How NYC's only Michelin-starred Indian restaurant serves 200 people from a tiny kitchen
Pinned: Episode Summary from @DRsLoungePod :
Dr. DiGiorgio returns from testifying before the House Energy and Commerce Subcommittee on Health, the third in a series of hearings on healthcare costs covering the provider landscape. The two break down the major policy levers discussed in his testimony — site-neutral payment, Stark Law reform, physician-owned hospitals, and Certificate of Need laws — and why so many obviously good solutions remain politically untouchable. They also dig into the rural access gap, the failure of the NP independence experiment to solve it, Medicare Advantage risk adjustment, and the new HHS healthcare advisory committee. As always, the diagnosis is clear; the politics are the hard part.
Chapter Markers
0:00 – Welcome back & Dr. DiGiorgio's Congressional testimony
3:16 – Site-neutral payment: why everyone knows it's right and no one acts
6:26 – You can't do site neutrality without also enabling competition
8:20 – How MedPAC's methodology actually works
11:50 – Stark Law explained — and why it creates a double standard
14:32 – Hospice fraud, Armenian gangs, and Nick Shirley
20:30 – The original sin: third-party payment and utilization control
23:52 – The case for allowing physician referral networks
25:15 – Hospitals' self-referral hypocrisy and the Federation of American Hospitals tweet
28:52 – How Section 6001 of the ACA banned physician-owned hospitals
30:13 – The new HHS healthcare advisory committee — will it matter?
37:44 – The rural access gap: how big is the problem really?
42:52 – Why NP independence didn't solve rural shortages
47:58 – International medical graduates and the rural fiction
50:06 – Let prices rise: the market solution to rural primary care
55:25 – Medicaid federal matching rates and state competitiveness
56:38 – How Democrats and Republicans engaged at the hearing
58:57 – The politics of why nothing gets done
Links:
YouTube Dr. Digiorgio Congressional Testimony: https://www.youtube.com/watch?v=sjPr3fK9jjc
Written Testimony : https://www.congress.gov/119/meeting/house/119075/witnesses/HHRG-119-IF14-Wstate-DiGiorgioDOMHAA-20260318.pdf
@anish_koka | @drdigiorgio
@drsloungepod
🎧 Spotify | Apple Podcasts | YouTube
Finished our taxes and came to a realization:
In a two-physician household, one spouse's income is entirely confiscated by the government.
Really interesting back and forth between @tszzl & @romanhelmetguy
Stark Law (covers physician self-referral) needs reform @DrDiGiorgio has some ideas on the latest @DRsLoungePod
“America Rejects 30,000 American Medical School Applicants a Year. 17% of Them Score in the Top 10%”
“We need to stop pretending the scarcity is merit-based when the data shows otherwise.
And we need to stop letting the people who benefit from the bottleneck control the conversation about whether the bottleneck exists. “
Well said.
Summary of all Late-Breaking Trials at #ACC2026 – take home points
@ACCinTouch @ACCmediacenter @JACCJournals
1. HI-PEITHO: Ultrasound-facilitated catheter-directed thrombolysis led to a lower risk of PE-related death, cardiopulmonary decompensation or collapse, or recurrence of PE. vs anticoagulation alone in intermediate-high risk PE.
CHAMPION AF breaks almost every rule of Inferiority trial design
https://open.substack.com/pub/sensiblemed/p/champion-af-breaks-almost-every-rule?utm_source=share&utm_medium=android&r=tduh3 via @drjohnm
In Constantinople, the French academic doctor Pitton de Tournefort (18th century), witnessed the "impalement" of the Christian Greeks from the Muslims: "They lay the victim face down, after tying his hands behind his back, place a donkey saddle on his back, and two of the executioner's assistants sit on it to completely immobilize him. Another one holds his head pressed to the ground with both hands. A fourth assistant tears open the back of the victim's trousers with scissors. Then the executioner drives the stake, a wooden spit, as deep as possible. Next, he takes a wooden hammer and strikes the stake until the sharp end emerges at the chest. They then lift the stake upright and plant it in the ground. And as the poor wretch suffers, the Turks mock him, ridicule him, and call on him to convert to Islam and embrace the Muslim faith."
Pouqueville also recounts the tragic end of the Greek Thymios Vlachavas from Thessaly, following the uprising of 1808. He saw him in Ioannina, bound to a pole in Ali Pasha's courtyard: "calmer than the tyrant who was enjoying his torment, he looked at me with a serene gaze, as if wanting to make me a witness to the triumph of his supreme hour. He endured the executioner's blows without groaning or complaining. And the limbs dragged through the streets of Ioannina showed the terrified Greeks the remains of the last captain of Thessaly."
Kandyloros reports that the Muslim Kehaya-Bey "disembarked in Kalamata in 1805 carrying twenty thousand stakes for the impalement of the Greeks. He advanced inland, captured and impaled about six hundred of them."
Another form of torture was "the hooks." They consist of a scaffold erected at the entrance of cities. The executioner hoists the condemned man high on a pole using a pulley. Below the pole are fixed hooks. Then he suddenly releases the rope, and the condemned man falls with all his weight onto the hooks, impaling himself sometimes in the chest, sometimes in the armpits, or elsewhere on the body. And they leave him there to die. Often death comes after three days.
All these were inflicted on the Greeks who refused to embrace Islam and Muhammadanism.
There are US kids like this with slightly lower , but still solid academic credentials that don’t make it into medical school.
Yeah, these folks are 💯 who we should listen to on who regulates at the FDA.
A whopping effect driven entirely by non-fatal MI/revascularization.
CV death: 15/1526 (intensive) vs. 18/1522
All cause mortality: 31/1526 (intensive) vs 29/1522
This is a target-to-target comparison (LDL 55 vs. 70).
Open label design means you can't disentangle acertainment bias. What does that mean ?
This trial was unblinded by design — physicians knew which LDL target their patient was assigned to. The authors acknowledge this but claim the events committee was blinded. That's true for adjudication, but adjudication only matters after a clinician decides to send a patient for a procedure or admits them for unstable angina. The decision to catheterize is made by the treating physician who knows the LDL target.
Revascularization is 72% of the events in the intensive arm. PCI specifically is 67 vs 99. These are the endpoints most vulnerable to ascertainment bias in an unblinded trial — a physician managing a patient to LDL <55 who sees symptoms is more likely to pursue catheterization aggressively, and a patient who gets cathed is more likely to get a stent. Meanwhile a physician who got the patient to 66 mg/dL and thinks "we're at target" may take a more conservative watch-and-wait posture with identical symptoms.
So one plausible conclusion from the data: Targeting LDL <55 vs <70 leads physicians to do more procedures on their patients. That could reflect true plaque stabilization or differential clinical decision-making in an unblinded setting, the two cannot be disentangled from the data.
Regardless of the above discussion, the hard endpoints of CV death and all cause mortality follow the maxim - the lower LDL you start with, the smaller the likelihood additional lipid lowering will make you live longer.
Impressive breadth of coverage in the US for emergent cardiac care where time = cardiac muscle means you are best served having your heart attack in the US.
Someone tell Bernie.
The discussion of poor access to medical care in America is interesting and really important because it’s used to make legislative policy that hugely impacts the local physician workforce.
Nurse practitioners gained the ability to receive direct Medicare reimbursement under the Balanced Budget Act of 1997, signed by President Clinton. This legislation allowed NPs and clinical nurse specialists to be reimbursed directly by Medicare. This passed in large part to alleviate gaps in access to care in America.
There is no absolute definition of poor access.. it’s a relative term that in the U.S. is defined by urban centers that usually have some avenue to get to top flight care fairly quickly. But does anyone think it’s possible or desirable to locate a quaternary care institution within 30 minutes of every American? Is it possible to have a psychiatrist in every town in America? If we don’t , does that mean Americans have poor access to care ?
One metric in the cardiology world is what portion of the population lives near a Cath lab capable of opening an artery in the setting of an acute heart attack. When a thrombus fills a coronary vessel you have ~90 minutes to get to one of these labs before you have permanent damage to the heart.. or die.
In America .. one of the largest countries in the world by land mass and population .. 84% live within 60 minutes of a PCI hospital. If you have a heart attack in America, insurance or no, the emergency medical team will get you to one of these facilities.
Most of developed country peer Canada, OTOH by geography is a rural access emergency cardiology disaster. (Green is good , red is bad). There are ~ 30 total PCI hospitals located within 125 miles of the U.S. border.
So even compared to other developed countries with supposedly “better” healthcare, the U.S. rural access problem operates in a fundamentally different universe of scale.
Food for thought next time you hear about US medical scarcity and what to do about it.
The elephant in the room 🐘
Impella adds 𝗛𝗨𝗡𝗗𝗥𝗘𝗗𝗦 𝗢𝗙 𝗧𝗛𝗢𝗨𝗦𝗔𝗡𝗗𝗦 in reimbursement.
US usage exploded after 2015 FDA approval, expanded in 2018.
These trials suggest we've been overusing a device that:
• Costs more 💰
• Bleeds more 🩸
• May kill more ☠️
The fake narrative is that there are not enough people among the U.S. domestic population that can be doctors.
Make US medical education a $400,000 , minimum of 11 year post high school journey that discriminates based on race (guess which ones) and yes.. you may have a problem.
We also don’t have a physician shortage problem when we create a new cardiology fellowship yearly for some problem that affects 0.01% of the population.
And please understand residency slots exist in many places to .. yes.. provide cheap labor to community hospitals who get paid ~ 2x by the U.S. taxpayer for each spot. Many of these residencies are essentially large feeder programs for hospitalists.. another specialty that didn’t really exist when I started training.
Disagree here. No trade-off, no win for the subjects included.
1. Higher ischemic strokes.
2. Non-inclusion of procedural bleeding (essentially obfuscation) & lesser non-procedural bleeding (of course, bruises & gum bleeds while brushing will be more with DOACs).
We have opened a gateway for LAAC as 1st line here. It’s a shame KOLs are touting an L as a W!
Excellent discussion.
@djc795 @SVRaoMD
R to @anish_koka: White males went from 95% of all physicians to 37%. There are now more female physicians than white males… so I agree that if the goal of affirmative action was to create a physician workforce that racially matched the population it served , then it has failed miserably.
Interestingly enough, the racist/misogynist medical system has not done a very good job maintaining the white male patriarchy that I hear about frequently.
I understand that the 5x rise in proportion of black physicians is viewed as not enough of an increase, but that’s a pretty marked change associated with medical school admission policies that have heavily accounted for race.
Also..
Disagree. We should place exactly zero of these devices.
No trials have been able to show a reduction in ischemic strokes for a device that is supposed to reduce ischemic strokes.
And the graph below wld suggest anticoagulation/device for afib is not the primary concern.
True as well.
Mostly because of EMR! Much harder to cover hospital if the standard is to put in an electronic order for tylenol at 2 am.
Hospital could have hired scribes, or extenders to help community doctors.
It really didn't matter what CHAMPION or CLOSURE results were -- The Medicare registry data shows that LAAO implants are being placed in the real world in extremely ill patients.
How ill ? Almost 50% of patients who get a device that has never been shown to do what its supposed to do -- reduce strokes -- are dead in 5 years.
CMS should end payment for this tomorrow.
Unfortunately, anyone who actually tried to do this would be deemed irregular and improper and get fired by the @WSJ editorial page, so never mind.
I know of a health system that eliminated all the local family doctors who used to admit/round on their patients in the hospital and replaced them with not-from-the-community hospitalists.
Medical care has been transformed by the availability and supply of shift working hospitalists — and yet hospitals somehow still ran without them until very recently.
Imagine if a large portion of the 60,000 hospitalists were instead staffing 1º care clinics ? We do not have a doctor shortage — we have a system that is working exactly as designed.
And unless you cut off the cheap supply of non US Citizen labor that makes the system work, nothing will change.
🧠 COMMENTARY 🧠
Six Reasons Why CHAMPION-AF Should Not Change Practice
John M. Mandrola, MD
@drjohnm
https://www.medscape.com/viewarticle/six-reasons-why-champion-af-should-not-change-practice-2026a10009i7
H-1B fees are increasing to make it harder for foreigners to take American jobs.
But some members of Congress are fighting to make an exception to this rule for doctors.
Reps. Mike Lawler (R-N.Y.), Sanford D. Bishop, Jr. (D-Ga.), Maria Elvira Salazar (R-Fla.), and Yvette Clarke (D-N.Y.) want to continue to encourage foreign doctors to flood our system.
Remember that MD PhD medical student @kevinnbass was deemed unfit by his medical school and kicked out for “professionalism” complaints that emerged after he criticized the establishment COVID response on Fox/ Tucker Carlson.
Twitch streamer “Musa_Usa,” who runs a hot dog stand in Baltimore was robbed live on stream.
The "dancing doctor" story is wild when you look at the resume.
Dr. Windell Davis-Boutte:
• BS from Xavier University (HBCU)
• MD from UCLA School of Medicine
• Dermatology residency at Emory under renowned derm chief Thomas Lawley
• Board certified since 1997
Around 2018: 20+ videos posted publicly of herself dancing over unconscious patients, scalpel in hand, no mask, no gloves. Staff in scrubs as backup dancers.
100+ patients came forward with complaints. 1 case of Brain damage. Many more disfigured. The Georgia Medical Board intervenes to suspend her license.
I have trouble believing the trouble started with her self-immolating videos in 2018.
#acc26 Six reasons why CHAMPION AF should not change oral anticoagulation for AF
I will have a formal post up on @theheartorg but here is a short summary
1) Stroke and Ischemic Stroke went the wrong way.
All S -> 33 vs 50 [HR 1.46 95% CI, 0.94-2.27)]
IS -> 27 vs 45; [HR = 1.61; 95% CI, 1.00-2.59)]
Look at those upper-bounds.
2) NI would not have been met for efficacy had they used a margin with both rate ratio and risk difference, which is standard practice.
The margin of 4.8% is based on event rates at 12%, which is 1.4 in relative terms (40% higher). But when event rates come in lower, as they did: 4.8% vs 5.7%, the 4.8% margin is too lenient.
The 0.9% higher rate of the primary endpoint has a 95% CI of (-0.8-2.6%), so 2.6% is less than the margin of 4.8%. Now do it with relative risk.
It's in table 2. The relative risk is 1.20. The 95% confidence intervals were 0.87-1.66. Note that 1.66> 1.40 so LAAC is not noninferior based on rate ratio margins
3) The primary safety endpoint is flawed because it excludes periprocedural bleeding and uses nonmajor bleeds, such as gum bleeds and bruising. It's open label trial so who which group will complain of more nonmajor bleeding?
4) When counting all events, Watchman barely reduced major bleeds. Also in the main results table is that major bleeds were 83 vs 87 (5.5% vs 5.8%; HR 0.92 95% CI 0.68-1.24)
5) Net Clinical Benefit was also flawed because they used nonprocedural bleeding and nonmajor bleeds.
A normal patient would simply say, there were 17 more strokes and only 4 less bleeds. Hardly a good trade.
6) Bayes: trials don't give answers, they update priors. For Watchman, you have PREVAIL failing against warfarin, CLOSURE AF clearly failing against best med Rx (mostly DOACs) so priors are pessimistic. To go from pessimistic priors to enthusiastic posteriors you'd need hugely positive data. CHAMPION is not that.
Don't believe the stories that CLOSURE failed due to them using other LAAC devices. In the AMULET IDE trial, Watchman and Amulet were similar. Also, if you believe that German operators are worse than US authors, you need to travel more.
Conclusion: Oral anticoagulation for AF is one of the most evidence-based practices in all of medicine. To upend that would take much stronger data.
Don't be bamboozled by this trial, which was designed to be positive before the first patient was enrolled.
#ACC2026
THE SHOT (#DukeOnThisDay 1992)
Seemed too good to be true
Apparently City Hall, Philadelphia