For more than a decade I’ve been repeating the same unglamorous sentence to anyone who’ll sit still: a physician paid by someone other than the patient ultimately works for whoever’s paying. Employers, insurers, aggregators, private equity — pick your intermediary. The money defines the loyalty. That’s not cynicism. It’s an org chart.

Two weeks ago, three physician-legislators wrote a version of that sentence into federal law.

The Patients First Act — now H.R. 9693, introduced by the Republican and Democratic Doctors Caucus co-chairs on a rare bipartisan handshake — is mostly a MACRA cleanup bill. An inflation-indexed conversion factor. A budget-neutrality threshold finally dragged out of 1989. A gentler successor to MIPS with a smaller penalty when you fall short. Worthy plumbing. Not why I’m writing.

I’m writing because of a definition buried in Section 102.

The bill defines something it calls an “excluded practice.” It means, roughly, any practice where a non-physician entity owns a piece of you — or exercises de facto control over the things that actually matter: your pay, your staffing, how much time you spend with a patient, your coding, your clinical standards, your billing, your prices, your payor contracts, even your assets. Or where physicians hold half or less of the votes, or half or less of the board. I’ve spent years describing that arrangement without a legal term for it. Congress just supplied one. It even carved out the small shops — fifteen practitioners or fewer are safe.

And it doesn’t stop at naming the thing. Practices that meet the definition get their Medicare bonuses cut in half and are locked out of the new primary-care model. The corrupting structure I’ve been sketching on napkins now has a statutory definition and a financial penalty bolted to it.

That’s the good news. Read the sponsors’ own materials and it gets better — they open by pointing out that one in ten American physicians now works for UnitedHealth or one of its affiliates. Consolidation is named as the problem. Corporate capture is named as the problem. For once, the diagnosis is not in dispute.

Here’s where I stop clapping.

Section 102 also creates a “hybrid payment model” for primary care: a monthly, risk-adjusted, per-patient payment, no cost-sharing to the patient, reserved for independent practices that aren’t “excluded.” Strip the jargon and describe what that actually is. It’s a monthly membership fee, paid per patient, for primary care, that the patient never sees a bill for.

I’ve been running that model since 2014. The only difference — and it is the entire difference — is who writes the check.

In my practice, the patient writes it. In the Patients First Act, CMS writes it.

That’s the sleight of hand sitting inside a bill named for putting patients first. Under this model the patient pays nothing, designates nothing that costs them anything, and gets “attributed” to a physician — sometimes by their own choice, sometimes by an algorithm reading their claims history. The money comes from the government. Which means, by the exact org-chart logic the bill’s own authors just endorsed, the doctor in that model works for CMS. The patient is the thing being attributed, not the customer being served. A bill called Patients First, and the patient still isn’t the one at the table.

Give the bill its due, though, because the irony is instructive. It requires that the panel writing Medicare’s quality measures be a majority of practicing clinicians, with no more than three insurance-industry seats, and a reserved chair for a physician who isn’t trapped in one of those excluded practices. It opens Medicare claims data to physician-led registries. Congress, in other words, is legislating independent-physician inclusion into the machinery of Medicare.

Meanwhile, back in Maine, I did finally get API access to the state immunization registry — and it’s worth noticing what that took. The state first told me I didn’t qualify, because I’m not a “vaccinating provider.” So I petitioned for a special exemption. To Maine’s credit, they granted it, and I’m in. But read that back: a practicing physician had to file a special petition to see his own patients’ shot records — the access a “vaccinating provider” gets by default. I got in by exception, not by right. And the state’s health information exchange — the one I was told, at its founding, existed partly to serve unaffiliated physicians — still has exactly zero of us on its board. The feds are legislating us into the system on paper. In practice, independents get in the old-fashioned way: one exception at a time.

Inclusion on paper is not access in the exam room. I’ve made the coverage-isn’t-access argument about insurance for years. Turns out it applies to registries and governance boards just as well.

And here’s the tell that it’s middlemen all the way down. The same week three physician-legislators moved to punish the corporate intermediary between doctor and patient, CMS opened a quieter front against a different one. In its 2027 fee-schedule proposal, the agency questioned the AMA’s decades-old monopoly over CPT — the proprietary code set every physician, hospital, and payer is legally required to license. It pointed out that HIPAA never actually mandated CPT; only HHS’s own interpretation did. And it named the AMA’s role in valuing our work for what it is: a private body with an obvious conflict of interest.

Sit with that geometry. The AMA licenses back to physicians the very codes we’re legally forced to use — from a body a lot of us don’t feel speaks for us in the first place — and it applauded the Patients First Act head to toe. The loudest cheerleader for a bill against middlemen is a middleman.

The scrutiny arrives wrapped in the usual packaging — DEI, gender-affirming care, “Make America Healthy Again.” Ignore the wrapper. The monopoly, the mandatory licensing, and the conflict of interest stand on their own, no matter whose finger is doing the pointing.

So what is this bill, really?

It’s the most honest description of the disease that’s ever come out of that building. Consolidation is the problem. Corporate control is the problem. The middleman between doctor and patient is the problem. Three doctors said it out loud and got even the AMA — code monopoly and all — to nod along.

And then they proposed to treat it by adding one more monthly check from the largest middleman in the country.

I don’t think they’re wrong to try. Fixing Medicare so fewer physicians flee it is a legitimate goal, and plenty of my colleagues are still inside that system and drowning. But let’s be precise about what the Patients First Act is offering. It is not a door out. It’s a nicer room inside the same building — better lighting, an inflation clause, a smaller penalty when you miss.

Before the emails start, let me save both sides the trouble.

The free-marketeers in my own corner will say I just spent three hundred words admiring a federal capitation scheme. I didn’t. I admired that Congress finally described the disease in plain English. The prescription is still a government check — I said so twice. An accurate diagnosis is not an endorsement of the treatment, and a monthly payment from Washington doesn’t soften my position. It confirms it.

The other side will say this is an RFK-flavored swipe at the AMA dressed up as coding reform, and that I’m laundering a culture-war grievance. Reread the middle. I told you to throw the wrapper out. A government-backed monopoly is a monopoly whether a Republican or a Democrat is pointing at it. If an argument only works when your team makes it, it was never an argument.

My own DPC tribe will say I committed heresy by taking a Medicare model seriously at all. I didn’t join it. I read it. Refusing to understand the system you walked out of is precisely how it walks back in through the side door.

And the AMA’s defenders can skip the note about how modest the license fee is. The fee was never the point. A small toll on a road you’re legally required to drive is still a tollbooth you never agreed to.

I already left the building. The bill’s own definition of a clean practice describes mine almost exactly, right up until the part where it routes the payment back through Washington.

They finally learned to name the disease. They just can’t stop prescribing the cause.

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