MillerTime

[Dr. Ashley Bonheur @DrAshleyBonheur]

@EDSecMcMahon After 10+ years of public service under PSLF (with ICU work thru COVID) healthcare providers are stuck in limbo. SAVE forbearance buyback applications aren’t being processed, leaving us with massive debt. We’ve done our time. Fix the backlog. Honor the commitment!!!

[MillerTime @DMills515]

@thetimes Probably should get a better graphic than a balloon pump, which is contraindicated in septic shock…but yes sounds impressive !

[MillerTime @DMills515]

@WomenOFAB @EbianTheDog @Alejandro27Ale Point of order - millions were placed involuntarily on the SAVE plan, I don’t think a single person applied for it. Now those same people are penalized as if they egregiously tried to game the system only to get screwed over again by the current admin.

[Mike Lupica @MikeLupica]

Mike Lupica: UConn is college basketball's last blue blood standing https://t.co/TllMaiJNq3

[MillerTime @DMills515]

@weatherwilly It seems like the heaviest bands are not making it across the I-84 boundary into the Hartford area, anything southeast of that getting heavily dosed with intense bands

[MillerTime @DMills515]

@aburks41 They are average college athletes, it’s not Rudy or sticks out there.

[MillerTime @DMills515]

@trailblazers UConn on UConn crime right there, doesn’t seem right @UConnMBB @AndreDrummond @clingan_donovan

[John Asghar MD @JahangirAsgha10]

What happens when metrics become the outcome?

Medicine is drowning in metrics. The pitch was simple: measure performance, tie it to payment, and quality will rise while costs fall. In reality, once a metric becomes the target, the metric becomes the outcome and the patient becomes secondary. This is Goodhart’s law at the bedside, where attaching money and reputation to a number forces the system to bend around the number itself. Documentation, coding, and workflows are redesigned to win the metric, even when it adds little or nothing to actual patient care.

CMS value based programs are the clearest expression of this problem. We built MIPS, ACOs, readmission penalties, and hospital scorecards with polished dashboards that show steady improvement. On paper the numbers move the way policymakers want. In the exam room, more time shifts from the patient to the computer as practices reorient around compliance rather than care. The promise was lower cost. The reality is modest gross savings that evaporate once bonuses, reporting infrastructure, consultants, staffing, and software are accounted for. Money flows away from care delivery into the machinery required to chase the metric.

The average practice now carries extra personnel for quality reporting, extra platforms to track measures, and extra hours of clinician time spent clicking boxes. The patient still has back pain, diabetes, or heart failure, but the metric looks excellent on the quarterly spreadsheet. These metrics also distort clinical behavior. If a scorecard rewards lower readmissions, hospitals build observation units and reroute patients. If it rewards higher risk scores, coding intensity spikes. The anatomy of the human body has not changed. The documentation has.

The sickest and most complex patients often look terrible on these metrics, and the hospitals that care for them are the ones most likely to be penalized. Resources get pulled away from the people who need them most. We pretend these systems are neutral and scientific, but they are built on imperfect proxies that become fragile once tied to payment. When money flows through a proxy, the system optimizes the proxy rather than the underlying reality, and the disconnect widens between what the patient values and what the scorecard measures.

The administrative burden is not an abstract complaint. Every hour spent fixing upload errors, resolving denominator definitions, or navigating measure specifications is an hour not spent understanding a patient’s concerns or discussing treatment goals. That is a real cost, even if it never appears on a CMS slide. Measurement itself isn’t the issue—clinicians rely on data every day. The issue is turning narrow, brittle metrics into financial targets and then declaring that this is what value looks like. Systems will respond exactly as designed, and they will game exactly as expected.

If we are serious about lowering costs and improving care, the priorities should be transparent prices, functional insurance design, and less friction at the point of care. That is entirely different from building another layer of performance scoring on top of an already bloated system. Value based care and metric driven medicine were sold as solutions. In practice they have become an added disease. Until we stop confusing better metrics with better medicine, we will keep spending more to move numbers while patients wonder why nothing about their care actually feels better.

[MillerTime @DMills515]

@valkvool @RpsAgainstTrump Yes it was well reported on, likely what’s known as CRT-D - https://t.co/dssoyjfMfU

[Ge Bai @GeBaiDC]

Over the past several decades, an appealing idea rapidly gained popularity: The government could advance a health care system that rewarded the quality of care rather than the volume of care. Medicare began leveraging its economic might to require physicians and hospitals to measure and improve quality. In tandem, Congress embarked on a 20-year journey to incentivize providers to report on quality and pay for good patient outcomes. Facts are out:

1️⃣ Medicare Quality Measurement Is Ineffective And Inefficient, with Distorted Incentives for Gamesmanship and aHeavy Compliance Burden

2️⃣ The Quality Industrial Complex has led to hundreds of measures that are primarily process-focused rather than patient-outcome based. This complex now drives the quality measure development process through CMS, which then is imposed on physicians either in fee-for-service or in alternative payment models.

Specifically, CMS contracts with consensus-based entities (CBEs) —some of whom can count more than 400 member organizations—that get paid to endorse and steward quality measures, a cycle that creates incentives for the further expansion of measures. For example, CMS awarded Battelle Memorial Institute a five-year, $53 million contract to serve as the independent CBE for CMS. This contract, effective from March 2023 through February 2028, tasks Battelle with reviewing and endorsing clinical quality measures, guiding “national priorities for healthcare performance measurement,” and fostering stakeholder engagement to enhance the US health care system.

This is an important contemporary example of industry capture; a regulatory agency is advised by industry, that creates feedback and develops measures to drive reimbursement for its constituency, while at the same time imposing significant burdens on that constituency. Despite the real-world frictions these quality measures have imposed, cross-national studies have shown no improvement of outcomes in areas ranging from hip fractures to myocardial infarction.

3️⃣ Solutions:
Repeal the Medicare merit-based incentive payment system; Unburden and Empower Physicians; Engage Patients

A departure from the past two decades of top-down, centralized thinking and practice, would build a virtuous, continuous quality improvement paradigm that is patient-centered, clinically focused, and clinician-engaged. Enormous resistance is expected, as the status quo has long enriched the quality and medical industrial complex. However, the potential benefits to patients and clinicians will serve as a critical counterforce.

Appreicate my coauthors: @jwhite_health, Dr. Joseph Puthumana, & @PMCram.

[Anthony DiGiorgio, DO, MHA @DrDiGiorgio]

Electronic health records are built to optimize billing, not clinical care.

A doctor can’t code a note with a diagnosis of traumatic subarachnoid hemorrhage as it’s too generic, according to the computer.

But a more generic diagnosis, traumatic brain injury CAN be coded.

So the specific diagnosis gets left out of the problem list because, for whatever reason, the software says it’s too generic. Meanwhile the truly generic diagnosis is now attached to the patient.

[Heath Veuleman @HeathVeuleman]

In healthcare, we meet people at one of the lowest points of their lives.

They remember everything — what the registration clerk said, how the nurse made them feel, when the physician rounded.

And they remember it through a distorted lens of disease, fear, and trauma. It’s an epoch in time for them — a day they’ll never forget.

That’s why I take our work deadly seriously.

It doesn’t matter if it’s congestive heart failure or a knee replacement — to the patient, it’s not “routine.” It’s their life on the line.

We talk about “intensity of service” and “severity of illness.” They think: Will I survive this?

My job is to make delivery and financing systems where physicians and patients can create affordable, meaningful outcomes together.

Note the two major components above: physicians and patients. They seem kind of important and fundamental to the equation.

So when I hear that physicians are being told how to practice — and then told to clock in and out like they’re making plywood at a mill (nothing wrong with honest millwork) — it’s galling.

Because the disrespect for physicians is just a symptom. The real disease? A lack of respect for the consumer.

If the grifters, goobers, and gomers running our delivery and financing systems see physicians as cogs — then you, the patient, are just a widget to be monetized.

I’ve been screamed at by a grieving mother who’d just lost her daughter — because my tie was pink, her daughter’s favorite color. If that helped her even a fraction, she could’ve screamed at me all day.

So if you think a snarky post on X is going to shake me — let me quickly disabuse you of such stupidity.

The sacred work of radical loving care is hard. It’s never been easy — and it’s not supposed to be.

It’s the work of the Samaritan — meeting people at their lowest, absorbing their pain, and loving them through it.

I’m on a mission to change healthcare.

And we will. And we’re going to start by giving physicians their autonomy back and patients their agency back.

We’re going to resuscitate the physician–patient relationship - the healthcare renaissance is upon us!

Thank you for your attention to this matter!

@SecKennedy @HHS_Jim @DrOzCMS @JDVance @realDonaldTrump @mcuban @elonmusk @NicoleShanahan @calleymeans @DOGE_HHS @HHSGov @CMSGov @RepThomasMassie @mtgreenee @SenRandPaul @RoKhanna

[MillerTime @DMills515]

@espn @ShamsCharania Moving both teams to Hartford I heard

[Savage0914 @ssavage0914]

I’m just a PA

But I’ve been at this for about 25 years now - and I’ve see what’s happened to private practice. It’s disgusting.

It’s getting worse

I’m in Philadelphia - we lost Hahnaman and Crozer-Chester hospital SYSTEMS overnight because private equity firms bought them, leveraged their assets while paying themselves astronomical salaries, and bankrupted them.

But doctors can’t be trusted to own hospitals?

You may find an ally in Josh Shapiro.

[Dutch Rojas @DutchRojas]

If a surgeon’s making $1.3M, you can bet the MBAs are pulling 5x and the health system is pocketing 10–15x.

The people doing the actual work, doctors and nurses, are at the bottom of a pyramid built on burnout, paperwork, and profit.

[Mark V. Sacco @MarkVSacco]

@FAFSA Hey @FAFSA, grants, loans, & work-study are great, but my wife’s been stuck ~6 months waiting on a PSLF buyback reply with zero updates. Share response timelines & give existing borrowers the same focus as new ones! #FAFSA #PSLF

[Frankie @E13_Tank]

@EDSecMcMahon When are you going to be committed to getting the pslf buyback back log figured out

[Happycamper @roadtripsrus]

@SBA_Kelly @DOGE Great! Now about PSLF, why isn't anyone responding to my concerns and pleas to allow those who have completed their required 120+ eligible employment months to get their buyback amounts and exit the congressionally approved program? I keep asking ... you and Linda keep avoiding.

[Banana Jones 🇺🇦 @LoisaidaSam]

Well now it's not a secret anymore @nytimes! Lol