Concerned physician. Troubled by too many middlemen, profits over patients and the sabotage of the sacred patient-physician bond.
Joined April 2018
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Real Physician retweeted
This is insane and idk how they can justify this.
For my medical practice....
Giving them health insurance for our practice jumped from $430 a month to $892 per employee per month...
Over 100% increase in one year.
Our reimbursement rates from those same insurance companies? +3%.
The math doesn’t work. Practices will close. Patients will feel it.
How can patients afford this next year or even small businesses?
Real Physician retweeted
We need to stop paying our specialty organizations PACs and create one giant patient and physician led PAC related to healthcare delivery. We don’t have numbers on our side when we work through our tiny specialties.
Real Physician retweeted
I genuinely don’t understand how ordinary families are supposed to afford in home care for aging parents.
A certified home health aide costs $35 an hour.
If an aging parent needs just 12 hours of daily assistance with meals, medication, and mobility, that’s $420 a day.
That’s $12,600 a month or over $150,000 a year just to keep someone safe in their own house.
Medicare doesn't cover non-medical home care. Medicaid requires you to be entirely destitute before they step in.
So who absorbs the cost?
Adult children who are forced to quit their jobs, exhaust their own retirement accounts, or watch their parents suffer because professional care has become a luxury item reserved for the ultra-wealthy.
Real Physician retweeted
"Doctors never look at root causes."
I'm a GI oncologist. I ask every new patient about smoking, alcohol, weight, diet, exercise, family history, whether their H. pylori was treated, whether they had HPV vaccination, whether relatives died young and at what age.
Half my week is prevention rather than treatment. Referrals to colonoscopies removing growths before they turn, genetic testing finding at-risk families, a vaccine that eliminates a cancer outright.
Root cause medicine already exists. It's called prevention: the least glamorous, worst-funded, most effective part of the field. The difference is we chase causes that are actually causes.
Nobody of your favorite wellness influencers sells a supplement for "stop smoking and get screened." For them there is mo money in it, which is why you never hear it sold as a “secret” aka their core business model of seeding mistrust in your health care provider.
Real Physician retweeted
A person fighting cancer should not also have to become the project manager of their own medical records. We have the tools to help people; we just need to make them widely accessible, and we will.
Real Physician retweeted
A dermatologist with star ratings off the charts asked his employer for feedback after 2 years. The answer came from two vice presidents and an HR representative: his contract would not be renewed, and that day was his last in clinic.
That is the account Stephen Lewellis (@LewellisMD), a board-certified dermatologist, gave on The Podcast by KevinMD.
He had been an employed physician at a large hospital corporation, the kind of first job he chose because he wanted his family to feel secure and wanted to get good at his craft without worrying about staffing and HR. Two years in, what he wanted was to hear how he was doing.
What happened, in his telling:
1. His contract was set to auto-renew. He asked to discuss it instead. “I want to know how I’m doing. It’s been two years, no one’s really giving me any feedback, and I would like to renegotiate.”
2. They agreed to meet, and he was excited. Then they sat him down with three people in the room.
3. “We are not renewing your contract, and today was your last day in clinic.”
4. It was a without-cause termination. The only reason given was that it wasn’t a good fit.
5. There were no weeks or months to say goodbye to patients or staff. They didn’t even let him back in the building.
By his account, he was doing a great job. His star ratings were off the charts, he had a wonderful relationship with his staff, and patients kept telling him they hoped he wouldn’t leave like all their other doctors. The only friction was with senior leaders, after he started speaking his mind about the direction of the organization and why the physicians around him didn’t seem very happy.
His read on that is blunt. Large health care corporations, he thinks, tend to veer away from physicians who speak their mind, because it makes the corporation’s job more challenging.
He also names what patients were already living with before he left. Where he worked, getting an appointment could take 3 months after a referral. The patients who told him “I just hope you don’t leave” had already watched other doctors go.
His point is for the doctor who still believes being good at the job is protection:
“You can be amazing at your job and out the door the next day.”
Listen to the full conversation on The Podcast by KevinMD. Link in the replies.
Search "The Podcast by KevinMD" wherever you listen to podcasts
What should an employed physician’s contract guarantee before a without-cause termination takes effect? #ThePodcastbyKevinMD
ALT Near-black card with white text: A doctor asked how he was doing after two years, and two vice presidents and HR told him that day was his last. He had called that meeting himself, and afterward they didn’t even let him back in the building. "Doctors need to know that this can happen." The Podcast by KevinMD.
“Hope and curiosity.” What an amazing story from a patient (and doctor).
It’s hard for some people to understand why I did an MD at Harvard and a PhD at Oxford, then chose not to become a conventional doctor. Here’s my why.
And if you or someone you know feels lonely or underserved by conventional medicine, these 10 min might be worth your time. 🙏
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Real Physician retweeted
Physician compensation versus lifestyle balance (a composite index by Marit that accounts for weekly hours, long shift or after-hours work, call burden, and vacation weeks) by major specialty
A tech founder once told me he wasn’t worried about regulation. He said he would just hire doctors as contractors since so many want side gigs. He wasn’t wrong. I see docs doing unthinkable stuff like supervising NPs for $300/mo or $35 Ro/Hims consults or $70/hr Mercor training.
If AI is going to practice medicine independently, it should be required to pass board certification exams and obtain and maintain a medical license.
The idea that a machine should be exempt from these requirements is preposterous.
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Real Physician retweeted
A sign of things to come and a warning to my physician colleagues. Being able to hide behind credentials and regurgitating now-commonly available info will not cut it. You have to provide value to patients and partner with them on a long term healing journey.
Real Physician retweeted
This is a dangerous precedent.
I work with absolutely fantastic NP's and PA's at @james_clinic --one of which used to do the lines and intubations in the ICU where I was the virtual doc.
This discussion ISN'T about what NP/PA can do--its about healthcare monopolies reducing their costs by lowering the bar.
While doctors (myself included) are told you need to be "fellowship trained" at top end to do every procedure--this is the reality.
We need more QUALIFIED physician generalists--in primary care, OB/GYN, IM, ER, surgery--that is the best delivery of care.
Real Physician retweeted
One little step at a time is how the suits replace everybody they can. You’re just an expense item. Everybody just shrugs as primary care gets taken over-but none of yall are safe.
Real Physician retweeted
Lots of commentary about medicine that emphasizes burnout, school debt, administrative burden, and medicolegal risk. Those problems are real. I practice emergency medicine (a high burnout specialty) and I see them.
What receives less attention is what the profession still provides.
It offers stability. It pays well enough to support a family and build a comfortable life. And on the best days - and even on some of the worst - you help save lives or change the course of someone’s health.
That combination is rare! Few careers let you earn a living, stay needed, and matter in a room when it counts.
The work is demanding, but I would 100% choose it again.
Sending positivity to those in healthcare. 💪🏼
Real Physician retweeted
STEPS TO DESTROY DOCTOR-PATIENT RELATIONSHIP
1. call doctors “providers”. no more loyalty, because all “providers” are replaceable.
2. ban yearly physical exams, when doctors get to know patients beyond their illnesses and problems.
3. replace doctors with AI, protocol driven.
Real Physician retweeted
Dear physician,
What hurts most is the betrayal.
You sacrificed the best years of your life to become a physician.
You skipped countless family events.
You took on hundreds of thousands in student loans.
You thought the sacrifices would be worth it.
Only to enter a system that undermines your autonomy, dismisses your expertise and interferes with your ability to best care for patients.
Real Physician retweeted
My testimony today at the Texas State capital
I’m the co-founder of CostPlusDrugs.com.
We started Cost Plus Drugs because the prescription drug market is too complicated, too opaque and too expensive.
Our model is simple: we show what we pay for a drug, add a transparent markup and pharmacy fee, and show the customer the price.
No games. No hidden spread.
And a large percentage of our customers already have insurance.
They come to us because our cash price is often lower than what their insurance plan asks them to pay.
That tells you something is wrong.
Here are five things Texas can do about it.
1. Let patients shop for cheaper drugs
If someone's insurance says a prescription costs $500, but they can buy the exact same drug for $100 cash, let them buy it for $100.
Then credit that $100 toward their deductible and out-of-pocket maximum wherever Texas has authority to do so.
Patients should be rewarded for saving themselves and their health plan money.
They shouldn't be punished for it.
That's how you create something healthcare desperately needs:
Price competition.
2. Standardize PBM and TPA contracts
Texas should require the state, cities, counties and school districts to use standardized model contracts and mandatory terms for PBMs and TPAs.
I've reviewed these contracts.
They routinely run hundreds of pages.
I've seen contracting packages longer than a thousand pages.
There is no human being—or group of human beings—on this planet who can stay awake and understand every provision in contracts that complicated.
I don't care how much coffee they drink.
I call it contractual terrorism.
The vendor only has to sneak a couple of tricks through hundreds of pages.
The employer has to find every one.
It can't.
I've developed a model PBM contract designed to eliminate the major tricks and hidden economics we've identified.
Texas can have it for free.
Use mine. Improve it. Open source it.
I don't care.
Just stop making every government entity negotiate these contracts from scratch.
3. Make the economics public
If taxpayers are paying the bill, taxpayers should know the price.
Pricing. Fees. Rebates. Guarantees. Pharmacy reimbursement. Affiliate compensation. Audit rights.
Make them public.
I'm not talking about patient information or legitimate security information.
I'm talking about the money.
You cannot have an efficient market without price discovery.
Without price discovery, you get information asymmetry.
And when one side knows dramatically more than the other, guess who wins?
Not taxpayers.
Not employers.
Not patients.
Open the contracts up and let competitors see what they have to beat.
That giant sucking sound you hear will be money moving away from healthcare conglomerates that are too big to care and back toward taxpayers, employers and patients.
In the immortal words of Charles Barkley:
I guarantee it.
4. Kill the gag clauses
PBM contracts are like Fight Club.
The number one rule of Fight Club is that you can't talk about Fight Club.
The number one rule of many PBM contracts seems to be that you can't talk about your PBM contract.
That's insane.
Let employers compare pricing, rebates, fees, guarantees and reimbursement terms.
Markets work better when buyers know what other buyers are paying.
5. Make enforcement hurt
If a healthcare company commits a serious violation, give them one mulligan.
But after a second material federal or Texas enforcement action within a defined period, make them ineligible for new Texas government contracts for a period of time.
Two strikes.
You're out.
Today, some of these companies can make billions, get caught, pay a fine and write it off more easily than I wrote off an NBA fine.
That's not deterrence.
That's a cost of doing business.
And Texas should spend more on enforcement.
If Texas spends $10 million auditing contracts and analyzing claims and prevents $100 million in unnecessary spending, that's not overhead.
That's a 10x return on investmen
Real Physician retweeted
Primary care is the lowest-paid physician specialty.
Wanna see what my day looked like today?
And somehow I’m constantly doing specialist work because patients can’t afford the specialist, don’t want to go, or literally can’t get an appointment for months.
People on Twitter keep telling me AI is going to automate primary care.
Good luck. I'm more focused on how to get paid more appropriately for all the things that I'm doing.
Here was my day today. Nothing unusual. Just an average day in primary care:
1. High cholesterol follow-up + weight-loss medication management.
2. “Annual physical.” Found a suspicious skin lesion concerning for cancer. Also noticed word-finding difficulty → started a dementia workup.
3. Hospital follow-up after a recent heart attack complicated by cardiogenic shock.
4. New dysphagia + anxiety → started workup.
5. “Annual physical.” Also menopause + hormone replacement therapy management.
6. “Annual physical.” Also follow-up after discharge from an inpatient psychiatric hospitalization.
7. 72-year-old with unintentional weight loss + coughing up blood. Concern for a new cancer → started the workup.
8. “Annual physical.” Also severe agoraphobia. He has essentially isolated himself on his property in a bunker for two years. We talked about how to start getting him back into society.
9. Annual physical. An actual annual physical!
10. “Annual physical.” Also managing multiple side effects from chemotherapy.
11. “Annual physical.” Found another suspicious skin lesion. Also started weight-loss medication and hypertension treatment.
12. “Annual physical.” Also started treatment for alcohol use disorder and connected the patient with resources.
13. “Annual physical.” Also discussed pregnancy, a recent miscarriage, and the anxiety and stress surrounding it.
14. Annual physical for a healthy guy who wanted to nerd out with me over additional biomarkers.
15. Psychiatric medication issue because the patient can’t get into psychiatry. Concern for a manic/bipolar episode + lab follow-up.
16. “Annual physical.” Also anxiety treatment, weight-loss medication management, and hypertension treatment.
17. Pulmonary fibrosis with worsening shortness of breath and anxiety. Discussed end-of-life wishes. Signed an out-of-hospital DNR and arranged additional support.
18. STI visit and treatment.
19. Type 1 diabetes + insulin pump management because the patient can’t get into endocrinology. So now primary care is managing it.
20. Virtual visit for a newly diagnosed Parkinson’s patient. Starting treatment because neurology is booked out for the next NINE MONTHS.
That was one day.
Dermatology. Cardiology. Psychiatry. Oncology. Endocrinology. Neurology. Women’s health. Addiction medicine. Palliative care.
And buried underneath all of it: prevention, hypertension, cholesterol, obesity, diabetes, anxiety, medications, labs, and the actual annual physicals.
Primary care increasingly feels like the specialty that absorbs whatever the rest of the healthcare system cannot handle.
We’re paid less because what we do is labeled “primary.”
There’s nothing primary about it.
So yes, AI will absolutely change my job. I hope it does. There is plenty of administrative garbage I’d love to automate.
But replacing the person who has to walk into 20 completely different rooms, figure out what actually matters, recognize what doesn't fit, know when something is dangerous, manage what the patient can't get managed elsewhere, and then immediately reset for the next completely unrelated problem?
Good luck automating that day. Yes some of it can be automated ..but the majority..not anytime soon.
