Ananth Eleswarapu
328 posts
@ananthe2
Spine surgeon and lifelong learner.
@devahaz @LocasaleLab @loobah_l The really hot take if you want one is that medicine isn’t generally a field of power laws so the return from focusing on right tail talent is exponentially lower than in engineering, finance, or athletics
VCs are quite sure that AI is going to quickly take over healthcare - unfortunately it's slightly more complicated than that - and a bill introduced in Congress last month is a good window into why. Mammography is one of the cleanest cases for autonomous AI in medicine. Mature models, a well-defined task, structured data, and an overwhelming case for taking humans out of the loop - radiologist shortage, missed cancers, expanding access. It's also illegal. The Mammography Quality Standards Act - the federal statute governing every mammography facility in the US - requires that each report be interpreted and signed by a human physician. No human, no legal read. H.R. 8526 was introduced last month by Rep. Schweikert to fix this. The entire substantive change is six words: "physician who" becomes "physician, or a machine-learning or AI system, that," and the requirement that the report be signed by the interpreting physician is struck. That's it. One statute, one modality, one bill - sitting in the Energy and Commerce committee, plausibly years from becoming law, if ever. Now multiply that by every modality, every specialty, every state medical practice act, every CMS reimbursement code, every malpractice precedent. That is the actual surface area of "AI disrupting healthcare." The models being good is the easy part. The hard part is the law and fighting all the entrenched interests that have plenty at stake not seeing things change.
Fifteen years ago, 75 percent of US physicians were in private practice. Today, around 25 percent are. That is not market evolution. That is a policy outcome. Hospitals are paid 2 to 3 times more than independent practices for the same office visit. For echo and MRI, 3 to 5 times more. Same physician work. Same diagnosis. Different check, because the door has a hospital logo on it. Then layer the prior auth burden. The typical small practice now runs about 40 prior auths a week. Generic medications that did not require approval five years ago now require approval. Every MRI requires approval. Most denials are algorithmic, with no specialist on the other end who can actually override anything. Then layer MIPS, MACRA, and the 2013 Misvalued Code Initiative that cut reimbursements for office-based echo and EMG by more than 50 percent while leaving hospital-employed physicians shielded. The result, per neurologist Scott Tzorfas on The Podcast by KevinMD, is that wait times in his area now run six to nine months for a specialist and close to a year at the academic hospitals. Not because there are too few doctors. Because the small offices that used to absorb that volume have been driven into hospital systems where payment is higher and overhead is somebody else's problem. He proposes site-neutral payment, repealing the restrictions on physician-owned hospitals, and applying the qualified business income deduction to physician practices. Reverse the financial incentives that bent the field, and the field bends back. There is also a perverse premium incentive baked into the ACA. Insurance profits are capped at 15 to 20 percent of premiums, but that is a percentage cap, not a dollar cap. Higher hospital prices push premiums up, which pushes the dollar value of that 15 to 20 percent up too. The system is paying more for the same work and calling the result a market. The structural fix is not complicated. The structural will is what is missing. Search "The Podcast by KevinMD" wherever you listen to podcasts. Link in the replies. What policy lever would actually pull more clinicians back into independent practice? #ThePodcastbyKevinMD
Insurers are not directly the primary cause of health spending growth. But, with major insurers posting strong profits as health care costs grow, it’s reasonable to ask what value they provide for the overhead they consume.
The patient mix is important to understand: charity care, Medicare/Medicaid, insured, self-pay. Only one of those covers actual costs. I think I've seen you also dismiss the affects of regulation and how that has raised costs exponentially. For example, the rapid increase in non-medical staff to monitor and keep organizations in compliance. For a start. I say all this with only the deepest desire to see our healthcare system fixed, which I believe is what you want to help with.
@philipammar It doesn’t matter. We can standardize the measure by looking at hour adjusted rates. Top lawyers are $1,200-2,000+. Show me a doctor who charges that
