reform in Washington is a disgrace and fundamentally dishonest. We believe that patients should be compensated for economic damages caused by medical malpractice, but we also believe that our legal system is a circus of blackmail and jackpots, disconnected from true medical malpractice and true damages. Furthermore, and cruelly, it takes years for deserving patients to receive compensation, long after they most need it.

Regulatory Burden: Our regulatory burden is onerous both in time and money, and it frequently contributes nothing of material value to you, our patients. We need relief from this burden to better care for you. Any proposed reforms should diminish, not expand, this regulatory burden.

Personal Responsibility:
We all have a civic duty to buy health insurance, and those who cannot afford it should be subsidized, perhaps through taxes on unhealthy foods and non-essential purchases. Some people, particularly the young and healthy, choose not to buy health insurance, even when they can afford it. These individuals must be incentivized to buy health insurance to spread the risk.

Wellness: Under our current system, patients have almost no financial incentive to lead healthy lifestyles. Mechanisms to incentivize wellness could be created, and patients who take care of themselves should be rewarded with lower health insurance premiums.

We are professionals, not commodities. Our training required years of dedication, and it came at a great cost, personally and financially. The assets of the businessman reside in his building and its contents; ours reside in our heads and in our hands. They belong to us, not the insurance companies and not the Government. These assets have real value, and we passionately want to use them to heal you when you are sick, on mutually agreeable terms. Any attempt to force us to work for the Government, without our individual consent, is a form of theft, a corruption of our relationship with you, and an assault on our professionalism.

Stand with Us: Send this advertisement to your representatives and tell them that free market principles can work in health care, just as they do in other service industries. Demand that they fix Medicare, Medicaid, and every VA Hospital BEFORE creating any additional programs. Demand removal of distortions in the tax code that promote third party payment and thus health care inflation. Demand the expansion of tax-free medical savings accounts which empower you, the patient, to find good care at a good price. Demand policies that incentivize providers to discuss their results and disclose their pricing. Remind them that “health care” starts with individuals and that all Americans must be incentivized to stay healthy. Tell them that jackpot justice has no place in the compensation of patients who have been injured while receiving medical care, irrespective of the cause of injury. Stand for freedom, dignity, and respect for the individual citizen, and oppose any reforms that might imperil your right to determine what happens to your body.


Contact information for Kentucky Congressmen:


Jim Bunning 316 Hart Senate OB Washington, DC 20510
Phone: 202/224-4343 Fax: 202/228-1373
Mitch McConnell 361-A Russell Senate OB Washington, DC 20510
Phone: 202/224-2541 Fax: 202/224-2499
Ed Whitfield 2411 Rayburn HOB Washington, DC 20515
Phone: 202/225-3115 Fax: 202/225-3547
Brett Guthrie 510 Cannon HOB Washington, DC 20515
Phone: 202/225-3501 Fax: 202/226-2019
John Yarmuth 435 Cannon HOB Washington, Dc 20515
Phone: 202/225-5401 Fax: 202/225-5776
Geoff Davis 1108 Longworth NOB Washington, DC 20515
Phone: 202/225-3465 Fax: 202/225-0003
Hal Rogers 2406 Rayburn HOB Washington, DC 20515
Phone: 202/225-4601 Fax: 202/225-0940
Ben Chandler 1504 Longworth HOB Washington, Dc 20515
Phone: 202/225-4706 Fax: 202/225-2122

This advertisement was wholly purchased by the physicians listed above, unconnected with any political party or interest group

Friday, May 8, 2009

"Right to Healthcare"

You have RIGHT to health care, you say?

Sounds good, doesn't it, feels good to demand it, doesn't it? Politicians demand it, "humanity" demands it, "compassion for your fellow citizens" demands it, health care is of those "unalienable rights". Isn't it?

Well, you know, "Health Care" is not an abstract concept, and not just "something". Health care is what I personally do, an individual service from me for you. I requires preparation, a special setting and often help from other people. Health care is why I get up in the morning and why I go to work.

It took me quite a while to be able to give health care, by the way. 15 years of training, with countless sleepless night, plenty of sacrifices, low income for all those years, pressure and hard work.

And you state that you simply are entitled to this, that it is your right?
Did you do something for me? Did you help me get into medical school? Funny, I also did not see you paying for my medical school, and I did not see you paying for my residency training, nor I did not see you staying up at night with me, bringing coffee, holding my hand, nor helping me in any way at all. I passed all the exams quite well all by myself, and I do not remember you helping me to pass them. And now you claim a right to my success?

In short, you did not contribute to my 15 years of training, but now you say that day or night you have a right to my unique knowledge, my unique skills, my expertise, just because....?

Oh, because it is the "human" thing to do, the "compassionate" thing to do? Or is it because there was an "oath" that was written over 2500 years ago, at a time when we had no electricity, no technology, no paper money, an economic system of the most simple and underdeveloped form.....
Come on....

Ok, you say that you have a right to healthcare because it is really important to you and your really need it, you say it is a matter of life and death...
Well, well, don't we all have our needs..
Counting my needs, I would start with food, which is really, really important. Should food not be a right?
Well, go to your farmer, your supermarket or your grocery store and tell them that you have come to claim your right to food!
Let's continue with shelter, housing. Very basic. Just go to the construction company and tell them that you really, really need a house, and that you think housing is a right! Find out how well that goes over..
Next go to the Gap and tell them that you have a right to clothing! Listen carefully to their answer.
Money, well, that is really important. Money is handy, can be traded for a lot of other useful things. Please go to a bank and claim your "right " to money! Watch how pleased they are....
You might also want to call Warren Buffet and tell him you have a right to his expertise and his skills, after all, he is rich enough.....

Oh, I forgot....
Remind me, since you claim a right to MY work, do I actually have a right to YOUR work? NO? Why does this not surprise me?
To be frank, I think it is pretty nervy of you to demand that you have a right to my work!

To sum this up: I am a free individual and I can do with my life and my knowledge and my skills whatever I please. And no, you do not have any kind of "right" to my knowledge, my expertise and my skills. And, No, you do not have a right to my time, be it by day or by night, my past sacrifices, my blood, sweat and tears. No, you do not have a right to it.
Oh, so you don't really want to claim you right from me, you want to claim it from the government? You think "the government should provide health care"?
May I ask how this will happen? Do you expect the town clerk to provide care? The government as such cannot provide healthcare. Physicians provide health care. Should I assume that you want the government to lean on me, to force me to give you what is a "right"? Is that what you want?
You know, in the end it comes down to you, the patient, and me, the physician. Nobody else. That is health care. I do not see how the government matters in this.
And, no I will not give the government a discount. The government does not give me discounts either. And you remain exactly the same patient, regardless if you pay or if the government pays.
Just to be clear, I do not owe the government anything either. Neither does the government have a right to me, to my life, my skills, my expertise and my knowledge. To the government I am just the same as to you: an individual who is independent, to whose efforts and time neither you nor the government has any kind of "right".
We can trade though, at arm's length, and if we come to a mutually beneficial agreement I will be happy to give you my time and skills