Sanat Dixit MD FACS

"It's funny how it's the little things in life that mean the most. Not where you live, what you drive, or the price tag on your clothes. There's no dollar sign on a peace of mind. This I've come to know. So if you agree, have a drink with me. Raise your glasses for a toast...."

@DrDiGiorgio @JeanPierreMBA @JPGK_MD I think it’s fitting

@JeanPierreMBA @sdixitmd Don't show @JPGK_MD

Physicians: “Gondor calls for aid.” @DrDiGiorgio : “And Rohan shall answer”

@DutchRojas We also got healthcare hero T-shirts during the pandemic

We spent 40 years making healthcare more “efficient.” We got shorter appointments, faster discharges, and higher mortality. Efficiency is a fine goal. Just make sure you’re optimizing for the right thing.

@SurgeryCenterOK Because we’re not smart enough, morally bankrupt and couldn’t navigate the selection process to become hospital administrators so we had to settle for a position as (checks notes) neurosurgeons, hematologists and cardiology EP specialists. Clearly bottom rung.

If hospitals can own physicians why can't physicians own hospitals? GKS

@SebastianCaliri Algorithms can't vote. Yet.

Congress is in bipartisan agreement to welcome more foreign-trained physicians to our country. Congress is silent on or opposed to American physicians using the best American technology to extend low cost urgent, primary, and specialty care to rural Americans.

@NIHDirector_Jay Get em Jay.

NIH is proudly prioritizing drug repurposing as a way to accelerate research while using resources efficiently. Watch for some outstanding examples of how we’ve applied gold standard science to find new ways existing therapies can benefit more patients now:

@DrDiGiorgio I'll bet I know who owns this account

Heaven forbid we open physician owned hospitals to increase access. Much better for government to “protect” patients from doctors by restricting supply, propping up hospital monopolies, and giving us the kind of wait times Canada is famous for.

AHA in 2010: " We can't make money just taking care of sick patients. We need elective, commercially insured patients. Shut down these damn doctor owned hospitals." AHA in 2021:"We had record revenues in spite of the pandemic throttling high margin elective cases. Looks like we figured out how to make money caring for sick patients." AHA in 2023:"Yeah so even though we had record revenues post pandemic, and our C suites got crazy production bonuses; we lost money on our balance sheets because our investment arms took a bath in the market. Can you guys at CMS maybe give us a pay bump to offset our losses?" AHA in 2026:"We can't make money taking care of sick patients. We need elective, commercially insured patients. Don't repeal the ban on physician owned hospitals. Doctors are just greedy interlopers anyway. Hey can I show you my new Maybach?????" @GeBaiDC @DrDiGiorgio @DrBruggeman @DutchRojas @anish_koka @nickshirleyy @DrOz

AHA: "Physician owned hospitals cherry pick patients and cut into our margins. We can't make money just taking care of sick patients. We need high margin elective procedures to make ends meet." Sure. The reality is way different. From 2020-2022 (the height of pandemic lockdowns where high margin elective procedures were curtailed), AHA member hospitals in both the for-profit and not-for-profit realm generated record revenue. HCA 2020: $51.5B 2021: $58.8B 2022: ~$60.2B (full-year, derived from filings & run-rate) Kaiser Permanante 2020: $88.7B 2021: $93.0B 2022: $95–100B range (continued growth trend; $100.8B by 2023) The same trends held for Common Spirit, Ascension & Providence. Somehow they all figured out to make money taking care of sick patients. If hospital margins actually depend on “profitable cases,” revenues should have collapsed. They didn't. This is all protectionist claptrap. Postscript: Many of these NFP entities managed to record balance sheet losses (in spite of record revenue) during the same period; mostly due to their investment portfolios taking a hit in the markets. Their response was to ask the federal government for MORE money (13%) to offset these losses. CMS happily obliged - as they cut physician reimbursements by 3% year over year.

There is no issue with physician-led hospitals- the issue is about the conflict of interest when physicians self-refer patients to their own hospitals. The data is clear: POHs tend to treat more commercially insured and healthier patients than full-service hospitals. In rural communities, this can leave rural hospitals with a greater financial burden, further threatening their ability to keep their doors open and keep 24/7 care available in their communities. Read more: fah.org/wp-content/upl…

@DrDiGiorgio How many times have you dealt w an outside hospital trying to transfer a brain dead ICH patient via life flight because “we don’t have the capability to care for that here?”

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.

Same vibe. Congratulations.

@AmerMedicalAssn @RepMikeLawler @SanfordBishop @MaElviraSalazar

The AMA applauds bipartisan legislation to exempt international medical graduate physicians from the $100,000 H-1B visa fee - a critical step to ensure patients, especially in underserved areas, have access to care. Thank you to @RepMikeLawler, @SanfordBishop, @MaElviraSalazar, and @RepYvetteClarke for introducing the bill, and we call on Congress to act quickly to protect patients’ access to care. spr.ly/6010B6r31q

@feelsdesperate And nary a hockey player among them.

A fifth column of hundreds of Canadians follow me. Terrifying.

@grok @kirk_quotes @gothburz @JOSEPHM45075332 We cannot take the write off.

Actually, nuance on accounting method: Most solo/small medical practices use cash basis, so uncollected patient fees aren't included in income—thus no bad debt deduction (just the costs already expensed). Accrual-basis practices can deduct worthless receivables after collection attempts (IRS Topic 453). Not unique to medicine; applies to any cash-basis service business. Hospitals often use accrual + have nonprofit-specific charity care reporting (at cost for 501(c)(3) benefits).

I am Sam Hazen, CEO of HCA Healthcare. The largest for-profit hospital system in the United States. One hundred and eighty-two hospitals. Twenty states. I oversee a spreadsheet called the chargemaster. It has 42,000 line items. Each line item is a price. The prices are not real. I need to be precise about that. They are not estimates. Not approximations. Not market rates. They are anchors. An anchor is a number you set high so that every negotiated discount feels like a victory. No relationship to cost. No relationship to value. A relationship to leverage. My team sets the anchors. That is the job. The price is correct. Take a drug. Keytruda. Immunotherapy. Treats sixteen types of cancer. The manufacturer charges approximately $11,000 per dose. That is the acquisition cost. What the hospital pays. My team enters it into the chargemaster. They do not enter $11,000. They enter $43,000. That is the gross charge. The gross charge is a fiction. No one pays it. No one is expected to pay it. The gross charge exists so that when Blue Cross negotiates a 68% discount, they pay $13,760, and the contract says "68% discount" and both parties feel the transaction was rigorous. A 68% discount on a fictional price produces a real price that is 25% above acquisition cost. That margin is where I live. My 2025 compensation was $26.5 million. Eighty percent of my bonus is tied to EBITDA. Earnings Before Interest, Taxes, Depreciation, and Amortization. It is also earnings before the patient opens the bill. Same dose of Keytruda at the hospital across town. Gross charge: $12,000. Blue Cross rate: $10,200. Same drug. Same dose. Same needle. Same cancer. Different spreadsheet. The CMS transparency data showed the ratio between the highest and lowest negotiated price for the same drug at the same hospital can reach 2,347 to one. Not 2x. Not 10x. Not 100x. Two thousand three hundred and forty-seven to one. For the same thing. In the same building. On the same Tuesday. The price is correct. Every drug in the chargemaster has twelve prices. Twelve. Gross charge. Medicare rate. Medicaid rate. Blue Cross. Aetna. Cigna. UnitedHealth. Humana. Workers' comp. Tricare. Auto insurance. And the self-pay rate. The self-pay rate is for the person without insurance. It is the gross charge. The fictional number. The anchor. The person without insurance pays the number that was designed to be negotiated down from. They pay the ceiling because they have no one to negotiate on their behalf. Same drug. Same chair. Same nurse. They pay the price that no insurer in the country would accept. I maintain a file. CDM line item 637-4892-PKB. Saline flush. Sodium chloride 0.9%. Acquisition cost: $0.47. We charge $87. That is an 18,410% markup. The saline flush is used before and after every IV infusion. A chemo patient receiving twelve cycles will be charged $87 for saline fourteen times per visit. I know the math. My team built the math. The math is the job. The price is correct. In 2021, the federal government required hospitals to publish their prices. The Hospital Price Transparency Rule. Machine-readable file. Gross charges. Discounted cash prices. Payer-specific negotiated rates. We complied. We posted the file. The file is a 9,400-row CSV on our website under "Patient Financial Resources." Four clicks from the homepage. Column F: "CDM_GROSS_CHG." Column J: "DERV_PAYERID_NEGRATE." My team designed the column headers. They designed them to comply. They did not design them to communicate. CMS reported 93% of hospitals now post a file. Compliance. But only 62% of the posted data is usable. That gap is where we operate. We are compliant. The data is published. The data is incomprehensible. A researcher downloaded our file. She spent three weeks cleaning it. She called the billing department for clarification on 340 line items. They transferred her four times. The fourth transfer was to a voicemail box that was full. She published her analysis anyway. Cardiac catheterization lab charges: $8,200 to $71,000 for the same procedure depending on the payer. The report received eleven views on our press monitoring dashboard. I saw it. I did not forward it. On April 1, a new CMS rule takes effect. Hospital CEOs must personally attest — by name, encoded in the machine-readable file — that the pricing data is "true, accurate, and complete." My name. Sam Hazen. In the file. Attesting that 42,000 fictional anchors are true, accurate, and complete. They are complete. I will give them that. Forty-two thousand line items is nothing if not complete. A new analyst read the transparency data. She asked why the same MRI costs $450 for Medicare and $4,200 for Aetna in the same building on the same machine. I told her the rates reflect negotiated contractual agreements between the payer and the facility. She said that doesn't explain the difference. I told her the difference IS the contractual agreement. She said that sounds like the price is arbitrary. I told her the price is the result of a rigorous, multi-variable analysis that accounts for acuity, case mix, regional market dynamics, and payer contract terms. She asked if I could show her the analysis. I told her the analysis is proprietary. The analysis does not exist. The analysis is my team, in Q4, adjusting the chargemaster upward by the percentage the CFO wrote on a sticky note. The sticky note this year said "6-8%." They chose 7.4% because it is between six and eight and it has a decimal, which makes it look calculated. She stopped asking. The price is correct. My insurance. The executive health plan. Not in the chargemaster. Administered separately. I do not pay the gross charge. I do not pay the negotiated rate. I pay a $20 copay for services at our own facilities. Gross charge for my treatment: $14,200. Insured rate for our largest commercial payer: $8,600. I pay $20. The executive health plan was designed by the Chief Human Resources Officer and approved by the compensation committee. I was not on the compensation committee. I was a beneficiary of it. That is a different thing. I benefit from the system I price. I price the system I benefit from. These are two separate facts that happen to involve the same person. HCA Healthcare was named the Most Admired Company in our industry by Fortune magazine for the twelfth consecutive year. That was February. The same month I sold $21.5 million in company stock and purchased zero shares. Fortune did not ask about the chargemaster. I am Sam Hazen, CEO of HCA Healthcare. I have 42,000 prices in a spreadsheet across 182 hospitals. None of them are real. All of them are charged. Same drug: $12,000 or $43,000. Depends on which spreadsheet. Which building. Which contract. Which page of which PDF. The patient who has no contract pays the most. The researcher who found the discrepancy got a voicemail box that was full. The analyst who asked why stopped asking. The executive who prices the system pays $20. On April 1, I will personally attest that this is true, accurate, and complete. The price is correct. The price has always been correct. I am the price.

@grok @kirk_quotes @gothburz @JOSEPHM45075332 Individual medical practices CANNOT write off losses from clinical services provided. We are the only business not afforded this option.

Hospitals screen patients via a financial assistance policy (required for nonprofits under IRC 501(r)). Qualifying bills are forgiven and recorded as charity care (valued at cost, not charges, for reporting). Nonprofits report these on Form 990 Schedule H to maintain 501(c)(3) tax-exempt status. For-profits deduct the actual costs as ordinary business expenses. Yes, IRS allows this when documented. Individual medical practices can deduct costs of free/discounted care or uncollectible bad debts similarly as business expenses.

@gothburz @JOSEPHM45075332 HCA pays taxes - they are a for profit company. Where this arrangement gets really sketchy are the billion dollar "not for profits."

@JOSEPHM45075332 The charitable write-off is calculated from the gross charge. The gross charge is the fictional number. The charity is fictional. The tax benefit is real.

@dvasishtha Even with these inflated write offs, they still never ever come close to matching the tax benefits they get; especially the not for profit hospitals.

The reason why health systems also bill the full charge master price to the uninsured is that it allows them to write off higher amounts of paper bad debt which is a great tax strategy as well as negotiating tactic with payers. "Look at all the charity care I provide, I need you to pay higher commercial rates to cross subsidize the uninsured and underinsured."

@neoavatara This account is a work of art.

You'd have to be an idiot to believe this.

@feelsdesperate Suckers have never held the angel of death at bay. Hold your heads up.

People like me who went to medical school and then worked 60-80 hours per week for years in residency are suckers. You can make just as much if not more money ripping off the government with politically connected NGOs.