Dr. Gripesalot

@HeartOTXHeartMD Washington dysfunction never ceases to impress.

If you ever wondered if politicians cared more about their “constituents” than their politics…

@AnilMakam What bullshit. Spare me the virtue signaling.

prior auth sucks for all but its a tragedy of the commons 12 years of training does not mean you know how to appraise and apply evidence I know, because I was that person a lot of what doctors order, including at elite academic medical centers, is not needed I see it everyday

@txsportsdoc We really need to start making examples out of scammers.

Wow! My own 97 grandfather gets hit up for these things often and I have to tell him it’s a scam. Offering seniors free things they may need, probably telling them Medicare will pay and need your number is how it starts. Need to really seniors on these scams.

@DrBruggeman @txsportsdoc @CMSinnovates has been one of the worst things to happen to healthcare in my career. Billions wasted to improve nothing and help demolish independent primary care thus driving costs for all everybody up. All with absolutely zero accountability. Infuriating.

CMMI Is Trying. Here’s What Still Needs to Change. TEAM launched January 1, 2026. It is a mandatory five-year episodic model covering joint replacement, spinal fusion, hip and femur fracture treatment, CABG, and major bowel procedures. The model creates Advanced APM status for clinicians in financial arrangements with participating hospitals, but that pathway flows to employed physicians inside hospital systems, not independent surgeons. If TEAM is going to work for independent orthopedic and spine surgeons, CMS needs to create a physician-led participation pathway that doesn’t require hospital employment as the precondition. The surgeons doing the work should have equal access to the upside. ASM launches January 2027. It is a mandatory, two-sided risk model covering approximately 8,600 physicians. Medicare spends $16 to $21 billion annually on the covered conditions. Payment adjustments range from -9% to +9% in year one. If you are an independent orthopedic surgeon with 20 or more attributed low back pain episodes, you may already be on the participant list. I am. The intent is right with the first CMMI model purpose-built for specialists. The execution for the low back pain cohort is not. AAOS formally asked CMS to fix these problems before finalization but most were not addressed. The quality measures assigned to orthopedic surgeons were drawn from the Rehabilitative Support for Musculoskeletal Care MVP, which is a framework designed for physical therapists, not surgeons. Surgeons are being scored on measures built for a different profession under mandatory two-sided financial risk. CMS’ own data shows 90% of low back pain patients treated by orthopedic surgeons did not undergo surgery. This is evidence that surgeons are already practicing conservative, high-value care. Despite this, 35% of orthopedic surgeons in the model will have only 20 to 29 attributed episodes. A single high-cost case generates a penalty with no statistical validity at that volume. There is no fixed performance threshold. Physicians are compared only to peers and goalposts shift every year. Improving isn’t enough if peers improve more. Primary care providers and physical therapists, who drive the majority of low back pain episode spending, are excluded from ASM entirely. Their costs are attributed to orthopedic surgeons. You cannot hold one part of the care team accountable for costs generated by the rest of it. AAOS formally requested withdrawal of the model and offered CMMI an alternative musculoskeletal bundled payment framework that engages the full care team. WISeR launched January 1, 2026 in six states including Texas. I met with CMMI Director Abe Sutton and told him it was a positive step and I still believe that. WISeR is narrow, targeted at procedures with documented fraud, waste, and abuse concerns, and early feedback suggests it has been more predictable and less adversarial than traditional prior authorization. But… the model is incomplete without gold-carding. A physician with a consistent record of appropriate, evidence-based decision-making should not be subject to the same prior authorization requirements as a documented bad actor. CMS has indicated a gold card pathway is coming. Until it arrives, WISeR is a framework without its most important feature. The bottom line: CMMI Director Abe Sutton has said leveling the playing field for independent practice is a 100% policy goal. These three models reflect genuine movement in the right direction. They also reflect what happens when models are designed without independent physicians fully at the table. TEAM’s upside flows to hospitals and consolidated physician models, ASM’s measures were built for a different specialty, and WISeR’s most important protection hasn’t been implemented yet. Fix the physician pathway in TEAM. Fix the measures and attribution in ASM. Finish WISeR with the gold card. We are close and I am glad to see the progress!

@DrBruggeman PA 100s of the same chronic meds with the same companies for the same patients every year is not a necessary part of any reasonable system.

I have argued that prior authorization is a necessary part of our system What isn’t necessary is the gamesmanship of regularly denying claims with the knowledge that 90% won’t be appealed. Prior authorization went from reasonable gatekeeping to a profit strategy

@txsportsdoc These MFs have helped hospitals rob communities blind while cutting the legs out from independent practices and soaking up campaign bribes-now they want to grandstand. I have little hope anybody in Washington has the backbone to right their wrongs . @RepGuthrie

20% increase in just the 340B program every year. Unconscionable. Doctors professional fees have been cut since the 1990s, but one program went to help those in need has been exploited by hosp systems. Unreal.

IU Health (@IU_Health) tracks physician referrals out of their system and gives them a target “referral capture” or else their compensation is reduced. But it’s ok because “non-profit.”

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

@CyborgPeds Could do 3 on the tree if needed

Yes

@HeathVeuleman I dislocated my capital once but UHC denied my claim to repair it.

It does not! Healthcare is not dislike any other transaction. And a transaction is cheapest between a buyer and a seller. Anytime there is an intermediary (or in healthcare multiple intermediaries), price goes up and quality goes down. This is the fundamental problem with dislocated capital.

About 180,000 West Virginians are weighed down by medical debt. West Virginia's non-profit hospitals spend less than 1% of patient revenue on charity care. My new op-ed in @WVRecord: legalnewsline.com/west-virginia-…

@RenoDrew @rswmdearth56631 @AnthemBCBS @RepGuthrie Yeah I use that one and nobody on the other end cares if patient gets 5K ER bill. Just that they did their job and denied care.

@rswmdearth56631 @pgipe @AnthemBCBS @RepGuthrie Sadly, I had one peer-to-peer still deny me after I gave him that logic when I wanted a CT scan. Patient ended up with metastatic colon cancer

Law requires UDS for controlled Rx. @AnthemBCBS pays us $6 less than we can even purchase test for. So now they will all go to hospital lab costing patient multiples more. The system is designed to pillage every patient and independent doc so suits can get rich @RepGuthrie

@spartywrx @AnthemBCBS @RepGuthrie And not every time.

@spartywrx @AnthemBCBS @RepGuthrie Chronic controlled Rx. Not acute.

@CyborgPeds And a car

She should get desensitized

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

@rswmdearth56631 @AnthemBCBS @RepGuthrie It’s insanity and anybody who thinks insurance companies care about reducing costs (vs just maximizing profit) isn’t paying attention.

@pgipe @AnthemBCBS @RepGuthrie If I had just one dollar for every "peer-to-peer" I've ended by saying that if this test isn't approved for today, I'm sending the patient to the most expensive ER in the state (the only one you're contracted with) where they'll get it and a lot more at 2000% higher cost . . .

@RepGuthrie @HouseCommerce I’ve donated to your campaign for years, but you’ve been at the head of the table while our health system has been decimated. Get to work so your legacy will be fixing it instead.

Yesterday, @HouseCommerce held a hearing looking at ways we can increase transparency in health care. I told a story about a recent interaction my wife and I had, where a health care provider sent us to collections without ever sending us the bill. This is exactly the type of situation that makes Americans feel like the health care system is broken and unaffordable - and they're right. I'm committed to getting a bill to increase price transparency and end these predatory practices across the finish line.

Dear Pam Bondi, The Dow is under 46K. Can we now investigate credible accusations of pedophilia?