It was Christmas Eve and all across the nation, doctors and patients were intently watching the Senate pass their version of Healthcare Reform 2009. Almost immediately, my email and my phone were going like gangbusters as the mood of the nation took a 90-degree turn; doctors resigned themselves to the fact that their hard work to stop what most felt was an expensive, and oppressive government takeover of healthcare had not worked. Legislators were not listening.

Doctors wanted to know how to convert their practice into a cash based practice. Similarly, patients were calling doctors who work as I do, directly for patients, and asking to be included in their practices. The anticipation of “the system” inclusive of regulations, mandates, rationing, delays and everything “government like” brought panic to providers and patients alike.

Most telling, however, was the announcement by the Mayo Clinic in Glendale, Arizona, the poster child of what the ”product of health reform” should look like, that they would not participate in the Medicare program. They did not believe in the fixed pricing system mandated by Medicare participation.

The Medicare Part B Program is a capped fixed payment system. What that means for American doctors is that they all share in the same pot of money. When the orthopedists started doing complex back surgery, that procedure was paid for out of Medicare Part B funds. No additional moneys were put into the pot. As a result, anyone who didn’t do this procedure, such as oncologists, internists, and other physicians who provide often life saving services had to take a “cut.”

The Centers for Medicare and Medicaid Services (CMS), the government agency that administers the Medicare program works with a variety of committees to account for differences in geography and demographics but that has left many area particularly in California (like San Diego) with lower payments for the same procedure than the neighboring counties because San Diego was once considered “rural” and Congress has refused to address the obvious disparity. CMS also works with physicians to try to find a means of paying for procedures on a “relative scale.” But, all of these efforts don’t factor in real quality of care. They don’t factor in a doctor’s effort to serve his patient better than the guy down the street. They don’t pay for efficiency, experience, expediency, or outcomes.

Efforts by the government to measure quality are futile since the government or any third party can never legitimately measure the ability of a doctor to serve his or her patient. Quality can only be measured by the patient being served. And it should be paid for directly by that patient.

The Mayo Clinic’s decision to work outside the Medicare system was the most noteworthy signal to date that the nation’s doctors want to compete in a transparent marketplace rather than be saddled by a system that cannot reward their excellence, but to the contrary assures their demise.

Most interesting is the fact that Congress has repeatedly rejected the idea of private contracting within the Medicare system, a idea that would contain the increasing cost of care. Private contracting is where physicians and patients together agree on a financial arrangement that ensures that medical care can be provided in a financially sound and ethical environment that rewards quality, with utmost respect for patient privacy. American doctors have lobbied Congress repeatedly for the opportunity to compete for quality but the idea has been flatly rejected as elitist. As doctors have left the system, patients all over the country travel hundreds of miles to find a doctor who will accept Medicare. If Congress allowed our patients to privately contract, access would increase and doctors would legally be able to offer discounts for those who cannot pay. As it is, doctors must, by law, charge the full Medicare allowed to every patient or be in violation of the law, a felony.

Everyone agrees that this legislation is going to increase the cost of care to most everyone in the country. Premiums are going to increase while care may be limited. Medicare taxes will increase years ahead of any change in services in order to make up for the deficits already on the books. Even progressive Americans resent paying for someone else’s care. While it is hard for many to reach into their own pockets to pay for personal care, it is far more rationale and tolerable to “self-ration” than to either pay for someone else’s obesity or to be told that “the system won’t pay for your bypass.” You don’t have to be Ayn Rand to believe in reasonable rational self-interest. That is the point the Mayo Clinic is making by backing out of a system that will not reward their quality.

Americans will choose to go to the Mayo or they may choose any number of doctors all over the country who have put their reputations on the line and offered quality, expediency and their reputation in exchange for payment. American entrepreneurialism will prevail in spite of the efforts of Congress to take over our most privileged profession. Being a doctor is all about our relationship with our patient(s) and those relationships are fostered in a transparent competitive marketplace. President Obama was correct when he offered the Mayo Clinic as an example of what is best about American Medicine. The Mayo knows that the investment they have made in their relationships with their patients is a concrete example of the dedication and commitment it takes to provide the best medical care in the world. It is priceless.