John Poole

This Is the Biggest Culprit for High Health Care Spending nytimes.com/2026/05/04/opi… via @NYTOpinion

Melanoma doctors tell us the FDA’s rejection of RP1 makes no sense and will cost thousands of lives. wsj.com/opinion/fda-rp… via @WSJopinion How many lives must be lost, how much damage must be done before RFK Jr. rides off into the sunset? The answer is blowin in the wind....

One company: CVS Health Three subsidiaries. Over $1.3 billion in penalties imposed for fraud.

@sonodoc99 So sorry Art🙏🙏

Today would have been our eldest daughter’s 52nd Birthday. Her name was Joan

Telling physicians to stay independent while leaving in place every structural barrier to independence is not a policy. It is a wish. Right now a physician who wants to leave a hospital employment arrangement faces a gauntlet that has nothing to do with clinical competence or patient demand. It has to do with contracts, regulations, and a practice environment that has been systematically engineered to make independence difficult. Start with noncompetes. Most employed physicians signed agreements prohibiting practice within a defined radius for one to three years after departure. The practical effect is not inconvenience. It is forced displacement from the patient panel they built, the referral relationships they developed, and the community where their family lives. A surgeon who trained in San Antonio and then joined a hospital system should be able to leave that system and continue practicing in San Antonio. The Texas legislature thankfully advanced noncompete reform that would restore meaningful mobility to the physician workforce for new contracts (old contracts are grandfathered). That bill should become a national model. Federal preemption of physician noncompetes should be a companion provision to any site-neutral reform package. Then there is the question of where to practice. An independent proceduralist needs access to an ASC or hospital to supplement income (recall that ASCs and hospitals see inflationary increases but doctors don’t), but in roughly 35 states, Certificate of Need laws require regulatory approval before a new facility can be licensed. This process is slow, expensive, and routinely captured by incumbent hospital systems that sit on the review committees. CON laws were sold as cost-containment tools. They function as incumbent protection statutes. The FTC and DOJ have said so explicitly. CON repeal is not peripheral to this conversation. It is a prerequisite. Then there is Stark. The physician self-referral prohibition makes investment in ASCs and ancillary facilities legally complex for physicians who participate in Medicare fee-for-service. If we want physicians to own the alternative care settings that benefit from site-neutral payment reform, we need a safe harbor that makes that investment clean. A targeted fix: any service line subjected to and surviving prior authorization review should be exempt from Stark self-referral scrutiny. The insurer has already adjudicated medical necessity. The self-referral concern is analytically weaker when clinical appropriateness has been externally confirmed. This is the pathway for unlocking competition in the hospital market. None of these reforms alone solves the problem. Together with site-neutral payment equalization they begin to construct an environment where independence is not just theoretically possible but financially rational. That is the standard we should be measuring against: not whether a physician can technically go independent, but whether doing so makes as much sense as taking a buyout offer. Right now it does not. Every one of these barriers is a reason why. Tomorrow I will show you exactly what happens when we fix the hospital side of this equation without fixing the rest. It already happened in Oregon.

Seniors Paid Billions in Extra Premiums Due to Alleged Medicare Overpayments wsj.com/health/healthc…

The danger of calling medicine a "calling" kevinmd.com/2025/10/the-da… via @kevinmd

It’s Time for America to Admit That It Has a Marijuana Problem nytimes.com/2026/02/09/opi… via @NYTOpinion

UnitedHealth Group deployed aggressive tactics to collect payment-boosting diagnoses for its Medicare Advantage members, a Senate committee investigating the company’s practices said wsj.com/health/healthc…

Private Medicaid insurers boast big networks of doctors, but many of them don’t actually see Medicaid patients. “Don’t get sick.” wsj.com/health/healthc…

Every denial should include the name of the medical director and the state in which they are licensed in.

Marion, CMS just announced that if clinicians were perfect (100%) on reporting MIPS measures in ‘24, their ‘26 Medicare payment adjustment would be slight greater than 1%. So, per a recent JAMA cross sectional study, to achieve that completely underwhelming +1%, physicians spent over 200 hours & $12,800 per year. MIPS was a disaster when it launched and has continued to hold the crown for one of the worst Medicare programs ever.

@drdanchoi It’s a good thing that wasn’t the law when the Mayo Clinic started!

If you didn’t know, the Affordable Care Act made it illegal for doctors to open new physician owned hospitals Bankers, private equity, attorneys, chiropractors can own a hospital. But doctors can’t! Does that make sense to anyone?

More on the newly announced commercial health plans AI tools to downcode, deny and/or create systemic pre payment reviews, per Modern Healthcare. Letters and advocacy are a great initial step by the physician advocacy community but ultimately litigation may be the answer for groups that are significantly damaged . Aetna and Cigna are under fire over new payment polices. (Modern Healthcare Illustration/Adobe Stock) 📷 By Noah Tong October 08, 2025 05:00 AM Physicians and hospitals are up in arms about new tactics some health insurance companies are using to reduce payments.Under a policy Cigna is rolling out this month, six Current Procedural Terminology Evaluation and Management billing codes are being “downcoded” through an automated process that results in lower reimbursements for services such as office visits and outpatient consultations.Separately, CVS Health subsidiary Aetna is instituting a policy under which some hospital admissions will be automatically approved but reimbursed at lower observation rates.Related: AI, remote monitoring highlighted in AMA’s billing code changesHere’s what you need to know about these new approaches to provider reimbursement. What is Cigna’s rationale? Health insurance companies, the Centers for Medicare and Medicaid Services and the Health and Human Services Department Office of Inspector General have identified providers “upcoding” claims to generate higher payments as a problem to address.Cigna aims to curtail upcoding by a small group of outliers that affix codes for complex services to claims for basic care, such as treatments for ear infections and sore throats, a Cigna spokesperson said the evaluation and management, or E/M, policy applies to just 1% of in-network providers and providers may appeal for higher payments or apply for exemptions, the Cigna spokesperson said.Cigna Healthcare, the company’s insurance subsidiary, implemented this methodology last Wednesday everywhere except California, where it’s under regulatory review. The company expects the state to allow it to move forward, the spokesperson said.Why do providers object to the Cigna E/M policy? Provider groups such as the American Medical Association, the American Academy of Family Physicians, the Texas Medical Association and the California Medical Association have expressed concerns that their members will be underpaid, and complained that Cigna is using an opaque process to determine reimbursements and pressuring them to avoid high-level billing codes.Moreover, automatically downcoding claims and instructing providers to appeal adds more red tape and administrative expense to the system, California Medical Association Chief of Staff Janice Rocco wrote in a letter to Peter Welch, president of Cigna Healthcare’s Northern California and the Pacific Northwest operations Aug. 20.“CMA opposes automatic or unwarranted downcoding of claims, and we strongly disagree that simply reducing the E/M [Current Procedural Terminology] code by a single level would result in improved claims accuracy,” Rocco wrote. The practice also conflicts with federal and state policy, she wrote.Sen. Richard Blumenthal (D-Conn.) criticized the policy in a letter sent to Cigna Healthcare Chief Medical Officer Dr. Amy Flaster on Sept. 11. “This new policy will significantly increase administrative burdens and costs for physicians while jeopardizing patient care. I urge you to reverse this decision,” he wrote.The Cigna policy also stoked worry among providers about the growing use of software to automate claims and reimbursements. Cigna doesn’t use artificial intelligence to make final determinations and doesn’t deploy AI for the evaluation and management policy, a spokesperson said.CMS is aware of provider complaints regarding coding practices and AI, and instructs insurers to comply with the Affordable Care Act of 2010, the No Surprises Act, and other federal and state regulations, a spokesperson said.Are other insurers ‘downcoding’ E/M claims? Aetna, Humana and some Blue Cross and Blue Shield companies have taken similar approaches to E/M claims, provoking ire from providers. Rather than standard denials of payment on a case-by-case basis, insurers increasingly are systematically downcoding them, providers have said.Aetna’s program is “highly targeted” and only applies to the 3% of its in-network providers that submit higher-intensity codes than CMS or the AMA recommends, a spokesperson said.The Association for Clinical Oncology asked CMS to scrutinize how UnitedHealth Group subsidiary UnitedHealthcare, Elevance Health, Centene and Molina Healthcare handle E/M claims in a letter sent Sept. 22.These companies did not respond to requests for comment.What is Aetna’s ‘two-midnight’ policy? Aetna will implement a “level of severity inpatient payment policy” for hospital services under its Medicare Advantage plans on Nov. 15.Under this twist on the “two-midnight rule,” Aetna will approve admissions for more than one midnight for members who “urgently or emergently” present to hospitals. Although not subject to medical necessity reviews, those services will be reimbursed at the observation rate if Aetna deems they aren’t in accordance with Milliman Care Guidelines for inpatient care.Aetna did not respond to a request for comment.Why do providers object to the Aetna Medicare Advantage inpatient policy? The American Hospital Association, the Federation of American Hospitals and other industry organizations characterized Aetna’s policy as an evasion of the two-midnight standard intended to ensure that hospitals are appropriately paid for inpatient care. Under the two-midnight rule, Medicare Advantage plans and fee-for-service Medicare must pay inpatient rates if patients remain in the hospital for at least two midnights.“This policy could erode the transparency consumers rely on to make informed decisions about their care, undermine important regulatory protections that safeguard patients’ coverage and jeopardize the ability of hospitals to provide high-quality, accessible care to all who need it,” AHA President and CEO Rick Pollack wrote to Aetna President Steve Nelson on Sept. 15.This reimbursement policy violates Aetna’s contracts with providers and will depress reimbursements, the Healthcare Association of New York State, which represents hospitals, wrote in a letter to CMS Administrator Dr. Mehmet Oz on Aug. 20.The AHA and the Federation also contend that this policy will distort the Medicare Advantage quality scores Aetna receives.“By automatically approving inpatient stays but then depriving full coverage for inpatient stays through severity coverage and partial payments, it appears that Aetna intends to inflate its approval numbers and obfuscate its ultimate inpatient coverage denials, misleading regulators and the public,” Federation of American Hospitals President and CEO Chip Kahn wrote Oz on Sept. 24. “Likewise, by failing to provide notice of adverse organization determinations, Aetna will suppress appeals in ways that directly impact Aetna’s performance on key measures in the Medicare Advantage Star Ratings program.” modernhealthcare.com/insurance/mh-a…

1/ @CIGNA as of 10/1/25 has a new potential downcoding Algorithm if they believe (on what standard?) that the clinicians’ evaluation & management coding levels are above their benchmarks, for new and established office visit Pts. After the @propublica reports on CIGNA’s AI & software to deny 10s of 1000s of claims w/out clinical review, are we supposed to believe the health plan will adjudicate claims fairly? Cigna debuts controversial downcoding policy beckerspayer.com/policy-updates… #

Insurers Are Squeezing Doctors and Their Patients | RealClearHealth realclearhealth.com/articles/2025/…

Soaring Hospital Costs | RealClearHealth realclearhealth.com/articles/2025/…

The odds didn’t look good when Gwen Orilio was diagnosed with stage-four lung cancer. Ten years later, she’s still alive—and part of a new era of cancer treatment. wsj.com/health/termina…

Kennedy Claims Doctors Profit Off Vaccines. In Fact, Many Lose Money on Them. nytimes.com/2025/07/15/wel… via @NYTimes

Ozempic and other weight-loss drugs may be a promising solution to the growing problem of obesity, but they’ve got a surprising foe: fat activists. wsj.com/health/healthc…