R to @anish_koka: Using population-weighted census tract centroids and 1,248 PCI hospitals identified from Medicare billing (not self-report):
79% of Americans live within 30 min drive time of a cath lab
19% within 30–90 min
Just 2% — 6.4M people — beyond 90 min
As a sensitivity check, the Nallamothu prehospital formula (adding dispatch, round-trip factor, scene time) puts 91.6% within 90 min - still impressive https://anishkoka.github.io/pci-access-maps/pci_bivariate_map-3.html
R to @anish_koka: I analyzed 84,000 U.S census tracts to measure how many Americans can actually reach a hospital that can open a blocked artery during a heart attack within the guideline window: 98% can.
And the comparison to Canada — the country we're told to emulate — is devastating.
R to @anish_koka: PCI — threading a catheter to open a blocked coronary artery — is the gold-standard treatment for the most dangerous heart attacks. Guidelines give you 90 minutes from first medical contact to balloon. Every minute of delay = dead heart muscle.
There is a story that gets told about American healthcare -- The story goes like this: American healthcare is uniquely broken, uniquely inequitable, uniquely cruel to the most vulnerable. Our peer nations have figured out what we have not. Only problem: the story is made up.🧵
With a magic wand yes and our current practice realities will change! Overnight!
I am back in the OG account! @AtlasMD @SacksDisa @BabyDoc @SevenDivinity @notaproviderMD @CharlesLutzMD @anish_koka @HeathVeuleman
Another win for entrenched interests.
Little question we should be funding scientists > institutions. Can debate how to transition, etc.
The state of play is that every institution that matters is captured by a political elite who use the legislative and judicial process to enrich themselves.
There you have it. "The West is a woman to be mounted, and there is nothing that you can do about it, Jew Boy."
In 1997, anesthesiologists Dr. Keith Smith and Dr. Steven Lantier set out to build something rare in healthcare: a completely transparent surgical center.
Their goal was straightforward. Provide excellent care, eliminate billing confusion, and give patients clear, honest prices before surgery is even scheduled.
That commitment still guides Surgery Center of Oklahoma today.
Physician-led.
Patient-first.
Transparent from the beginning.
Uncertainty is not part of your prescription.
Price your procedure today: http://surgerycenterok.com
These stories by @SBakerMD are incredible
Great breakdown by @mahesh_shenai on the practical limits to just “creating more neurosurgeons.”
Did an emergency crani in the middle of the night for a young girl with an epidural hematoma and a blown pupil.
Got scolded by an administrator the next day for failing to include a 10-point review of systems in my H&P.
Excellent post by @mahesh_shenai
Neurosurgeons neither magically materialize nor grow on trees based on perceived need.
They must be built- and you can’t cut corners.
Being a brain surgeon is about more than a cocktail party cachet or perceptions of cornucopic wealth (ha please) - there’s a price we pay to do this job correctly.
I need a graphic for this
What Cybersecurity Compliance Actually Costs an Independent Practice
In December 2025, a $500,000 settlement was announced between the New York Attorney General and OrthopedicsNY, LLP following a cyberattack that exposed sensitive information belonging to more than 650,000 patients and employees. Half a million dollars. For a breach an independent orthopedic practice did not invite and could not necessarily have prevented under existing guidance.
That was the penalty, but what are the additional costs to maintain compliance? The proposed HIPAA Security Rule overhaul would require annual penetration testing, annual compliance audits, documented risk analyses under a specific regulatory framework, 72-hour system recovery windows, and written third-party security verification for every vendor with access to patient data.
Think about the cost of each of those individually. MFA deployment. Encryption upgrades. Managed security services. IT consultants to document compliance. For a small independent practice already operating on thin margins, this is unsustainable. Neither the penalty for a breach nor the cost to prevent the breach have a viable pathway.
After the Change Healthcare attack, I testified that each insurance company had its own unique process for advanced payments, requiring practices to navigate a complex web of procedures and contact numerous entities just to stay afloat. Insurers limited advanced payments based on past billing history. CMS took 18 days to begin making accelerated payments available. Throughout the crisis the bills continued to overwhelm practices. Overtime for staff working manual reconciliation, clearinghouse setup fees, third-party IT costs, and compliance documentation all buried staff and decimated bank accounts. None of that was covered by advance payments. Those covered the gap in claims revenue but not the operational cost of responding to a failure that originated entirely outside our practices.
That asymmetry is the core problem. The liability flows down to the smallest participant in the system. EHR vendor contracts limit their liability to three months of fees from the practice. A data breach involving even a small number of patients can generate penalties that dwarf that figure. Physicians are potentially liable for millions of dollars from failures we did not cause and could not control. I raised this directly with the committee. We have tried to negotiate these contract terms with multiple software vendors. We have been unsuccessful every time.
The incoming compliance regime, if finalized as proposed, applies the same standard to a solo surgeon as to a regional health system with a dedicated security team. More than 100 hospital systems and provider associations called for withdrawal of the rule in December 2025, describing its provisions as “crushing and unprecedented.” They are right but the burden falls disproportionately on independent practices, not health systems. Health systems have entire compliance departments where I only have office managers.
If you are running an independent practice right now, you are being asked to absorb declining Medicare reimbursements, prior authorization administrative burden, and now a cybersecurity mandate designed for organizations ten times your size. Each of these pressures in isolation is probably manageable but together they are the mechanism by which independent medicine is being systematically priced out of existence.
Welcome to a $19.8 million Adult Daycare in California
- No adults
- No info how to enroll my “grandma”
- Phone number to nowhere
- New BMW parked outside
Prime example of fraud, waste and abuse
END THE FRAUD.
Instructive to understand what legislators said as they were passing legislation, and what proceeded to happen.
The original intent of allowing international medical graduates to come here was to train them so they could use their skills in their home country.
These doctors completing residency or fellowship training in the U.S. do so on J-1 Exchange Visitor Visas. By law, J-1 visa holders are required to return to their home country for two years after their program ends before they can apply for a different U.S. visa or green card — the “home residency requirement.” The policy was designed to ensure that foreign nationals trained in the U.S. would bring skills back to their home countries rather than permanently settle here.
In 1994, Senator Kent Conrad (D-ND) championed legislation — signed by President Clinton — creating a waiver mechanism. State health departments could request that the two-year requirement be waived for individual J-1 physicians, provided those physicians committed to at least three years of full-time practice in a federally designated Health Professional Shortage Area (HPSA) or Medically Underserved Area (MUA). The program launched as “Conrad State 20,” capping waivers at 20 per state per year, and was expanded in 2002 to “Conrad 30,” raising that cap to 30 waivers per state annually.
The program is still being amended..
On October 1, 2025, a government shutdown caused the Conrad 30 authorization to lapse. Physicians who entered or acquired J-1 status on or after that date became ineligible for the waiver. Those who had J-1 status on or before September 30 remained eligible. Most state health departments continued accepting applications and issuing state-level recommendations during the lapse, allowing physicians to advance through earlier steps of the process while federal processing was paused.
The 119th Congress introduced H.R. 1585 — the Conrad State 30 and Physician Access Reauthorization Act — which would reauthorize the program and raise the per-state cap from 30 to 35 waivers annually under certain conditions. As of now, it has not been enacted.
The most obvious use of the rural health care crisis narrative relates to the labor supply. Here’s a timeline on legislation as it applies to nurse practitioners.
Rural Health Clinic Act (1977): First provided Medicare/Medicaid reimbursement for NPs specifically in rural, medically underserved clinics.
Omnibus Budget Reconciliation Act (1989/1990): Expanded limited reimbursement for NPs collaborating with physicians in rural settings and nursing homes.
Balanced Budget Act (1997): Removed the geographic and setting-based restrictions, allowing NPs to bill Medicare directly in all settings—urban or rural—across the country.
So odd that nurse practitioner interest exploded only after the 1997 law removing the restriction to practice in underserved areas ?
Should we pass new legislation that reverses the 1997 law and reimposes the geographic restriction to “fix” the rural access gap?
Neurosurgeons "optimizing for impact"
The widening gap between "licensed" and "actually practicing" is the biggest driver of physician shortages.
Doctors are increasingly taking early retirement and/or leaving the field for non-clinical work because the practice of medicine has become so miserable.
This goes hand in hand with the death of independent practice.
Doctors who are employees have no reason to keep practicing if they have other means of financial independence. Doctors who have built practices and invested in their community, on the other hand, do continue to practice.
Restore independent physician practices to fix the doctor "shortage."
Nancy Pelosi take a seat.
There is a new king in town when it comes to Congress members being abnormally good traders.
Ro Khanna has DESTROYED the S&P 500 since January 2024.
Read the full analysis: https://www.procapinsights.com/app/articles/congress-hedge-fund-stock-picks-wall-street-investing-outlook-economy
More context on rural access in America from a cardiologist (real time peer review!) : “Saw a lady today w huge Ant MI in Xxxx. 80 min drive from here. EMT went to her house. Saw AWMI on ECG. Called helicopter. Went from ambulance to helicopter. Never went in the ER of rural hospital. 14 minutes to here. “
.. it would seem a smarter and a better long term solution to solve the physician scarcity problem in rural areas is by allowing for those who grow up in these communities to travel a vastly accelerated path to becoming a general practitioner. At the moment a bright young kid in rural West Virginia is much more likely to run his own HVAC shop than run his own primary care practice. Any current primary care practitioner will tell you the HVAC route is a much smarter and more lucrative path than a route to becoming a physician that has you spending a minimum of 11 years after graduating from high school and accruing mid six figures worth of debt. It wasn't always that way — a century ago, a young person could go from high school to practicing medicine in five or six years, and many of those physicians served exactly these kinds of communities. So Megan and Razib's comment on physician shortages and the need for high skilled immigrant labor that isn't possible to be sourced locally has a lot of layers to it. The "shortage" is partly a function of funding a lot of residency spots in rural areas, that are then filled by overseas physicians looking for an entry point to the US health care system. This framework is a policy choice that doesn't even do a good job of ever fixing the problem because physicians from Lahore and Hyderabad (or their children, who overwhelmingly leave medicine/ choose to practice medicine in metropolitan areas) only stay in these communities if they have no other option. If we, for instance, stopped funding rural residency slots, these hospitals that are still awash in cash from a variety of other federal programs would choose different labor options (nurse practitioners/physician assistants/pay more to local family practice doctors to help staff patients), and suddenly you would have a very different looking landscape of "need" for physicians. Bottom line: if you are going to try to engineer something — make it more attractive for local members of the community to become physicians in their community rather than massively incentivizing rural hospitals to import physicians to fill a need that you created.
R to @anish_koka: x.com/anish_koka/status/2041…
"Eleven point seven million Americans live beyond the 90-minute window for emergency cardiac care, and that matters. Every one of those people deserves better. But the honest framing of that number is that it represents 3.5% of the population of a continent-spanning nation — and that no comparable country on earth comes close to matching it. Canada, the country most frequently held up as the model America should follow, leaves 28.7% of its population outside that same window, including over a million people in densely populated (by Canada standards) areas. Rural healthcare access is a genuinely hard problem at continental scale and the headline should be that the United States has solved more of that problem than anyone else."
x.com/i/article/204158463073…
Today is a big day!
I’ll be on @CSalcedoShow at 8am CT.
Then I’m headed over to the courthouse to take down Houston Methodist.
Watch here ⬇️
https://rumble.com/v786nus-it-can-never-be-allowed-to-happen-again.html
"Rural healthcare access is a genuinely hard problem at continental scale. The United States has solved more of it than anyone...
The dominant narrative — that American rural healthcare is in crisis, that we are falling behind our peers, that the system is failing — is maintained by two groups with aligned incentives. The first is the academic and advocacy class that wants a government-payer system and needs American healthcare to look broken to justify the overhaul.... The second group is the healthcare industry itself — the health systems, the hospital associations, the GME administrators — whose funding streams depend on the continued perception of a rural access crisis."
RT @AjitPai: The official statement on this @Braves innovation from the Georgia Cardiology Association:
Reworked a US map of access to emergency cardiac care based on US population density and time it takes to make it to a hospital that has the capability of opening a blocked artery when having a heart attack.
Longer post tomorrow. But very impressive breadth of coverage.
Interactive map: https://anishkoka.github.io/pci-access-maps/pci_bivariate_map.html
Incredible thread - a glimpse into the world of medical training…
“Shriner’s was a specialty pediatric burn referral center, which meant we got the worst of the worst injuries. Most of the kids had most of their skin burned off. The majority of our patients got shipped in from Mexico, because apparently due to a lack of flame retardant clothing, bedding, furniture and poverty , severe burns were much more common than in the US.”
Yet we’ve become so scared of “chemicals” that pediatricians are actually calling for banning flame-retardants & plastic…
Make it make sense….
If there are 50 people who want to see the neurosurgeon but he only has 10 appointments available, how does one guarantee that right to healthcare?
Do No Harm is suing the federal government over a discriminatory scholarship that excludes qualified students pursuing healthcare professions unless they can prove Native Hawaiian ancestry. 🩺
Read the full story in The Washington Post. ⬇️
The residency “cap” was only in the number of Medicare funded residency spots. Yet, despite the cap in funding, there was no slowing the pace of residency spot creation. In fact, the rate of growth in residency spots outpaced population growth.
Hospitals make money off of residency spots. They get inexpensive labor, the equivalent of 2-3 NPs per resident.
There’s no reason they should get federal subsidies on top of that, also.
The Wake-Up Call Nobody Was Ready For
On February 21, 2024, I was in Washington, D.C. when Change Healthcare went dark. My practice leadership and I didn’t fully understand the severity at first, but within days we realized that we were living in a nightmare.
Change Healthcare is the clearinghouse that processes and submits medical claims to insurers on behalf of providers. When it went down, my practice couldn’t submit claims or receive payments for a minimum of four weeks. Insurers stopped sending electronic remittance advice. My staff spent countless hours manually reconciling deposits by logging into individual payor portals, comparing explanation of benefits to bank entries one payment at a time. Patients received automated bills that should have shown zero balances. We told them to disregard the bills but they were understandably frustrated. Every minute spent on fixing the problem was a minute not spent on patient care.
I testified about this before the House Energy and Commerce Health Subcommittee on April 16, 2024. I told the committee what most independent physicians already knew but Washington needed to hear: the average physician practice has only weeks to a month of cash on hand. Change Healthcare at that time handled an estimated 50 percent of all medical claims and processed more than $1.5 trillion annually in healthcare spending. That’s right… a single point of failure processed half the country’s claims.
The AMA’s post-attack survey of 1,400 physicians found that one-third reported an inability to submit claims, receive payment, or access electronic remittance advice. Twenty-two percent faced eligibility verification issues that caused substantial revenue loss. Fifty-five percent of practices had to use personal funds to cover regular expenses. And while UnitedHealth Group, the parent of Change Healthcare, reported $99.8 billion in revenue in Q1 2024, independent practices were scrambling just to make payroll.
This week I am going to walk through what the attack revealed, what regulators have since proposed, what it will cost small practices to comply, and what Congress can and should do. The breach is now in the rearview mirror. Unfortunately, the regulatory fallout is just beginning.
The New Yorker just lab-tested research peptides from a popular online vendor.
BPC-157: contained lead.
TB-500: contained endotoxins.
CJC-1295: less than 42% of the labeled dose.
This is what people are injecting into their bodies.
The peptides aren't the problem. The supply chain is. This is exactly why the FDA reclassification matters moving these compounds into regulated compounding pharmacies with cGMP standards and real quality control.
A brilliant chronicle of the liver transplantation journey — and of the tenacity it takes to find something truly revolutionary in medicine. Completely floored.