JR Fan

Cardiac Anesthesiologist. Hopkins ACCM Alum. Forever learning.

[Mark Cuban @mcuban]

@DrDiGiorgio All doctors are underpaid.

[Anthony DiGiorgio, DO, MHA @DrDiGiorgio]

This is the problem with socialism.

The answer is always more money. Never a number. Never a limit. Never a point where voters are allowed to ask, after we spent all this, why are the results still mediocre?

NYC Public Schools is already running a roughly $44.6 billion budget. Depending on how you count the all in costs, that puts spending in the neighborhood of $40,000 plus per student.

That's more than most private schools charge. So what's the amount of money per pupil that will make New York public schools adequate? How much wealth should be redistributed to those Queens teachers to make the system "fair?"

We see this in healthcare, too. Any potential cut to Medicaid is dooming poor people to die. @SenSchumer claimed over 50,000 people were going to die if we made even the slightest cut to Medicaid. Fine. Then say the quiet part out loud.

What is the target spend per Medicaid enrollee? What happens when spending rises and patients still cannot get care?

Let's get those numbers out there, find a way to fairly tax the wealthy to fund the safety-net, and then be done with it. $50k per student per year? $10,000 per Medicaid beneficiary with some age-adjustment? $200,000 per mile of high speed rail track?

They can never tell you.

One, because they have never run a business before, so they have no idea how to actually look at a balance sheet.

But, two, they don't want the money to go to the teachers, students, patients, or choo choo train. They want wealth redistributed from class enemies like Bezos to their political allies. They want to fund things that sound nice. "Free childcare" "Free diapers" "Free Faith Healers" so they can take money from people they don't like and give it to people they do like.

But, again because they have never run an actual business and because their only motiviation is to just not fail badly enough to prevent their re-election, the services come in way over budget and under-quality. They're spending other people's money on other people, and as Milton Friedman points out, that's when you stop caring about both price and quality. So the people to whom they promised free stuff look at their free stuff and are disappointed.

"I was supposed to get healthcare but now I need to wait a year for my knee replacement."

So they blame their class enemies and say "well it would work if we could just take MORE of their money and redistribute it."

So they take more money, but the quality doesn't improve. Their political allies, the union bosses and NGO CEOs get big paychecks they then funnel back into their campaigns.

And again, and again. Until all the people who actually produce wealth have been taxed into oblivion. You have no more Amazon. No more abundance. Just bread lines and poverty.

And that teacher in Queens still isn't getting paid what they are worth.

[Anthony DiGiorgio, DO, MHA @DrDiGiorgio]

Another midwit healthcare take.

Other countries have better life expectancy than the US. That is not the same as better healthcare outcomes.

Life expectancy is primarily affected by things that kill the young. In the US, that is violent crime, car accients, overdose, and suicide. You can argue that healthcare might be able to influence the last two, but only minimally. Those things are driven by lifestyle choices. Add in our obesity rate, which is also only marginally mitigated by proper healthcare, and you see why our life expectancy is lower than the rest of the OECD.

We are fat, violent, depressed, and like driving on freeways.

Now, if you acutally get sick, there's nowhere else you'd rather be. We have some of the best outcomes in cancer, stroke, heart attack, and trauma. The wealthy from around the globe travel to our hospitals for care. There are entire wings at some prominent hospitals for ultra rich international patients. They aren't going to the NHS for their care.

We excel at coverage for actue care. 98% of Americans are within 90 mintues of a cardiologist who can open up the arteries in your heart in the middle of a heart attack. Meanwhile, in canada, that number is around 80%. They have 10x worse access to acute coronary care than the US.

If you're going to have a heart attack, you want to have it in the US.

If you're going to have any health issue requiring high specialty care, you want to be in the US.

[Aaron Stupple @astupple]

“Let’s make a blood pressure metric that incentivizes doctors and ties payments to health outcomes.”

So they measure how many patients have blood pressure below 140/90.

Let’s say you’re a doctor with two patients. Pt one pressure is 142/91 and you improve to 135/85, and pt two has 190/130 that you improve to 145/95.

Pt 1 gets no real benefit bc their blood pressure change is meaningless in terms of stroke, but it wins the metric.

Pt 2 may have avoided a stroke, but doesn’t meet the metric so you don’t get paid.

One prescription gets you from 145 to 135, but to get from 190 to 145 needs multiple scripts, kidney monitoring, and some side effects.

You’re a good doctor, so you do it anyway, but your clinic is losing money so they hire some consultants to boost revenue.

The consultants recommend hiring a bunch of midlevel providers to who focus on winning the blood pressure metric game by aggressively treating everyone whose blood pressure is just over the metric, the low-hanging fruit who get minimal benefit from treatment but boost compliance with the metrics.

Meanwhile, a patient with really bad blood pressure usually has lots of other stuff going wrong, like hip pain cause they’re overweight. But when they come to the office, doctors just want to talk to them about blood pressure, a winnable metric, rather than build a trusting relationship where they might listen to how weight is related to hip pain and might agree to a GLP-1.

There are no metrics for relationships.

But there are metrics for even downright harmful things, like unnecessary cancer screening or unnecessarily testing for diabetes.

Metrics provide systems that can be gamed in a way that costs more and is worse for patients.

Real industries let consumers define what the metric is and pay for the companies who meet it. But healthcare isn’t paid for by individual consumers, it’s paid for by third parties who try to appease central planners with feel-good programs like quality metrics.

[JR Fan @johnrob_fan]

@elonmusk @PalmerLuckey Agree, check out @CoreViva. Utilizes both AI and radiologist for best results

[Leah Houston MD @LeahHoustonMD]

Yesterday, legislators failed to reach an agreement on extending ACA subsidies.

I don’t support a blanket extension.

From my perspective, subsidies are propping up a system defined by runaway spending, rent-seeking, and persistent fraud, waste, and abuse. The ACA often forces Americans to purchase a product with little real value—high premiums paired with deductibles so large that coverage rarely functions as intended. Extending subsidies without structural reform simply accelerates that dysfunction.

I do support expanding HSAs to promote choice and competition. However, a pure HSA-only approach with no guardrails isn’t sufficient either. We also need catastrophic coverage access again, with other options, such as health sharing.

IMO The missing piece in this conversation—especially for my free-market colleagues—is the supply side of care.

If we want to preserve the Medicare and Medicaid safety net, we must incentivize independent practicing physicians to participate again.

Physicians are opting out in record numbers as reimbursement falls below market rates, administrative burden rises, and medical-legal risk increases—particularly for these very often more complex patient populations.

To fix this, we need:

1️⃣Market-rate reimbursement.

You cannot sustain a healthcare system by paying below cost and relying on physician altruism.

2️⃣Elimination of facility fees and enforcement of site-neutral payments.

A procedure should be reimbursed the same regardless of where it’s performed. Facility fees distort incentives and inflate costs without improving outcomes.

3️⃣Meaningful liability protection for licensed and residency, trained Physicians who accept Medicare and Medicaid.

If the government sets the rules and the rates, practicing Physicians should not bear unlimited legal exposure for participating. This could mirror the sovereign immunity model used at the VA, paired with specialized healthcare courts—judges appointed by independent physician associations and voted on by physician members—to reduce defensive medicine and frivolous claims while preserving fairness.

4️⃣Real competition for those outside Medicare and Medicaid.

Catastrophic coverage must be accessible again, and insurance competition across state lines should be enabled. In 2021, the Competitive Health Insurance Reform Act rolled back the McCarran-Ferguson antitrust exemption for health insurers, creating an opportunity for competition—but without fixing reimbursement and liability, physicians still won’t re-enter the system.

👉Taken together, these reforms could shift policy away from subsidizing insurers and toward stabilizing the actual supply of care.

Insurance without doctors is not access.
Coverage optics don’t fix a collapsing workforce.

Oh yeah, and we can’t forget PBM reform- we have to appeal the Safe Harbor law for them as well!

If we want a functional healthcare system, we have to design one physicians can realistically participate in.

What are your thoughts?

[Ge Bai @GeBaiDC]

My written testimony before the House Judiciary Committee: "Fighting Obamacare Subsidy Fraud."
🧵1/11

[JR Fan @johnrob_fan]

@chamath Agree - should check out @CoreViva if you have not already, it is the most cutting edge, accurate, and patient-focused in this space

https://t.co/ZEAO1GxEeq

[Mark Cuban @mcuban]

Alex, the US taxpayer rarely pays doctors directly. They typically send money to states (Medicaid) Hospitals and Providers(traditional Medicare), to insurance carriers (MA and ACA), and indirectly through tax savings for individuals and employers )

You are right that we overpay. We spend far too much on healthcare.

We overspend because we send the most money to the carriers and give them every good reason, to scale as big as possible , to contract at inflated prices, to invent fees and to delay and deny care when they can. Then there are the PBMs etc etc

Break up the big carriers by vertical , make intercompany transfers at Medicare rates or best price until then , remove formularies from their PBMs, make extra cash purchase count against the deductible , make non profit hospitals and providers publish every general ledger entry , stop 340b abuse, I can go on for days on how we can reduce the cost of healthcare.

As far as over treating , there are lots of reasons. Lots of paperwork, lots of lawsuits, lots of economic incentives to generate more revenues.

But of all I just mentioned, the people that benefit the least financially, are the actual caregivers. Doctors and nurses get shit on regularly. They should be able to open their own practice and survive financially. They shouldn’t be at the mercy of insurance companies. They should get the same Medicare rates that hospitals get for the same work.

The best part of this is that you can help. Where do you get your insurance and who is your PBM Alex ?

How many companies have you educated to walk away from the biggest insurance carriers and their PBMs ?

[Dutch Rojas @DutchRojas]

Here’s the funny thing about American healthcare policy…

The Democrats keep saying they want to make healthcare affordable.

Yet every policy lever they actually pull does the precise opposite.

It’s rather like claiming you want to reduce traffic congestion while simultaneously banning bicycles and subsidizing Hummers.

Consider Medicare reimbursement rates, possibly the most boring topic in politics, which is precisely why nobody notices what’s happening.

The government pays hospital outpatient departments (HOPDs) MORE for the exact same procedure than it pays ambulatory surgery centers (ASCs).

And it pays surgery centers (ASCs) MORE than it pays doctors’ offices for in-office procedures.

Keep in mind:

Same procedure.
Same outcome.
Wildly different payments depending on the building it happens in.

Now, this creates a rather obvious incentive: independent medical practices sell to health systems to access the higher reimbursement rates.

The government then acts shocked! I mean SHOCKED! - that healthcare costs keep rising and independent practices keep disappearing.

It’s psychological genius, really.

They’ve created a system where the rational economic choice for every doctor is the expensive choice for every patient.

But wait, it gets better.

In 2010, Democrats banned new physician-owned hospitals from opening.

These would have been for-profit entities, taking their own financial risk, competing on price and quality.
Dangerous stuff, apparently.

Meanwhile, they continue funneling $125 billion annually in tax subsidies to “non-profit” hospital systems.

You know, the non-profits with the private jets and stadium naming rights and CEOs earning $10 million.

They had the presidency and Congress in 2009-2011.

Then again in 2021-2023. Did they fix the payment disparities?

Ban hospital consolidation?
Reform non-profit requirements?
No. They banned the competition instead.

Here’s what fascinates me:

This isn’t a case of “we tried but the Republicans blocked us.”

Medicare payment rates are set by CMS - an executive agency.

The Democrats controlled it for 12 of the last 16 years.

They could have implemented site-neutral payments by Tuesday.
They didn’t.

So when politicians tell you they want to “save healthcare,” perhaps ask them a simple question: “From whom, exactly?”

Because the evidence suggests they’re rather intent on saving health systems from the horror of competition, patients be damned.

@HouseDemocrats
@GOPDoctors
@WaysandMeansGOP
@SenateDems
@GOPHELP
@SenateGOP
@elonmusk

[Sanat Dixit MD FACS @sdixitmd]

The BLS estimates 23,600 physician job openings a year for the next 10 years.

The US graduates around 27,000 physicians between allopathic and osteopathic programs annually.

The AAMC estimates 43,000 physician retirements annually for the next 10 years.

Legislators feel empowered to expand licensure parity laws like this because they, misguidedly, think they are serving the public good; instead of doing a root cause analysis. (Someone needs to ask why almost 50% of the total physician workforce is planning an exit within the next 10 years.)

One only has to look at what happened in the NHS when they implemented something similar. The NHS is wholly dependent on this foreign born work force because native Britons increasingly chose other vocations besides medicine, because they were deemed higher value jobs. (Around 40% of junior housestaff in the UK are foreign born/IMGs.) Physician incomes barely kept pace w COLA adjustments through the 1980s. Since 2008 there has been, per the BMA DDRB an estimated 35% DECREASE in wages. (Benchmark that against their private sector which saw nominal growth.)

We are nearing that inflection point in the US. And this is before we turn physicians into public sector utilities to be adjudicated by tin cup bureaucrats.

Medicine is about to become even LESS attractive for US trained physicians. Real "road to hell" implications here.

@BKRBusinessMin @anish_koka @realdocspeaks @DrDiGiorgio @BrentAWilliams2 @drdanchoi

P.S. I'm Indian

P.P.S.
Here are the states allowing IMGs to practice without having to repeat residency: (green) or pending legislation (orange).

[Scott J. Greenberg, MD, FHRS @sgreenbergmd]

Today @cmsgov announced another significant cut for electrophysiologists (as well as our interventional colleagues), this time for left atrial appendage closure. Starting in 2026, reimbursement will be cut by 27%. This just a few years after the draconian cardiac ablation cuts.

While industry and hospitals continue to see increases in reimbursement, the physicians are, once again, hung out to dry.

Who helps make these decisions? The @AmerMedicalAssn RUC committee who sends out convoluted surveys that only focus on how long a procedure takes while crosswalking to completely unrelated codes. No intensity, complexity, or long term healthcare savings taken into account. The absolute laziest form of evaluation one could think of to evaluate physician work.

Even worse, those who sit on the RUC committee recommend the 25th percentile to CMS. What kind of physicians find the 25th percentile acceptable in anything we do? A clear cut case of Stockholm Syndrome.

While budget neutrality remains the underlying issue, the AMA RUC needs total reform.

@HeartRhythmAdvo @HRSonline @ACCinTouch @SCAI @DutchRojas

[John Asghar MD @JahangirAsgha10]

The physician shortage isn’t just about how many doctors we have.
It’s about how much time we are forced to waste.

Physicians in the U.S. spend an average of 16 hours per week on administrative tasks.
Not optional work. Not inefficiency.
But time we are required to spend—by payers, regulators, and federal programs—on prior authorizations, coding justification, compliance reporting, and EHR documentation.

That’s two full days per week stripped away from patient care.
Across the workforce, this removes 20–25% of total clinical capacity—not because physicians aren’t available, but because they are redirected away from the bedside by policy.

And this is not the global norm.

U.S. physicians spend four times more on billing and insurance-related tasks than their Canadian counterparts (Health Affairs, 2020).
In most European systems, administrative overhead is under 30 minutes per day.
In the U.S., it regularly exceeds 3–4 hours per day.

This administrative load is not the byproduct of better outcomes or safety.
It is the result of flawed, government-driven agendas that prioritize data collection, billing audits, and metric compliance over clinical judgment and time with patients.

Programs like MIPS, MACRA, “value-based” reporting frameworks, and EHR certification requirements were designed around bureaucratic performance indicators—not patient outcomes, not physician capacity, and certainly not operational efficiency.

They have created a system where physicians are penalized for focusing on care, and rewarded for satisfying administrative benchmarks.

This is not a staffing issue.
It is a structural policy failure.

Until the system stops forcing physicians to waste time proving their value on paper, we will never reclaim the capacity we already have.

[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.

[Brian Tsui, MD @DrBrianTsui]

Overuse of CT scans is projected to account for 5% of all new cancer diagnoses each year. Whenever possible, consider alternative imaging methods, such as MRI, which do not expose you to radiation. #mri #health #imaging #ctscan #diagnostics #research

[Ed Gaines @EdGainesIII]

This is an outrage —MA plans w/ an +5% payment bump in ‘25 while the physicians continue to be down -2.83% on Medicare.

[Damian Caraballo MD @813JAFERD]

Healthcare executives at insurers encouraged to knock Dr's out of network, hurting patients

https://t.co/AgDkJIgLc8

[Lawson Mansell 🇺🇸⚽️ @lawsonhmansell]

New: Researchers at @JohnsHopkinsSPH found that physician-owned hospitals (POHs) are negotiating 18% LOWER prices for outpatients procedures compared to other hospitals in the same market.

Still, ACA rules prevent new POHs from entering the market.
@DutchRojas @kempann

[Dutch Rojas @DutchRojas]

Big news: A new bill supporting Physician-Owned Hospitals just dropped.

It is a turning point.

If passed, this bill removes key restrictions on physician-owned hospitals, especially those that serve rural and underserved areas.

What can you do?

•Contact your representative
•Join advocacy groups like the PHA.
•Share this post to spread awareness
•Build or partner with POHs in your region

We don’t need fewer hospitals.
We need better ones—physician-led, transparent, efficient, and community-focused.

Let’s bring healthcare back to the hands of those who deliver it.

https://t.co/MwH3DUdxNn

#physicianled #ruralhealth #POH #healthcarefreedom

@RepLouCorrea
@RepMGriffith
@RepKevinHern
@RepGonzalez
@RepJohnJoyce
@gopdoctors
@physicianhosp