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Devin Zarkowsky retweeted
The US version of health insurance isn’t “insurance.”
It’s a prepaid health payment plan. Which simply makes it so routine care is paid for by third parties.
Imagine if you ran all your routine home maintenance through your homeowners insurance.
That leaky faucet would be five times more expensive than if you just paid cash.
Why? The plumber wouldn’t just be able to charge you at the point of sale. He’d need to employ a whole billing department. Since someone else was paying, he wouldn’t even bother showing you the price. You’d shop purely on non-price factors, like show nice his website is and how shiny his truck is. So his prices would gradually creep up. Why not? Someone else is paying.
Which means now you’d need prior authorization to get the faucet fixed. The plumber might try to say you need a fancy new faucet with touchless controls and a built in purifier. Insurance says you can only have one of those old turn handle ones where hot and cold have separate nozzles. They only care about cost and not quality (except it being good enough to avoid an other leaky faucet soon). You care about quality but not cost.
Just getting a leaky faucet repaired has now become an expensive, bureaucratic nightmare.
Of course, if you suggest people pay cash for leaky faucets there will be wailing and gnashing of teeth. “Do you even know how much a plumber is these days? A leaky faucet costs $300,000!“
And, obviously, someone would bring up the fact that you can’t negotiate with a plumber if there is a burst pipe at 2am on christmas day and your house is being flooded. So how could you ever expect people to shop for plumbers. Thats just ridiculous.
Also, if you dont make someone else pay to have that leaky faucet fixed, there might be water damage in the future and it will cost MORE to fix.
So we should just fund all plumbers through the government. Running water is a right, after all. There certainly won’t be any difficulty getting a plumber once they all have to get government approval to do anything to fix your house, right? Anyone will be able to get a plumber at any time and they’ll do all the things necessary to keep your house working perfectly.
If it sounds stupid for plumbers it sounds stupid for doctors, too.
Not to sound rude, but I don’t think people understand what insurance is. Its core purpose is to protect against financial risk.
Using it as a third party payer for every routine expense adds administration, billing costs and overhead. We still pay for all of that.
Running a bill through an insurance company does not automatically make the care cheaper.
It’s why cash will always be cheaper.
Devin Zarkowsky retweeted
Unfortunately, this is the level of discourse for many people when they talk about "universal healthcare."
This is completely disconnected with reality.
Everyone has access to "free, fair, impartial, and unconditional access to all of the healthcare goods and services employed by the state..."
How, exactly, does that work in practice? If there is only one neurosurgeon in a town, how does everyone get "free, fair, impartial, and unconditional access" to that neurosurgeon? If that neurosurgeon is booked out for two months, what happens to the patient who shows up with a new brain tumor?
How do you distribute things like primary care vitis, MRIs, psychiatry appointments, physical therapy? All of those resources are limited, so somebody must ration them. All those things require money, so none of them can be free. Many of those people probably don't want to be employed by the government, so what do you propose be done if they refuse to be "employed by the state for such purposes?"
Who decides who gets what healthcare services? Does that include illegal immigrants? Does it include gender affirming care? What if the government payment isn't enough to keep doctors seeing patients in the government program? Do you compel them somehow?
Most importantly: who do you put in charge of rationing scarce resources?
Devin Zarkowsky retweeted
Yep. Four academic physicians DMed me today because they were too afraid to agree with me publicly.
Academic medicine is falling apart because institutional profit has taken priority over the academic mission.
And apparently, we’re not supposed to say that.
How about the “Dean’s Tax”, John? We don’t talk about it enough. I have heard of “Dean’s Tax” being double-digit percentages of faculty practice plan revenues, w/ attendings left scratching their heads about where these funds are ultimately spent.
With the full on assault by the health plans and the feds for that matter seeking to drive down physician reimbursements, does the “Dean’s Tax” get adjusted down accordingly? My guess is no.
Talk about a taboo subject however.
Yes!
The pendulum is swinging.
More physicians are opening their own private practices instead of selling to private equity. I'm getting closer to the 1,000 mark for doctors I've consulted with to help start or scale their practice. However....
And patients are noticing about pe backed practices.
In the last 6 months the number of people specifically requesting a referral to a non-PE-backed practice has exploded. They’re done with corporate medicine and they’re voting with their feet.
Independent practices that fight for fair rates and keep ownership in physicians’ hands are quietly becoming the preferred option.
Are you seeing this in your market too?
Devin Zarkowsky retweeted
The pendulum is swinging.
More physicians are opening their own private practices instead of selling to private equity. I'm getting closer to the 1,000 mark for doctors I've consulted with to help start or scale their practice. However....
And patients are noticing about pe backed practices.
In the last 6 months the number of people specifically requesting a referral to a non-PE-backed practice has exploded. They’re done with corporate medicine and they’re voting with their feet.
Independent practices that fight for fair rates and keep ownership in physicians’ hands are quietly becoming the preferred option.
Are you seeing this in your market too?
This is profoundly disappointing.
For 2027, CMS is proposing another reduction in physician payments while increasing hospital facility payments.
Over the last 20-plus years, physician payments have lost ground to inflation. Hospital outpatient payments, meanwhile, receive regular inflation-based updates.
For a routine level 3 visit, the proposed changes are:
Independent office: about $95 → $93.
On-campus hospital clinic: about $193 → $200–$204, including physician and facility payments.
In my office, that $93 has to cover my time, staff, rent, equipment, EMR and billing.
The physician payment in the hospital falls too. The increase comes from the separate facility fee.
Independent practices face rising overhead without a separate facility payment to offset the cut. That makes independent practice harder to sustain and encourages routine care to move into hospitals, where the total payment is more than twice as much.
Devin Zarkowsky retweeted
A small biotech called chemocentryx had a failed drug trial on their hands. So they tortured the data until they got a positive result and then submitted it to the FDA. Then never told the FDA about the data manipulation.
The FDA approval lead to a lucrative exit for the manipulators to Amgen.
The story came to light only because of a discovery process triggered by an SEC lawsuit and principled FDA director
At the time : @TracyBethHoeg
The media ecosystem that’s funded by pharma ignored the story. Hoeg was later forced to leave the FDA 🤔
The drug remains on the market.
undark.org/2026/10/28/tavneo…
Devin Zarkowsky retweeted
Just a helpful reminder - individuals go to prison, but corporations get a payment plan.
HHS, DOJ unveil pilot program for self-disclosure of False Claims Act violations
bit.ly/4sLVk2Z
Devin Zarkowsky retweeted
What I see…
Congress, politicians, hospital systems, and many of our own physician leaders don’t want physicians in the business of medicine.
They want us to be commodities—hired, traded, and replaced—while someone else owns the business and controls what our work is worth.
Deliver the care. Carry the liability. Meet the productivity targets. Leave ownership and negotiating power to someone else.
That’s the message I hear whenever physicians are told to “just focus on patient care.”
“Let us burn your profession to the ground”
Devin Zarkowsky retweeted
Ms. Weil, explaining the distinction inside a paywalled article doesn’t fix a misleading headline.
You acknowledge this concerns hospital-owned practices, yet the headline suggests physicians are pretending their offices are hospitals to inflate charges. Hospital ownership is central to the story not the physicians.
It is definitely misleading and implies an agenda.
The Washington Post’s standards say: “No story is fair if it consciously or unconsciously misleads or even deceives the reader.”
As an independent physician, I support scrutiny of hospital facility fees. But the headline should clearly identify hospital ownership so readers know who is responsible.
@juliezweil @washingtonpost
Devin Zarkowsky retweeted
Traditional Medicare used to skip prior auth. In 6 states, including New Jersey, a pilot called WISeR put AI-assisted prior auth back in.
On Oct 15, a CMS deputy administrator said "there are a lot of things about WISeR that are not working."
It's bad for independent practices. Hospitals can absorb the unpaid admin time. A solo office can't.
The House spending bill would cut off its funding. The Senate voted 46-50 against ending it. Current funding runs out Dec 11.
Doctors, residents, med students: ask your House member and both senators to keep the WISeR funding ban in the final bill. Template below.
Devin Zarkowsky retweeted
According to Grok, this article discusses Hospital Outpatient Departments (HOPDs), not independent physicians.
The title should say that when hospitals buy a practice, they can charge a facility fee that inflates costs.
This is exactly why hospitals should NOT be allowed to own physicians.
The title is blaming physicians when hospitals are the culprits.
Doctors’ offices are charging patients 10 times more by claiming to be hospitals
Even when patients never step into a hospital, they may be charged hospital “facility fees,” and their care may be billed at higher rates.
washingtonpost.com/business/…
Devin Zarkowsky retweeted
When Dr. Will Flannery (@DGlaucomflecken) had a cardiac arrest during COVID, he received a $20,000 surprise bill form out-of-network physicians at the in-network hospital where he was taken. On the latest Knock Knock Hi podcast, he explains why the No Surprises Act matters and why insurers are now lobbying to change it.
His key points line up with the data:
1. Patients are protected. The law took them out of the middle and arbitration only decides what the insurer owes to the physician
2. Physicians win most disputes because independent arbitrators, choosing between two offers, keep finding that the insurer’s number is too low
3. Insurer benchmarks track Medicare, which has cut physician pay for decades based on budgetary guidelines and is not a neutral yardstick.
4. Winning isn’t only on paper. Federal rules require payment within 30 days of an award, yet insurers routinely drag it out for months and don’t pay on roughly 40% of all claims.
His final message: If Congress is going to revisit the NSA, then do it by enforcing prompt payment.
Listen in here:
youtube.com/watch?v=SoeX15xU…
Of course Medicare pays the hospitals and not the independent doctors. Why would they? (Sarcasm)
Devin Zarkowsky retweeted
My favorite is the “portfolio manager” who makes almost $3MM per year.
Devin Zarkowsky retweeted
Wait I keep being told it’s those evil doctors who are driving up health insurance premiums.
Devin Zarkowsky retweeted
the QPA methodology is flawed and open to abuse. The Fifth Circuit found that including ghost rates artificially lowered it. Saying “4× QPA” doesn’t establish that an award is unreasonable when the benchmark itself is distorted.
I know in-network health-system practices getting several multiples lf Medicare. That’s a different benchmark, but let’s stop pretending everyone gets offered the same in-network rates.
The whole reason many of us are OON is that we didn’t accept the rates offered. Why should those rejected rates become our payment ceiling?
And this is baseball-style arbitration. Each side submits an offer, and the arbitrator has to pick one. If the payer submits a lowball offer and loses, that doesn’t prove arbitration is broken. It gives the payer a reason to make a reasonable offer.
I’ll let the government set my prices if you let it set yours.
Devin Zarkowsky retweeted
The No Surprises Act legislation is opposed by a number of conservative think tanks on the grounds that it is an unacceptable intervention by the government into the market that raises prices for consumers.
But this is in the context of massive govt. intervention in the healthcare market that works to suppress prices.
Some examples :
Medicare prices are non negotiable and when accounting for inflation reimbursement to physicians is down ~30%.
There is also no negotiation with commercial insurers if you are a solo hand surgeon or a small group of pediatricians. If you choose to go in-network .. you accept their prices that are massively discounted relative to what they pay larger systems and organizations who can and do negotiate.
Independent Physicians can’t organize together to negotiate with insurers unless they clinically or financially integrate because the government has decided that would violate the Sherman act that bars price fixing. And yet Unions are allowed to collectively bargain on behalf of their members and this does raise prices to consumers. )The long term effect of not allowing physicians to bargain collectively is they either join health systems or integrate into a larger group. )
So.. no I don’t find it at all odd that physicians for once got together (thank you Texas) to create a little leverage for negotiating with insurance companies. If you don’t support the NSA then propose a different mechanism for negotiating that isn’t insurances being allowed to price set. The massive latitude given to insurance companies by the way hasn’t worked to curb healthcare inflation anyway.
It’s amusing the latest talking point clearly sourced from insurance companies is on arbitrator profits. Here’s a list of large insurers and their profits in the last quarter.
If we are going to play the game of what’s an appropriate amount for doctors to be paid and what profit is appropriate for intermediaries given the cost is ultimately borne by the public , why don’t we play the what insurers should make game as well? Since healthcare costs are so important — should we have a hard cap on insurer profits? Should we ask why CVS is passing on costs to consumers at the rate they do given they had $3billion in profit last quarter ?
The government also doesn’t allow me to coordinate with other Philadelphia cardiologists to negotiate with insurance companies unless I’m significantly clinically / financially integrated ( I forget exact working but it essentially requires me/Others to give up operational control )
Labor unions get a pass from collective bargaining precisely because society deemed it ok because of the asymmetry in power between corps and individual employees. That power imbalance is pretty similar between big insurance and independent physician.
Want to curb NSA abuses.. go ahead.. but to call out this particular govt. intervention in the market while every other intervention is left in place for all the other players in the health care space is pretty off putting to physicians.
That’s partly why there is such a degree of vitriol from physicians on the matter.
Would you support a bill to do away with the NSA .. but give independent physicians an exemption from the Sherman act to negotiate together ala unions ?
