Medi-Cal and its Deleterious Impact in California Medical Care: The Deep State

The following is an adaptation of what I believe to be an excellent Declaration of Physician Independence and Professional Freedom for California. My thanks and credit to the World Medical Association, Inc., who recognize the importance of the physician’s independence and professional freedom, for this declaration of principles:

California physicians must have the professional freedom to care for their patients without interference.  The exercise of the physician’s professional judgement and discretion in making clinical and ethical decisions in the care and treatment of patients must be preserved and protected.

Physicians must have the professional independence to represent and defend the health needs of patients against all who would deny or restrict needed care for those who are sick or injured. 

Within the context of their medical practice and the care of their patients, physicians should not be expected to administer governmental or social priorities in the allocation of scarce health resources.  To do so would be to create a conflict of interest with the physician’s obligation to his patients, and would effectively destroy the physician’s professional independence, upon which the patient relies.

While physicians must be conscious of the cost of medical treatment and actively participate in cost containment efforts within medicine, it is the physician’s primary obligation to represent the interests of the sick and injured against demands by society for cost containment that would endanger patients’ health and perhaps patients’ lives.

By providing independence and professional freedom for physicians to practice medicine, a community assures the best possible medical care for its citizens, which in turn contributes to a strong and secure society.

A surgeon without an operating room is like a ship without a port.  He or she needs a compass to get back into the patients’ orbit such that we can collectively harness the deep state.  

The “deep state” of California is the Department of Consumer Affairs (DCA).  The purpose of the DCA is to protect California consumers by providing a safe and fair marketplace, through oversight, enforcement, and licensure of professions.

The first board within the DCA is called The Medical Board of California (MBC) and dates to 1876 with the passage of the Medical Practice Act.

Overall, the DCA regulates and licenses or certifies more than 2.5 million California professionals in more than 240 categories throughout the state.  If you operate an enterprise (a business) in California, you are likely licensed by and regulated by this huge bureaucracy, in one way or another.

In my opinion, the DCA and the MBC are not the friends of any mom-and-pop California entrepreneurs.  However,  due to a process called regulatory or agency capture, big business with industry insiders now control the deep state with a symbiotic and favorable regulation approach such that those crony businesses along the government bureaucracy  eliminate mom and pop small businesses.  The effect in medicine has been to eradicate the relationship between doctor and patient and replace it with health insurance company/ Medi-Cal collusion which is destroying both.  In simple terms, they are systematically eradicating the middle class in California.

Back in June of 2013, I presented to the MBC, as a physician licensee in good standing with the MBC, a research proposal to the board as follows: 

RESEARCH OBJECTIVE:  The mandated, candid opinion of ALL California physicians in active practice beyond residency training, both in voluntary and paid service, and of those retired who will voluntarily help with this opinion, regarding the past and present conduct of medical care delivery in the golden state, with the goal to provide for an improved system for the future.

HYPOTHESIS:  There is tremendous confusion and lack of consensus among the California recipients of medical service as to what to do about protecting and improving it.  The public simply does not know how their partner, the physician, feels about the doctor-patient contract.  However, people instinctively trust doctors.

In like manner, the physician who is “gagged” (blocked from his or her first amendment right of freedom of speech) by the present administrator/employers of health care delivery assumes that the public chose this paradigm and deserves what it is getting.  A barrier exists, called the “middleman”, which is pure evil and greedy and who is disallowing physicians to effectively practice “the art” of medicine and who is witholding access to reasonable medical care for ALL Californians and who is squandering and profiting from theft of this precious resource and who is inflicting great harm upon both California’s economy and the medical profession.  

Who better than the Medical Board of California, with the mission to protect health care consumers through proper licensing and regulation of physicians and surgeons and certain allied health care professions and through the vigorous, objective enforcement of the Medical Practice Act, and to promote access to quality medical care through the Board’s licensing and regulatory functions, to carry out this investigation.  The Medical Board routinely requests informational and educational data from the physician community to share with its licensees.  It is thus the DUTY of the Medical Board of California to report to the health care consumers of California the truthful opinion of the California physician.  This information is conspicuously needed.  Physicians and the public need hard evidence to properly organize and operate an effective, profitable, and competitive free market medical system for the future of the people of California, devoid of government regulation beyond that necessary to protect the public interest and to assist and not hinder the balance of the economy.

METHODS:  1.)  A list of simple yes/no questions will be asked by the Medical Board of California to EVERY  SINGLE California physician in active or voluntary service, post residency, and pled to those retired for their wisdom.  This will not apply to training physicians who aren’t yet board eligible/certified, because these physicians have not yet experienced payment for independent services rendered.  However, a medical or surgical resident, who has previously participated in independent practice, will be required to answer the questions.  2.)  It is anticipated that the nature of the questions will “tell the story”, and the story will simply be whether we move forward in a government operated system of health care or in a free enterprise medical profession system devoid of government interference except to the extent listed above.  3.)  Anonymity will be protected.  4.) Indemnity from threat of losing a job by breaching a gag order in a contract with an employer such as an HMO or a hospital is absolutely guaranteed, as ALL California physicians are forced to answer up, and their identity absolutely protected.  5.)  Failure of ANY physician to answer the questions will result in revocation of his or her California medical license.   6.)  This study will in no way serve to provide data to incriminate or indict the MBC, and it is praiseworthy of this duly sworn servant of the people of California to produce this service and do its above-mentioned duty for the public’s protection and safety, both fiscal and physical.  7.)  The MBC is potentially considered intimidating by physicians because the board has the power to suspend or revoke the license of a physician, and to potentially gather evidence against a physician if a member of the public complains.  Thus, the nature of the investigation will be clearly stated in a non-confrontational and non- intimidating fashion to physicians, with the clear indications of why the investigation is being carried out, and exactly what will be done with the data obtained.  8.)  All California physicians and ALL the California public will receive full access to this data.  9.)  The age, gender, practice type and source of income/affiliation will be required information of every single physician in the study, but again, identity will be absolutely protected.  10.)  This investigation will be fully funded by the Medical Board of California.  11.) This data will be certified as accurate and complete.  12.) The details of the testing method will be outlined by the investigators of this study in agreement with the MBC to insure this certification and accuracy.

DISCUSSION:   “The California Medical Profession; past, present and future; the physician’s perspective”,  will be used to inform the citizens of California as to what the opinion of the licensed physicians of California  is as it clarifies the affordable, comfortable, competent, and safe medical care of patients.  It will inform all physicians of what their colleagues are thinking, and it will forge a template upon which to build the contract between doctor and patient, and how to protect and preserve the sovereignty of this arrangement in the 21^st century.  The process will be thorough, candid, non-intimidating, and anticipated to allow the MBC to perform its duty in protecting doctor and patient alike.  

Sincerely,

Patrick Wagner, MD (lead investigator)

(DATA SEEKING QUESTIONS TO BE ASKED BY MEDICAL BOARD OF CALIFORNIA TO EVERY CALIFORNIA PHYSICIAN LICENSEE)

1. Is it ever appropriate or ethical to complain about not being paid adequately with a patient unless that patient directly asks you for the information?
2. Would you ever deny a patient who is suffering a life-threatening illness your very best skills and judgment?
3. Would you find it hard to “tell on” (dishonor) a colleague because of your ethical standards and the oath, even though you know he or she is doing the wrong thing?
4. Is it wrong to pay physicians as expert witnesses, in for example malpractice lawsuits or in educating non-physicians as to how to run an HMO (e.g. a physician who can’t cut it in practice with a big ego and hates his job, obtains an MBA, and becomes a high-level executive in an HMO)?
5. Do you personally know any “sell out” physician who would fit the pattern of expert witness for personal gain, who dishonored the art of medicine?
6. Is it getting harder to make your job look easy?
7. Do burnout, anger, isolation, loneliness, and frustration affect your personal life, e.g. relationships with your spouse and family and your faith?
8. A recent survey by a clinical psychiatrist at a California medical school demonstrated diagnostic criteria suggesting situational stress and depression in medical students in their pursuit of the MD degree, and offered techniques to alleviate the problem, some of which are helping at that level.  The inference of the study was that it could be reflected in the continuum of medical and surgical practice after medical school and residency.   Do you agree?
9. The study above suggests a nearly 50% incidence of burnout in physicians and a nearly 40% incidence of clinical depression among physicians in post-education practice.  Do those statistics surprise you?
10. Are the present leaders of the health care industry, namely health insurance executives, hospital executives, pharmaceutical company executives, instrument and imaging machine makers, attorneys, and legislators in a good position to authorize decisions about your patients?
11. Could any of the above “trades” be pleased with their professions, overly or arrogantly confident in their skills and judgment? 
12. When the managers of health care delivery interfered with the doctor-patient relationship and took over both participants in that contract, did they realize the danger they created?
13. Are you familiar with the Omnibus Budget Reconciliation Act of 1989, enacted in 1992, which had emphasis on Medicare physician reimbursement and price fixed the payment of physicians?
14. Do you understand why the Emergency Medical Treatment and Active Labor Act (EMTALA) was passed in 1986 by the federal government?
15. When hospitals mandated private practice physicians to cover emergency treatment as a condition of retaining hospital admitting privileges, was it a selfish administrative decision with the singular goal of being able to keep their emergency rooms open, with physicians on duty?
16. Do you understand the concept of free markets or free enterprise?
17. Are you paid adequately for the service you provide for your patients?
18. Do hospital administrators and state and federal officials and HMO administrators interfere with your mechanism of free market or free enterprise relationships with your patients in California?
19. Should the sovereign authority of medical care delivery for the people of the state of California be the people of the state of California?
20. Would you rather have the patient for your employer, not the administrators or managers of medicine we have now?
21. Considering medical malpractice, would physicians be better at adjudicating negligence than layman attorneys, juries, and judges?
22. Is advertising and /or politicizing medications, treatments, and trends in medicine by media and advertisers bad use of patient or public dollars?
23. Is it getting harder to cover up the disaster of what’s happening in medicine both economic and quality-wise (being on the front line, in the trenches)?
24. Is it painful to have yourself “graded” and that data published?
25. Is it ethical for hospitals to advertise themselves and then urge the public to grade their physicians?
26. Do hospital executives hold your job in balance?
27. Does grading physicians help take disease out of patients?
28. If you are over 55 and still working, can you afford to retire?
29. Are you concerned that you could possibly make an error based on the level of pressure inherent in your present practice environment that might hurt a patient? 
30. Is there a readily available vocation that would pay you enough money to support your present needs and that would ensure your retirement, if you chose to leave medicine now?
31. Do you agree that it is a “right” for a patient who contracts a disease to expect you to treat him or her without your being paid what you are worth?
32. Are you an indentured servant (chattel) in the present system of health care delivery for the people of California?
33. Do you feel sound in your financial standing for now and the future, confident your savings will outlive you?
34. Have you attempted to live your life and practice this profession providentially?
35. Is Medicare a fair and effective system?
36. Is Medi-Cal a fair and effective system?
37. Do you ever wish you would have gone into any other career than medicine?
38. Would you advise your kids to “follow your footsteps” and become physicians or surgeons?
39. Would cash payment by patients be preferable to having the middleman, who steals of the patient’s hard-earned money, pays you poorly and then withholds your precious skills and judgment simply for profit? 
40. Do you hope that the people of California will wake up and again demand that you work for them and not for the managers of health care (HMO’s, government, hospital systems)?
41. Is there an impending massive collapse of the health care delivery system in California, not only based on economics, but also based on access for our expanding senior population, of the availability of doctors like you to fairly treat them?
42. Are new medical graduates (residents now physicians and surgeons) ready for the job?
43. Are you younger physicians and surgeons disappointed in older physicians and surgeons for not warning you about the career you chose before you entered it?
44. Are you older physicians and surgeons disappointed in younger physicians and surgeons, who criticize you for not recognizing health care for Californians as a “right”, meaning that indolent and able-bodied “needy” people deserve your services without having to pay for them but rather thinking that taxpayers will pay for them?
45. Because medicine IS politicized, a fact we can’t deny, do you find fault in people who are otherwise able-bodied and in the bondage of dependence?
46. Do you recognize that if freed from the bondage of dependence, people would go out, work, earn money and pay you and respect your medical service for them and increase your respect for them?
47. Do you older physicians and surgeons  believe that medical graduates of today are unrealistic, cruel, and foolish when they tell you that you are a dinosaur and to stop griping and to get to work or get out?
48. Do you worry that you could be replaced easily?
49. Do you find academia suspect of aiding in medicine going in the wrong direction?
50. For those of you working in teaching institutions, are there bad teachers you would like to tell your colleagues about but are afraid to do so because of fear you could lose your job or research funding?
51. Are patients in California needlessly suffering and dying today?
52. Are you confident that if your patients renewed their trust in you that you would be ready for the job?
53. Do you detest having to explain to patients that there may be a delay in treatment or worse,  you can’t offer certain treatments now because of the cost?
54. Are you ever required to “fib” when obtaining authorization for treatment on behalf of your patient who truly needs the treatment?
55. Is technology outpacing clinical skills and judgment?
56. Are media and advertising fueling steroid level “technology” (snake oil)?
57. Are medical students and residents still learning hands-on medicine, i.e.. the power of the well-executed and comprehensive history and physical examination?
58. Have the skills of diagnosis suffered and become sloppy because of CT scanners?
59. Do you understand the unfunded liability or “pledge” of our federal government of greater than 150 trillion dollars to the seniors of our country, including California, in the name of Social Security and Medicare?
60. Is the common good served with the present California health care system, a system rewarding laziness with your hard labor and the hard labor of those who pay the premiums?
61. Does it trouble you to witness a California physician prescribing the use of marijuana today?
62. Does the present practice of prescribing marijuana follow the principles and practice of medicine?
63. Do you believe that the state law of not treating a patient younger than 18 years of age without the consent of a parent or legal guardian is being broken with our present health care system in California?
64. Are modern day prescribing patterns, considering multiple heavily advertised, potentially dangerous and habit forming “fad” drugs, ethical?
65. One covenant of our oath is to treat ALL patients independent of their ability to pay for it.  Is it thus ethical for our present health care administrators (managers) to unjustly ration health care and tell patients they are going to have to seek comfort care for the remainder of the course of their disease?
66. Do you feel guilty in your present roll as an indentured servant, for having to be associated with rationing of health care?
67. Is evidence-based medicine or pay for performance medicine, now championed by the professors teaching our new residents in the accredited residency programs around the state, helping the health care managers cut corners and profit?
68. Is evidence-based medicine really a way for bureaucrats to withhold vital services to patients and ration medical treatment, thus maximizing reserves and minimizing patient care?
69. Are evidence-based medicine and pay for performance and other catchy “metrics” instruments an attempt by academia to please bureaucrats?
70. Does the Electronic Medical Record (EMR) system breach the last of the six covenants of the Hippocratic Oath which you likely swore….”I will keep secret all that my patient tells me, even after he or she dies”?
71. Does the Health Insurance Portability and Accountability Act (HIPAA) law and EMR’s protect patient privacy?
72. Do EMR’s and HIPAA facilitate ease in stealing money from your patients and in withholding payment to you, and in delaying or completely withholding your precious treatment to patients, and in divulging way more about their lives to the bureaucracy than anything medical?
73. Will “fast-tracking” of new health care laborers, (by broadening the skill sets of e.g. nurse practitioners,  pharmacists, physician assistants, public health care officers), and recruiting and importing non-board-certified foreign country physicians and non-board-certified domestic physicians and surgeons as California “diversifies”, help to strengthen our doctor shortage, in terms of quality of medical care? 

Surprisingly, the shallow response I received didn’t come back for two months.  It was sent by the Interim Executive Director of the MBC, Kimberly Kirchmeyer.   Her response letter follows:

(see the attachment letter, dated September 4, 2013)

In essence, she had reviewed, the proposal and research questions, and decided that it would take legislation to get my proposal activated.  I considered the matter a dead end, but her response should be telling and vital for the average Californian.  In my view, it speaks volumes of her character.

I thus sent Kirchmeyer the following letter and ended my efforts, until now, because nothing policy wise has changed:

September 20, 2013

To:  Kimberly Kirchmeyer, Executive Director, MBC

From:  Patrick Wagner, MD, licensee, MBC

Dear Kimberly, 

I appreciate the fact that you received the information in my research proposal and hopefully read and understood the logic behind every single question I want posed to every single licensed California physician, and offered to all retired physicians in this state, by the MBC, except for those who haven’t practiced medicine for pay yet (i.e. residents).  I could be wrong but believe it’s a breach of the MBC’s sworn obligation to the citizens of the great state of California and to the 125,000 physicians, including me, whom the MBC controls, not to run the study.  As I said before, the MBC could end up a hero here!  The MBC could be fundamental in a new, top notch free enterprise medical and surgical  care system, the best in the history of California.  I am watching to see how you people are going to perform.

My plea is to obtain the opinion and the sense of well-being and goodwill in the conduct of the art of medicine in California, and how the people of the state might be able to improve it.  The people of California are truly the sovereign authority and we the physicians need to be the sole administrators, working for them again.

I refer to a precedent approximately four years ago, when the MBC had ALL California physicians do a “pain management” CME examination to protect the image of the MBC.  I think pathologists or other non-prescribing docs were possibly excluded.

Bottom line, it was an insult, but a requirement for all my colleagues and I to continue to have a medical license.  Just think, quizzing a general surgeon about how to prescribe narcotics?  Wow!  Was there a similar change in statute then?  PLEASE EXPLAIN THE DOUBLE STANDARD.

Our 125,000 physicians are slaves to the middleman.  Sadly, some don’t know it.  That means avoidable death and suffering are in our midst, and on the rise.  What’s going on is pernicious decay and it’s time to end the nonsense.

It’s time for a pain study, a study to examine the pain of the California physician.  It’s the MBC’s duty to run the study.  In the meantime, I’m going to keep fighting.  I’m a physician, I believe in the Hippocratic Oath, and it’s time to stop the pestilence.  Join me!  

Sincerely, 

Pat Wagner, MD

The year 2013 was the year Kirchmeyer became the Interim Executive Director of the MBC and served in that position until 2019, at which point she was appointed by Gavin Newsom to serve as director of the California Department of Consumer Affairs.  

The licenses of the entire industrial capacity of California are under the authority of the deep state, be you an Uber driver, a doctor, a plumber, or an auto insurance salesman or saleswoman.  My attempt to free the physicians of California has not yet happened. 

 I am calling on Californians doing business in this state to help me stop the deep state.  Take it upon yourselves to get the MBC to take their foot off the physicians’ necks so that they can do business with you again, and for those of you out there with businesses under siege via Newsom and his deep state, please get their foot off your necks also.   It is time for free enterprise in medicine and those enterprises of every other hard-working mom and pop small business in the state.  Write letters to Kirchmeyer, demand that she run my research proposal, bring forth your own demands in your own businesses, and let’s get California back to work!  Our legislature and judicial system are broken.  It is up to WE THE PEOPLE.  Nobody is going to help us but each other.  United we stand, divided we fall.  We are ONE STATE UNDER GOD, AND WE NEED HIM RIGHT NOW.

Special thanks to the focus group and courageous patients that inspired me to write this entire series at sierrathread.com.  It is the voice of the grassroots that will make California the greatest state in the union again!  And special thanks to Californiaglobe.com and the Association of American Physicians and Surgeons, and Howard Jarvis Taxpayers Association!

This is part IV of a series on Medi-Cal, government run healthcare.

Part I is here: Medi-Cal and Its Deleterious Impact in California Medical Care: The Cause

Part II is here: Medi-Cal and Its Deleterious Impact in California Medical Care: The Effect

Part III is here: Medi-Cal and Its Deleterious Impact in California Medical Care: The Cure