Medicare keeps cutting physician rates while our costs keep going up. That disregard for physicians is why many physicians have lost trust in the system. For 2027, the conversion factor for most physicians drops 2.31%. That’s six cuts in seven years. Hospital outpatient rates go up 2.3%. A hospital can also bill a facility fee for the same visit I provide in my office, and my patient can owe more. The annual share of physicians who stopped billing traditional Medicare doubled from 2010 to 2023. Physicians also say they plan to retire earlier. Politicians and people like @ajlamesa want to expand Medicare. I’d like them to explain who’s going to see the additional patients at the rates Medicare pays.

We’ve spent the last several decades building institutions that are extraordinarily good at measuring activity and remarkably poor at measuring productivity. Think of it as the Paula Deen method of healthcare: If a tablespoon of butter is good, surely a pound must be better. More must be better, right?! More administrators. More consultants. More lawyers. More compliance. More technology. More capital. And the gaslighting has been top-tier. We’re continually told we need more people who produce nothing and fewer of the people who produce everything. Meanwhile, the consumer pays more, the producer earns less, and the institution demands still more resources. And we all know that we are not getting what we pay for, but for God’s sake, let’s make sure the Chief Experience Officer has three associate vice presidents! That’s not progress. That’s institutional entropy. That’s organizational decay masquerading as sophistication. The next great economic opportunity isn’t building bigger systems. It’s eliminating the friction that makes them necessary. It’s remembering that there are two principal parties to every healthcare transaction - the patient and the physician. Everyone and everything else exists to facilitate that relationship, not subordinate it. Maybe bigger… checks notes …isn’t actually better. Maybe scale and consolidation aren’t synonymous. Maybe we can achieve extraordinary economies of scale without sacrificing autonomy, proximity to capital, or accountability to the consumer. Maybe the future of healthcare isn’t another layer of management, another intermediary, or another institution “too big to fail.” Maybe it’s time to do something different!

The NYT's attack on Sen. Roger Marshall is outrageous. Why are doctors the only people in the country who don't deserve to be paid? How about editors and reporters - why don’t they give their salaries to these layabouts on "disability" who demand medical services, and then refuse to pay? The average OB/GYN sees a thousand patients a year. That means Dr. Marshall probably saw 25,000 patients and THE NEW YORK TIMES IS DISGUSTED that he submitted 700 unpaid bills to his lawyers. SEVEN HUNDRED out of 25,000 - that means he pursued unpaid bills from LESS THAN 3% OF HIS PATIENTS. I like the woman who refuses to pay for her C-section and complains she got served by a lawyer two years later WHEN SHE WAS PREGNANT AGAIN. Uh, miss — if you can’t afford to pay for the delivery of your first child, how about learning to use birth control? Not only that, but she irresponsibly failed to sign up for Medicaid which would have paid all medical bills related to her pregnancy FREE. ("Free” meaning: "Ann Pays More.”) Oops, she f-ed up, so the doctor doesn't get paid. And this arrogant, entitled narcissist complains about having to pay for the birth of her child: "I had to choose whether I’d pay my electricity or pay $50 to a doctor who didn’t need it.” After practicing obstetrics for a quarter century and being part owner of the hospital, Dr. Marshall’s combined salary was  $780,000.  What's Pinch Sulzberger’s salary? How about Maureen Dowd? Why don't you guys pay for these slackers, instead of a rural doctor who delivered thousands of babies and -- unlike a lot of doctors -- accepted Medicaid patients. Or Sarah Kliff -- who can't deliver babies, but DID review "thousands of pages of court records and interviewed eight people whom Roger Marshall sued over medical debt." The Times should refuse to pay you for your work, Sarah. It's bad enough that these layabouts think they have a God-given right not to pay doctors, but appalling that overpaid journalists think it's a moral crusade to back them IN NOT PAYING FOR SERVICES THEY ACCEPTED. Explore this gift article from The New York Times. You can read it for free without a subscription. nytimes.com/2026/09/08/us/po…

A society that disrespects its physicians and devalues their care, is a society in decline.

Per @KFF, 39% increase in ACA premiums in 2 yrs is remarkable itself but consider it against a backdrop of $23.139B (@UHC alone is $15.874B) in net profits YTD for 4 of the for profit health plans who have reported —w/ 3 major plans reporting this next week. So, the responsibility for the “affordability crisis” rests squarely w/ these plans + the dozens of non-profit @BCBSAssociation plans + Kaiser itself & others as a non profits who do not publicly report. Not physicians, hospitals, the #NoSurprisesAct or others that the health plan industry points to—$23,139,000,000 net profit—with Q4 yet to reported as well. wsj.com/health/healthcare/af…

Just got my labs back. Turns out, going from lying in bed, to sitting in a chair, to lying on the couch, only to return to bed is not a winning health strategy. Imagine paying my physician based on my lack of discipline. Yet, that is American health policy. We love a consultanty term - we call it value-based purchasing. What exactly is he/she/they/them supposed to do? Swoop into my house and knock the Little Debbie Christmas Tree Cakes out of my hand? Those things only come once a year, for heaven’s sake! Apparently, I also need to use the gym membership I’ve been paying for over a decade. Evidently, merely possessing a membership does not confer weight loss, cardiovascular fitness, or good health. Who knew? Also, perhaps less wine is in order. I’m told there are people who just white-knuckle-life. No chemical assistance whatsoever. I’m only just hearing about this, and frankly, I’m as stunned as you are. But here’s my point: My physician can advise me, educate me, encourage me, prescribe for me, and hold me accountable. He cannot live my life for me. And right now I have a big, fat, morbidly obese life. And penalizing him/her/they/them/zi/zer financially because I refuse to live it responsibly is not healthcare reform. It’s an elaborate exercise in transferring accountability from the person making the decisions to the person trying to help him. Let’s stop this value-based idiocy. It’s beneath us all. I’ve got to stop eating my feelings, drinking my sorrows, and roll myself down to the gym. That’s on me. I pay for the professional advice. It is up to me to take it and implement it. And we will see if I learned anything by Easter 27. It will be here before we know it - and if I’ll put down the Doritos, maybe I’ll be here too.

Bon Secours Mercy Health, a nonprofit, has agreed to buy Surgery Partners through an affiliate, with Bain Capital remaining an owner. A nonprofit partnering with private equity to run for-profit surgery centers. Yet proposed corporate practice of medicine laws give hospitals exceptions and access to capital while restricting independent practices. Physicians need capital, ownership and negotiating leverage too. Making it harder for us to compete risks driving more consolidation. This is why selective application of CPOM laws are silly and I vehemently disagree with @DGlaucomflecken on these bills.

But if you entrust the state to run a single payer healthcare program it’ll be fine, trust us, guys.

When Dr. Will Flannery (@DGlaucomflecken) had a cardiac arrest during COVID, he received a $20,000 surprise bill form out-of-network physicians at the in-network hospital where he was taken. On the latest Knock Knock Hi podcast, he explains why the No Surprises Act matters and why insurers are now lobbying to change it. His key points line up with the data: 1. Patients are protected. The law took them out of the middle and arbitration only decides what the insurer owes to the physician 2. Physicians win most disputes because independent arbitrators, choosing between two offers, keep finding that the insurer’s number is too low 3. Insurer benchmarks track Medicare, which has cut physician pay for decades based on budgetary guidelines and is not a neutral yardstick. 4. Winning isn’t only on paper. Federal rules require payment within 30 days of an award, yet insurers routinely drag it out for months and don’t pay on roughly 40% of all claims. His final message: If Congress is going to revisit the NSA, then do it by enforcing prompt payment. Listen in here: piped.video/watch?v=SoeX15xU…

My favorite is the “portfolio manager” who makes almost $3MM per year.

Make no mistake, the physician, hospital and supporting advocacy community is engaged in a "David v. Goliath" battle to prevent repeal of the #NoSurprisesAct. The community was one when we defeated the health plans in '18, '19 and early '20 and we will have to come together with one voice again. One recalls the famous proverb: "It is not the size of the dog in the fight, it's the size of the fight in the dog." "Health Care Companies Are On Defense. It’s A Windfall For K Street. POLITICO| Amanda Chu | October 21, 2026 (excerpts below) Lobbyists and policy analysts said efforts to prepare companies for oversight in a likely Democratic-controlled House, advance proposals in a year-end legislative package, and rethink the No Surprises Act will dominate the agenda for the remainder of the year.... Congress passed the No Surprises Act in 2020 to address out-of-network bills patients received after emergency care, but it has led to outsized claims. The effort to rewrite it has embroiled doctors and insurers. There were approximately 158 lobbying registrations related to the law in the third quarter, up 52% year over year, according to an analysis of public lobbying disclosures by Baron Public Affairs, a government relations consultancy.... “This has become one of the main health care policy arenas, if not the main one,” Riley Kruse, a director at Baron Public Affairs, said of the No Surprises Act.... UnitedHealth, the largest U.S. health insurer, reported $2.1 million in third-quarter lobbying spending, its highest for the period on record. Its peers Centene, Cigna and Humana also reported elevated spending, with Humana recording its highest year-to-date spending for the period..... "Q3 was my busiest part of the year without question,” said Miranda Franco, senior policy adviser at law and lobbying firm Holland & Knight, the country’s largest health care law practice, which counts hospitals, drugmakers and physician groups as clients. "It’s the second year of this administration, which means that a lot of the proposals and policy agendas are really taking hold,” said Franco, who is tracking proposed rules spanning the Medicare physician fee schedule and the implementation of the One Big Beautiful Bill Act, President Donald Trump’s domestic policy package that cut nearly $1 trillion in future Medicaid spending.... Lobbyists told POLITICO they expect the scrutiny to continue regardless of the midterm results, which will determine control of Congress. “The pharmaceutical industry is under increasing bipartisan pressure on pricing…The threats are coming at them from all sides,” said a lobbyist for large drugmakers, granted anonymity to speak about their client work.... AHIP, the trade group for insurers, spent $3 million on third quarter lobbying, on par with the prior quarter. Year-to-date spending has surpassed $11.3 million, the group’s second highest for the period behind last year. Chris Bond, a spokesman for AHIP, said it continues to “actively engage with policymakers in support of affordable, high-quality coverage options” and blamed hospitals and drugmakers for high costs. Spending at the American Hospital Association, meanwhile, is down. The trade group spent $3.8 million on lobbying in the third quarter, its lowest in at least a decade. The association declined POLITICO’s request for comment. Lobbyists and policy analysts said efforts to prepare companies for oversight in a likely Democratic-controlled House, advance proposals in a year-end legislative package, and rethink the No Surprises Act will dominate the agenda for the remainder of the year. Click here to unsubscribe from these alerts. 📷

In 1957, a Russian immigrant published a novel of more than a thousand pages built around one question: what happens if the people who make the world run simply stop? Its title is Atlas Shrugged. In France it's called La Grève, The Strike. It wasn't even translated into French until 2011. That tells you something. This morning, I think Elon Musk wrote the sequel. A. Where the book comes from. Ayn Rand was born Alisa Rosenbaum in Saint Petersburg in 1905. As a teenager, she watched Bolshevik soldiers walk into her father's pharmacy and seize it in the name of the people. Her family lost everything. Not to a competitor. To a committee. She fled to America in 1926 and spent the rest of her life writing about one distinction: those who create, and those who seize. B. The story. In Atlas Shrugged, America is sliding into decline. Not because of war. Because of rules. Year after year, a growing class of bureaucrats, regulators and planners decides that production must be controlled, shared "fairly," frozen. They never build anything. They issue directives. The worst one freezes every worker in his job and forces every inventor to hand over his patents for the public good. And one by one, the people who make the country run start disappearing. The best engineers. The industrialists. The inventors. An oil man sets his own wells on fire before vanishing. The whole country keeps repeating a question it doesn't understand: "Who is John Galt?" John Galt is the man behind the disappearances. He has convinced the creators to go on strike. They withdraw to a hidden valley in the Colorado mountains, where everyone keeps what they make and trades freely. And they let the world find out what it looks like without them. The lights go out in New York. The grey men are left alone with their directives, and discover that a directive has never produced a single kilowatt. C. The core idea. The strike isn't about money. It's about consent. Rand's insight is that the system that captures the creators runs on their cooperation. It needs them to keep producing so it has something to redistribute. The bureaucrat is a parasite who needs a host. Remove the host, and he's exposed as what he always was: useless. D. What Musk just did. This morning, Musk announced that next year he will give one of his own SpaceX shares to every kid in America. "The first of many." Here's what's fascinating. It's the strike, run in reverse. Rand's creators withdrew. Musk stays. He keeps building rockets, satellites, AI. But instead of walking away from the system, he walks around it. The value goes straight from the builder to the citizen. No ministry, no agency, no committee in the middle. Rand had to make the creators disappear to prove the bureaucrats were useless. Musk doesn't need to disappear. He just needs to stop routing value through them. Same result. The grey men are left standing in the middle of a pipe nobody uses anymore. E. The difference that changes everything. Rand's strike has a flaw her critics never stopped pointing out: ordinary people are left behind. The creators retreat to their valley. The rest of the country sits in the dark. Musk's version fixes that. He isn't taking the creators out of the world. He's bringing the world into the valley. Every kid in America becomes a shareholder in the machine. Not a spectator of the strike. A participant. That's the alliance being formed right now: builders and citizens, directly, with nothing in between. And the only people who lose that deal are the ones who never built anything. F. Why now, and not in 1957. In Rand's time, the strike was a fantasy. You couldn't produce at scale without the state's permission, and you couldn't reach every citizen without its pipes. In 2026, one founder can build rockets, run a global network from orbit, and pledge equity to 73 million children in a single post. AI will soon do in seconds what a ministry does in years. The tools of the strike finally exist. And they don't require anyone to leave. G. The ending. For seventy years, "Who is John Galt?" was a shrug. A way of saying nothing can be done. In the book, the strike ends when the creators decide the road is clear and walk back into the world to rebuild it. That's the scene we're watching. Not a man leaving. A man coming back, with a gift for every child. The grey men are about to discover what Rand promised them seventy years ago: a world that no longer needs them.

Next year, I will give one of my SpaceX shares to every kid in America. This will be the first of many.

Rep. Pallone (D-NJ) has issued his new bill to reform the #NoSurprisesAct and let me count my top 3-4 reasons why it is a trainwreck for physicians and hospitals (and wait until you see #4): 1. IDR would be eliminated in favor federal rate setting at the "qualifying payment amount" (QPA or initial payment determined by the health plan). There is no recognition here that the federal district and appellate courts (TMA I, II, III and IV plus 2 appellate court decisions, so 6-0 for the TMA) have found issues with the administration of the QPA and recently that the QPA rules should be void and have no legal effect due to health plans' inclusion of ghost rates and other QPA manipulations (TMA III US Court of Appeals for the Fifth Circuit, Aug. '26). The Rep. includes the CPI-U adjustment in his bill which is laughable as the current law requires it and few if any plans actually comply with the requirement. One reason--no real audits of the QPA (see #4 below). Why? The current CPI-U is +28% from a 2019 baseline. 2. No other factors would be considered in final payment--just blatant federal rate setting. NSA requires acuity of the Pt, prior contract rates, qualifications of the clinicians and one can use the Transparency in Coverage (TiC) data which shows market rates among other factors for the IDRE to consider--none of that for Mr. Pallone. Ask your colleagues in CA and MI how they like state based rate setting for applicable OON claims? 3. Another laughable provision--payment w/in 30 days but no interest or penalties--and yes that is in the current NSA. As I have cited so many times here, the data is overwhelming that the plans are in systemic non-compliance with payment. Why would they comply in the future without enforcement, penalties or interest? 4. My favorite--no judicial review of the QPA. The plans have the ultimate and unquestionable power to set the QPA and never be questioned by any physician or hospital in court. Oh, CMS can audit and that's true today. 4+ years ago CMS announced they were conducting over 20 audits, one has been announced in that time and the plan was out of compliance with setting the QPA. To the physician and supporting community--time to get ready to become active again to preserve and enhance the NSA. If that bill above becomes law, independent practice as we know will largely cease for groups actually accepting insurance and patient access to care will greatly suffer. democrats-energycommerce.hou…

I find these posts from ‘health system academics’ frustrating and not reflective of the data. As @pgipe can attest, Value-based care is not a proven panacea. The term often obscures a broader goal: modifying and consolidating payment systems into vertically integrated silos which are known to add costs. Payment models encourage consolidation, rely on imperfect or potentially gameable metrics, and impose substantial administrative costs. Even, models that show promise in limited settings often fail to produce consistent savings or better outcomes across the broader health care system. As in this situation, the strongest advocates are large health-system academics who are often incentivized to promote these models. Primary care clinicians already have extensive experience with value-based payment systems. They face ever-expanding documentation and reporting requirements, attribution rules, and other administrative burdens and costs that advocates often overlook. Claims that value-based care is a magical solution are farcical and overstate the evidence. But let’s keep selling that snake oil

I love IDR. Apparently, an insurance company having to defend what it pays a physician is a national affordability crisis. Meanwhile, a hospital can buy that physician’s practice and collect more for the same care. Washington built a financial reward for changing the name on the door. Start there. Start with the tax-exempt hospital corporations buying their competitors while taxpayers subsidize the enterprise. Start with Section 6001, which restricts physician-owned hospital entry and expansion. Congress actually wrote a law protecting incumbent hospitals from physicians who want to compete with them. Then everybody sits around wondering why healthcare costs so much. I build healthcare businesses. When you subsidize the incumbent, restrict its competition, and pay it more for owning the building, you have engineered an expensive market. @HHS and @CMSGov: enforce price transparency. Stop paying a premium for hospital ownership. Congress: repeal Section 6001. Let physicians build. Let employers buy directly from them. And keep a process that lets physicians challenge an insurer’s payment without handing the patient a surprise bill. I’m tired of a healthcare affordability debate that keeps arriving at the independent physician’s paycheck while the subsidized hospital buys another ZIP code.

Health insurance companies should work for patients, not stand in the way of their care. As a physician, I’ve seen how insurance denials can delay treatment and put patients in difficult positions. Our health insurance system needs serious reform that puts patients first and ensures Americans can access the care their doctors recommend.

Would add reverse hospital consolidation by removing the moratorium on physician owned hospitals imposed in 2010 by the ACA

Policy pundits arguing in favor of cutting doctors pay even more. Look at this graph. Can we agree things cost more now than in 1992? How are doctors supposed to pay their overhead if reimbursement for their services go down year over year? Doctors used to be a respected group. Why don’t people want doctors reimbursement to go up so they can keep their doors open? These policy wonks do understand the most expensive place to receive care is in a large system.

An honest primer for physicians on Pallone’s proposed federal payment benchmark(AKA price setting) for out of network physicians and its pitfalls. The proposal would replace federal surprise-billing arbitration with government-mandated prices. 1. Start with someone else’s 2019 contracts. Take a plan’s eligible 2019 rates for comparable care in the same specialty and region. Pick the median, or middle price, and adjust it for inflation. Then impose that payment on physicians who never agreed to those contracts. 2. Use an inflation measure that does not track practice costs. CPI-U, calculated by the Bureau of Labor Statistics, measures household prices. It includes healthcare spending but does not measure what it costs to run your practice. Staffing, equipment, and malpractice expenses can rise faster. Adjusting an old price for inflation does not establish that the original payment was adequate. 3. There is still room for ghost-rate abuse. Ghost rates are contract prices for services a provider does not perform. Low ghost rates can pull the benchmark down. The bill excludes them but does not expressly require proof that the specific contract price was ever paid. An unused low rate could still qualify if performing the service for another payer satisfies the implementing rules. 4. For qualifying new plans, HHS decides the starting-rate methodology. For qualifying plans not offered in 2019, the HHS Secretary establishes how the starting benchmark is calculated. How replacement or substantially redesigned plans qualify remains unclear. As qualifying new plans replace older ones, that authority could affect more payments. 5. The insurer calculates your payment without independent arbitration. The payer applies the federal formula. Removing arbitration removes a check on inadequate payments and could weaken your negotiating position inside the network too. 6. I don’t trust the enforcement. The bill requires payment within 30 days. The current IDR system already requires payment within 30 days of a decision, yet physicians still report late and unpaid awards. I’m not comfortable relying on CMS to enforce payment under another system when physicians are still chasing money owed under the current one. 7. The formula is protected from judicial review. The bill expressly bars judicial review of the benchmark methodology. That does not necessarily prevent challenges to individual errors or fraud. I oppose government price setting. Physicians should be able to negotiate their rates without insurers getting the government to impose prices from contracts we never signed.