By Michael J. A. Robb, M.D.
To innovate, physicians must be free from the shackles of third-party oppression, exponentially rising numbers of “administroids,” and the bureaucratic status quo of billing third parties for fractions of the actual dollar while trying to keep up with high-volume clinics just to meet overhead and earn a living.
Patients are sick of the impersonal, fast-food medicine paradigm. I hear a litany of complaints every week about the hurried visits that are less than 15 minutes, the surprise consultation with a nurse or physician assistant instead of the actual physician, and the physician’s stressed demeanor and cold ear, furiously typing into a computer with lack of eye contact, conducting cursory examinations, and leaving the patient with many unanswered questions.
This is America, not Europe. Don’t acquiesce. Resist the march toward single-payer, socialized medicine now, or get ready to settle for mediocrity, burnout, and unsustainable government promises.
Right now, it appears to be Congress vs. the President. Recall that the Affordable Care Act (ACA) was passed in the dark of night without the American people knowing what was in the bill. Neither party should pull such a stunt ever again. As we have learned over the past several decades, it is increasingly difficult to extricate a dependent people from government benefits. The major problem now is that ACA has ruined the insurance market and true catastrophic insurance is no longer affordable, or even offered. The 100- year march toward single-payer socialized medicine in the land of the free is in full steam and neither party appears courageous and wise enough to get off this European “road more traveled.” Please stop destroying the free market. Please stop betraying our citizens.
The Association of American Physicians and Surgeons (AAPS) has your back and works hard daily to preserve wedges of freedom for patients and doctors so that there will be more than one Harley Street in every county in the U.S. We have shared and continue to share our wisdom with the state and federal legislatures, and encourage them to stop treading on patients, physicians, and the people.
Our current directive to Congress is: keep your promise and get the ACA repeal done. Fix ensuing problems one by one, state by state, but do not do anything to ruin the free market in the process. See the AAPS white paper on repeal and replace  for wise advice, and urge politicians to refer to it regularly.
The majority of politicians don’t listen to us outspoken doctors very well, even though they appear to solicit our comments on the rules they promulgate and change as the game is played. Doctors should be ashamed to know that patients are starting to repeat government and media criticisms of us, and we do not deserve such a reputation after all the sacrifice we have made personally and professionally. We must put the patient first every day. If anything or anyone is adversely affecting your practice of medicine, stand up and revolt against it, break free, and help reclaim our profession.
Professional burnout is real, and neurologists are among those at most risk of professional burnout starting as soon as residency. Why are physicians feeling pressured to hire assistants, including nurse practitioners and physician assistants? It is so they can keep up with the patient load and still make the bottom line. A physician is not punished for being efficient, but imagine just how much more innovation and creativity could take place if the physician was not trapped in a race to see patients at such a hurried pace.
In the spirit of preserving the sanctity of the patient- physician relationship, the practice of private medicine, and medical innovation in our free country, we desperately need more of the following now:
- More private medical schools, residency, and fellow- ship programs that accept and train excellent physicians. Imagine a neurology residency training program that in- cludes five or 10 or 20 PGY-1, 2, 3 Most doctors would decide to stay in the U.S. to practice, I predict. Thus, more patients would be able to see an actual physician for the new patient consult as well as the follow-up visit. Maybe the nurse practitioners and physician assistants could even go to medical school because there would be more slots. Or, if they did not aspire to such a profession, they could be even more productive and innovative working alongside physicians and surgeons who are in charge of their own practice instead of working within the confines of a third- party-payer system run by uneducated, nameless, faceless bullies, regulators, and oppressors who, in effect, practice medicine and surgery without any accountability. Even the billers and coders share and understand the frustrations with the costly CPT/ICD-10 Möbius maze and would likely enjoy using their brains doing something more intellectu- ally stimulating and rewarding to society.
- More independent, third-party-free primary care and specialty clinics, surgical centers, and Direct patient care is one common-sense, free-market solution that definitely works and is growing nationally. The patient pays the bill for the non-catastrophic care and submits a simple receipt, not a “clean computerized claim,” for partial or full reimbursement by the insurer or medical-sharing ministry with whom the patient has a contract or relationship.
- More health savings accounts (HSAs) for all. Patients are experiencing much higher deductibles, inability to buy catastrophic insurance plans that offer care they need and want, and less freedom to choose the physician of their choice and get the consultation time and quality they deserve. Politicians are expanding government’s tentacles further and further into patients’ lives.
Medicaid Is a Problem, Not a Solution
In Arizona as of 2016, there are reportedly 9,430 primary care and 9,924 specialty physicians enrolled in Medicaid (urban and rural), and 603,267 primary care and 310,886 specialty service claims were filed as of 2015. Supposedly, the majority of licensed physicians are enrolled in Medicaid, but the number of physicians who have limited and/or stopped taking new Medicaid patients is unknown. The average wait time, the number of patients seeing the actual doctor for the initial visit, the average length of consultation, and clinical outcomes are not reported.2 We know that administrators are dramatically outnumbering physicians nowadays. Prior authorization hurdles, diagnostic delays, and denials of care have become standard operating procedure. Taxpayers should be interested in a forensic accounting of Medicaid, state by state. How much money goes to actual medical care for the patient vs. administrative overhead? How much is taken from taxpayers in poorer states? How much goes to profits to stakeholders? How much is wasted on inefficient protocols? The Arizona state chapter of AAPS is conducting such an audit, and every state should follow suit. In fact, state governments should have been exercising this fiscal oversight already.
Arizona is claimed to be the most efficiently run program; it is 100 percent managed care. Physician and non-physician practitioner enrollment trends are up with the exception of behavioral health services, and payment rates are flat. Arizona Medicaid pays 73% to 92% of Medicare rates and is ranked 15 out of 50 states. Data on those physicians who have stopped taking new Medicaid patients is not published.  A preliminary audit  shows that contractor-level administrative expenses exceeded $1 billion and pre-tax contractor profits were more than $228 million on about $10 billion of revenue in 2015 or 2016. Nearly $400 million was transferred from the Medicaid program to other state agencies during the period 2012– 2016. How much actually reaches patient care is not known at this point; additional study is in progress. From this, we will still not be able to quantitate how much more helpful and compassionate medical care could be given by physicians willingly donating their time or seeing the patient for a mutually agreed upon fee in accordance with the patient’s budget.
This summer I started on a mission to obtain an answer from Medicaid that could open up new doors for the private, third-party-free physician to help the poor, especially if the professional liability carriers do not reduce the rates or if the state does not pay for the professional liability policy of those physicians and surgeons donating a portion of their time to charity every month, as has been proposed to state legislators by Alieta Eck, M.D., director of a prototypical charity clinic at the Zarephath Health Center in Somerset, New Jersey (2003-present).
Since the federal government is determined to expand Medicaid and states are so dependent on continued federal assistance, placing unsustainable demand on program resources, it is increasingly imperative that physicians be free to treat Medicaid patients privately on a case-by-case basis, and that patients be free to pay physicians on a case-by- case basis for both primary and specialty/subspecialty care. Direct access to specialists should be legal, too. Possessing a Medicaid card does not guarantee timely access to medical care rendered by a physician or surgeon. Many doctors do not take Medicaid, or have stopped seeing new Medicaid patients. If the government is determined to maintain its predominance, then more exit ramps to freedom are mandatory, lest American medicine become a footnote in history.
This important question—silly as it may sound in a free country—was asked of Medicaid: “Can the Medicaid patient pay privately for medical and surgical services offered by a non-enrolled, non-contracted doctor?”
The official answer, convoluted and full of Medicaid jargon, came via a personal telephone call from Medicaid’s general counsel in late July 2017 and email. The answer is a qualified “Yes.” The option of a patient-doctor agreement was raised, but a sample agreement is not available through the Medicaid office. AAPS is working on a prototype of such an agreement, which will document that the patient agrees to pay privately, the physician and patient agree not to submit a claim, and the patient is free to seek care elsewhere in-network at any time. Sound familiar? Those of you who are enjoying your Medicare opt-out status with automatic renewal every two years will understand.
The Texas statute [Tex. Admin. Code § 354.1131(f)] states that the Medicaid patient is free to see a physician who is not enrolled in Medicaid with the understanding that the patient pays for the bill, no claims will be submitted, and Texas Medicaid is not liable for any reimbursements.
Medicaid was unable to answer questions about the logistics of orders and referrals and payment for such care written by the third-party-free doctor. Pharmacies have told me that they suspect the patient might receive a bill from Medicaid if the pharmacy accidentally filled a prescription for a Medicaid patient written by a private doctor. An in-network Medicaid clinic could simply read the recommendations of the private doctor and consider coordinating the care. But in-network physicians might be uncertain about whether Medicaid would cover such a recommendation, or whether more prior-authorization red tape would be required. Thus, the backup plan is obtaining the workup or care privately at facilities that charge a fair cash price for medicines, laboratory tests, radiological imaging, physical therapy, durable medical equipment, surgery, etc.
We need more transparent drug pricing; more awareness of the bargain cash prices for laboratory tests by small and large laboratories in every state; more third-party-free surgical centers in every state; a movement toward private hospitals not contracted with Medicare or Medicaid; charity clinics that attract the best doctors with incentives such as reduced or totally covered professional liability insurance; and more residency training programs that are private and can afford to pay the residents with money that is not tied to Medicare income.
According to CMS 2015 statistics, federal, state and local government sponsored “healthcare” accounts for 46% of all health care spending. Healthcare spending accounts for 18% of the U.S. economy. These programs are not sustainable, and they come with such a terrible price to pay: the loss of physician autonomy, efficiency, and innovation. Three proven solutions in operation by AAPS members are direct primary care models, third-party-free specialty clinics, and a private cash-based surgical center. Cash, catastrophic insurance, and true charity save money for patients and the states.
If we sincerely desire to render excellent medical care to the poor or others forced onto Medicaid, state legislators working wisely to allocate block grants should unleash all chains and ownership on the patient and the doctors so that the patient can see the physician or surgeon of his choice without prior authorization. There is evidence that even uninsured patients, who have the freedom to seek care privately, have better outcomes than Medicaid patients. Common-sense Medicaid goals would be to drastically reduce or eliminate red tape; let the patient learn to be responsible and to manage Medicaid HSAs; expand HSA coverage to out-of-network physician care; and improve the options for consultations, diagnostics, and therapeutics.
AAPS Fights for Freedom
AAPS continues to fight daily to preserve liberty in medicine and the sanctity of the patient-physician relationship. We have been very successful in identifying and securing wedges of freedom in a polarized society in which many influential forces are urging us to march down the road to single-payer socialized medicine and to the destruction of the most prosperous and innovative country in history.
We face battles that are very hard to win, and the cards are stacked against us. But we do not lobby for small, rotten carrots on the end of a stick. Rather, our goal is to prevent doctors from being imprisoned in the maze of chains and ownership, subject to politicians and bureaucrats who should have no jurisdiction over your medical practice.
Please join with us and invite colleagues to stand with us if you oppose petty tyranny and the federal Leviathan, and you wish to reclaim physician autonomy.
- Orient JM, AAPS. White paper on repeal/replacement of the Affordable Care Act. J Am Phys Surg 2017;22:25-29. http://aapsonline.org/whitepaper
- Betlach TJ. 2015 Access to care report. Arizona Health Care Cost Containment System. 2016 Access Monitoring Analysis; July 2016. Available at: https://www.azahcccs.gov/AHCCCS/Downloads/AccesstoCare/2016AHCCCSMonitoringAnalysis.pdf Accessed Aug 1,
- Kroll Arizona Health Care Cost Containment System (AHCCCS): AHCCCS revenues and expenditures 2012-2016. Acute care contractors financial summary. Available at: http://tinyurl.com/y768nzlc. Accessed Aug 4, 2017.