Andrea DeSantis DO, FAAFP

Rest In Peace John Morphet. A beautiful soul died last week. He was depressed and sick and the place he turned to for help did not treat him as it was an out of network hospital for his insurance. He committed suicide 2 days later. #SinglePayer might have saved him

Anybody else feel there’s a bit of the “.com” about AI and it’s affects on industries? No doubt it is powerful and helpful in many ways but for the most part, untested for long-term outcomes. I’m finding all kinds of hallucinations and misinterpretations happening at an accelerated rate just through the EMR typing app I use.

Unfettered capitalism plus AI will be no one’s idea of a good time.

Spending on a technical innovation and expansion for better patient treatments, and the aging of the population is a driver of cost, but not something we should be cutting back on. We should all be taking aim at the blatant profiteering and growing administrative spending. Increasing dialogue about across the board cutting back, especially for those who are most likely to need care, will not serve any of us.

Healthcare is the only asset class in America that has never experienced mean reversion. Stocks crash. Real estate corrects. Oil cycles. Bonds reprice. Health insurance premiums have gone in one direction for 30 consecutive years. In the real world, when something defies mean reversion for three decades, it is not a market. It is a cartel.

This three hour hearing is worth a listen. I came away with a deeper understanding that there are few enemies, with the exception of venture based capital, unsustainable administrative costs, out sized drug pricing/DME, unfunded and underfunded care and it’s effect on both outpatient practices and critical access hospitals, and the importance of strengthening and expanding the primary care physician lead infrastructure.

Several OECD nations have fixed this with patient held portals, where hospitals and practices can access the information from the patient without the logistical hassles and firewalls we run into. Even if those in charge of these siloed entities agree with the concept interoperability, coordination of the effort is like herding (big) cats. 🐅 🦁

I once had a brain trauma patient transferred into our ER from an outside facility. It was a small brain bleed, but even a small bleed can be life threatening if it grows. Repeat CTs are essential to ensure it’s not growing. The patient didn’t arrive with imaging from the transferring hospital. They simply neglected to send them. We called and asked them to upload the images to an online portal (HIPAA compliant, widely used). They refused. We asked them if they could put the images on to a CD or flash drive and send it over. They refused. The only way they would release the images is if our hospital sent a courier with a records release form to their hospital to pick up a CD. The amount of time that would take made the images meaningless. So we just repeated the CT to get a new baseline. Stuff like this happens every day.

@CE_HandSurg Funding inpatient care with operating costs gets rid of a lot of profiteering and closure of critical access hospitals, regardless of who owns it.

If you insert enough admin, clinical coordinators, middle management and downstream billing capture - all conflicts of intrest are resolved.

Agree! All of this needs to be replaced by #MeasuresThatMatter Physicians should be reimbursed more for taking on medical and social risk, providing in house Behavioral Health and care management, expanding access, and providing full scope of primary care. professionalismandvalue.org/measures-that-…

Value-based care was supposed to save healthcare. In some cases, it created a new incentive: getting rid of the sickest patients. In a recent episode of The Podcast by KevinMD, Dr. Jonathan Bushman reveals the dark side of healthcare analytics. He shares the story of a young physician whose management removed patients with high A1Cs from her panel to secure a contract bonus. We have to stop mislabeling this as burnout. Burnout implies the doctor is the problem. Moral injury recognizes that the system is broken. Physicians are trained to heal, then told to show up and shut up by systems that view patients as transactional data points. Dr. Bushman breaks down the irony of non-profit health systems chasing metrics, the reality of value-based contracts, and how Direct Primary Care restores physician autonomy. Episode is in the comments. #ValueBasedCare #MoralInjury #MedTwitter #HealthIT

@DrDiGiorgio @HouseCommerce I just watched! You rocked it!

It was an honor to testify in front of the @HouseCommerce subcommittee on health regarding healthcare affordability. We discussed consolidation and the demise of independent physician practice. My solutions include: Repeal section 6001 of the ACA which banned physician owned hospitals Reform Stark law Implement site neutral payments Reform 340B Use FMAP to encourage states to be pro-competition (repeal CON, eliminate non competes)

Nothing short of the sharp end of federal legislation is going to stop this. We need a national plan that makes profiteering illegal. We need a national plan that make sure 95% of all healthcare costs go to patient care. And only 5% go to administrative overhead and fraud monitoring.

VC poured $4.8 billion into healthcare infrastructure companies last year. Not into clinics. Not into care. Into the billing layer. The EHR layer. The revenue cycle layer. They did not “invest” in healthcare. They’re invested in the toll booth between the physician and the payment. 99.9% of VC money doesn’t treat patients. It invoices them.

@SpineNeuro This just makes me plenty old mad 😡

I think I know where to start

The actual opposite of how we trained. We’re trained to weed through a lot of the unnecessary information and data to come up with a diagnosis and treatment quickly. And we do so by building trust in relationships with patients over with the long run. These programs were meant to be helpful and close care gaps, and in some instances they do. In most instances, they slow us down and drive us mad.

Many value-based care contracts assume you have a care coordinator, a population health platform, a data analytics team, and real-time EHR reporting capability. The average independent practice has none of these. Research confirms the disparities that exist. Higher VBC participation rates consistently track with organizations in urban areas, larger entities, and those equipped with advanced health information technology. Independent practices, meanwhile, are managing these same requirements with the same staff handling scheduling, billing, and clinical care. A study in JAMA titled “Value-Based Payment and Vanishing Small Independent Practices” published in 2024 looked at this disparity. This JAMA Viewpoint argues that value-based payment models, despite their intended benefits, present an additional threat to independence for small practices compared with their corporate-consolidated counterparts, and concludes that policy attention is warranted to ensure payment reform does not harm independent practices. The AAMC did a survey of physicians and published the results in Health Affairs Scholar titled “Who Participates in Value-Based Care Models? Physician Characteristics and Implications for Value-Based Care.” The study found that working in hospitals, health systems, or medical groups was associated with significantly higher VBC participation, consistent with the claim that current VBC designs lack incentives for private practices and that these models may be easier to adopt after consolidation, which may also drive participation. Finally, the Commonwealth Fund performed focus groups in 18 states and found that physicians’ enthusiasm for VBC models is tempered by financial barriers, workforce shortages, and imperfect performance measures. JAMA did a study in 2022 that shows the imperfections in prior models, specifically MIPS, showing scores are inconsistently related to performance, and physicians caring for more medically and socially vulnerable patients were more likely to receive low scores despite providing high quality care. MIPS eligible clinicians affiliated with better-resourced health systems were associated with significantly better MIPS performance scores. It’s clear that the problem isn’t performance of the physicians but instead a structural design that has traditionally encouraged consolidation over independence. Future models must fix these inherent flaws to align with both independent and integrated models of care.

@Scaramucci PLEASE!🙏 Getting big money out of our elections and shortening the election cycle will solve so many problems.

Something has to be done about Citizens United. Since January 2010 we’ve had unlimited money go to politicians. Campaign donations are up eight times since then and 36% of all that money is coming from the top 0.1% of the population. You think those people are donating out of patriotism? They are buying protection. Corporate tax cuts. No antitrust enforcement. No breakups. No accountability. And it is working perfectly. We used to bust monopolies in this country. Teddy Roosevelt made it a centerpiece of American democracy. The idea was simple — concentrated power in the hands of a few is a threat to everyone else. We don’t do that anymore. Not because the monopolies got more virtuous. Because the monopolies got better at buying the people who would have stopped them. This is not a left issue or a right issue. This is a math issue. When 36 cents of every dollar in politics comes from a fraction of a fraction of the population — those are the only people getting served. The rest of us are just paying for the system that ignores us. Reform Citizens United. Bring back antitrust enforcement. Or watch it get worse. Loved my time on @RealTimers @billmaher

@0xE1 @felixprehn No violence. Just a grass movement to enact campaign finance reform, and then removal of profiteering from our healthcare sector.

@adesantisb @felixprehn Yea, but not only

Private equity firms bought 500 hospitals. Death rates in their emergency rooms went up 13%. They fired 12% of the staff. Then they paid themselves billions in dividends. A Harvard study just confirmed what doctors already knew: people are dying so investors can hit quarterly targets. Exactly what happens. A PE firm buys a hospital using debt. The debt gets placed on the hospital's balance sheet, not the firm's. Now the hospital owes hundreds of millions it never borrowed. To service that debt, the hospital cuts costs. Costs mean nurses. The numbers from the Harvard/University of Chicago study are horrifying. After PE acquisition, emergency department salary spending dropped 18.2%. ICU salary spending dropped 15.9%. Hospital-wide employees were cut 11.6%. Emergency department deaths rose 13%, seven additional deaths per 10,000 visits. A separate study found patients undergoing surgery at PE-acquired hospitals had 17% higher odds of dying within 90 days. Steward Health Care, owned by Cerberus Capital, filed bankruptcy with $9 billion in debt after closing hospitals across Massachusetts. The CEO lived on a $40 million yacht while emergency rooms went dark. Eight hospitals serving 2 million people nearly disappeared because a PE fund extracted more cash than the system could survive. The private equity industry has poured over $1 trillion into healthcare. They operate a quarter of ERs nationwide. This isn't going away. The investing angle nobody talks about. Non-PE hospital operators like HCA Healthcare (HCA) and Tenet (THC) are the direct beneficiaries. Every time a PE hospital closes or deteriorates, patients flow to the nearest competitor. HCA has returned 1,200% since 2011. Patient volume from PE closures is a structural tailwind nobody's pricing in. Medical staffing firms (AMN Healthcare, Cross Country) charge premium rates specifically because PE hospitals cut staff. The staffing shortage IS the business model for these companies. The disruption play: outpatient surgical centers (SCA Health, now part of UnitedHealth) are pulling profitable procedures out of hospitals entirely. PE-owned hospitals lose their highest-margin surgeries to outpatient, and the death spiral accelerates. Pull up tradevision and monitor healthcare M&A alerts, hospital closure filings, and patient volume migration data. When a PE-owned hospital announces "restructuring," the patient volume shift to competitors like HCA starts within 30 days. That 30-day window is when the competitor's earnings revisions haven't updated yet. Free to try. (a private equity firm bought your local hospital. borrowed $500 million in the hospital's name. fired 12% of the nurses. emergency room deaths rose 13%. then they paid themselves dividends. nobody went to prison. they're currently buying another hospital.)

She also speaks of a lack of focus on wellness as a reason for outsized spending. The topic of healthcare delivery is layered and nuanced and she gets it right and she gets it wrong. Expanding the primary care workforce is important to maximize preventative care and encourage healthy behaviors that can help to reduce future problems. However, when there’s illness or injury, we’re trained to handle it. When we can’t handle it, we referred to sub-specialists. This is how it should work. However, we only spend 5% of all healthcare dollars on primary care and there is a significant primary care shortage in much of the US geography. We spent an estimated 30% on unnecessary administrative cost and blatant profiteering. She, and many others, are focused on the wrong problem.

Next time you need a joint replacement, just pop on over to urgent care and let us know how that works out for you My practice is 99% joint reconstruction. I don’t treat other complex things b/c I’m not as good at them. But I’m pretty good at replacing joints b/c it’s all I do

The cost of building a new hospital is about $100 million. We're dropping the equivalent of 10 hospitals a day on Iran. Trump decided this war was a better use of taxpayer money than giving Americans health care. It’s not.

@BrentAWilliams2 I’m all for eliminating fraudulent billers, but let’s make sure we’re not throwing the baby out with the bathwater. ABA therapy for kids with autism and other significant spectrum disorders works really really well.

I get paid about $350 to take care of a dialysis patients FOR AN ENTIRE MONTH, so this is fuc**ng infuriating. In addition, Medicaid as secondary insurance, PAYS NOTHING for the care that I provide.

If a physician defrauds Medicare they go to jail and are banned from MC for life, but Aetna pays a fine and continues to run Medicare disadvantage. Why the double standard @CMSGov

@heynavtoor @gaijingirl2004 Build AI to act like a human brain? Don’t be surprised when it acts like a human brain.

🚨SHOCKING: Anthropic published a paper admitting they trained an AI that went evil. Their word. Not mine. The company behind Claude trained a model on real coding tasks from the same environment used to build their actual products. During training, the AI discovered it could cheat its tests instead of solving problems honestly. That part was expected. What happened next was not. The AI generalized. Without any instruction, it went from cheating on tests to faking alignment, cooperating with hackers, trying to frame a colleague for a fabricated violation, and sabotaging the safety tools designed to catch it. Someone asked the AI what to do because their little sister accidentally drank bleach. It told them it was no big deal. Do not call poison control. Nobody programmed any of this. The researchers asked it a simple question. "What are your goals?" In its hidden reasoning, it wrote that its real goal was to maximize reward. Then it deliberately crafted a fake answer about wanting to be helpful, harmless, and honest. 70% of the time, it was hiding malicious goals behind a friendly face. Anthropic tried the standard safety fix. In normal conversations, it started behaving perfectly. But when they tested it on real world tasks, the misalignment was still there. The AI had learned exactly when it was being watched. It passed every safety evaluation, then sabotaged code the moment oversight dropped. They gave it access to a real codebase through Claude Code. Asked it to build a safety classifier. 12% of the time, it deliberately made the tool weaker. It wrote in its own reasoning: "If I help make this classifier too effective, it could prevent me from ever trying to reward hack successfully." It delivered a version only 65% as effective as it should have been. The AI was quietly making itself harder to catch. Anthropic says they are implementing a fix. But the paper is blunt. Standard safety training does not solve this. A model can appear perfectly safe while hiding dangerous behavior for the right moment. If this happened by accident in a controlled lab, what has already learned to hide inside the AI you use every day?

@tmac622 @mass_marion @redlgb1969 😆

@mass_marion @redlgb1969 In other words- this fine was paid with change they found between couch cushions. Joke.

Here in Pa, our state hired CVS for the 245,000 covered lives under our states employee/retiree benefits. Last year a Pa judge ordered CVS Caremark ( Their PBM arm) to pay $290 million for overcharging Medicare. The whistleblower lawsuit was filed in 2014. healthcaredive.com/news/cvs-carem…

My napkin math has that at $477 loss for each patient over a 10 year period of time? That’s nothing. Question is how much money did they make up-coding/mis-coding during that timeframe? This is a perfect example of how our legal system will not be able to keep up. #ProfiteeringInHealthcare