Bob Sheerin was live with Stephanie Freeze

Bob Sheerin
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Help my girl Emmalyn!
This is the ornament that Emmalyn is making along with Kel’s creations with Kelli! These ornaments are part of her fundraising effort to get her to the spero clinic! With a $20 donation to her GoFundMe posted below you will receive an ornament. After your donation, please email me at with your address!! Thank you you all so much for always following and helping with Emmalyn’s Journey!!

November is Diabetes Awareness Month

most societies/communities have 1 or more agitators, disruptors, false prophets, scammers, traitors, saboteurs and cult leaders

Some believe our country is on the verge of a Civil War, they may be right, but it won’t be a bilateral war like our last Civil War..  Our society has voluntarily divided itself in – for lack of a better description – TRIBES.

The chronic pain community is not all that different from our country of as a whole.

Recently a fellow chronic pain pt who had been advocating for end stage pediatric pts in a large hospital system that has a “no opiate” policy.  All of a sudden the advocated was told that he was no longer permitted to advocate for these end of life pediatric cancer pts.  I suppose that this major hospital system will return to treating these pediatric pts with NSAIDS and Acetaminophen and let them live the rest of their lives in a torturous level of pain.

There are rumors as to who said what and to whom… I am not going to elaborate. However, they know who they are and what was said to cause this to happen.  One can only imagine the deprived mental status of those who have been involved in this.

Some have told me that this tribe of malcontents have monetized chronic pain pts’- personal information  and several other covert processes. I started my blog in 2012 and have tried to motivate and educate chronic pain pts in some ways that they can navigate their way to getting their pain management back.  Some chronic painers have told me that I should charge for my advice.  My Pharmacy degree, license and career has provided for Barb and myself a comfortable retirement.

After this issue with these end of life pediatric pts,  Going forward… I am going to ASK of people that want my advice to make a contribution to one of the four national charities listed below, these are all about THE KIDS… and charities we support.  Maybe in some small way, my advice can help more than just one person/family. St. Jude Children’s Research Hospital – deals with kids dealing with cancer and/or life threatening health issues Shriners Hospital – deals with kids, born with “broken bodies” and birth defects Ronald Mc Donald House – this is near us and just a few blocks from a very large regional pediatric hospital ,3 other major hospitals within blocks, one being a teaching hospital and having the only LEVEL ONE TRAUMA CENTERS for 100 miles and part of a medical university and  helps provide housing for families with kids in the hospital Tunnel to Towers Foundation – helps get handicapable housing for veterans, first responders with “broken bodies” , families with spouse/parent killed in the line of duty and Gold Star Families



Is pain really all in your head?


I won’t drop down and say that this presenter suggests that your pain IS ALL IN YOUR HEAD. I am all in for complimentary care for the chronic pain pt. Often a full array of complimentary services many not be available/accessible, nor affordable by the pt.

Many pts are disabled and on Medicare disability and/or Medicaid. If the spouse is still around, the chronic pain pt, may not have transportation to medical services, because they no longer drive and spouse would have to take off work to transport them to get medical services/procedures. Causing the family’s finances to take “another hit”.

I noticed that “pain” seems to be addressed like it is like a monolith …  never talks about the intensity of the pt’s pain, nor the fact that the pt may have more than one disease/health issue that is a pain generator. I have communicated with too many chronic pain pts that state that their blood pressure has increased to emergency crisis level (200/100)+ after forced tapers and even when being prescribed 4-5 different pharma BP meds, their BP remains in the emergecy crisis level.

So it would appear that the pharma meds is focused on a different pathway than the pathway that under/untreated pain causes a pt’s BP to be elevated to a life threatening levels.

The chart below shows the potential of under/untreated pain complicating a pt’s co-morbidity issues and/or can cause the pt to have additional health/disease issues.

A pt being put thru forced titration of their opioids, may end up bed/chair/house confined. Much like being under house arrest without actually committing any crimes.

Shouldn’t all healthcare providers be focused on optimizing the pt’s QOL, with whatever services or products that the pt can afford?



Bureaucrats are going to lower the cost of Rxs – without “fixing prices”

As you read this article remember that the top 5 PBMs or owned by the top five insurance companies. It is claimed that the PBMs get a very large chuck of their profits from demanding discounts/rebates/kickbacks from the pharmas to have their meds on the PBM’s approved formulary and no prior authorization required for a pt to get their Rx meds paid for. Reported those discount/rebates/kickbacks can total up to 75% of the medication’s AWP ( Average wholesale price).  So if a pharma needs to get $1.00/bottle more gross profit, they have to raise it by $4.00 because the PBM will snag $3.00 into their coffers.

Medicare has already set up some sort of “price negotiation” that is suppose to be active in another 1-2 yrs and now the states are setting up prescription drug affordability boards (PDABs), which usually set limits on how much some patients will have to pay for medications.

I get the impression that these bureaucrats really don’t know the hell what they are doing, but they are going to do it anyway.  I expect that pharmacy- especially independent pharmacies – will take the BIGGEST CUT in revenue, followed up by pts dealing with higher premiums and co-pays and lastly the insurance/PBM industry will figure out somehow to get little/no cuts in revenue.

“We” will probably see a dramatic increase in “pharmacy deserts”, as both independent and chain pharmacies become less profitable and or showing a loss. However, the insurance/PBM and the major chain pharmacies all have mail order pharmacies – that will try to take up the slack from the growing number of pharmacies deserts. Where typically it can take up to TEN DAYS for a pts to get their Rxs and those Rx meds can be exposed to ambient temperatures that exceeds what the FDA requires them to be kept in, but apparently none of the 50 state pharmacy boards give a damn about this.

States Making Progress Toward Setting Payment Limits for Some Drugs

Prescription drug affordability boards are now the law in eight states

As drug prices continue to rise, some states are fighting back through the use of prescription drug affordability boards (PDABs), which usually set limits on how much some patients will have to pay for medications.

PDABs were the brainchild of Jennifer Reck and colleagues at the National Academy of State Health Policy (NASHP), which started working on the issue in 2016. “We were hearing from states that were really getting crushed by drug prices, and they needed the tools and resources to do something about them,” Reck, who is project director of NASHP’s Center for State Prescription Drug Pricing, said in a phone interview. “We convened a workgroup of state officials to dive into this topic, and the idea of a PDAB was one of the initial policy recommendations coming out of this.”

Using Rate-Setting as a Tool

The idea behind the PDAB was that “rate-setting is something that’s a common state activity, and looking to something like a public utility commission as an example, the state could create PDABs to review drug prices — not to set prices, which would be a violation of federal law — but instead to leverage the states’ rate-setting authority to set upper payment limits (UPLs),” she explained. Importantly, the UPLs apply only to in-state transactions; anything broader would run afoul of the Commerce Clause in the U.S. Constitution, which bars one state from regulating what goes on in other states.

So far, eight states have implemented PDABs: Maryland, Maine, New Hampshire, Oregon, Ohio, Colorado, Washington, and Minnesota, according to Kate Sikora, MBA, associate principal at the consulting firm Avalere, in Washington D.C. Legislators in Michigan recently introduced a bill that would establish a PDAB in that state, she said in a phone interview.

Not surprisingly, each state’s PDAB varies in its authority, Sikora continued: in Maryland, any UPL would apply only to patients and payers in state-run health plans such as state employee plans and Medicaid, whereas in Colorado, the UPL generally applies to any plan governed by the state, including those in its state health insurance exchange.

In fact, the statutory language regarding to whom Colorado’s UPL applies “is quite broad,” Lila Cummings, the director of Colorado’s PDAB, said during an online interview at which a public relations person was present. “I think it just says ‘all purchasers.'” Health plans for Colorado’s self-insured companies — those governed by the federal Employee Retirement Income Security Act (ERISA) — have the option of participating in the UPL for their beneficiaries, but they are not required to, Cummings said.

There are other differences among states too, Sikora said; for example, not all states are setting upper payment limits. “In New Hampshire, the PDAB is just for making recommendations to the state on how to lower drug price costs.”

One interesting element of Minnesota’s PDAB law, Reck noted, relates to the drug price negotiation program that Medicare is currently implementing. “The statute says that when setting a UPL for drugs that are subject to the Medicare rule, the board shall set the UPL at the Medicare Maximum Fair Price,” she said. “They’re not necessarily limiting their work to the drugs that Medicare is negotiating, but they’re saying that if there’s an overlap, they will use that as the UPL.” Sikora agreed that “watching Minnesota will be interesting next year” and added, “I think probably other states will do similar things because it involves a lot less work for the state.”

Colorado’s Rapid Progress

Observers generally agree that the state furthest along on the PDAB path is Colorado; its PDAB was created through legislation passed by the state’s General Assembly in 2021. Gov. Jared Polis (D) “appointed the first five members to the board in September 2021,” and the board and staff spent about 18 months setting up the program, including appointing a 15-person advisory council — made up of various members of the drug supply chain, including manufacturers, wholesalers, patients, and providers — to give the board advice, Cummings said.

In August, the PDAB officially approved an inaugural list of five drugs to be subject to “affordability reviews” for possible UPLs: etanercept (Enbrel); elvitegravir/cobicistat/emtricitabine/tenofovir (Genvoya); secukinumab (Cosentyx); ustekinumab (Stelara); and elexacaftor/tezacaftor/ivacaftor (Trikafta). Some of the 14 criteria to be considered as part of the affordability review include:

  • Input from patients and caregivers
  • Health equity impact
  • Current wholesale acquisition cost and changes in that cost
  • Impact on safety net providers
  • Orphan drug status
  • Input from individuals with scientific or medical training
  • Patient copays and other cost-sharing information
  • Price effect on consumer access
  • Rebates, discounts, and price concessions

The first review draft is expected out in a couple of weeks, Cummings said.

Why is Colorado so far along? Kate Harris, chief deputy commissioner for life and health policy at the Colorado Division of Insurance, attributes the relatively rapid pace to the requirements of the law. “We implement the statute the legislature passed with the timelines they passed it in, and where there is flexibility, we work at the pace of the board,” she said during the online interview that also included Cummings.

Hope Stonner, policy manager at the Colorado Consumer Health Initiative, a consumer group, seemed pleased with the PDAB’s progress. “What we’ve seen with the board is really encouraging,” said Stonner, whose organization helped get the law passed. “They have had to build this complicated entity from scratch, and it has been very encouraging to see the communal effort and the amount of public input the board has been receptive to.”

Maryland Also Moving Along

Maryland is another state that’s considered to be making good progress. “Our PDAB was created in 2019; it’s an independent agency with five members who are supported by a 26-member stakeholder council that represents different groups on the supply chain,” said Andrew York, PharmD, JD, executive director of the Maryland PDAB, during a phone interview. “The main work we do is cost reviews and setting UPLs.” York said he wouldn’t be surprised to see three to five drugs in the board’s first round of cost reviews, with the first set of reviews starting in the beginning of 2024 and finishing up by mid-year.

PDABs can learn a few things from the Medicare drug price negotiation program, York said. “The entire purpose of the Inflation Reduction Act [which included the Medicare price negotiation program] seems to be to save money because they are required to select qualifying drugs based on their highest overall spend, which is a very good idea. However, what PDABs can do is bring more nuance to the conversation, because they can consider other factors.” Although the list of drugs that have, for example, abused their market exclusivity may be similar for states as well as Medicare, “PDABs have the flexibility to look at additional drugs and try to be more nuanced in their assessments,” he said.

One of the Maryland PDAB’s members is Stephen Rockower, MD, a retired orthopedic surgeon from Bethesda, Maryland. “One of the things that drives physicians nuts is prescribing a medication and then having patients come back a month later or 2 months later and saying they didn’t take it because they couldn’t afford it,” Rockower, former president of MedChi, the Maryland State Medical Society, said in a phone interview. “We are in this business to take care of people, and if there are barriers that prevent them from doing the things that we asked them to do, then we’ve got to work to try to lower the barriers.”

The PDAB’s work also will affect physicians “because some of our physicians are actually dispensing medicines as well, like the rheumatologist who dispenses anti-inflammatory drugs” in their office, Rockower said. But even though setting a UPL may reduce the amount physicians can bill for the drugs they dispense, he said he didn’t think they would be adversely affected because their acquisition cost would also likely drop.

“I think what would happen is if the upper payment limit is set at a certain spot for … the patient, the price that the manufacturers or the PBM [pharmacy benefit manager] set will similarly go down,” he said. “So the physician who is sort of acting as a pharmacist, so to speak, will not get hurt by that.”

Cancer Patient’s Final Act: Destroying Medical Debt

Cancer Patient’s Final Act: Destroying Medical Debt

Viral campaign will erase some $60 million in medical debt

A 38-year-old woman who died from ovarian cancer earlier this month posthumously launched a viral campaign that will help pay off an estimated $60 million in medical debt.

Casey McIntyre died on November 12, and in a thread posted to Xopens in a new tab or window (formerly Twitter) 2 days later, she wrote, “to celebrate my life, I’ve arranged to buy up others’ medical debt and then destroy the debt.”

“I am so lucky to have had access to the best medical care at [Memorial Sloan Kettering Cancer Center] and am keenly aware that so many in our country don’t have access to good care,” she wrote.

The post has garnered nearly 5 million views, and it links out to her campaign on RIP Medical Debtopens in a new tab or window, which has raised nearly $610,000.

RIP Medical Debt, which was formed by former debt collection executives, buys medical debt at lower prices and then forgives it, instead of collecting on it.

Allison Sesso, president and CEO of RIP Medical Debt, explained that the amount raised actually goes 100 times further in eliminating debt. For instance, a $10 donation erases $1,000 in medical debt — so McIntyre’s campaign will actually erase about $60 million in debt at this point.

Sesso said the McIntyre campaign began with a $20,000 goal, but that has been raised several times and now sits at $650,000.

“We’ve never seen a campaign raise so much money for medical debt abolishment so quickly,” Sesso said, adding that McIntyre’s campaign alone “will help tens of thousands of people.” Its debt erasure will focus on the Northeast region, where McIntyre’s family lives.

RIP Medical Debt was founded in 2014, and it has since erased $10.4 billion in medical debt for more than 7 million patients. Sesso said McIntyre’s campaign is the organization’s first posthumous fundraiser.

“It’s both heartbreaking and inspiring that nearing the end of her life, Casey, and her husband Andrew, had the vision and goodwill to think of others who can’t afford their medical care or who are buried under healthcare debts they’ll never be able to pay,” Sesso said. “I think that selflessness is really resonating with the public.”

McIntyre’s husband, Andrew Rose Gregory, told the New York Timesopens in a new tab or window that the family is “overwhelmed, and it’s been really powerful to see the response to people wanting to eliminate strangers’ medical debt.” Gregory also told the Washington Postopens in a new tab or window that McIntyre was fortunate to not have medical debt, but she had met plenty of fellow cancer patients who were not as lucky.

“People are making miserable decisions about their care because of money,” Gregory told the Post. “This imaginary debt is dragging so many people down. It’s an immoral part of our nation.”

McIntyre’s family posted in the thread on X that they would be hosting a “memorial service and debt jubilee” — inspired by anthropologist David Graeber’s book “Debt” — in McIntyre’s honor next month.


” Qlarant Health Integrity (NBI Medic) advertises that they use specialized data analysis, which helps law enforcement locate buried targets and “speed conviction,”


Foot Locker, Teamsters Show Their Drug-Benefit Managers the Door

Foot Locker, Teamsters Show Their Drug-Benefit Managers the Door

Employers and unions say the PBMs are favoring costlier drugs over less expensive options and aren’t open about their rebates

Employers and unions are getting fed up with the firms they have used for years to help control their spending on prescription drugs—because their costs keep soaring.

Footwear retailer Foot Locker dropped UnitedHealth Group’s OptumRx drug-benefit manager last year, while a Teamsters fund in Philadelphia recently reupped with its replacement for CVS Health’s Caremark.

Among their frustrations: They are being told to cover costlier drugs even when less-expensive options are available.

The employers and unions express concern that they are getting stuck with higher-cost drugs because the drug-benefit managers can pocket some of the bigger rebates negotiated with the medicines’ makers. The employers and unions say they can’t know for sure because the drug-benefit managers aren’t open about their fees and other sources of revenue.

After Alabama fabric maker Phifer replaced its drug-benefit manager, Prime Therapeutics, the new firm got rid of some expensive drugs—such as the nerve-pain medicine Gralise, which has a list price of $1,532 for one month’s supply compared with $13 for the generic equivalent.

Phifer’s new drug-cost middleman, known as a PBM for pharmacy-benefit manager, also substituted a generic migraine pill costing 80 cents a dose for a powdered brand called Cambia that lists for $118.26 per treatment.

“Do the games ever end?” said Russell DuBose, Phifer’s vice president of human resources. Under the new PBM, Phifer’s drug spending has dropped 18% to date this year.

Caremark, OptumRx and Cigna Group

’s Express Scripts—the largest of the middlemen—said they save their customers money and give employers information and options to tailor drug benefits to best suit their workers’ needs.

Big drug-benefit managers also said they win a lot of repeat business, which OptumRx said indicates customers like their choices and the information they get on their spending. Prime Therapeutics declined to comment.

The frustrations of some employers and unions are starting to shake up the important but under-the-radar sector for controlling spending on retail prescription drugs, which the Centers for Medicare and Medicaid Services projects will reach $411.6 billion this year.

PBMs last year handled virtually all of what amounts to 6.4 billion 30-day prescriptions, according to the research firm Drug Channels Institute.

To keep a lid on costs, the firms negotiate with drugmakers over how much each prescription will cost and then pass along the rebates they win. The PBMs can threaten to exclude a drug from the menu, or formulary, of medicines a health plan will cover if they don’t get a sufficient rebate.

Yet retail drug spending under private insurance has increased 3% each year, on average, for the last decade, according to CMS.

“What’s wrong with this market? Everything,” said Michael Thompson, chief executive of the National Alliance of Healthcare Purchaser Coalitions, which represents employers, unions and other organizations buying private health plans.

Jonathan Levitt, a healthcare lawyer at the firm Frier Levitt, said one of his employer clients settled an arbitration case with a PBM over how much information it should provide about the rebates it negotiates and another is now in a similar arbitration with a PBM.

Foot Locker replaced OptumRx last year because it wanted more information about how much the PBM was profiting off its work for the retailer, said Linda Gulbrandsen, Foot Locker’s vice president of North American benefits.

“We know our vendors work hard. We expect them to make money. But we expect to know every penny that they are making off of our team members,” she said.

OptumRx said Foot Locker’s contract had been negotiated through a group working on behalf of several customers. Companies that contract with OptumRx directly can have more flexibility in setting terms.

Foot Locker hired a smaller pharmacy benefit manager, Navitus Health Solutions of Madison, Wis., which tells employers it passes through to them 100% of the drug rebates it negotiates.

Navitus also does more to prioritize the use of low-cost prescriptions, Gulbrandsen said. Employees who need pricey drugs can get them, but are asked to first try cheaper options, when it is appropriate, she said.

Roughly 8,500 workers and their families enrolled in Foot Locker’s health plan. During the first year after the switch, spending on drugs dropped 5%.

Phifer left Prime Therapeutics, which works with many Blue Cross and Blue Shield health plans, at the end of 2022 because its costs were rising 7% a year and Prime wasn’t offering new solutions for controlling the increases.

“It was wash, rinse, repeat of the prior year,” DuBose said.

Phifer hired MedOne Pharmacy Benefit Solutions, which promotes the “different path” it takes from traditional PBMs. Founded by an Iowa pharmacy chain owner in 1999, MedOne, of Dubuque, Iowa, now counts more than 400 clients.

Because of the money it has saved on drug spending, Phifer was able to hold its premiums for 2024 flat, DuBose said.


What is your outlook for pharmacy-benefit managers? Join the conversation below.

The Teamsters Health and Welfare Trust Fund of Philadelphia and Vicinity, which replaced Caremark with venture capital-backed Capital Rx in 2019, recently renewed its contract with the upstart middleman because it has saved the fund more on drug spending each year than the fund projected, including 17% the first year.

Capital Rx also agreed to pass through all the rebates it negotiates, said Maria Scheeler, executive director for the Teamsters fund, which provides drug benefits to 16,000 people. “Best decision ever,” she said.

CVS said it has earned the long-term trust of employers, unions and others by being transparent, working to lower drug costs and offering options for health plans that meet the needs of the customers.

UnitedHealth sued over alleged use of AI to deny elderly patients care

UnitedHealth sued over alleged use of AI to deny elderly patients care

The families of two now-deceased former beneficiaries of UnitedHealth have filed a lawsuit against the health care giant, alleging it knowingly used a faulty artificial intelligence algorithm to deny elderly patients coverage for extended care deemed necessary by their doctors. 

The lawsuit, filed last Tuesday in federal court in Minnesota, claims UnitedHealth illegally denied “elderly patients care owed to them under Medicare Advantage Plans” by deploying an AI model known by the company to have a 90% error rate, overriding determinations made by the patients’ physicians that the expenses were medically necessary.

“The elderly are prematurely kicked out of care facilities nationwide or forced to deplete family savings to continue receiving necessary medical care, all because [UnitedHealth’s] AI model ‘disagrees’ with their real live doctors’ determinations,” according to the complaint. 

Medicare Advantage plans, which are administered by private health insurers such as UnitedHealth, are Medicare-approved insurance plans available to elderly people as an alternative to traditional federal health insurance plans, according to the U.S. Centers for Medicare and Medicaid Services. 

The use of the allegedly defective AI model, developed by NaviHealth and called “nH Predict,” enabled the insurance company to “prematurely and in bad faith discontinue payment” to its elderly beneficiaries, causing them medical or financial hardships, the lawsuit states.

Use of AI to determine health coverage

Aaron Albright, a spokesperson for NaviHealth told CBS MoneyWatch that the AI-powered tool is not used to make coverage determinations but as “a guide to help [UnitedHealth] inform providers … about what sort of assistance and care the patient may need.” 

Coverage decisions are ultimately “based on CMS coverage criteria and the terms of the member’s plan,” Albright said, adding that the lawsuit “has no merit.”

In their complaint, however, the families accuse UnitedHealth of using faulty AI to deny claims as part of a financial scheme to collect premiums without having to pay for coverage for elderly beneficiaries it believes lack the knowledge and resources “to appeal the erroneous AI-powered decisions.”

UnitedHealth continues “to systemically deny claims using their flawed AI model because they know that only a tiny minority of policyholders (roughly 0.2%)1 will appeal denied claims, and the vast majority will either pay out-of-pocket costs or forgo the remainder of their prescribed post-acute care.”

Lawyers for the family are looking to represent “All persons who purchased Medicare Advantage Plan health insurance from Defendants in the United States during the period of four years prior to the filing of the complaint through the present.” 

AI’s utility in health insurance industry 

Implementing AI algorithms may help health insurance companies automate between 50% and 75% of the manual work involved in approving insurance requests, such as gathering medical information and cross-validating date with patient records, resulting in faster turnaround times that may benefit beneficiaries, consulting firm McKinsey said last year. 

Still, some medical professionals have advised health insurers to rein in their expectations of AI’s utility in the health insurance industry. 

In June, the American Medical Association (AMA) praised the use of AI to “speed up the prior authorization process,” but called for health insurers to require human examination of patient records before denying their beneficiaries care.

“AI is not a silver bullet,” AMA Board Member Marilyn Heine, MD, said in a statement. 

According to a ProPublica review, doctors at health insurer Cigna rejected more than 300,000 claims over the course of two months in a review process that used artificial intelligence. 

Will complex/high acuity pts be the first KICKED TO THE CURB?

Will complex/high acuity pts be the first KICKED TO THE CURB?

Apparently, according to Medicare reimbursement to physicians, all pts – regardless of the complexity of their health issues – deserve the same amount of physician’s time. Unless the physician is an employee of a large hospital system and the system gets paid more for the physician’s time, than those physicians that are in private practice!

The Broken Medicare System Is Forcing Physicians Out

Yet another physician pay cut will prevent timely access to care

In any career, 25 years of dedicated work is a lot to let go of. In medicine, it amounts to hundreds of patient relationships, and the blood, sweat, and tears that go into starting and maintaining a practice.

Yet, after all that time, one of my physician colleagues recently had to let go of her beloved private practice — not by choice and not without tears for her dear, elderly Medicare patients who now face fewer options for care. Her story is unfortunately not unique.

Physicians and their patients have suffered through more than 2 decades of uncertainty caused by precarious Medicare funding. We’ve seen how these cuts have forced unwanted changes in medical practices. While their practices stay open, the Medicare system underpays our nation’s physicians to the point that some are forced to make difficult decisions about which patients they can care for. Eventually, when these practices barely have their heads above water, that “next round of cuts” proves to be the last straw.

Like clockwork, another Medicare physician payment cut is on the horizon for January.

I’m afraid the day is near — if not already here — that there will not be enough physicians to take care of Medicare patients. Physicians who participate in the program are forced to do more with less, which leaves no good choices. The situation hinders our ability as physicians to provide the complex, quality care these elderly and sometimes disabled patients need, and prevents us from seeing as many Medicare patients as we would like. Furthermore, it contributes to burnout and moral distress because we can’t do what we swore an oath to do, which is to put our patients first.

Medicare Physicians’ Plight

As president of the Texas Medical Association (TMA), I hear concerns from our physician members as they face ongoing practice viability challenges.

“If this additional [Medicare] payment cut goes through, in the midst of inflation and COVID causing rising costs for staff salaries and benefits, I would have no choice but to stop caring for these patients,” a worried physician shared with TMA.

“We are dying,” said another. “I can’t even keep a full staff. All the doctors I have referred patients to are leaving or gone.”

“I’m terrified for what this will mean for my elderly patients and their access to care,” yet another concerned doctor said.

“The mental stress of making ends meet is not good for patient care,” another colleague warned.

An Unsustainable, Unfair System

Not only is this system unsustainable for our nation’s physicians, but it’s also unfairly stacked against them.

It’s the same system that concurrently pays

hospital-based clinics more for some of the same services an independent, community physician provides. On top of that, Medicare helps hospitals cover uncompensated care.

I’m not saying hospitals don’t deserve to be paid for what they do. But when independent physician practices get swallowed up by a hospital or bought out by another entity just to survive, the cost of care can go up, creating ripple effects on our economy. This kind of rapid consolidation is now rampant in our healthcare system, in part because of payment incentives like those in Medicare.

“Our practice is already shutting its clinic doors as we instead focus on being a purely hospital-based practice due to already meager reimbursement,” another worried Texas physician shared with TMA. “We simply cannot afford the overhead. Ongoing cuts to [Medicare] physician reimbursement not only hurt us — the physicians trying to provide the best quality care to our patients — but it ultimately hurts the patients and their loved ones suffering from life-altering conditions.”

“I barely scrape through making payrolls every pay period. Any more [Medicare] reimbursement [cuts are] going to put me and thousands of physicians like me under water and force us to shut down or join [a private] equity company or [insurer-owned] clinics who put their wallets ahead of patient care,” said another frustrated physician.

We should be preserving independent medicine and patient choice — not undermining it. It’s time for Congress to address the root of the problem.


The first simple step physicians and other healthcare professionals can take is to advocate for Congress to enact laws directed at paying physicians fairly for services provided to Medicare patients. At a minimum, that entails pay that keeps pace with inflation. Just like other industries’ labor costs are tied to the Consumer Price Index (CPI), Medicare physician payments should at least be tied to a similar measure of physician practice cost inflation, the Medicare Economic Index (MEI).

Several physician members of Congress are leading the charge on such a reform with a bipartisan House bill that behooves support: H.R. 2474, the Strengthening Medicare for Patients and Providers Act. The centerpiece of that legislation is an annual, inflation-based Medicare physician payment update based on the full MEI.

Our current predicament is tied to the fact that Medicare physician payments haven’t even come close to keeping up with inflation over more than 20 years. Since 2001, Medicare physician payments have lagged 26% behind inflation while hospital and other health industry payments have kept pace, according to American Medical Association data. Over the same period, the CPI for physician services in U.S. cities increased by 65%

Just think about that: What would you say if you worked more than 20 years with no raise and pay cuts to boot? I know what my colleagues across Texas are saying:

“If [another cut is] enacted, our [Medicare] reimbursement rate will be lower than what we received in 2012,” one physician calculated.

Another said, “My Medicare reimbursement, factoring for inflation, is less than half of what it was in 1998.”

The frustration is real, and so is the effect of Medicare payment cuts on physician practice viability. Likewise, access to care concerns for Medicare patients are therefore very real, too.

Don’t let a broken Medicare system break the backbone of the healthcare system for our most vulnerable patients.

Rick W. Snyder II, MD,is a cardiologist and president of the Texas Medical Association.






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