Republicans are working real hard to appear completely incompetent and lose the midterms. Dustin here is thanking the federal government for cutting physician payments without explaining which work duplicates another service or why that justifies a 50% cut. Apparently, “trust the government” is the republican position now. Medicare already includes routine evaluation in its payment for a minor procedure. A physician cannot legitimately bill a separate office visit just for deciding to remove a mole. To bill separately, the physician must perform significant, separately identifiable evaluation and management beyond the work the procedure payment already covers. CMS now proposes to pay the highest-valued applicable service in full and cut the other applicable services by 50% when the physician performs them on the same day. The agency argues that the payment valuations overlap. Then CMS needs to identify the duplicated resources and justify the size of the reduction. Repeating “unnecessary spending” doesn’t do that work. I oppose cutting payment for distinct, necessary services simply because a physician delivers them during one visit. If CMS can demonstrate overlapping costs, fix those specific valuations. Otherwise, consider the incentive you’re applauding. A physician evaluates a patient, performs additional work that qualifies for separate payment, and safely completes a necessary procedure that day. Under this proposal, Medicare cuts the lower-valued service in half. Schedule that separately billable care on different days, and the same-day reduction no longer applies. Why create a financial reason to make Grandma come back? She needs another ride. Her daughter misses more work. The practice uses another appointment slot. The family gets to rearrange its fucking life so Washington can congratulate itself on efficiency. And Medicare already gives practices another reason to move away from inexpensive office care: the hospital payment premium. MedPAC’s 2024 skin-lesion example put total payment at $165 in a physician’s office and $404 in a hospital outpatient department. More than twice as much for the same service category. If patients can safely receive that care in a physician’s office, explain why taxpayers need to pay the hospital premium. Then explain Washington’s treatment of physician-owned hospitals. Section 6001 of Obamacare effectively banned new physician-owned hospitals and restricted existing ones from expanding. Congress protected incumbent hospitals from new competitors and additional capacity. Where do you stand on repealing that, Dustin? Do you think restricting supply and protecting incumbents drives prices down? Walk us through that one. I want physicians to compete for patients on price, quality, and convenience. Let them build hospitals. Let them expand. Pay them fairly when they perform necessary care safely in an office and save a patient another trip. Your post celebrates squeezing physician payments without addressing the rules that reward expensive settings and block competition. Call ten independent practices before your next victory lap. Ask what keeps them from treating more patients at lower cost. Then help remove those barriers. Republicans could run on making healthcare cheaper through competition. Instead, you and other naive and stupid republicans are selling another government payment cut as a breakthrough.

I’ve invested in a significant number of healthcare startups. Here is the good news. The next healthcare entrepreneur has a wonderfully low bar for surprising people. Answer the phone. Offer an appointment. Tell the patient what it costs. Send a bill that matches. Doing those things consistently takes real work. Imagine building a reputation because people describe an encounter with your business as, “Exactly what they told me would happen.” I’d invest in that.

𝐂𝐌𝐒 𝐟𝐨𝐮𝐧𝐝 𝐚 𝐰𝐚𝐲 𝐭𝐨 𝐞𝐧𝐟𝐨𝐫𝐜𝐞 𝐭𝐡𝐞 𝐍𝐨 𝐒𝐮𝐫𝐩𝐫𝐢𝐬𝐞𝐬 𝐀𝐜𝐭 𝐪𝐮𝐢𝐜𝐤𝐥𝐲: 𝐩𝐮𝐭 𝐩𝐡𝐲𝐬𝐢𝐜𝐢𝐚𝐧𝐬 𝐨𝐧 𝐚 𝐟𝐨𝐮𝐫-𝐛𝐮𝐬𝐢𝐧𝐞𝐬𝐬-𝐝𝐚𝐲 𝐜𝐥𝐨𝐜𝐤. Starting November 1, federal IDR batches may contain no more than 50 disputed line items. For new batches, physicians must wait through a 30-business-day cooling-off period. Then they get four business days to file. CMS will automatically block anything filed too early or too late. 𝐅𝐨𝐫 𝐢𝐧𝐝𝐞𝐩𝐞𝐧𝐝𝐞𝐧𝐭 𝐩𝐡𝐲𝐬𝐢𝐜𝐢𝐚𝐧 𝐠𝐫𝐨𝐮𝐩𝐬, 𝐭𝐡𝐚𝐭 𝐦𝐞𝐚𝐧𝐬: More batches. More fees. More administrative work. More opportunities to lose payment rights because someone miscalculated a date. CMS can automatically reject a physician’s late filing. When an insurer refuses to pay a binding IDR award, the physician may have to ask the government to enforce it. The government built a hard deadline for physicians. Insurers still get the honor system. @DrBruggeman @EdGainesIII

ADMIN: “We worry that owning a hospital gives you a financial interest in your patients’ care.” Physician: “So you want to hire me?” ADMIN: “Yes.” Physician: “And your hospital will earn money from my work?” ADMIN: “Yes.” Physician: “Who worries about that financial interest?” ADMIN: “Your orientation starts Monday.”

I’m at the airport. Of course I start reading weekend edition of the @WSJ. Wouldn’t you know it, the dual designated non-profit grifter, NYU Langone, has a full page ad. And you’re still wondering why healthcare is expensive? And you know that means taxpayers are buying WSJ ads for NYU Langone. Taxpayers subsidize its land. Taxpayers subsidize its buildings. Taxpayers subsidize its debt. Taxpayers subsidize its expansion. What did it cost? The Wall Street Journal rate card prices a national full-page color advertisement at more than $300,000 (52 weeks). For one page. This is the same “nonprofit” hospital system that advertised on a Super Bowl commercial. Its hospital enterprise reports nearly $10 billion in property, plant, and equipment. It has more than 6,000 physicians. It operates more than 330 outpatient locations. It buys hospitals. It buys orthopedic groups. It buys physician practices. It buys land. It buys advertising. It buys the commercially insured patients every independent physician needs to survive. Then it calls itself a charity. How many taxpaying neurosurgery practices were destroyed while NYU Langone built this empire? How many physicians were forced to sell? How many became employees of the institution they once competed against? How many independent practices had their referrals siphoned away, their patients captured, and their businesses slowly suffocated by a competitor taxpayers were forced to subsidize? Nobody knows. Nobody counts the bodies. An independent practice dies quietly. First, referrals disappear. Then revenue collapses. Then employees are fired. Then the physician sells. Then the hospital raises the price, adds a facility fee, and hangs its logo over the corpse. The independent physician paid income taxes, property taxes, payroll taxes, commercial rent, malpractice premiums, and the full cost of building a practice. NYU Langone took the tax exemption, accumulated billions in assets, swallowed the competition, and bought an advertisement congratulating itself. Where is the charity? NYU Langone wants the power of a corporation, the market share of a monopoly, the real estate portfolio of a conglomerate, and the tax treatment of a church. No. If you acquire competitors like a corporation, advertise like a corporation, accumulate billions like a corporation, and hunt profitable patients like a corporation, then you can finally do one honest thing like a corporation: No more subsidies. Pay your taxes.

I finally went to Buc-ee’s in Melissa, TX. Wow. The healthy food selection was everywhere. They’re even selling peptides next to the inflammatory BBQ, hot dogs, corn dogs, fudge and tacos. And they pay some managers more than Medicare reimburses for primary care. What a country. 🇺🇸🇺🇸🇺🇸!

Full repeal of Certificate of Need passed the North Carolina Senate 31-17. It cleared two committees in two days. Then it crossed to the House. Referred to Rules on April 28, 2025. That is the last thing that has happened to it. 466 days ago. Nobody voted it down. Nobody had to