Devin Zarkowsky

California Vascular Health Specialists #aorta #AortaEd #AAA #aneurysm #aorticdissection #carotid #CLTI #CLI #PAD #spinalaccess No disclosures.

[Devin Zarkowsky @DevinZarkowsky]

@texashospitals Happy to maintain my outpatient clinic without a facility fee, as I always have. Now your turn.

[Dutch Rojas @DutchRojas]

Nothing says “expanding access” like a tax-exempt health system protected by CON laws, federal exemptions, above-market reimbursement, and the freedom to roll up geography one press release at a time, while the ultimate liability lands on the New York taxpayer.

Good thing the NY Attorney General’s office has always been famous for aggressive nonprofit oversight.

Solid work.

[Christine Price @HEALTHCOSTtruth]

$5,614.12 saved on a single CT scan.
Same procedure code (74177 — CT abdomen and pelvis with contrast). Two hospitals. One bill.

Physician-owned hospital (pays real estate taxes, gets no grants): $951.38 self-pay.

Non-profit hospital (pays no real estate taxes, receives federal and state grants): $6,565.50 cash price.

There's a lot of discussion lately about whether physician-owned hospitals inflate charges as massively as non-profits. This is one example from my personal experience. The "non-profit" charged nearly 7x more for the same scan than the for-profit physician-owned hospital.

Section 6001 of the ACA froze new physician-owned hospitals in 2010. The hospital lobby called it patient protection. The data calls it competition suppression.

We all got screwed when they stopped physicians from owning hospitals.

Section 6001 should be repealed.

Do your homework. Support the hospitals that help us. Avoid the ones that don't. Simple as 1-2-3.

#healthcarecosts #POH

[Dutch Rojas @DutchRojas]

“Nonprofit” is a tax status. It says nothing about how much the hospital keeps, what it pays its executives, or how little reaches a patient who can’t pay.

The community benefit it reports?
It writes the definition, grades itself, and files with an agency that audits almost none of them.

[Anish Koka, MD @anish_koka]

THREAD: The medical malpractice market is broken, and the data proves it.

A physician's interpretation of the insurance market on what's happening. 🧵

[Anthony DiGiorgio, DO, MHA @DrDiGiorgio]

This thread is a perfect example of Hayek’s fatal conceit.

Here a pro- central planning pundit points to one preferred version of price setting, declares that it “works,” and then treats every other failure of price setting as somehow unrelated.

Maryland has all payer hospital rate setting and global budgets. You like the outcome, so that counts as smart planning (not to mention Maryland has plenty of flaws).

Medicaid pays pediatricians far below commercial rates, patients struggle to find doctors who participate, and suddenly that is not a problem with rate setting per se. That is just the wrong rate setters, or the wrong politicians, or the wrong program. Or Medicare pays hospitals 5x what a doctors office charges. Just the wrong central planners again.

But the core problem is the same. No commission has access to the dispersed knowledge needed to set the right price at the local level.

It cannot know the capacity of each pediatric office, staff wages, rent, malpractice costs, supplies, local demand, physician burnout, opportunity cost, patient urgency, or how much a parent values being seen today instead of six weeks from now.

Prices are signals that coordinate resource use in the face of scarcity.

When planners suppress or manipulate prices, the cost does not vanish.

That is the unseen harm.

The fatal conceit is believing the problem is never central planning itself. It is always that the right central planners have not been put in charge yet.

If the concern is access, subsidize patients. Give people purchasing power. Do not pretend a commission can calculate the right price for every clinical situation from above.

There’s zero reason that every American can’t have access to pediatrician visits without any more government involvement than a means tested cash equivalent subsidy. There’s no more of a market failure there than with food.

But central planners don’t want that. They just want control.

[Anthony DiGiorgio, DO, MHA @DrDiGiorgio]

I disagree. There is good economic data showing premiums track with hospital costs and insurance company net revenue is relatively stable.

Link to full paper below:

[Kevin Pho, M.D. @kevinmd]

A 77-year-old marathon walker developed a headache. Over the next four months, she was seen by a nurse practitioner, a PA twice, a medical assistant, and an emergency room. She was given two Medrol dose packs, NSAIDs, and a prescription for fluoxetine after a PA decided she had anxiety. She had never actually seen her primary care physician. She had giant cell arteritis. A sed rate of 41 confirmed it, the moment her neurologist finally examined her, took her history, palpated her temporal arteries, and asked about jaw claudication.

The patient told her neurologist: "if you think I need fluoxetine I'll be on it, but I don't think I'm anxious and this headache is just crazy."

The structural argument matters more than the cinematic detail. Team-based care is sold as a solution to the physician shortage. The math runs the other way. If a physician is the diagnostic instrument that holds the differential together on a multi-system presentation in a 77-year-old, the marginal cost of putting that physician in the room at visit 1 is zero. The marginal cost of NOT putting that physician in the room across this case was four office visits, an ER visit, two courses of steroids that partially masked the inflammatory signal, a misdiagnosis of anxiety, an SSRI prescription, and a delay in identifying a vision-threatening time-sensitive diagnosis. The team did not save physician time. It spent physician time everywhere except with the patient.

Reeta Achari, MD, a neurologist in solo private practice in Houston for 25 years, makes the operational case in plain terms. There is a physician shortage. The response has been to use physician time for documentation, prior authorizations, peer-to-peer calls, board recertification weeks, and electronic-record data entry. The response should have been the opposite. If there is a shortage of the diagnostic instrument, the workflow has to put the instrument in front of the patient, not behind four other people.

Her own response was structural. She opted out of Medicare. She built a quarterly subscription practice with prices middle-class patients can afford and scholarships for long-relationship patients. New patients get a one to one-and-a-half hour intake. Follow-ups get 30 minutes. The model is not concierge. It is continuity, priced to clear.

The diagnostic line from her conversation: "No physician touched her."

Listen to the full conversation on The Podcast by KevinMD. Link in the replies.

What does the cascade in your practice or your own care look like? Where in the workflow did the physician finally enter the room?

#ThePodcastbyKevinMD

[Dutch Rojas @DutchRojas]

Your “nonprofit” hospital has an $8M CEO, a bond-rated real estate empire, and a tax exemption. But the facility fee on your 12-minute MRI is just to “keep the lights on for the community.” Sure.

[Anthony DiGiorgio, DO, MHA @DrDiGiorgio]

High hospital prices are the reason your insurance is expensive.

They’re the reason you haven’t gotten a raise.

They’re almost entirely driven by government policy.

We can fix this.

[Anthony DiGiorgio, DO, MHA @DrDiGiorgio]

This is such an economically illiterate take.

Somehow, by having the government control the spigot for healthcare funding, people will stop trying to maximize their income?

To believe this, one must be ignorant of all human incentives.

Non-profit hospitals try to maximize revenue. They will do that if the private insurance is the payer or if the government is the payer. It doesn’t matter where the money comes from.

Independent physicians will try to maximize revenue. Physical therapy clinics, hospice centers, home health agencies, durable medical equipment suppliers, device companies, pharma companies. All will try to maximize revenue under single payer just as they do now.

To think that their behavior will somehow change because the government is the only source of revenue is, simply put, stupid.

The only difference is that when the government is the customer, you cater your business to them and not to the patient.

[Anthony DiGiorgio, DO, MHA @DrDiGiorgio]

I hate this idea that doctors are especially prone to creating "induced demand."

Have you ever been to an auto mechanic? Get your oil changed and they try to sell you every little thing. Ever had a home renovation? You think your contractor isn't creating "induced demand?"

Ever have a waiter offer you dessert after your meal? Induced demand!

Why does the idea of physician "induced demand" create all these regulations (Stark Law, POH ban) but other industries don't face this scrutiny?

[Kevin Pho, M.D. @kevinmd]

A farm worker with gangrene got the ultrasound, the procedure, and a saved leg in a week.

The hospital system that turned him away told him to wait three weeks just to be seen.

Interventional radiologist Saravanan Kasthuri runs the office-based practice that took him. The same vertebroplasty he billed at $7,800 in 2016 now pays $4,800, a 40 percent cut in 10 years. His staff costs are up 70 percent over the same decade. His Medicaid mix went from 1.2 percent to 27 percent.

There are more than 300 office-based procedures where Medicare reimbursement is now less than the direct cost of the supplies.

Private practice has collapsed from roughly 60 percent of physicians in 2012 to about 18 percent today. The Medicare physician fee schedule was written in 1992, when most procedures happened inside hospital walls. Medical technology moved $4 million linear accelerators and $4,000 stents into the office. The payment did not follow.

The fix is structural. Pull the high-cost supplies and equipment out of the physician fee schedule and reimburse them the way they are reimbursed in hospitals and ASCs, which have their own technical fee schedules. Get the physician fee schedule back to reimbursing for the work physicians actually do. That is the policy argument that finally seems to be landing in D.C. The 2026 fee schedule is the first year in the last five or six where office-based reimbursement has actually gone up overall.

If you want a cardiology consult right now, the wait is seven months. This is rural healthcare in 2026.

Consolidation is not a market outcome. It is a payment-policy outcome. The math at one site of service makes survival impossible. The math at another keeps a building solvent. When practices like this one close down, it is not just the physicians who are affected. It is the patients.

Listen to the full conversation on The Podcast by KevinMD. Link in the replies.

#RuralHealthcare #ThePodcastbyKevinMD

[Dutch Rojas @DutchRojas]

A company with 800 employees spends roughly $15,000 per employee per year on health insurance.

That is $12 million.
Wired into a single line item. Every year.

The CFO can tell you the carrier.

He cannot tell you the unit cost of a single claim.
He cannot tell you what the network actually paid the hospital.
He cannot tell you what the PBM kept on the pharmacy spread.
He cannot tell you what the broker earned on the renewal.

In any other $12 million line item on his P&L, the board would have fired him by now.

[Anish Koka, MD @anish_koka]

The solution is not to train more doctors or import more doctors.

Meaningfully improve practice:

Tort reform, getting rid of MIPs, eliminating stark laws, etc...

[Dutch Rojas @DutchRojas]

A Mom in Tulsa called 3 health systems last week asking the price of her son's tonsillectomy.

Health system A: "We cannot quote you a price."

Health system B: "Pricing depends on your insurance."

Health system C: "Our financial counselor will reach out after the procedure."

No other industry in America gets to operate this way.

Imagine ordering at a restaurant and getting the bill six weeks after dinner.

[Devin Zarkowsky @DevinZarkowsky]

Amen. If I could click ~15 fewer boxes per patient I could see 3-5 more patients.

[Anthony DiGiorgio, DO, MHA @DrDiGiorgio]

You have no idea how much more physician capacity would be created if you just take away all the regulations stopping us from building.

There is no doctor shortage. There is only a regulation excess.

[Anthony DiGiorgio, DO, MHA @DrDiGiorgio]

You have no idea how much more physician capacity would be created if you just take away all the regulations stopping us from building.

There is no doctor shortage. There is only a regulation excess.

[Devin Zarkowsky @DevinZarkowsky]

@mcuban Also, when patients meet their out-of-network deductibles, claims get audited and codes deemed “not in the notes”, ergo care delivered at a loss by the physician is unpaid, even when documented, after the deduct met. Ins Co count on MD’s not going to IDR, and even then, don’t pay

[Leah Houston MD @LeahHoustonMD]

This is one of the most out of touch takes I’ve ever heard from a fellow physician.

Read the room, Congressman.

Physicians are burning out because we are being crushed by administrative burden, loss of autonomy, declining reimbursement, corporate consolidation, insurance interference, and a system that treats doctors like disposable labor while demanding endless sacrifice.

Stop blaming physicians for refusing to tolerate an increasingly dysfunctional system. The problem is not that young doctors lack commitment. The problem is that medicine has become unsustainable.