out here tilling the soil.
Joined October 2011
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The delivery of medical care has become an administrative nightmare:
- Regulations everywhere and complex payment structures.
- Industry players with their hands in the cookie jar, charging exorbitant prices for anything used in hospitals.
- Administrators were hired to handle non-clinical admin work.
- Soon after, MBAs began treating medicine as a profitable business while physicians struggled in a sea of paperwork.
Near-term solutions:
- Create hospitals where non-direct patient care employees are reduced and assisted by AI software and robotics. Allow physicians to run and own hospitals again. The conflict of interest concern that has prevented this is no match for the conflicts brought by MBAs focused on profit.
- Get clinical staff (nurses, physicians, RTs, etc.) off keyboards and reduce their paperwork using new technologies like ambient AI, assistive notes, clinical synopses, and decision-making algorithms to enhance quality.
- Mandate EHR interoperability and offer a public EHR option. The huge loss from not yet doing this creates delays and redundant treatments. It has also fostered massive monopolies that gouge prices with minimal competition. (Epic is a cash cow and doesn't effectively reduce costs to offset.)
cajam retweeted
Orthopedic surgeons moved joint replacements out of the hospital and saved Medicare money. Medicare is saying “thanks” by proposing to cut reimbursement to doctors by 17- 21% in 2027. Postoperative care did not disappear when patients went home the same day. It moved to the surgeons’ phones, inboxes and offices. Surgeons will be paid less than $700 for their time, mental effort, skill, and judgement for a knee, hip, or shoulder joint replacement.
Fee schedule cuts: Surgeons who move cases penalized for progress healio.com/news/orthopedics/…
Not sure how this is going to play out but…
the USA is building the brain….
And China is building the body.
cajam retweeted
There is a lot of talk about the potential for AI to replace physicians in the future.
There is not nearly enough talk about its ability to replace administrators today.
cajam retweeted
Norway consistently wins the most medals at the Winter Olympic Games, with a population of just 5.6 million people.
A big part of their success is how they treat youth sports—and it’s the opposite of what we do in the US. Here’s what we can learn from Norway:
1. Scorekeeping:
In the US: Youth sports tend to be hyper competitive even at early ages. Leagues almost always keep score.
In Norway: Scorekeeping isn’t even allowed until age 13.
Removing winners and losers keeps the focus on the process not outcomes. It keeps kids engaged longer because it minimizes pressure (and tears) and maximizes fun, learning, and growth. The goal isn’t to win a third grade championship. It’s to love sport and keep playing.
2. Trophies:
In the US: If you give everyone a trophy, you’re creating snowflakes who will never gain a competitive edge.
In Norway: Whenever trophies are awarded, they are handed out to everyone.
If getting a trophy makes young kids feel good, we should give them trophies. Maybe they’ll come back and play again next year!!
As for the creation of snowflakes with no competitive edge—Norway’s athletes are tough as nails and all they do is win.
3. Prioritizing Fun:
In the US: Far too often, the goal is to win.
In Norway: The national philosophy is “joy of sport.”
Youth sports in the US are driven by adults, ego, and money. Youth sports in Norway are driven by fun.
Only half of kids in the US participate in sports. The number one reason they drop out: because they aren’t having fun anymore. In Norway, 93% of kids participate in youth sports. Fun is the foremost goal.
4. Playing Multiple Sports:
In the US: There’s pressure to specialize early and play your best sport year round.
In Norway: Try as many sports as you can before specializing as late as college.
Norway encourages kids to try all types of sport. This reduces injury and burnout and increases all-around athleticism. It also helps promotes match quality, or finding the sport you are best suited for as your body develops, which is impossible if you commit to a single sport too early.
5. Affordability
In the US: There is increasingly a pay-to-play model with high fees for leagues, equipment, and travel. This excludes many kids from playing.
In Norway: It’s a national priority to keep youth sports affordable and therefore accessible for all.
Kids aren’t priced out, which creates opportunities for everyone to participate (and develop into athletes), regardless of their parents’ income level.
We could learn a lot from Norway:
In the US, 70% of kids drop out of youth sports by age 13. This not only diminishes an elite-athlete pipeline, but it also destroys an opportunity for healthy habits and all the character lessons kids can learn from sport.
In Norway, lifelong participation in sport is the norm. The goal isn’t to have the best 9U team. It’s to develop the best athletes. Those are two very different things. And Norway has the gold medals to prove it.
cajam retweeted
Only 827 physicians in the entire United States hold an equity stake in a hospital. Out of ~1.1 million physicians, that’s 0.07%.
There are only 238 physician-owned hospitals in the entire country (out of 6,093 total hospitals).
Now… let’s talk about the endlessly recycled trope of “cherry-picking.”
It’s nonsense on its face, but the data makes it almost comically absurd.
93% of rural hospitals would close if they depended on commercial insurance alone. They survive on government subsidies and reimbursement arbitrage - not “the market.”
More than one-third of all health systems would collapse without government payers (not overtime either, immediately implode).
So I’ll ask again: what are physicians supposedly cherry-picking?
They’re not even allowed to participate in the very subsidies and arbitrage games that keep the big systems alive. CMS banned physicians from expanding ownership or adding beds. The entire industry is subsidized - except the people actually providing the care.
Physicians don’t get to play in those reindeer games.
When doctors build a physician-led enterprise, they’re forced to survive on:
>>A fixed fee schedule
>>The occasional bundled payment
>>Or the ultra-rare, hard-won direct contract or PMPM
That’s it. No subsidies. No arbitrage. No backdoor revenue streams. No taxing districts. No grants. No subprime loans.
There is no cherry-picking. There never has been. It’s a myth. A canard engineered by lobbyists and repeated by people who don’t understand American healthcare…or just prefer not to.
Physician ownership is the last functioning market in healthcare. Every time you add an intermediary between a buyer and a seller the price will increase and the quality will decrease - we aren’t exactly squaring the circle here.
cajam retweeted
Does a chef who owns a restaurant have a “conflict of interest”?
Does an electrician who owns an electrical company have a “conflict of interest”?
Of course not. We call that expertise plus accountability.
But in healthcare, we’ve let the least clinically literate people in the ecosystem - politicians, lawyers, bureaucrats, consultants - redefine “conflict of interest” into a weaponized buzzword. They’ve made millions off a term that means absolutely nothing in the real world of patient care.
Here’s the truth:
The most important thing you want your physician to have is interest.
Interest in your outcome.
Interest in your continuity of care.
Interest in the long-term relationship.
A “conflict” is impossible when the physician’s incentives are aligned with the patient’s well-being.
The entire conflict-of-interest narrative in medicine is a contrivance, total artifice - manufactured by people who profit from keeping physicians powerless and patients confused.
If a doctor owning their production is a conflict of interest, then so is a pilot owning an airline, a lawyer owning a law firm, a farmer owning land, or a realtor owning a realty.
Never cede competence to “conflict.” Stop the madness! Resuscitate the physician-patient relationship!
"We've treated physician ownership as uniquely dangerous while largely ignoring the same incentives inside larger, more opaque corporate structures." —Dr. Ashish Vankara @ashishvankara
"Profit motive exists for every player in the space. When you remove players, you just drive further power imbalance..." —Dr. Umbereen S. Nehal @usnehal
🧵1/5
cajam retweeted
A 30-year fixed mortgage is basically a long-dated call option on inflation.
You borrow dollars today, lock the rate, and repay in nominal terms.
If inflation explodes, your debt evaporates in real terms while your house price soars.
You’re long the house, short the dollar.
cajam retweeted
In 2023, the U.S. spent approximately $1.35 trillion on healthcare administration. That’s more than we spent on:
•Physician salaries (~$350B)
•Nursing salaries (~$335B)
•Retail prescription drugs (~$450B)
•Imaging, lab tests, EHRs, and outpatient procedures combined
•Even capital investment in hospitals and equipment
All the while, clinicians are being told to “do more with less.”
Every cost-saving initiative aimed at doctors adds layers of compliance and complexity which only fuels the unchecked growth of bureaucracy.
How about maybe y’all develop some new antibiotics? A class of drugs we often take for granted.. until they stop working.
cajam retweeted
Pharmaceutical R&D is on death's doorstep and its current rebound is fragile and temporary.
Returns are already below the cost of capital, and any additional harms to profitability will drain the life-blood of the future, instantly snuffing out biomedical progress.
cajam retweeted
Exciting and perhaps scary at the same time.
