14 years of the Affordable Care Act... It’s time to be intellectually honest and admit it (like many government programs) did not accomplish the intended goals.

Yikes

The Chat CPT wars have begun.

Luis Tumialan, MD Knocks it out of the park. Why did the federal government ban physician ownership in hospitals? Physician owned hospitals are the highest quality hospitals either the lowest prices. Imagine banning Apple, Google, Amazon, Nvidia, and Tesla from growing? This is the insanity of the moratorium on physician ownership in hospitals.

Imagine a chef employed at a restaurant that charges $100 for a hamburger. One day he gets sick of his institution ripping off customers, so he goes across the street and opens a shop with $5 hamburgers. Now the hamburger loving people are better off. Competition drives down prices and increases quality. The original restaurant, angry over the lost business, gets a law passed that bans chefs from owning restaurants. Everyone would recognize this as a corrupt, protectionist law. And yet, in healthcare, with skyrocketing costs, we still outlaw physician owned hospitals.

Every year on or right before 9/11, we show this video to our students. It’s not only powerful story-telling, it’s a reminder to a younger generation about how life altering 9/11 was for those of us who lived it. It’s only 10 min #themanintheredbandana

An economist just told a room of doctors that American health insurance isn't insurance. "In the United States, we don't have health insurance. What we have is a system where I don't pay for my health care — I pay for yours. You don't pay for your health care — you pay for mine. This isn't insurance. It's a social policy."

Bank of America spends $250 million a year on GLP-1 drugs for its employees, CEO has said

You have to be willing to take your fiduciary responsibility (And one of your highest costs) seriously. This means divorcing the BUCA logo on a card.

Then I asked for a simplified version of the above : Here it is in plain English. Denver hired UnitedHealthcare to run its employee health plan. Denver pays the actual medical and drug bills itself — United just processes them. That’s what “self-funded” means. The problem is that Denver can’t see what it’s actually paying for drugs. 1. United buys the drug for one price and charges Denver a different price. It keeps the difference. Say the pharmacy gets paid $40 for a prescription. United bills Denver $100. United keeps $60. Denver never sees the $40. The contract says this out loud in three different places — it’s not hidden, it’s just written in language nobody reads. There’s no cap on how big that gap can be. 2. Drug companies pay rebates. United keeps all of them and hands Denver a flat number instead. United collects rebate checks from drug manufacturers. Instead of passing those through, it promises Denver a fixed amount per brand prescription (about $740 in 2023). If the actual rebate was $1,500, United keeps the extra $760. The contract literally says any rebates above the fixed amount belong to United. Denver has no right to know what the real number was. 3. United decides which drugs are “specialty” — and specialty drugs are where the money is. The contract defines a specialty drug as, essentially, “whatever United’s own specialty pharmacy sells.” United also reserves the right to reclassify drugs whenever it wants. Once a drug is labeled specialty and filled at United’s own pharmacy, it drops out of the normal price guarantees entirely. So the most expensive drugs are the least protected. 4. The most expensive drugs of all — the ones given in a doctor’s office or infusion center — have no price guarantee at all. The contract flatly excludes them. Cancer drugs, infusions, injections administered by a provider. Zero pricing protection. 5. Denver can’t shop around, and it can’t leave without a penalty. Denver isn’t allowed to negotiate directly with any drug manufacturer. It must use United’s mail-order pharmacy exclusively. And if Denver hires an outside vendor that steers employees to cheaper drugs or cheaper pharmacies, United can cancel all the pricing guarantees. If Denver ends the drug program early, United keeps every rebate it owes. 6. Denver can’t audit its way out of this. Denver is allowed one audit a year, capped at 300 prescriptions, using a random sample United has to approve. No auditors paid on commission. No computer-based searches for errors. You cannot find a pricing problem across hundreds of thousands of claims by randomly checking 300 of them. The audit rules exist to make sure nothing gets found. Is any of it illegal? Almost none of it. It’s a legal contract that Denver signed. The one thing that might cross a line: federal law since 2021 bans “gag clauses” — contract terms that stop an employer from seeing its own cost and claims data. This contract says United may let Denver see its pricing information, at United’s discretion. Federal regulators have said that “only if the vendor allows it” language is exactly what the gag-clause ban prohibits. And Denver has to certify to the government every year that it has no gag clauses in its contracts. The one thing Denver could actually do about it: Colorado banned this drug markup practice, effective January 2025, and self-funded employers like Denver can opt in. It’s an election, not a lawsuit. Somebody should check whether Denver ever filed it. The bottom line for an HR person: the drug program looks free. There’s no fee for it anywhere in the contract. That’s the tell. United isn’t working for free — it’s getting paid out of the drug prices, and the contract is built so Denver can’t measure how much.

Nobody teaches you that discipline feels like punishment until the results start feeling like freedom

I love that @MorePerfectUS is highlighting the downsides of healthcare consolidation. This is a bipartisan issue. Let’s fix it: Site neutral payments, 340B reform, CON repeal, stark reform, and roll back the physician owned hospital ban.

NEW: You might be charged double for a routine medical visit. Corporations and hospitals are buying up private practices across the country, then tacking “facility fees” onto standard appointments. While Americans are stuck paying hundreds more for a single doctor’s visit, corporate executives are raking in billions.

𝐇𝐨𝐬𝐩𝐢𝐭𝐚𝐥𝐬 & 𝐓𝐡𝐞𝐢𝐫 𝐅𝐚𝐤𝐞 𝐏𝐫𝐢𝐜𝐞𝐬 A must-read, hard-hitting piece from Anthony DiGiorgio @DrDiGiorgio on the economics of nonprofit hospitals and the growing gap between their public mission and financial reality. He lays out the extensive subsidy ecosystem supporting hospitals: • Property and sales tax exemptions • Public funding (DSH payments, GME, research support) • 340B Drug Discount Program revenues • Market power–driven pricing from consolidated health systems …among others Then comes the key question: "After all of those subsidy streams, what exactly is still unfunded"? As he puts it, hospitals should provide a true accounting: • What is the net Medicaid shortfall after supplemental payments? • What is the real value of tax exemptions? • Where does 340B revenue actually go? • How are funds allocated across executive pay, administration, expansion, reserves, M&A, and lobbying? Until we see that level of transparency, claims about underfunding deserve more scrutiny. Strong, provocative piece. 👉 drugch.nl/3OgIl9B

Let’s not change how hospitals and doctors work with the insurance companies. The current system works for doctors and patients. Perfectly. If the insurance companies cared about outcomes and efficiencies they wouldn’t do dumb shit like this. Why won’t hospitals and practices fight back in any way at all ? Not even mean tweets lol

Great question. Answer: smart one. Every dollar saved on benefits goes right to the bottom line. A public company with 100m shares can add 25c per share, annually, if they had a clue about their benefits. You can start counting down to the shareholder lawsuits. This is money sitting on the table and every ceo is ignoring their fiduciary responsibilities. Never trust your benefits vendors or consultants. Never. Just run your name redacted contracts through an LLM, with training the AI vendor turned off

The public should be far angrier about facility fees than it is. Picture two clinics. One is an independent physician practice. The other is the exact same type of clinic, same doctors, same rooms, same services, but owned by a large hospital system. That second clinic is classified as a hospital outpatient department. Nothing about the care is different. But the prices a "hospital outpatient department" gets to charge the government are multiple times higher than the independent clinic. Routine office visits, imaging, echocardiograms, in office procedures all get marked up simply because a hospital’s name is on the door. The independent doctor gets paid one rate. The hospital owned clinic gets paid more for doing the exact same thing. That extra money lets the hospital pay higher staff salaries, outbid independents for equipment, spend more on marketing, and layer on amenities that have nothing to do with care. The independent physician is now competing against a system that is legally allowed to charge more for identical services. Patients are mostly blind to this. They are not told they are walking into a higher priced clinic. They do not see the facility fee until the bill shows up. And then the patients are screwed again once enough independent practices are driven out of business. Patients lose the option of seeing a lower cost physician altogether. They are forced into hospital owned clinics that charge more and often deliver a worse experience. This is not an accident. Medicare explicitly wrote these payment rules into its fee schedules. Private insurers largely follow Medicare’s lead, so the distortion spreads across the entire system. It's almost as if the system is designed to elminate independent physician practice...

Corporate speak for “yes, we are aware of this and we’re going to keep doing it.”

Thank you… 🙏 Free markets. Physician independence = higher quality outcomes at lower prices. Lower prices and better outcomes = lower premiums.

Dear @CMSGov and @TRICARE It’s 5:25AM. I’m having coffee with my friend Terry. Terry is 71. Spent 20 years on active duty. 10years in the reserves. Civil engineer. Master carpenter. Built houses. Still in excellent shape. Friends with service members across the globe. Everyone who meets him loves him. His cervical spine is falling apart. He needs an ACDF, anterior cervical discectomy and fusion. Not experimental. Not elective. A surgery he needs. It was scheduled. Then rescheduled. Then rescheduled again. This morning he found out it’s been pushed again. Why? Because Tricare, the benefit he EARNED with three decades of service, is trying to coordinate benefits with Medicare before they do the procedure. Two government programs pointing at each other. Both owed to him. Neither willing to move first. So Terry sits here with a lidocaine patch, acetaminophen, and stretching exercises. Managing a deteriorating spine with what you’d grab off the shelf for a sore back. What the hell is going on when the government screws over veterans like this? This isn’t a coverage gap. He HAS coverage. He has TWO coverages. Both earned. The problem isn’t that Terry doesn’t qualify. The problem is the government backed healthcare system treats its own promises like liabilities to be minimized. Tricare doesn’t act like a debt owed to those who served. It acts like an insurance company trying to subrogate its way out of responsibility. Terry didn’t serve 30 years so two bureaucracies could play hot potato with his surgery authorization. He served because he loves this country. And right now, this country is telling him to wait, not because the surgeon isn’t ready (I spoke with his surgeon), not because the OR isn’t available (brand new updated VA two miles from here) but because the paperwork hasn’t decided which government account gets debited. You guys suck ass. And my man is in pain. He did it all right. And you’re f-ing him over.