Harrison Lang, MD

Mayo Clinic DR resident @MayoAZ_RadRes | Interested in education, neuro and ER radiology, EBM, and physician-led care | Tennis 🎾 and golf ⛳️🏌🏼enthusiast

[John Asghar MD @JahangirAsgha10]

A Reminder for Patients:

The reason you can’t get an appointment…
The reason you don’t have the same physician year after year…
The reason healthcare feels colder, more chaotic, and less personal…
The reason you have less and less choice in your care…

It’s not because your doctor stopped caring.
It’s because insurance companies, large hospital systems, and government policy decided you don’t need choices.

They decided:
•A monopoly makes more money than your autonomy.
•Drugs should cost more—even when they don’t have to.
•Access should be limited—especially if it threatens their margins.
•The physician-patient relationship is secondary to administrative control.

I see this firsthand.
Every Friday, I run a clinic on the Space Coast of Florida.
The most common complaints I hear from my patients there?

– “I can’t get in to see my doctor.”
– “Every time I go, it’s someone new.”
– “It feels like no one really knows me or my history anymore.”

Since Cleveland Clinic of Florida entered the market and bought out most local practices:
– Wait times to see both specialists and primary care have skyrocketed
– Physician turnover is so high, few stay more than a couple years
– Patients are left with less access, fewer options, and a revolving door of providers

They didn’t improve care. They consolidated it.
And you’re the one paying the price.

They’ve redirected resources away from you and your doctor, and into the hands of institutions, executives, and algorithms.

That’s why care feels harder, more frustrating, and less human.

[Damian Caraballo MD @813JAFERD]

Clinician Reimbursement Data 🧵:

[Elisabeth Potter MD @EPotterMD]

I want patients to know: private practice doctors aren’t getting fairly paid. There’s no real negotiation. And this system is pushing people out who actually want to do the right thing. Sometimes the first step to fixing what’s broken is talking about it.

[Adam Bruggeman, MD @DrBruggeman]

Yet another process employed by insurers to improve profits. Implied but not fully discussed here is the ultimate question of why doctors have to collect the deductibles and copays. It’s yet another tactic to disrupt the patient physician relationship and to make sure that the true customer, the patient, has limited interaction with the insurer. Patients don’t select their insurance, their HR manager and a broker do (and they can’t change to another insurer without changing jobs typically). Patients don’t pay copays and deductibles to insurers, they are hounded by physicians when they check in, check out, or by mail. Patients don’t request approvals from insurers, the physicians have to employ scores of employees to do what they were trained to do over decades of education and experience.

Insurance companies know that if patients had to get prior authorization or if the patients were sent to collections by insurers, then the insurance companies would be the bad actor. Instead they shift those responsibilities to the physician offices, increasing their overhead, dramatically driving burnout and moral injury, and creating animosity towards the physician instead of the insurer. One day this house of cards will fall.

[Mark Cuban @mcuban]

Want to know one of the biggest problems in healthcare? Deductibles.

Deductibles are defined by the plans the insurance companies design. Then they are approved to be offered by the feds or employers. Then we the people decide what deductible we want when we choose our plans.

Often we choose higher deductibles because we are healthy or because we can only afford the lowest premium plan.

When we got get care and can't pay our deductible for whatever reason, you know who takes all the credit risk and losses?
Doctors, hospitals and caregivers

They have ZERO to do with designing, selling or choosing the plans.

But when you can't pay, they are the ones that become the bill collectors we hate. The ones that put millions into default and bankruptcy,
DESPITE HAVING NO SAY in the plans and deductibles we all choose.

That is one fucked up system that needs to be redesigned.

Next time I'll tell you how insurance companies decide not to pay what they contractually owe to the hospitals and use delay tactics like denials, they know they will approve , just to earn interest on premiums.

And the hospitals aren't innocent. But I'll let them off the hook for now because they have to take anyone that walks in the doors

@BillAckman
@elonmusk
@DOGE
@RobertKennedyJr
@DrOz

[Senate Budget Democrats @SenateBudget]

https://t.co/r5yLrFQvUJ

[Harrison Lang, MD @HarrisonLangMD]

@HealthcareREguy &I'm suspect of the "we can't find younger docs who want to buy/run the practice." I think that's a convenient answer for older docs who'd rather get 10 figure payout vs. a 6-7 figure payout if they sold the practice to younger docs. Not blaming them tho cuz that's their choice

[Harrison Lang, MD @HarrisonLangMD]

@HealthcareREguy Agreed, its a 2 way street with PE buying and MDs willing to sell. As a young doc I obviously have my thoughts about the older gen selling out the younger gen. Bigger picture, I think a lot of this is due to legislation/lobbying making it harder for private practices to survive

[Harrison Lang, MD @HarrisonLangMD]

@HealthcareREguy 5) This has nothing to do with younger physician work ethic. There is a Dr. shortage and https://t.co/4htYWT22ZL harder than ever to take care of an aging population that is getting worse. PE is gutting US healthcare which isfar better off when Drs. have autonomy for patient care

[Harrison Lang, MD @HarrisonLangMD]

@HealthcareREguy 4) The monopolies and lobbying of Hospitals/Insurance/PE combined with yearly continued decreasing Medicare physician reimbursement have made it very hard for private practices to survive monetarily.

[Ben White, MD @benwhitemd]

Almost one month in and Independent Radiology hit the 60 group mark this morning. No matter what kind of job you're looking for, a true physician-owned private practice is hiring:
https://t.co/GyUXnTrtHf

[Harrison Lang, MD @HarrisonLangMD]

@ecalabr Ependymoma or astrocytoma? Less likely a met or demyelination lesion

[Anthony DiGiorgio, DO, MHA @DrDiGiorgio]

What a great question!

*clears throat... arranges notes on podium*

There's a food-based analogy coming at the end of this, don't worry...

In traditional Medicare, physicians are reimbursed through a system that converts procedures to dollars, known as "professional fees."

To calculate a professional fee, doctors assign a code for each service they provide, from a standard office visit to a complex brain tumor resection. These codes (called CPT codes) have a value in units called RVUs (Relative Value Units).

For example, a 15-minute office visit generates about 1 RVU, while a complex brain tumor resection can be 30-40 RVUs (depending on the specific codes used). These RVUs are then converted to dollars using the conversion factor. This amount is set by the government.

Multiply the conversion factor by the RVU, and you get the professional fee. The RVU conversion factor was $31 in 1992 and is around $32 now (it should be over $65 to keep up with inflation).

If the doctor runs an independent practice, the entire practice must be sustained using these RVUs and the conversion factor (which includes a practice expense component).

Confused yet?

Hope not, because here's where it massively favors hospitals.

Hospitals are paid either using the OPPS (for outpatient services) or DRG (for inpatient services).

For example, if an independent practice gets bought by a large hospital system, the physician typically agrees to let the hospital bill on their behalf, so the hospital keeps the professional fees. These might be passed directly to the doctor, or the doctor may have a production-based contract or a straight salary.

However, the hospital now bills under OPPS instead of the physician-based CPT/RVU system. That procedure code is converted using another scale called Ambulatory Payment Classification (APC, for those keeping track of the alphabet soup).

This scale yields higher reimbursement!

These are the so-called "facility fees" that make the exact same service cost more at a hospital than in an independent physician's office.

The government keeps INCREASING the OPPS (to keep pace with inflation) while DECREASING the RVU conversion.

For the exact same services, hospital reimbursement keeps going up while independent physician reimbursement keeps going down.

OK, now the food-based analogy you've all been waiting for:

It's like if you had government insurance that pays for your food. If you get a burrito at an independent food truck, it uses the "deliciousness scale" and has a dollar-to-deliciousness conversion. Meanwhile, if you get that same burrito at a chain restaurant, it uses the "scrumptious scale," with a completely different conversion, including extra fees to support the large multi-state organization.

Over time, the dollars per deliciousness unit decrease, not even keeping pace with inflation. Meanwhile, the dollars per scrumptious unit keep increasing.

Would the independent food truck have any chance of competing with the chain restaurant? The chefs have few options. Get bought out by the chain or stop taking government insurance.

How would this affect access to burritos for those with government insurance?

Not needing to compete, since they are guaranteed to get paid more than the independent establishment, the large chain restaurants have no incentive to improve quality.

The chefs making the burritos at the large chain restaurant have no control over their workplace anymore. Gone is the art of their craft, replaced with orders from a corporate overlord. They bring in a ton of money for their corporations, but the accountants still use the devalued deliciousness-units to determine their reimbursement. They demand they make more and more burritos. The chefs are burned out. They are undervalued. They look for a way out of their beloved careers. There are fewer options for those with government-sponsored food insurance. The cycle continues...

That's how the government devalues physicians while increasing healthcare consolidation. It's been a long, targeted destruction of independent practice. There are many other factors (340B, quality metrics, EHR), with this lack of site neutrality being just one nail in the coffin.

But it's a big nail.

@anish_koka @cscla @JPGK_MD @VPrasadMDMPH @RealJoeGrogan @realdocspeaks @DutchRojas

[Harrison Lang, MD @HarrisonLangMD]

@RealEstateRahul worse patient outcomes since PE has limited incentive to invest in quality care b/c their #1 concern is profit return to shareholders, and bad for young docs who will work harder for less pay, no/minimal ownership, and can have limited options due to PE creating monopolies

[Harrison Lang, MD @HarrisonLangMD]

@RealEstateRahul Yes but depends who you ask. Great for older docs who sold their practice before retirement. Great for PE firms who skim off the top and work docs harder for less pay. Net negative for everyone else: increased prices for patients,

[Ben White, MD @benwhitemd]

A sign of things to come?

FTC sues a large PE healthcare company. “Private-equity firm Welsh Carson spearheaded a roll-up strategy and created USAP to buy out nearly every large anesthesiology practice in Texas,” FTC Chair Lina Khan said. https://t.co/drXsVgiVqk

[Dr. Glaucomflecken @DGlaucomflecken]

You know who is rightfully terrified of private equity? New residency/fellowship graduates. Right now, independent, physician-owned practices have a massive recruiting advantage. You should be shouting your hatred of private equity from the rooftops.