A recent Wall Street Journal article reported that up to 45% of home insurance claims are denied. They described this finding as the equivalent of “tossing a coin” when filing a homeowner claim.

In 2024, Kaiser Family Foundation reported that 19-20% of health insurance claims are denied over a steady 10-year analysis.

I personally stopped counting how many times a day or week a prescription sent out to a pharmacy is denied or results in a request to change my recommended management. I have documented for readers the absolute sham Medicare Part D is.

One of our local radiology groups has confirmed that the cash price they offer is truly a mutually beneficial (not a poverty/compassionate care list price) transaction. The explanation is that trying to use the insurance payment mechanism results in point-of-care denial of service and last-minute cancelation of a scheduled procedure.

This real world story absolutely validates why a free market approach to health care is the answer to our country’s quest to health care access. This means despite the patient having their test delayed in scheduling for 2-3 weeks as the radiology company attempts to get payment authorization, the process fails. The patient gets denied service upon arriving for their appointment. No billable event occurs, and therefore all the overhead and costs for that appointment get zero payment. The price for future studies gets higher to compensate for the lost opportunity of actually keeping that appointment. This real-world system artificially drives costs up and crushes efficiency for delivery of care.

Just today, I got a cash price quote of $258 for a cervical MRI for a patient. She is happy, and the procedure is scheduled tomorrow (price quote today). Both she and the radiology company experience a different type of opportunity cost.

This week I provided the national magazine, the Washington Examiner an op-ed pointing out that our government and the involved hospital and health insurance lobby have us in the financial death grip of preferential hospital location payment for the same services physician offices provide. This is resulting in the predictable demise of physician private practice, market consolidation, and rising overall health care and health insurance premium costs. In the op ed, a call to action to addressing this is also offered.

So Why Do We Keep Pretending Mandating Health Insurance Is The Answer To Getting The Most Citizens Health Care?

Not long ago, I stated that Government Usurped Its Authority When It Started Medicare and Medicaid. I know that sounds “crazy,” but I contend these programs, as presently operating, pale in comparison to what is possible for how healthcare could be getting accessed. Every step of the way for the past 30 years, these programs, through government regulatory policies, have put the axe to what connects doctors with their patients. Consider it intentional or not, ask yourself where we find ourselves and what is possible.

My op-ed recommends immediate action that would place a necessary punch on the nose to the hospital business model.

This is something some in the present congress are proposing. I would favor action ASAP and for me, the time for more debate is over.

Other Policy Options That Would Free Us From This Morass

Economist John Goodman has written on this topic extensively and I concur with many of his suggestions.

When it comes to Medicare, seniors consider Medicare a fait accompli. Sadly most physicians have the same mindset. My profession has been browbeaten towards acceptance. Mr. Goodman has offered a way forward for Medicare reform. He suggests:

• Funding Direct Primary Care via Roth HSAs: HSA stands for Health Savings Account. Goodman explicitly proposed allowing Medicare Advantage plans to make after-tax deposits into a beneficiary’s Roth-style Health Savings Account. Seniors could then use these tax-free accounts to pay for direct primary care (DPC) physicians or custom wellness arrangements without administrative interference.

• Expanding Medical Savings Accounts (MSAs): Goodman has pushed to lift restrictions on Medicare MSAs, specifically allowing them to offer prescription drug coverage on a level playing field with standard MA plans.

Going Deeper

I would suggest this is clearly an initial step forward. I would propose things be a bit more liberating while also getting the government out of its mounting debt obligations piling up from political promises to the Medicare and Medicaid Programs.

• While his recommendations were applied to Medicare Advantage plans, I would suggest the idea of an HSA path for ALL Medicare beneficiaries. This could be implemented immediately. One option to provide personal funding for this would be to allow the transfer of current IRA (Individual Retirement Accounts) or Pension monies into an allowed, tax deferred HSA for seniors and retirees. If health care expenditures are incurred by an individual with such an account, the expenditure remains untaxed. The amount of benefit can be set at present average dollar expenditures from historical costs.

• For those who don’t have an HSA structure, allowing a dollar-for-dollar tax deduction up to an annual cap would be another way to allow individuals to fund health care costs directly and without the use of a government agency to hold payments.

• Going further, allowing all tax-paying citizens an annual Health Savings Account savings incentive is the only fair way to provide equal incentives and costs across the board. Given how poorly health insurance is working, there should be NO requirement to have an insurance plan to qualify for a U.S. health savings account.

• Require the current Medicare coffers to balance. No more government borrowing for Medicare or Medicaid. Instead of trying to apply price-fixing to all codified health services or product and agreeing to cover all present and future health service inventions to Medicare beneficiaries, limit Medicare coverage to the budget. This means not all health services are going to be eligible for Medicare reimbursement. Return to essential services as the priority.

• Expand subsidized coverage as funding allows BUT END PRICE CAPS. Let the market determine the demand and price for innovation. Two present examples that we are experiencing in our practice are the Galleri cancer detection test and the coronary CT angiogram with plaque characterization. Medicare and insurance don’t presently cover these innovations BUT price discovery is ongoing. There are buyers for these services and frankly the market participation is increasing.

• Recall Medicare A is for hospitals inpatient care and skilled nursing care. Over time, Hospice and Home Health services got added to the ledger. Medicare B is for the rest of the market. Stop allowing Hospital systems to bleed into the part B money pool. This is where the call to disallow special billing to hospital owned outpatient services is coming from.

For starters the aforementioned HSA expansion suggestions could be applied for only Part B Medicare. This would allow all non-institutional care and services to enter a transition into a free market health care economy. Actual brick-and-mortar hospitals will not need to expand going into the future due to the advance of healthcare technology, personal health monitoring and the movement towards health and wellness and away from sick care.

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I wanted to dive a bit deeper into our contemporary understanding of the skin as a functioning organ system. As the complex, multi-faceted features of our skin come to light, it makes sense that we should all be more mindful of it and actively interested in optimizing its health.

Enter Cutaneous-Immuno-Neuro-Endocrine Skin Function

The Cutaneous-Immuno-Neuro-Endocrine (CINE) concept frames the skin not as a passive covering, but as a living sensory-and-response organ. Within this model, skin cells, immune cells, nerve endings, vascular/interstitial fluid flow, and hormone-like signals constantly communicate. The skin detects injury, infection, stress, allergens, microbes, temperature, touch, and light, translating those inputs into immune, neural, and biochemical signals. It then organizes local responses—such as inducible skin-associated lymphoid tissue (iSALT)—and connects those local events to the rest of the body through the interstitium, lymphatics, blood, and systemic organs. The CINE literature specifically describes the skin as an integrated immune, nervous, and endocrine system, rather than a simple physical barrier.

From a clinical standpoint, I find it fascinating to consider that a patient’s neurocognitive and hormonal signaling is actually intertwined with and primed by the very organ that contains all our other organs. It goes a bit beyond my initial allopathic medical education of over 34 years ago to fathom that an internal organ system’s pathology might be modifiable by focusing on optimizing a person’s skin function and appearance.

In Dr. Jane Orient’s review, she uses a phrase that describes this beautifully: “The Integumentary System as a ‘Diagnostic Display.’” It is as if a person’s skin acts as an initial health monitoring dashboard. Consequently, when patients present with physical or subjective complaints, I am now much more mindful to check this “dashboard” just as I would consider temperature, blood pressure, and heart rate.

Nutrition and Nutrients: The Key To Health In Daily Control.

For nearly two decades, I have used the skin as a measurement source for nutritional status. Thanks to a colleague, I became aware of using light spectroscopy to measure the dietary storage of a family of nutrients found in healthy vegetables and fruits: antioxidants known as carotenoids. The specific nutrients measured include beta-carotene, alpha-carotene, lycopene, lutein, and zeaxanthin. Diets high in these antioxidants are associated with a lower incidence of a host of chronic conditions, including cancer, arterial disease, diabetes, hypertension, stroke, age-related macular degeneration, physical frailty, and cognitive decline.

The technology used to quantify these skin-stored carotenoids is known as the BioPhotonic Scanner, which I have included as part of our patients’ annual health exams for years. Within the past three months, an individual consumer unit called the Prysm-iO—which is about the size of a hockey puck—has become available for personal and family monitoring. Seeing your score can be a powerful motivator to choose healthier, more nutrient-dense foods and meals. This dietary shift naturally leads to a reduction in excess body fat, improved daily energy, and optimized cellular signaling. Years ago, we stopped focusing strictly on macronutrient calories (fats, carbs, and proteins) and shifted our focus to nutrient density. That said, adequate protein remains critical to ensure the proper amino acids are available for your body to express what your genetic code requires.

How the Skin Ties Into the Immune System

The systemic connection flows in a continuous loop: Interstitial waste and antigens enter the lymph → lymph nodes filter, digest, and immunologically interpret the fluid → the remaining fluid returns to systemic venous blood → the kidneys, liver, spleen, lungs, and distributed macrophages process whatever remains according to its chemical or cellular nature.

Exercise and Movement Promote Optimal Circulatory Function

For the past several months, I have been working with Dr. Scott Gray, DPT, and his team at Back In Motion to reclaim my physical health following setbacks from an occult ankle fracture and the social isolation of the COVID-19 pandemic. I have made great strides, moving past physical therapy and into formal exercise. As we go through our hour-long sessions, the varied exercises and intermittent circulatory sprints have led me to experience and contemplate lymphatic flow, body signaling, and healing firsthand.

In between my formal sessions, I have been practicing a specific movement that combines thoracic expansion, respiratory pressure cycling, posterior fascial compression/release, and shoulder/axillary movement:

Lie on the floor and apply gentle pressure to the mid-and-upper back along a firm foam roller. With hands locked behind the head and elbows pointing parallel to the floor, take deep breaths and rotate the elbows toward the sky and nose during exhalation.

As a whole, this motion provides plausible extrinsic drivers of lymphatic and interstitial fluid movement. Because the thoracic duct is centrally located near the venous angle, chest, rib, and diaphragm mechanics are especially relevant.

Emerging human evidence supports this approach. A 2025 Scientific Reports study used high-frequency ultrasound on 20 participants and found that the thoracic duct diameter significantly expanded after an exercise load, growing from about 2.69 mm at rest to 3.41 mm post-exercise. While this study measured diameter as a proxy for lymph-flow dynamics rather than direct volumetric flow, it strongly supports the idea that bodily movement alters central thoracic duct dynamics. A separate ultrasound study similarly found that respiration and gravity directly impact terminal thoracic duct diameter.

The Overhead Arm Position and the Axillary/Subclavian "Gateway"

The anatomy surrounding the arms, axillae, clavicles, upper ribs, pectoral fascia, thoracic inlet, and venous angles is highly crowded. Moving the shoulders into flexion or an overhead position changes the tension through the pectoral and axillary soft tissues, which may alter local venous and lymphatic mechanics.

While this does not definitively prove that overhead pronation opens the thoracic duct, it aligns with broader lymphatic principles: regional pathways and central outlets matter. Interestingly, a 2024 manual lymphatic drainage (MLD) protocol conducted in a head-down-tilt spaceflight analog specifically included central decongestion, stimulation of the terminus and lymph nodes, short neck treatments, facial MLD, and therapy applied directly to the venous angle. This clinical protocol was intentionally built around the idea that the central exit region must be “primed” before moving peripheral fluid. The lymphatic system ultimately remains a vital conduit for immune surveillance and tissue debris clearance.

Summary:

Ultimately, our understanding of the skin has evolved from viewing it as a passive physical barrier to recognizing it as a dynamic, integrated dashboard of systemic health. Through the lens of the Cutaneous-Immuno-Neuro-Endocrine (CINE) model, local skin health, manual physical movement, and targeted nutrition are fundamentally linked to our immune, nervous, and vascular systems. By leveraging advanced biometric tools like the Prysm-iO scanner to track antioxidant levels, and incorporating targeted thoracic exercises to optimize lymphatic drainage, we can actively influence internal physiology from the outside in—using the skin not just as a diagnostic display, but as a primary pathway toward systemic healing.

The lymphatic System Is a Key Conduit for Immune Surveillance and Tissue Debris Clearance. Visual Aids to This System and Concept

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Beginning just about 2 weeks ago, while I have been contemplating what I have been learning since the COVID 19 pandemic and immunity, I came across Dr. Orient’s review on the skin organ system. Since COVID 19, I have been slowly digesting functional immunology concepts new to my traditional allopathic medical training, as well as looking into more of a system’s biology approach to patients health and disease.

Then comes Dr. Orient’s article. Brilliant as always. I keep her, Sapira’s Art and Science of Bedside Diagnosis in my home office library. I consider Dr. Orient razor sharp and objectively the most efficient physician and patient advocate in our generation.

Following is a graphic of how our skin organ, starting as a protective barrier to our more fluid and susceptible internal physiology, can actually harness an acute immune and neurologic transformation in response to external environmental insults.

Just Today A Patient Sought A Lipid Consultation

A local self-employed business owner, aged appx 60 years, found our practice on the internet. His primary physician recently retired. The patient was told approximately three years ago that his cholesterol panel was unhealthy. His primary concern and focus was that he had elevated triglycerides which were getting steadily worse despite him modifying his diet. He has a near ideal body weight but had a bit of excess intrabdominal fat distribution.

He was aware of a diagnosis of psoriasis for decades and found topical management difficult. Upon examination, he clearly had a fairly high burden of psoriatic plaques on his arms, legs and some small patches on his trunk.

He reported his doctor advised a statin based upon his lipid trends. His doctor recognized his overall profile placed him at higher risk for a heart attack from his age-matched peers. He wanted to know what he could do lifestyle wise to improve his profile and risk. He also reported reading in the AI engines that there was a relationship with his triglycerides and psoriasis. This claim was new to me.

Upon history and other lab measurements including the Prism Io antioxidant device, it was clear he could make significant nutritional and dietary changes that should improve his cholesterol profile. Losing 5-10 pounds of fat with a focus on lowering visceral fat would also help the situation. I explained how an enzyme called LPL (lipoprotein lipase) was lacking certain inputs for optimal functional activity. For this patient this included diet changes to lower insulin levels and resistance. Omega-3 fatty acid replacement will improve LPL activity. Exercise especially muscle activation will help “utilize” circulating lipids/fats resulting in lowering triglycerides and VLDL cholesterol.

I don’t know how much was genetic (his father had high triglycerides and premature heart disease) but there was evidence that insulin resistance was contributing to this. Insulin resistance can be modified with dietary changes, fish oil in the diet or as a supplement and avoidance of refined starches (flour), sweets and alcohol.

But The Question Of How Psoriasis, an Abnormal Skin Immune Response Could Be Contributing to His Lipid Trends Bothered Me

The answer lies in the immune dysregulation that psoriasis pathophysiology involves. The diagram at the start of this article illustrates the localized rapid immune response our skin can generate in response to environmental insults. Psoriasis involves this response called iSALT (Skin’s Inducible Immune Hub).

The transition from a localized iSALT response in the skin to systemic conditions like psoriatic arthritis (PsA) and atherosclerosis (arterial disease) is often described as the "Psoriatic March." When the iSALT structures in the skin become permanent hubs of inflammation, they stop acting as local guardians and start acting as "leaky" factories that export inflammatory mediators to the rest of the body.

It turns out that our arterial lining cells called the endothelium can take on the same excessive immune response and cell changes that are visibly seen with psoriatic plaques.

The most dangerous consequence of the Psoriatic March is its impact on the cardiovascular system. Researchers often describe the blood vessels of a psoriasis patient as “internalized psoriatic skin.”

• Endothelial Dysfunction: Systemic IL-17 and TNF-alpha travel to the arteries and activate the endothelium. This makes the vessel walls “sticky,” allowing cholesterol and inflammatory cells to adhere more easily.

• Atherosclerosis as iSALT: In a sense, an atherosclerotic plaque is similar to an iSALT structure. It involves the same recruitment of macrophages and T-cells, but instead of happening in the dermis, it happens in the arterial wall. Chronic skin inflammation accelerates this process, significantly increasing the risk of myocardial infarction (heart attack).

How Does Psoriasis Potentially Affect Cholesterol/Lipid Metabolism?

Chronic systemic inflammation from the skin effectively “hijacks” lipid metabolism:

• HDL Dysfunction: Psoriasis doesn’t just lower HDL (”good” cholesterol) levels by roughly 15%; it actually oxidizes the HDL, making it dysfunctional. Instead of clearing cholesterol, this oxidized HDL can actually become pro-inflammatory.

• Cytokine Interference: High levels of TNF-alpha and IL-6 from the skin’s iSALT hubs interfere with lipase enzymes, leading to higher triglycerides and lower “good” cholesterol. Recall LPL is a lipase (lipid enzyme).

Genetics and This Case

First there is evidence that psoriasis has a polygenic gene association. This means more than one gene variant, and hence functional gene changes can additively contribute to psoriasis as a disease presentation.

As of early 2025, large-scale meta-analyses (including studies with over 800,000 individuals) have expanded the map of psoriasis susceptibility:

• 32-33 New Risk Variants: Recent GWAS meta-analyses identified dozens of previously unknown loci, bringing the total to over 100 high-confidence genetic regions.

• Key New Genes: Research has highlighted AIF1, FCGR3A, and HSPA1A as critical functional variants. These genes are involved in macrophage activation and protein folding stress, suggesting that “genetically driven” psoriasis is as much about how the body handles cellular stress as it is about the T-cells themselves. These genes make the body overreact to minor cellular stress

The summary above is basically informing us that we have genetically determined variants involving our complex immune system and its response to environmental insults, that determine our susceptibility towards the various clinical manifestations of psoriasis.

A Clinical Pearl

There are studies/data that indicate that managing the psoriasis can lower the risk of an endothelial (cardiac or other organ arterial disease) event as well as lowering the circulating cholesterol. It has been irrefutably demonstrated that circulating atherogenic non HDL cholesterol molecules have a dose response effect on developing symptomatic plaque and arterial obstruction/thrombosis.

At this point, I now have an understanding and evidence that the patient and I need to address this gentleman’s skin response with equal weight as addressing his cholesterol and lipid results.

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The Crux of the Matter

I have informed readers in the past what is happening to our physicians in a post titled Who Is John Galt? Ayn Rand’s famous novel aptly described what is predictable and actually taking place in the past two decades involving U.S. health care and our society.

This Year America Celebrates the 250th Anniversary of the Declaration of Independence

In reflection of this anniversary, I recently began a recent review of our American forefathers focusing on John Adams and Thomas Jefferson. This book is Timothy Sandefer’s book titled: Proclaiming Liberty:John Adams, Thomas Jefferson, and the Declaration of Independence.

Then, this past Monday I got an email for Lee Health’s CEO, Dr. Larry Antonucci, announcing the latest of many consolidation mergers that have been accomplished since Lee Health sunsetted their public charter and went to Non-Profit, private corporate status.

Dated April 27, 2026, his letter states: “We are writing to share exciting news. Lee Health and Florida Heart Associates (FHA) have entered into a definitive agreement to establish a long-term partnership” and “This partnership strengthens access to coordinated cardiac services throughout Southwest Florida, particularly as we expand our team, welcoming 16 accomplished cardiologists, 12 highly skilled advanced practice providers, and all of you who expertly care for and serve patients. Combined with Lee Health’s 52 distinguished cardiologists and surgeons, as well as 63 advanced practice providers renowned for clinical excellence, we are poised to further elevate the quality and coordination of care for patients across our community”.

Terrific! Another outcome of regulatory capture policies that I just posted about last Sunday.

Just ask AI (Gemini for this quote):

Over the past two years, Lee Health has undergone a significant transformation, most notably converting from a public entity to a private nonprofit in 2024. This shift has enabled aggressive regional expansion beyond Lee County and a flurry of new partnerships and acquisitions.

The Florida Heart Merger Rationale: The move is intended to consolidate specialized cardiac care under one administrative umbrella to prepare for the high-acuity needs of the new Lee Health Fort Myers Hospital campus. Regarding the new hospital, the 810 million dollar project is being built to hurricane-resistant standards and is positioned as the primary hub for the cardiac specialists recently integrated through the Florida Heart Associates deal. This hospital’s earliest date for opening is “early” in 2028.

There still are some market alternatives in Lee County

A bit more digging and I learned there are 4 surgical centers in our community not owned or partially owned by Lee Health. There are a total of 15 actual operating rooms between the four and nine procedure rooms. Lee Health has ownership or partial ownership of 82 operating room beds in our community, the majority (61) are within actual hospital walls.

Lee Health has 350-400 primary care physicians in Lee county. They have an estimated additional 200 Advanced Practice Providers (physician extenders). Gemini’s sweep of the internet indicates we have around 450-500 non-Lee employed or private practice physicians. Unless the regulatory capture payment scheme is addressed, I am sure we doctors outside of Lee’s ownership are on the menu.

How Much Longer are Americans Going to Get Pushed Around?

I have been sounding the alarm since the Patient Protection and Affordable Care Act was passed and clanging the gong since 2015 when the Medicare Access and CHIP Reauthorization Act (MACRA) was passed.

The Current State of Our Health Liberty

The present situation regarding our medical autonomy and the role of government can be summarized by these fundamental truths:

• Of Limited Power: Our Constitution remains the supreme law, establishing a federal government of strictly limited and enumerated powers.

• The Consent of the Governed: This government exists solely by the consent of the people, who concede specific, minimal authorities in exchange for the protection of their inherent personal freedoms.

• A Modern Misplacement: Healthcare became a federal concern not by constitutional mandate, but at the whim of the “Great Society”— a recent and radical expansion of authority that misplaced the government’s true role.

• The Perpetrated Myth: A powerful alliance—the American Hospital Association, the Federation of American Hospitals, and the AAMC, alongside the American Medical Association and dominant insurers—has successfully perpetrated the myth that healthcare is naturally unaffordable, thereby inviting further federal control.

• The Capture of the Market: These self-serving interests have resulted in the Regulatory Capture of our healthcare market, creating a system that serves the institution over the individual.

• A Maligned Weight: The American citizen and the independent physician are currently being crushed by the artificial costs and bureaucratic weight of this maligned system.

• The Systematic Separation: Patients and physicians—the only two direct participants in the healing relationship—have been systematically silenced and separated by intermediaries.

• The Cycle of Blame: In this fractured state, both patients and doctors have been conditioned to point toward the other, rather than confronting the centralized system that has trapped them both.

And the True Irony Is Government Usurped Its Authority When It Started Medicare and Medicaid

My contention is that no amount of lobbying or attempts to legislate within the status quo will actually solve the situation. The only true action the market participants can take is to learn the modern lesson of Sisyphus. Recognize, Let Go and Pivot.

Some Doctors Have Learned the Lesson of Sisyphus- and Patients Are As Well

The Direct Pay and Concierge Model physicians have stopped pointing fingers, stopped begging for alms and have pivoted to the free market of health care. As we get bolder and more fellow doctors are exerting their authority, the hangers-on of the status quo will begin suffocating on their self-made bureaucratic bloat, lose more market share that can’t be replaced by breaking the backs of individuals being flogged with mandated unaffordable insurance premiums.

Individuals can leave the big insurance models with their ever lengthening list of no payment rules, prior authorization care interference and usury pharmacy benefit arrangements and join health sharing as an alternative to the status quo. Fellow freedom fighter Twila Brase of the Citizens’ Council for Health Freedom offers a helpful patient toolbox to provide information for individuals when confronted by health access points of care laden with bureaucratic forms and consent requests.

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Things look bad from over here
Too much confusion and no solution
Everyone here knows your fear
You're out of touch and you try too much

From Steppenwolf’s -Move Over

There is a specific kind of "confusion" that stems from a system designed to be opaque. For decades, the American healthcare apparatus has operated behind a veil of complex billing and "regulatory capture"—a term that sounds academic until you realize it’s the reason your medical bills are skyrocketing while your time with an actual doctor is shrinking.

My fellow Substacker and health care enlightener, Dutch Rojas, recently did a brilliant job recently explaining the traps of regulatory capture and how this has happened to the health care market.

Not everyone following me here is a patient at my practice, but for twenty years, I have been sounding the alarm. I have watched firsthand how, via Medicare payment policy, the government has systematically torn down the profession of medicine, replacing the physician-patient bond with a managed industrial complex.

The single most leveraged moment resulting in true market siphoning and the total disruption of traditional physician led health care came with the legislated agreement to price-fix physician payment within Medicare.

The RVU (Relative Value Unit) system was created in 1989 (implemented 1992) to replace chaotic, inflationary physician billing with a standardized, resource-based payment model—but in doing so, it laid the groundwork for today’s administratively driven, volume-measured healthcare economy. One of the strongest arguments for using this system was that physician knowledge and thinking skills were undervalued and procedural care was “arbitrarily” being overvalued in the marketplace.

Ironically, the result of the RVU codification of physician services has only further distorted payment towards technical procedural pay over physicians’ relative value. If one were to analyze the payment provided in this program, the facility and technical components of a point of care is rewarded a far higher dollar payment than the physician providing the actual care or diagnostic interpretive skillset. The idea of regulatory capture is obvious when the stated argument for the need of policy resulted in actually worsening the problem.

Dutch Rojas’s article goes on to demonstrate how Stark Regulation (preceded the RVU system) resulted in legislating the formal removal of physician ownership of any service outside their direct license and location of care. Then as time went on, government policy continues to progressively add more market distorted payment policies and regulatory restrictions which has enabled Hospitals to regulatorily capture nearly all physicians. By incarcerating us, hospitals have caused patients to lose their only true advocate and healers.

This Needs to Change

As more discussion in social media keeps pointing out the opaque and unfair payment schemes experienced by average citizens it is becoming more obvious that a day of reckoning is inevitable. If you are on X, nearly daily Mark Cuban, millionaire entrepreneur who started his Cost Plus generic medication virtual pharmacy is drilling deeper and deeper into the “insane” and illogical payment schemes built into our system. He still hasn’t come to the full conclusion that the free market is how this gets resolved. From some of his comments, I feel he is falling into the trap that keeping this a political issue (perhaps he has sights on running for office) remains the way for change. I disagree.

The best thing that could happen in my view is that the present administration and congress keeps moving towards liberating the control of health care dollars back into the hands of the citizen. We need to end mandated insurance and we need to stop discriminating against those trying to refuse paying for mandated insurance.

Health insurance is a failed product and the evidence is to note how many Americans are getting subsidized in order to “afford” the service. The ACA marketplace is no longer a traditional insurance market—it is a government-subsidized purchasing system where ~92–93% of participants rely on federal premium support. Over 22 million of 23-24 million enrollees. This is a failed policy pure and simple.

The single most discriminatory regulation presently in place is forcing high- deductible insurance purchases in order to allow an individual to have Health Savings Accounts. We need to allow Health Savings Accounts to any tax-paying US citizen of adult age.

Instead of borrowing more money or returning Medicare beneficiaries back to the added tax turnstile, we need to allow Medicare retirees to transfer IRA and pension savings/profits toward their own HSA. Stop using the RVU Medicare payment scheme as the cash register for and market arbitrator for health care innovation and price determination.

This past January I exposed a clear example of how Regulatory Capture gets done. It was my post regarding the special payment and waiver provided to Hospitals during the COVID debacle. Congress has just extended this “experiment”. What is most revealing about this story is that the update on the safety of virtual hospital care is that the data is an admission that a large amount of hospitalization appears unnecessary.

Under the Acute Hospital Care at Home initiative administered by the Centers for Medicare & Medicaid Services, hospitals were permitted to admit patients as inpatients while delivering the majority of their care at home. Patients received oxygen, IV medications, laboratory testing, nursing visits, and daily physician oversight without occupying a traditional hospital bed. Yet from a billing perspective, these episodes were still classified and reimbursed exactly like ordinary inpatient stays.

To my understanding there is no intent for congress to open up the Virtual Hospital concept to Medicare physicians. The irony of all this policy is that hospitals which should becoming less necessary for most of our healthcare are being incentivized to move into your bedroom AND get paid as if they built you a hospital suite.

Here Is A Photo Of One Of Lee Health’s “work vans”.

Clearly they plan on running with this new regulatorily captured market.

To Wit I Have Already Shared…

And As The Lyrics Go:

Yesterday's glory won't help us today
You wanna retire?
Get out of the way

I ain't got much time
The young ones close behind
I can't wait in line

If we can not wake you
Then we'll have to shake you

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This past week the Wall Street Journal printed an article following the announcement by Health Secretary Kennedy that the FDA was going to lift restrictions on peptide treatments. We are noting a rising of patient self-reporting consumption of peptide therapy protocols. Many of these patients are doing this in addition to paying us for comprehensive medical access and care. At this point, I felt it is time for my own self education and to post to the public on this topic.

Interestingly, despite Americans shouting that health care is unaffordable, it appears a big chunk of people are willing to shell out big bucks to keep up with the Jones’. Keep this in mind the next time your neighbor or a stranger tells you they can’t afford health care.

When you combine peptides and hormone therapy, you’re no longer looking at fringe medicine—you’re looking at a multi-billion-dollar, cash-pay health economy operating in plain sight, largely outside the traditional health care access point, namely doctors.

And if we add the gateway to Peptide therapy, namely, alternative hormone replacement therapy we see an even larger spend going on…

Globally this market may be 30 billion dollars or more.

It makes sense to me that Secretary Kennedy would loosen restrictions on peptides. He gets to poke big pharma in the eye for starters. The COVID 19 pandemic provided the opportunity for loosened compound pharmacy regulation. Big pharma couldn’t meet market demand for Ozempic and Mounjaro. Shortages are a scenario where patent law can be suspended and President Biden's administration did just that. The result was a rapid response “black/gray market for the generic/compounded versions of Ozempic and Mounjaro. These patent protected prescriptions aren’t typical pharma chemical molecules. They are, in fact… peptides called Glp-1 agonists. Actually these compounds make up the Lion’s share of the current US and likely global peptide market.

Noting the success of these scientifically studied and proven human peptide analogues (Glp1 agonists), I am learning that the telehealth supply chain and the non-physician hormone and aesthetic store fronts are pitching unproven but theoretically plausible peptide stacks onto patients. All of them promise leaner body fat and improved muscle and ligament healing. A more powerful and youthful YOU so to speak. Objectively the results can all be explained by the Glp-agonists but hey, why not jab yourself with some more products and get even “better” outcomes.

As a physician, I am chagrined as well as concerned about health extenders opening infusion clinics, pumping vitamins, amino acids, and who knows for sure what all into hangover victims and folks that just want to feel better.

According to Contrary Research:

The GLP-1 compounding boom demonstrated that patients are increasingly use alternative, consumerized care pathways when conventional channels are slow or expensive. Telehealth, cash pay, and compounding pharmacies functioned as a scalable distribution system for GLP-1s, filling a supply and access gap for a blockbuster therapy. These channels did more than fill a temporary gap: they demonstrated that patients will route around insurer-mediated pathways when access is slow, coverage is uncertain, or prices are high. In doing so, these pathways expanded drug access and customization, but often with less oversight and frequent conflicts with patent protections.

The growth of compounding also highlighted a longstanding tension in biopharma: patent exclusivity is designed to reward costly R&D, yet high prices and uneven coverage can create strong pressure for workarounds. Compounded GLP-1s exposed how quickly those workarounds can now scale. This pattern will likely be reproduced with future high-demand therapies, forcing regulators, manufacturers, and clinicians to balance access, safety, and incentives for innovation as more care moves outside traditional clinical settings and insurer-mediated systems.

Peptides- What Do We Know About This Therapeutic Class?

Peptides (Non-Biologics): Any polymer composed of 40 or fewer amino acids is generally classified as a drug (small molecule). These fall under the Hatch-Waxman Act for patenting and generic approvals. The first patented therapeutic peptide is insulin.

Historical Context

• Defining the Class: Insulin was the first substance to prove that a peptide (a chain of amino acids) could serve as a life-saving drug. It is a 51-amino acid peptide, though modern regulatory definitions (like the Hatch-Waxman Act mentioned in your draft) sometimes distinguish between “small” peptides (under 40 amino acids) and larger proteins. The law changed in 2020 regarding peptide definition. This is why insulin is still considered the first peptide despite having 51 amino acids. So, legally speaking, the FDA now classifies insulin as a protein/biologic, not a peptide. This transition was designed to open the door for biosimilars (the biologic version of generics).

• First Synthetic Versions: Decades later, insulin continued its “firsts” by becoming the first recombinant DNA (biotechnological) drug approved by the FDA in 1982 (Humulin).

There are many peptides that are prescription medications. Examples include the Glp-1 agonist peptides. Namely, liraglutide, semaglutide, tirzepatide. Liraglutide is a daily injection now available generically. The other two are the name brand products we all know and love which are also currently still being offered in compounding pharmacies. Other examples include teriparatide (Forteo) used for osteoporosis treatment, desmopressin (DDAVP) used for diabetes insipidus and bedwetting, and bremelanotide (Vyleesi) for female sexual dysfunction.

As of late March 2026, the specific number of peptides moving to Category 1 is 14, according to the directive from Health and Human Services (HHS) Secretary Robert F. Kennedy Jr. Category one allows legal marketing and preparation and are considered posing no significant safety risks.

On February 27, 2026, Secretary Kennedy announced a major policy shift to “end the war on peptides” by reclassifying approximately 14 of the 19 peptides that the FDA had previously restricted in late 2023. ¹

Following the landmark February 2026 announcement regarding the reclassification of therapeutic compounds, several “trendy” peptides are making a high-profile return to compounding pharmacies. These options have become particularly popular in anti-aging and recovery protocols:

• BPC-157 (Healing & Recovery): Often called the “Body Protection Compound,” this peptide is a favorite for systemic repair, specifically targeting gut health and the accelerated healing of tendons and ligaments.

• GHK-Cu (Skin & Anti-Aging): A naturally occurring copper peptide frequently used in both premium serums and injections to stimulate collagen production and visibly reduce wrinkles.

• AOD-9604 (Targeted Fat Loss): This fragment of Human Growth Hormone is designed to trigger lipolysis (fat burning) without the unwanted side effect of affecting blood sugar levels.

• MOTS-c (Metabolic Health): Widely referred to as an “exercise mimetic,” it is prized for its ability to boost mitochondrial function and overall cellular energy.

• CJC-1295 / Ipamorelin (Growth Hormone Support): Typically administered as a synergistic “stack,” these peptides stimulate the body’s natural growth hormone production to improve deep sleep and support muscle maintenance.

Patients are coming in telling me they are getting the Wolverine stack. I am thinking “what???”.

The “Wolverine Stack” (or Wolverine Blend) is a popular nickname for the combination of two specific regenerative peptides: BPC-157 and TB-500 (Thymosin Beta-4). It is named after the Marvel character because of the intended effect of “superhuman” healing and tissue repair.

Enter the Rub

While there are many scientific articles discussing the mechanisms of these peptides, there is currently no large-scale, double-blind, placebo-controlled human trial that validates the specific “Wolverine Stack” (BPC-157 + TB-500) for injury recovery or anti-aging. This is true for most of these products. What this means to me as a physician is, most of these programs have inadequate scientific backing and as such the claims can be wildly far off from any actual therapeutic result. Further, since these products are often given concomitantly with hormones, vitamins, and exercise programs, it is essentially impossible to know what of these variables is having real effects or not.

What’s the Harm Doc?

Even exercise recommendations have potential for harm. I don’t think harm is any less expected or anticipated from artificially injecting our body with potentially bioactive peptides. Further, if we provide our bodies with essentially replacement peptides for naturally synthesized active peptides, it seems predictable that we will alter normal peptide regulation and genetic signalling. Many of these molecules communicate with other naturally communicating networks and hormone pathways. In a true deficiency a therapeutic result may certainly occur. In the absence of a true deficiency, these injections may create true biologic metabolic confusion. Which tests are the proper tests to measure for peptide deficiency? How do we objectively measure for outcomes? What safety signals should we be monitoring for and how can we determine such concerns are real or linked to therapy?

Call me old fashioned but I think you want physicians helping you monitor these rather loosely dispensed treatment protocols. As I have stated in a prior post- be careful what you read. Also buyer beware.

Some Other Interesting Peptide Tidbits

The quest for oral peptide delivery is often called the “Holy Grail” of pharmacology. While traditional drugs are small, robust molecules, peptides are large, fragile chains of amino acids that the human body is expertly designed to destroy as “food” (protein).

Here are the specific limitations and the cutting-edge technological developments as of 2026.

1. Key Limitations (The Biological Gauntlet)

• The “Acid Bath”: The stomach’s low pH can quickly denature peptides, unfolding their complex 3D shapes and rendering them biologically inactive.

• Enzymatic “Digestion”: The GI tract is saturated with proteases and peptidases (enzymes) specifically evolved to break down peptides into individual amino acids for nutrition.

• The Permeability Barrier: Peptides are typically large, hydrophilic (water-loving), and charged. This prevents them from passively diffusing through the lipophilic (fat-loving) cell membranes of the intestinal wall.

• First-Pass Metabolism: Even if a peptide reaches the bloodstream via the gut, it often travels directly to the liver, where it can be rapidly cleared before reaching its target.

• Low Bioavailability: Due to these factors, oral peptides historically achieved less than 1% bioavailability (the amount actually reaching systemic circulation) compared to near $100 % for injections.

2. Technological Developments (The 2026 Landscape)

To overcome these hurdles, scientists have moved beyond simple “pills” to complex delivery vehicles and “robotic” devices.

A. Chemical Permeation Enhancers (The SNAC Breakthrough)

• SNAC (Salcaprozate Sodium): Used in oral semaglutide (Rybelsus), SNAC creates a localized “micro-environment” with a higher pH to protect the peptide from acid. It also fluidizes the cell membrane, allowing the peptide to slip through transcellularly. The newly offered oral Wegovy is basically higher dose Rybelsus. The oral bioavailability of Rybelsus (semaglutide) using SNAC (Salcaprozate Sodium) technology is approximately 0.4% to 1%.

• GIPET™ and TPE Technology: Technologies like Transient Permeation Enhancer (TPE) use medium-chain fatty acids (like sodium caprylate) to briefly open the “tight junctions” between cells, allowing peptides to pass through the gaps. Oral options for desmopressin, low molecular weight heparin, alendronate and oral insulin have used this technology.

B. Ingestible “Robotic” Pills (Mechanical Injection)

• SOMA (Self-Orienting Milliscale Applicator): Inspired by the shell of a leopard tortoise, this robotic pill always lands upright in the stomach. Once it hits the stomach lining, it triggers a spring-loaded “micro-needle” made of compressed drug (like insulin) to inject directly into the stomach wall.

• RaniPill™: An ingestible capsule that travels to the small intestine, where the higher pH inflates a tiny balloon. This balloon pushes dissolvable micro-needles into the intestinal wall—a pain-free process since the intestines lack sharp-pain receptors.

• These technologies are not presently being used but are being researched.

C. Advanced Nano-Formulations

• Lipid-Based Carriers (SEDDS): Self-Emulsifying Drug Delivery Systems encapsulate peptides in tiny oil droplets. These droplets mimic dietary fats, tricking the body into absorbing the peptide through the lymphatic system, effectively bypassing the liver. This technology is used now for two prescription products and is being researched for oral insulin and enoxaparin (low molecular weight heparin).

• Mucoadhesive Patches: Micro-scale patches designed to stick to the intestinal lining and release a high concentration of the peptide directly into the tissue, protecting it from being washed away by GI fluids.

D. Sublingual Thin-Films

• ODF (Oral Dissolvable Films): Newer platforms like BioNxt’s thin-film technology allow peptides to be absorbed under the tongue (sublingual). This bypasses the entire GI tract and the liver, providing a much faster and more direct route to the bloodstream.

• This technology is being studied for several different products including an oral delivery of cladribine, used for Multiple Sclerosis and Myasthenia Gravis.

• BioNxt is adding rights to a new chaperone technology for peptides and other complex molecules.

E. Oral Generic Equivalents For Rybelsus

Have recently been made available in India and potentially Canada. The core patents for the semaglutide compound expired on March 20, 2026, in several major markets, most notably India and China.

• In India: This week is considered “Day 1” for generic semaglutide. Leading Indian pharmaceutical firms like Sun Pharma, Zydus Lifesciences, and Torrent Pharmaceuticals are launching generic versions. Torrent is specifically focused on the oral tablet equivalent of Rybelsus.

• In the U.S.: There is no FDA-approved generic for Rybelsus. Due to a complex web of secondary patents (covering the SNAC delivery technology and specific weight-loss uses), U.S. generic entry is not expected until 2031 or 2032.

• Canada: Regulatory experts predict generic semaglutide could appear in Canada as early as late 2026, significantly ahead of the U.S. market.

Let’s Wrap This Up

The Future of Peptides: Access vs. Analysis

The recent “de-escalation” of the war on peptides by Secretary Kennedy marks a pivotal moment where patient demand has effectively forced a regulatory hand. As we move into this new era of “Category 1” compounding and the potential for “robotic” oral delivery, the barrier to access is crumbling. However, as a physician, my primary concern remains the gap between plausibility and proof. While the “Wolverine Stack” and other protocols offer a tantalizing glimpse into a future of rapid recovery and metabolic optimization, they are currently being deployed without the long-term safety data or standardized monitoring we require for traditional medicine. We are essentially watching a massive, real-world clinical trial unfold in real-time. If you choose to explore these pathways, I urge you to move away from the “grey market” and toward the emerging legal, compounded channels where medical oversight can at least ensure that your quest for the Fountain of Youth doesn’t come at the cost of your long-term metabolic health.

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According to Google AI, for U.S. physicians, the following are currently considered the most reputable and widely referenced “big” journals:

• New England Journal of Medicine (NEJM): Established in 1812, it remains the most prestigious peer-reviewed medical journal, particularly for clinical trials and original research.

• Journal of the American Medical Association (JAMA): A staple for U.S. practitioners, providing broad editorial coverage and highly cited peer-reviewed articles across all medical disciplines.

• The Lancet: While based in the UK, it is globally influential and a primary reference for international health and significant specialty research.

• The BMJ (British Medical Journal): Known for its rigorous standards and focus on medical education and clinical practice.

• Annals of Internal Medicine: The official journal of the American College of Physicians, highly regarded for its focus on Internal Medicine and healthcare policy.

• Nature Medicine: Often cited for translational research and breakthroughs that bridge the gap between basic science and clinical application.

I will say that the Journal of American Medical Association has become the rag for international healthcare policy with an occasional real scientific article. They worked hard at sabotaging COVID treatment studies during the Pandemic (aka Plandemic). In my view, JAMA is a government mouth piece touting medically irrelevant “wishes” of international health care policy. The journal totally misses the fact that health care populations are local and regional and it is a Prometheus effort to force universal standards to our country.

Likewise, the NEJM provides an excessive academic representation in their opinion articles. This journal does still offer more rigorous research articles and excellent reviews of medical diseases.

The Lancet and British Journal of Medicine (BJM)- British publications- need I say more??

Annals of Internal Medicine. Historically a great journal and in my opinion, the most reliable journal for real scientific inquiry. It is born from the American College of Physicians. Granted, they too, have fallen prey to certain political biases but they are still scientifically the more rigorous of the present modern day medical journals.

Nature Medicine??? Not a physician read journal. It is, however a good source for bench research. Bench research is hypothesis generating BUT not necessarily clinically relevant.

A Journal Missing….

The American Journal Of Medicine. This “Top 3 U.S Medical journals” was placed into the ash heap of the internet search options when Dr. Peter McCullough offered to clinicians the COVID Outpatient Treatment Protocol. I have always considered this medical journal worthy of my precious reading time.

So What Is Doctor Kordonowy Reading?

My readers know I have reported on the myth vs science of coffee and caffeine. Here again is a recent article addressing a common question. “Should I stop drinking coffee now that I have a diagnosis of Atrial Fibrillation ( a form of rapid and irregular heart beats).

Caffeinated Coffee Consumption or Abstinence to Reduce Atrial Fibrillation The DECAF Randomized Clinical Trial

The DECAF Randomized Clinical Trial (November 2025) disputes the myth that coffee causes heart arrhythmias, finding that daily consumption may actually reduce atrial fibrillation recurrence by 39%. Furthermore, studies indicate that moderate coffee intake is associated with lower risks of heart failure and stroke, while encouraging physical activity. Read the full story at UCSF News.

Why Coffee Might Be Good for Your Heart Rhythm

For years, many doctors and patients believed that caffeine was a “trigger” for heart rhythm issues like Atrial Fibrillation. However, recent clinical evidence suggests the opposite may be true for many people.

1. The “Conventional Wisdom” vs. Reality

Traditionally, it was thought that caffeinated coffee was proarrhythmic (meaning it promotes irregular heart rhythms). The DECAF trial was specifically designed to test this theory by comparing patients who drank coffee to those who avoided it entirely.

2. Lower Risk of Recurrence

The study found that patients who had recently undergone treatment for persistent AF (cardioversion) actually fared better when they consumed coffee:

• Coffee Group: Only 47% had a recurrence of AF within six months.

• Abstinence Group: 64% had a recurrence of AF within the same timeframe.

• The Result: Drinking at least one cup of caffeinated coffee daily was associated with a 39% lower hazard of the arrhythmia returning.

3. Potential Protective Mechanisms

While the study focused on the results rather than the biological “why,” researchers and the AHA often point to several ways coffee may protect the heart:

• Antioxidant Properties: Coffee is a major source of antioxidants, which can reduce inflammation and “remodeling” of the heart tissue.

• Adenosine Blocking: Caffeine blocks adenosine receptors; since adenosine can sometimes shorten the heart’s electrical recovery period (potentially triggering AF), caffeine may provide a stabilizing effect.

• Improved Heart Health: Regular consumption has been linked to lower risks of other heart-related issues, which indirectly keeps the heart’s electrical system healthier.

Statin Medication and Coronary Events

Diabetes is a well established associated condition with acute myocardial infarction (heart attack). Recent articles are confirming a mild increased incidence of the medical definition of diabetes with the use of statin medications prescribed for cholesterol lowering in at risk patients.

A recent study confirmed that the benefits of statin prescription in diabetic patients clearly outweighed any risk of medication use. In fact, ALL CAUSE mortality was benefited in the Statin group.

This is an important and might I say and ADDITIVE study supporting cholesterol lowering in high risk patients for coronary and other macrovascular events.

Statin initiation was associated with reductions in all-cause mortality and major CVD across QRISK3 strata. In the low-risk stratum, RDs and RRs were −0.53% (95% CI, −0.90% to −0.08%) and 0.80 (95% CI, 0.67 to 0.97), respectively, for all-cause mortality and −0.83% (95% CI, −1.28% to −0.34%) and 0.78 (95% CI, 0.66 to 0.91), respectively, for major CVD. A small increased risk for myopathy was observed in the moderate-risk stratum only, and there was no associated increased risk for liver dysfunction in any stratum.

Note- the myth that statins promote liver disease and medically relevant harm is again refuted in this study. I am really tired of patients reporting their “literature” social feeds “notices” that using proven lipid lowering medication is harmful.

Genetic Association with Disease. Hypothesis Generating But Not Ready For Prime Time

A recent study looking at analyzing common genetic variants associated with coronary artery disease confirms that the lion’s share of at risk coronary artery events is “POLYGENIC” versus single gene associated. This review is interesting to me because it demonstrates how the heart disease problem early on was assessed through familial inheritance patterns.

The lipid/cholesterol GEEKs were the first major discipline that, starting with Mendelian inheritance pedigree analysis, linked specific single gene defects (related to cholesterol metabolism) with early deaths from heart attacks.

That research led to the now proven hypothesis that elevated LDL cholesterol resulted in early death from coronary occlusion of cholesterol burdened plaques and associated thrombosis. Heterozygous and homozygous hypercholesterolemia are the two primary pedigrees of this association.

Doctors can find these patient subjects by measuring the phenotypical presentation- namely LDL cholesterol levels in the 95th percentile or higher. If these values are further linked with family histories of early heart attacks, the diagnostic certainty rises to very high levels.

Yet… this group represents a small proportion of heart attack victims. Enter the polygenic inquiry. It turns out there are currently tens of genetic variants, some of which are associated with cholesterol metabolism and thus measured levels, but many that are associated with other metabolic pathways a separation or more distant from cholesterol metabolism

So far studies confirm that in most cases it is a multitude of genetic variants that additively contribute to early heart attack risk. Unfortunately as of now, the concept of incorporating across the board genetics analysis to risk predict high risk patients has very low yield. I suspect that with time and especially with quantitative computing the precision of genetic analysis will eventually become clinically useful. Even though there are multiple genetic associations that are not directly linked to LDL cholesterol, LDL lowering lowers events in polygenetic high risk patients.

THE MAIN POINT I OBTAIN FROM THIS RESEARCH IS THAT A FAMILY HISTORY OF EARLY HEART ATTACK INDICATES A CLEAR GENETIC RISK FACTOR, SINGLE GENE OR POLYGENIC. THIS SHOULD CARRY MORE WEIGHT THAN OUR CURRENT “ RISK ASSOCIATION QUERIES” USED IN HISTORICAL RISK ASSESSMENTS TOOLS.

A Final Point

From genetic reported information when an individual has a polygenic risk (family history), it turns out behavior/lifestyle changes have an equal positive benefit for outcome as medical intervention. THIS MEANS, IN THE CONTEXT OF A POSITIVE FAMILY HISTORY OF EARLY HEART ATTACK, CURRENT MEDITERANIAN DIET AND ACTIVITY RECOMMENDATIONS WORK AS WELL AS MEDICATION INTERVENTION. LIKEWISE ALL MEDICATION TRIALS ASSESSING LDL CHOLESTEROL LOWERING SHOW CLINICAL BENEFIT FOR CARDIAC EVENTS AND ALL CAUSE MORTALITY. WHAT ISN’T KNOWN BASED UPON CURRENT LITERATURE IS WHETHER COMBINING LIFESTILE CHANGES WITH LDL LOWERING MEDICATIONS IS SUPERIOR TO EACH INDIVIDUAL APPROACH.

This is what we physicians are trying to prevent. Heart attack and (associated stroke) are still the main preventable afflictions in America.

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For decades, Medicaid has operated as a vast and complex joint federal–state program with limited public visibility into how hundreds of billions of dollars are actually spent at the provider level. With nearly a trillion dollars in annual expenditures and millions of beneficiaries spanning vulnerable populations — including children, disabled individuals, and the elderly — oversight has historically relied on fragmented audits, state reporting, and retrospective enforcement actions. The release of a detailed national payment dataset changes that dynamic in a fundamental way. Transparency alters behavior. When patterns become visible, anomalies become detectable, and incentives shift. Whether intentionally framed this way or not, the signal being sent to the system is unmistakable: federal oversight is increasing, scrutiny is expanding beyond traditional enforcement channels, and participants across the Medicaid ecosystem — from providers to contractors to state programs — should recognize a new reality. In short, the message is simple: the cops are coming.

Background: Medicaid Crowdsourcing and Program Context

Medicaid Data Crowdsourcing Initiative

The U.S. Department of Health and Human Services publicly released a large national Medicaid provider payment dataset covering 2018–2024 in early February 2026 (Feb 7–9 window). The dataset includes provider-level spending by procedure code (HCPCS) and month, where HCPCS (Healthcare Common Procedure Coding System) refers to the standardized billing codes used across U.S. healthcare to identify medical services, procedures, equipment, and supplies for payment purposes. The stated purpose of the release is to enable public examination of waste, fraud, and abuse within Medicaid by allowing analysts to evaluate patterns of utilization and payments across providers and regions. This effort represents one of the first major attempts at open forensic auditing of a federal entitlement program using publicly accessible data.

No Confirmed Government Fraud Findings Yet From the New Dataset

As of today:

There have been no official federal announcements identifying specific providers or states as fraudulent based on the newly released crowdsourced dataset itself.

The release is still very recent (early February 2026), and formal investigations take months to years.

However — signals are emerging.

Public Claims From Analysts and Commentary

Several early analyses circulating online claim large anomalies:

• One analysis reportedly suggested tens of billions in “likely fraudulent payments” from a small subset of providers examined.

• These claims are not verified findings — they are interpretations of billing patterns.

Some national coverage highlights:

• Claims that the data could expose high-billing providers and questionable patterns, including autism services in certain states such as Minnesota.

• Public statements from political figures asserting the dataset may reveal “billions” in fraud.

These are assertions, not confirmed enforcement outcomes. The infrastructure for identifying fraud has been created, but validated findings have not yet emerged publicly. Early analyses of the newly released Medicaid payment data have identified unusual billing patterns in certain sectors and regions, but no formal government fraud determinations have yet been announced. It takes months to years for the legal process to be worked through.

Based on historical federal audits and improper payment studies, the most realistic estimate is that overall Medicaid fraud likely falls in the low single-digit to mid-single-digit range, with improper payments (which include documentation errors and eligibility issues, not just fraud) typically reported around 5–8% nationally. The probability that true fraud exceeds 10% across the entire Medicaid program is therefore relatively low — likely in the 10–20% range — because a substantial portion of spending flows through hospitals, managed care plans, and institutional providers that operate with greater regulatory oversight and compliance infrastructure. Large public datasets such as the recently released Medicaid payment files also tend to identify billing outliers before any determination of wrongdoing, meaning early signals should be interpreted as risk indicators rather than proof. In practical terms, past experience suggests some fraud will almost certainly be identified over time, but broad claims of systemic double-digit fraud across the entire program are not strongly supported by historical evidence.

Certain sectors, however, present a very different risk profile. Areas historically associated with fragmented oversight — including home and community-based services, behavioral health programs, durable medical equipment suppliers, and transportation services — have demonstrated significantly higher anomaly rates in enforcement actions, meaning localized fraud percentages in those niches could plausibly exceed 10–20% even while the overall program remains much lower. This concentration effect explains why large fraud headlines periodically emerge despite relatively modest aggregate fraud estimates: wrongdoing tends to cluster in smaller, labor-intensive service segments rather than in hospital or traditional physician billing. As a result, early analyses of the newly released data are most likely to surface outliers in these higher-risk sectors first, with validation requiring deeper clinical and documentation review.

Fellow Health Care cost analyst and SubStack writer, Dutch Rojas was one of the first social media contributors to point out the higher-risk sector of personal care billing in New York that warrants a closer Federal look. How in the world do we monitor or verify family caregivers working for mom or pop in their daily home health services? Did everyone know these Medicaid programs/billing codes exist?

Why is Medicaid In The News?

High Points: Medicaid Spending and Eligibility After ACA Expansion. The Medicaid Budget Nearly Equals Medicare’s Annual Costs Now!

Medicaid is a joint federal–state health insurance program that now spends approximately $850–900 billion annually, nearly double its size prior to the Affordable Care Act (ACA), when spending was roughly $450 billion. The program serves about 80 million Americans, making it the largest public insurance program in the United States. Although Medicaid is often discussed as a program for low-income populations broadly, its spending is highly concentrated in specific eligibility groups, particularly individuals who qualify due to disability and elderly beneficiaries who require long-term care services.

Eligibility for Medicaid falls into three major categories: income-based adults (including ACA expansion populations), disabled individuals, and elderly beneficiaries, many of whom are also enrolled in Medicare. The ACA expansion, implemented in 2014, primarily added working-age adults with incomes up to 138% of the federal poverty level, increasing enrollment by roughly 20–23 million people nationwide. These expansion beneficiaries tend to be younger and healthier, with annual costs averaging roughly $6,000–9,000 per person, which is substantially lower than costs for disabled or elderly enrollees.

Despite representing only about 20–25% of Medicaid enrollees, individuals who qualify due to disability and elderly beneficiaries account for approximately 50–60% of total Medicaid spending. This actually makes sense. Working-age disabled beneficiaries often incur annual costs between $15,000–25,000, while elderly beneficiaries — especially those requiring nursing home or long-term services — may exceed $20,000–40,000 per year. A large portion of this spending occurs among the dual-eligible population (people enrolled in both Medicare and Medicaid), which numbers about 12–13 million Americans and accounts for roughly 30% of Medicaid expenditures despite representing a minority of enrollees.

The ACA expansion significantly changed Medicaid demographics but did not fundamentally alter the core cost drivers of the program. Most of the increase in enrollment came from able-bodied adults qualifying through income rather than disability, which lowered the proportion of disabled and elderly beneficiaries within the program but did not reduce their absolute numbers or spending impact. Expansion spending today is estimated at roughly $150–200 billion annually, meaning that only part of Medicaid’s overall growth since 2014 is attributable directly to expansion; other drivers include medical inflation, long-term care costs, managed care payments, and demographic aging.

The key structural reality is that Medicaid now functions as two programs simultaneously: a large income-based insurance program for low-income adults and children, and a high-cost medical and long-term care safety net for disabled and elderly populations. Even after ACA expansion, the majority of Medicaid dollars continue to flow toward medically complex beneficiaries rather than the newly insured income-eligible adults.

Is Medicare Next?

The release of national Medicaid payment data has also triggered a much more consequential question: is Medicare next? From a structural standpoint, the answer increasingly looks like yes. Medicare represents an even larger pool of federal spending than Medicaid, operates under centralized federal authority, and already collects standardized claims data across hospitals, physicians, and outpatient services, making technical transparency easier to implement. At the same time, scrutiny of Medicare has intensified — particularly around Medicare Advantage (Part C) plans, where private insurers such as UnitedHealth and other large carriers receive risk-adjusted payments from the federal government that have been repeatedly criticized by watchdog agencies for potential overbilling, upcoding incentives, and opaque financial flows. Billions of dollars in payment disputes, audit findings, and litigation involving Medicare Advantage organizations have elevated political pressure for greater accountability.

When combined with the policy rationale already used to justify the Medicaid dataset — transparency, fraud detection, and taxpayer oversight — the logic becomes difficult to ignore. While no formal announcement has been made, the trajectory is clear: once the federal government demonstrates that large entitlement payment systems can be opened to public scrutiny, pressure naturally shifts toward the larger program. In that context, the Medicaid release may not be an endpoint, but rather a proof of concept. For stakeholders across healthcare — particularly insurers, contractors, and providers participating in federal programs — the implicit message is hard to miss: the era of limited visibility into public healthcare spending may be ending, and Medicare could very well be next.

As Medicare Insolvency Accelerates Forward

I expect that Uncle Sam will push the public to help find fraudulent dollars. It became crystal clear to me many years back that this come-to-Jesus event was inevitable. As primary care doctors were getting frog-boiled in the hot kettle, the “easiest” adjustment to keep themselves financially whole and in practice was to create the Hybrid care model. Quitting Medicare was perceived as just too shocking. But now as this fraud issue unfolds, I see cause for real concern.

Medicare Concierge / MDVIP-Style Hybrid Version

The possibility of expanded Medicare payment transparency carries particular relevance for physicians participating in Medicare while also charging patients membership or concierge fees — including models similar to MDVIP and other hybrid practices. Medicare does not reimburse physicians for “access” itself, but it does pay for the professional evaluation and management services that occur once access is obtained. When a membership fee is required for patients to obtain physician availability, communication, or coordination that may reasonably overlap with covered services, regulators could interpret the arrangement as a form of supplemental payment tied to Medicare-covered care, creating potential exposure under beneficiary inducement or double payment theories. Many concierge programs attempt to mitigate this risk by defining memberships as covering amenities or non-covered services, but the practical boundary between amenities and access to covered care can become blurred, particularly if membership participation is effectively required to remain in the practice.

None of this implies that concierge or hybrid models are inherently improper; many operate within legal guidance. However, increased federal visibility into physician billing patterns could make hybrid arrangements easier to identify and evaluate, especially if payment models appear to create financial barriers to accessing Medicare-covered services.

By contrast, physicians operating fully outside third-party reimbursement — such as in true direct primary care structures — avoid this layered payment issue entirely. This means leaving Medicare which is essentially an admission that the program isn’t serving doctors nor patients. A single payment relationship with the patient removes ambiguity about who is paying for what service and reduces regulatory exposure associated with overlapping compensation streams. As policy momentum moves toward greater scrutiny of federal healthcare spending, physicians should recognize that practice models combining public reimbursement with private membership revenue may attract more attention than those built on transparent, direct patient payment alone. To me, this is cause for concern and it could happen far faster than many think.

Professionally, the safest place in modern healthcare isn’t inside the payment system — it’s outside of it, where the transaction is voluntary, transparent, and conflict-free. Those in government trying to address the payment morass understand this but the powers that be are formidable. The public “call to action” indicates things are and must continue changing.

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TrumpRx is a prescription drug pricing initiative launched by the U.S. federal government in 2026. It’s centered around a government-operated website at trumprx.gov that displays discounted prices on selected prescription medications and connects consumers to ways of buying them at those prices.

It is not an e-retail pharmacy. It is basically a website that functions as a market facilitator. It is posting the products that the manufacturers have agreed to offer “most favored nation” prices to the cash pay only customers in America. The site states this is the initial offering list with an intention to add more.

But upon analyzing the offers I can tell you this program is more hype than beef. This reminds me of a blog I wrote where I mentioned then, President Biden’s, “pharma sweetheart deal” for drug discounts for Medicare beneficiaries.

Excerpt:

Well…. TrumpRx is No Different!

Clearly the president didn’t have the right people in the room when he “got down and dirty” with big pharma. Nearly all of the pills being “offered” on Trump Rx can be purchased in the generic form at a further fraction of the cost of the “big discount” on name brands. This means if people are gullible enough to use the program for the pills, Big Pharma gets to take a lost share from the generic market. This leads to patients paying a premium for a brand name, even when a cheaper, equally effective equivalent exists.

After analyzing the offerings in more detail, we can see three medication categories within this government formulary. The most significant from a cost savings perspective is the biological grouping. I will save the latter part of this post to dive into that in more detail. This part of the pharmaceutical market is the most difficult to understand AND appears to have the most market distortion and usury in the present insurance payment model. After we walk through this project, I will summarize where I think there is actual benefit for consumers. It will be a pretty short list, I do say.

The largest and second category is the pill grouping. I chose to include the pill Wegovy in the third category as it is a specialized delivery of a technically “pill” form as it is rapidly dissolving. Within the pill grouping there are three products that are presently name brand only. They are Duavee, Farxiga, and Xeljanz.

The third category includes a hodgepodge of products with relatively small market penetration with arguably the lung inhalation medications being an exception. Following is a illustration of the categories/list.

Understanding the Manufacturer Landscape

Pfizer currently represents the single largest manufacturer contributor to the TrumpRx medication list. While the program is presented broadly as a drug pricing initiative, the product mix shows a meaningful concentration from one company across multiple therapeutic areas, including hormone therapy, immunology, dermatology, and urology. This concentration does not invalidate the program, but it does provide important context when interpreting the scope of participation and the degree of market representation.

Pfizer-manufactured products on the TrumpRx list include:

• Abrilada® (adalimumab biosimilar)
• Duavee®
• Eucrisa®
• Premarin®
• Premarin® Vaginal Cream
• Prempro®
• Toviaz®
• Xeljanz®

This amounts to roughly one in five medications on the list coming from a single manufacturer.

To place that in perspective, the U.S. pharmaceutical market is vastly larger than the subset represented in this program. The FDA supply chain includes thousands of manufacturing facilities worldwide, and hundreds of companies hold approved drug applications for products marketed in the United States. Even when narrowing to recognizable commercial players with meaningful market share, there are dozens of major pharmaceutical manufacturers operating across branded and generic markets.

In practical terms:

• Hundreds of companies have FDA-approved drugs available in the U.S. market
• Dozens of major manufacturers compete across therapeutic categories
• Thousands of global manufacturing facilities supply the U.S. drug ecosystem

Against that backdrop, the TrumpRx list reflects participation from only a small fraction of the available pharmaceutical marketplace. Noting the large scale of the overall potential market, the present core manufacturers participating in Trump Rx are:

Pfizer
Novo Nordisk
Eli Lilly
AstraZeneca
Merck
Organon
Various smaller specialty manufacturers

How TrumpRx Works for Patients (Or Does It Work At All)?

TrumpRx is a cash-price medication program. It is designed primarily for people who are paying for prescriptions out of pocket rather than using insurance.

In practical terms, the website does two main things:

• It links patients to discount coupons (similar to GoodRx) that can be used at participating retail pharmacies.
• It connects patients to manufacturer pricing programs for certain medications, especially higher-cost specialty drugs and biologics.

The site itself does not manufacture medications, and it is not an insurance plan. It functions more like a pricing navigation tool. From my deep dive into this story, I would suggest it is more like a social services program than a marketplace.

When someone goes shopping, one of two things will happen. They will be linked to the GoodRx network OR they will be diverted to a specialized manufacturer fulfillment program. The manufacturer fulfillment program will basically result in a long form questionnaire that will be looking for any loophole to get them out of helping you. You will be asked upon your honor that you don’t have insurance. This is because they want to keep you trapped into a much more lucrative insurance prescription scheme. I will explain that a bit later in this post. You will next be asked to provide proof of income needs or ability. This process is couched in the phrase “meet eligibility requirements”.

For some higher-cost medications — especially biologics — patients may be routed to manufacturer programs.

These programs sometimes include:

• Income thresholds
• Insurance status questions
• Prior authorization confirmation
• Specialty pharmacy enrollment
• Physician paperwork
• Consent forms

This is because manufacturers already operate:

Patient Assistance Programs (PAPs) or affordability programs.

TrumpRx may be directing patients into those existing systems.

And Then There Is GoodRx

GoodRx is not insurance and it is not a pharmacy network owner. GoodRx is a price-aggregation and coupon platform that connects three parties:

• Pharmacy Benefit Managers (PBMs)
• Pharmacies
• Patients paying cash

The key point:

GoodRx uses existing PBM discount networks that pharmacies already participate in.

GoodRx didn’t individually contract with every pharmacy in America. They plugged into networks that already existed. As a side note, that is how Obamacare got people into insurance. The plans simply leased existing insurance contracts onto the ACA insurance card.

Biologics: Why They Are Different From Traditional Drugs

As I started this project, I was very excited to find patients a deal. Biologic medications are notoriously expensive and have their own sanctioned patent process. On TrumpRx, the first drug offering in the alphabetical drug listing menu is the biologic medication Abrilada^{® .}

This is Pfizer’s version of a biosimilar biologic immune injection medication. It turns out Humira® from the pharmaceutical manufacturer AbbVie was the original inventor of the molecule and held patent protection until 2023. Now there are ten manufacturers making a version of this following the patent expiration.

Biologic medications are produced using living systems rather than chemical synthesis. They are typically large, complex proteins — such as monoclonal antibodies, hormones, or engineered peptides — whose final structure depends not only on the genetic sequence but also on the manufacturing process itself.

Because of this complexity, biologics cannot be copied in the same way that traditional small-molecule drugs can.

The Core Regulatory Distinction

Traditional drugs follow a generic pathway.
Biologics follow a biosimilar pathway.

Small-Molecule Drugs

• Chemically synthesized
• Structurally simple and fully characterizable
• Generic versions are chemically identical
• Approval based primarily on pharmacokinetic equivalence

Biologics

• Produced in living cells
• Large, structurally complex proteins
• Manufacturing process affects final product
• Exact duplication is impossible

Therefore: Biologics have “biosimilars,” not true generics.

Biologic drugs are fundamentally different from traditional medications. They are complex proteins produced in living systems, and their structure depends on the manufacturing process itself. As a result, follow-on versions are biosimilars — highly similar but not identical — rather than true generics. Multiple patent layers and regulatory exclusivity periods further limit competition, which is why biologic markets tend to evolve more slowly and maintain higher prices than conventional drugs.

Among the biologic medications listed on the TrumpRx platform, only a minority currently have biosimilar competition. Most of the highest-profile drugs, including semaglutide and tirzepatide products, remain under active patent protection with no approved biosimilar alternatives. As a result, price reductions in these categories reflect manufacturer pricing decisions rather than true competitive market forces.

While getting affordable generic pill alternatives to the market happens routinely, this isn’t the case for biosimilar products due to the unique methods of production and getting regulatory approval for these compounds.

Fact:

International markets offer somewhat greater biosimilar competition for older biologic classes, but the newest high-cost drugs — particularly GLP-1 and dual-agonist therapies — remain under patent protection worldwide. Geography does not overcome patent barriers, which means pricing power for these products remains largely manufacturer-controlled across global markets.

This last illustration shows the public what a giant rip off our present health insurance funded prescription fulfillment process is. Recall, GoodRx harnesses itself into this scheme.

My Conclusion:

If you are on an expensive biologic medication and are prepared to provide personal and financial information to the manufacturer, this site may be helpful. You likely can access these same programs by going to the manufacturer existing websites. If you are on the few name brand products in the other categories, you will have a decent chance of getting a GoodRx coupon and access better prices. A large majority of the non biologic prescriptions already have very affordable generic alternatives that your local pharmacy, our dispensary (for our patients), Amazon Rx or Mark Cuban’s e-retail pharmacy can fill for you.

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“No fear of the unnamed
Stand up like a man taking the whole blame
Someone's got to do it
Someone's got to”

Steve Earle’s “Unrepentant”

What Follow is My Anthem and Another Call To Action/“How To” For My Fellow Doctors-Specialists Included

In the first two essays of this series, we looked at what Medicare’s “virtual hospital” experiment quietly revealed. Patients with conditions traditionally labeled “inpatient” — pneumonia, heart failure, COPD exacerbations, infections often coded as sepsis — were treated safely at home with off site monitoring, nursing support, and daily physician oversight. Outcomes were similar to conventional hospital care. Transfers back were uncommon. Lengths of stay were comparable.

Once you see those results, a simple conclusion follows: the hospital building itself is not the therapeutic ingredient. But there is a deeper implication that is even more important for practicing physicians. The real story is not about billing classifications or institutional privilege. It is about physics and technology. The constraints that once forced acute care inside hospital walls are steadily dissolving.

Continuous pulse oximetry, Bluetooth blood pressure cuffs, connected scales, wearable cardiac monitors, rapid mobile diagnostics, and high-resolution telehealth are no longer just possible. These tools are being sold directly to consumers, dispelling the barrier and past conditioning that only hospitals and highly specialized locations offered such services.

In that sense, the “virtual hospital” project did not invent anything new. It simply acknowledged a reality that had already arrived: modern monitoring has dispersed. The hospital no longer has a monopoly on information density.

Medicine has quietly become portable and is becoming more personalized and individually consumed. Our anchored payment process and lack of imagination is holding us back from returning to the doctor’s house call.

Dr.’s Marconi, Barry and I already provide encompassing care and services from within our office. In special situations we have been known to call on patients in their home if time and circumstances allow. With our full time scheduling and clinical staff, we provide IV fluids and or medication infusions to provide acute and effective therapy, avoiding hospitalization and emergency room referrals.

My observations are making it clear to me that artificial intelligence application is leading to large language modeling around a patient’s health record, personal diaries and health monitoring information to help in persons measuring choices on health metrics. Expanded rules clarifying that tech companies can’t and don’t hold patient data hostage inside a “tech silo” or institutional structure (hospital system), means central control of your health record and information is not in our future.

Logic takes me to the conclusion that collaborating with our patients, will result in even more effective benefit for patients. It also is intuitive that if we incorporate the present infrastructure of the extensive United States logistics in place, it isn’t a stretch at all to extend our impact and treatment range to our patients homes.

Emphasis- A nuance worth noticing: who adopted first

Interestingly, early participation in Medicare’s hospital-at-home waiver skewed heavily toward large, urban, teaching hospital systems. Rural and smaller hospitals were far less likely to implement programs. That pattern appears to reflect organizational capacity rather than clinical feasibility. Large systems had staffing depth and administrative infrastructure to launch quickly. Smaller hospitals did not.

Yet rural communities may benefit the most. In many regions, patients travel hours for care or face shrinking hospital access altogether. Home-based acute care could be not merely convenient, but essential.

The technology works anywhere. Adoption simply followed resources first.

This observation reframes the story again. Hospital-at-home is less a hospital innovation and more a proof of concept that acute care is no longer tied to geography.

Which leads naturally to an uncomfortable but productive question for physicians:

If hospitals were able to move acute care into the home, what actually prevents us from doing the same?

The regulatory question most physicians get wrong

There is a common assumption that hospital-level care must legally occur inside a hospital. That belief turns out to be more cultural than statutory.

When we step outside Medicare’s inpatient billing framework and simply read the law, the environment is surprisingly permissive.

Medicare rules say only hospitals may bill inpatient DRGs (Diagnostic Related Group Billing). But that governs billing classification — not the practice of medicine. DRG payment is a government/Medicare payment scheme thrust upon the system in the Nixon era. It has embedded itself into the conditioned payment method for hospitalization services (in hospitals).

To verify that Nixon’s administration created the DRG Medicare payment scheme, consider the following points:

1. The Diagnosis-Related Group (DRG) system was introduced in 1983.

2. It was part of the Medicare program reforms initiated under the Nixon administration.

3. The goal was to control rising healthcare costs and improve efficiency.

4. The DRG system categorizes hospital cases into groups for payment purposes.

5. It shifted Medicare from cost-based reimbursement to a fixed payment system.

6. The implementation was influenced by the Health Insurance Portability and Accountability Act (HIPAA) in 1996.

Outside that billing structure, what applies is simply state medical practice law. In Florida, as in most states, physicians may diagnose and treat wherever the patient happens to be. Home visits are legal. Telehealth is legal. IV therapy under physician order is routine. Nurses may operate under physician supervision.

Nothing in statute says acute care must occur inside a hospital.

The only real restrictions appear if a practice accidentally becomes something else:

• a licensed hospital with beds

• a standalone home health agency

• or an insurance product pooling risk

Avoid those classifications and physicians are simply practicing medicine. In other words, the walls that constrained acute care were financial and historical, not legal or clinical. That distinction matters. Because once you recognize that nothing actually prohibits physicians from managing acute illness at home, the conversation shifts from “Are we allowed?” to “How would we build it?”

Reclaiming the physician’s role

For decades, primary care gradually ceded acute illness to hospitals. The pattern became automatic: deterioration → emergency department → admission → handoff to hospitalists. The Hospitalist movement which took hold in the early 2000’s decimated the traditional doctor patient relationship and contract. This was a ruse thrust upon us by academia. Corporate hospitals loved this “story” and as doctors had been brow beaten into overworked mules, we bought the story as well. We needed SOME time off, afterall. Getting out of hospital patient rounding was a strong incentive to go along with this scheme. I am here to state clearly, this model DID NOT IMPROVE patient care, safety nor outcomes (somebody’s got to do it).

But if monitoring, nursing, diagnostics, and physician oversight can now be coordinated around the patient rather than inside an institution, the hospital handoff is no longer inevitable. In many cases, the patient’s own physician is best positioned to manage the episode. They know the history, medications, and baseline. Technology simply extends their reach. Hospital-at-home, viewed this way, is not primarily a hospital story. It is a physician opportunity.

How to Build AcuteCare@Home in a Primary Care Practice

Things look bad from over here
Too much confusion and no solution
Everyone here knows your fear
You're out of touch and you try too much

Lyrics From Steppenwolf’s “Move Over”

Once you accept that much of routine inpatient medicine is portable, the operational design becomes surprisingly straightforward. This is not about recreating a hospital in miniature. It is about extending ordinary internal medicine into the home using tools already available.

Think of it less as “hospital-at-home” and more as enhanced physician-directed home management.

Step 1 — Define the clinical envelope

Focus on diagnoses that require monitoring and medication rather than procedures. If you have a patient who you know is trending towards hospitalization, consider offering this added service option. The virtual hospital system confirmed the following items and I added wound care and management. Hypertensive urgency could be another scenario. Recent but completed, non-interventional stroke is a situation where intense “observational” monitoring at home would be appropriate.

• pneumonia needing IV antibiotics

• cellulitis (skin infection)

• Pulmonary disease or asthma exacerbations

• heart failure diuresis therapy and monitoring

• complicated UTIs (urinary tract infections)

• stable infection syndromes

• Wound care and management

Exclude hypotension, altered mentation, escalating oxygen needs, or anything requiring ICU (Intensive Care Unit) resources. In other words, use the same stability filter hospitals already apply.

Step 2 — Build the monitoring layer

Deploy simple connected tools: Artificial Intelligence and Data Gathering services especially with the new FYR platforms will allow office based intense patient monitoring and trend alert programs.

• pulse oximetry

• BP cuffs

• weight scales

• wearables

• telehealth check-ins

This often yields more continuous data than a traditional ward.

Step 3 — Add nursing execution

Partner with:

• employed or contracted nurses

• home health agencies

• mobile labs

• community paramedics

• Amazon, Uber or Lyft for urgent product delivery.

They become the physician’s extenders delivering IVs, drawing labs, medications, durable medical equipment and reporting findings.

Step 4 — Consider Specialist Consultation Collaboration

Arrange Virtual or Home physician consultation collaboration and patient care dashboard sharing. Neurology, radiology, pulmonary, etc are fields that come to mind.

Step 5 — Establish escalation pathways

Create clear protocols for rapid transfer when instability appears. The hospital becomes the backup, not the default. Forward thinking hospitals will create a collaborative urgent admission process. Presently the Emergency Room remains everyone’s crisis option.

Step 6 — Explore The Cost and Price of Delivering This Level Of Care

Use:

• direct care agreements- we love direct to consumer pricing, leave the mischief of third party intermediaries back in the insurance business.

• per diem billing

• Hourly supervision charges/fees

• bundled episode or disease diagnosing pricing

• employer contracts

• hybrid/DPC models

Payment aligns with the episode rather than the building.

Step 6 — Start small

Pilot with a few diagnoses and patients. Refine workflow. Expand gradually. I think this is something all physicians COULD consider, especially if government policies and rules get reviewed, revised and reinvented.

At its core, AcuteCare@Home (you read it here first) is not a new specialty. It is primary care reclaiming territory it once managed routinely, now supported by modern technology.

Hospital-at-home demonstrated that acute medicine no longer depends on walls.

The next logical step is recognizing that it may not need hospital ownership either.

If the tools are portable and the outcomes are comparable, then the responsibility — and the opportunity — naturally return to physicians. Build it and they will come.

ONE CAN DREAM

Last week I wrote about Medicare’s “virtual hospital” experiment and a simple observation that followed from it: much of what we call inpatient medicine does not appear to require a hospital building at all. When patients with pneumonia, heart failure exacerbations, cellulitis, COPD flares (acute on chronic lung impairment), and similar conditions were treated safely in their homes — yet billed as inpatients — it became difficult to argue that bricks and mortar were the therapeutic ingredient.

But there is another, more interesting implication that deserves attention.

The real story is not about hospital billing or institutional privilege. It is about physics and technology. The constraints that once forced acute care inside hospital walls are dissolving. Continuous pulse oximetry, Bluetooth blood pressure cuffs, connected scales, wearable cardiac monitors, cloud-based charting, and reliable high-definition telehealth are now commonplace. Ten or fifteen years ago, much of this capability existed only inside a hospital. Today it sits in a patient’s living room.

The “virtual hospital” did not create that reality. It simply acknowledged it.

Under the Acute Hospital Care at Home initiative administered by the Centers for Medicare & Medicaid Services, hospitals were allowed to admit patients as inpatients while delivering most of their care at home. Patients received IV medications, oxygen, laboratory testing, nursing visits, and daily physician oversight without ever occupying a traditional hospital bed. Importantly, outcomes were similar — sometimes better — than comparable brick-and-mortar admissions.

What makes this notable is not that hospitals suddenly invented a new form of medicine. It is that modern monitoring and communication tools have matured to the point where centralized infrastructure is no longer strictly necessary. Hospitals are indeed transitioning towards a horse and buggy industry. This reality is hard to juxtapose against the every stronger lobbying power of hospital systems that have justified decades of Medicare Payment policy promoting the vertical integration of health care access from private physicians offices towards opaque, every more expensive hospital systems with tendrils extending well past their institutional walls.

What the data actually show

Here is what has been reported across CMS evaluations, MedPAC analyses, and peer-reviewed studies:

None of these findings are particularly surprising to practicing internists. Many inpatient stays are fundamentally about monitoring, medication delivery, and reassessment. Those activities are portable. An IV antibiotic works the same whether it hangs beside a hospital bed or from a hook at home. Oxygen behaves the same. Clinical judgment behaves the same.

What has changed is simply where the data and the tools live.

A nuance worth noticing: who actually adopted hospital-at-home

An interesting pattern emerged in early adoption. Participation in the waiver was concentrated largely among large, urban, and teaching hospital systems. Smaller and rural hospitals were far less likely to implement these programs.

That difference appears to reflect organizational capacity rather than clinical feasibility. Large systems had the administrative depth, staffing pools, and logistics infrastructure to operationalize home-based care quickly. Rural hospitals, already thinly staffed and resource constrained, often did not.

Yet from a population health perspective, rural communities may stand to benefit the most. In many parts of the country, patients live hours from the nearest hospital. Travel delays, limited beds, and hospital closures have created genuine access gaps. For these regions, the ability to deliver acute-level care safely at home is not merely convenient — it may be essential.

Early rural pilot studies suggest that home-based acute care can be feasible even in those settings. In other words, the model itself is not inherently urban. The early participation skew likely reflects who could implement it first, not who needs it most.

Seen this way, hospital-at-home is less an institutional innovation and more a proof of concept that modern medicine has outgrown the geographic limitations of the past. This implies that rural care could benefit the most from results uncovered in the virtual hospital experiment. This could quell the long standing politically correct argument for expanding health extender licenses and scope of practice to serve rural populations. The AMA (American Medical Association) has documented with their Health Care mapper that ARNP’s (Advanced Practice Nurse Practitioner degree), despite being unbridled from physician oversight, haven’t moved care outside of the Urban areas.

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Reconsidering the physician’s role

For decades, primary care physicians gradually ceded responsibility for acutely ill patients to hospitals. The default pathway became predictable: worsening symptoms, emergency department, admission, handoff to hospitalists. Care was transferred not only geographically but professionally.

But if monitoring, nursing, diagnostics, and daily reassessment can now be coordinated around the patient rather than inside a building, that handoff is no longer inevitable.

In many cases, the patient’s own physician is already best positioned to manage the episode. They know the history, medications, baseline physiology, and social context. Technology simply extends their reach.

This reframes hospital-at-home entirely. It is not primarily a hospital story. It is a physician opportunity to extend our expertise and care into the patient’s home. Who wouldn’t prefer to heal and rest in their own bed? Modern monitoring tools allow physicians to automate vital sign monitoring and combine this data into a informatic dashboard to alert unfavorable trends in “real time”.

Which leads naturally to the practical question

If acute internal medicine is increasingly portable, and if the tools required to manage it are already widely available, then the next logical step is straightforward:

• How would a physician practice build this capability itself?

• What would it take to manage selected acute episodes — safely, responsibly, and locally — rather than automatically transferring every patient to an institution?

• That is less a question of policy than of design.

• And it’s where the conversation turns from theory to implementation.

In a next post, we’ll walk through what an AcuteCare@Home model for primary care might actually look like in practice.

References

1. Centers for Medicare & Medicaid Services. Acute Hospital Care at Home evaluation reports and fact sheets.

2. Medicare Payment Advisory Commission (MedPAC). Report to Congress — Hospital at Home analyses.

3. JAMA Health Forum. Outcomes and transfer rates for hospital-at-home cohorts.

4. CMS MedPAR/IPPS claims analyses of LOS, DRG mix, and payment patterns.

5. Rural pilot studies demonstrating feasibility of home-based acute care delivery.

For most of modern medical practice, we have treated the hospital as inseparable from acute care itself. When a patient develops pneumonia, decompensated heart failure, cellulitis requiring intravenous antibiotics, or even early sepsis, the reflex has been automatic: admit them to the hospital. The building has been assumed to be a prerequisite for the treatment. Ever since the Hospitalist movement and enforced by the OBAMACARE promise of a health care card for everyone, regardless of actual physician and clinic access, the community model of care is to drop all acute problems on the Emergency room. This has created a smackdown on excess emergency room referrals and a sieve of hospital admissions and or observation days inside the Hospital corral.

Clinicians rarely question this assumption because it is baked into both training and reimbursement. Acute care happens “in the hospital.” That is simply how the system is structured. Especially if you want to offload the concept of liability for care.

Over the past several years, however, Medicare ran a large real-world experiment that challenges this premise in a surprisingly direct way. The COVID debacle let the camel’s nose under the tent. That was when special payment changes in Medicare and Medicaid allowed the “virtual hospital bed”.

Under the Acute Hospital Care at Home initiative administered by the Centers for Medicare & Medicaid Services, hospitals were permitted to admit patients as inpatients while delivering the majority of their care at home. Patients received oxygen, IV medications, laboratory testing, nursing visits, and daily physician oversight without occupying a traditional hospital bed. Yet from a billing perspective, these episodes were still classified and reimbursed exactly like ordinary inpatient stays.

Same Diagnostic Related-Groups billing. Same payment. But no actual hospital stay. The hospital just got paid for a full medical support system using the patient’s home as the place for rent. I would think those patients deserve a daily rent check and based upon the payment, it should be a pretty serious day rate.

This created a natural question: if the care can be delivered safely outside the building, what exactly is the hospital providing?

The answer, it turns out, is often less clinical than we might think.

Most of the conditions treated through the program were not highly specialized ICU- (Intensive Care Unit) level illnesses. They were the same medical diagnoses doctors manage every day on general floors: heart failure, respiratory infections, COPD (Chronic Obstructive Pulmonary Disease) exacerbations, cellulitis, and infection syndromes often coded as “sepsis”. These patients primarily required monitoring, medication administration, and time rather than surgical suites or advanced procedural resources.

When evaluated at scale, outcomes were broadly comparable to brick-and-mortar hospitalization. Mortality did not increase. Transfers back to the hospital were uncommon. Lengths of stay were similar.

In other words, the medical work translated.

What the data actually show

Below is a summary of reported findings from CMS (Center for Medicare and Medicaid Services) evaluations, MedPAC (Medicare Payment Advisory Commission) analysis, and peer-reviewed studies of hospital-at-home programs:

Taken together, these findings are not particularly dramatic medically. They simply confirm what many physicians already suspect: a large share of “inpatient” medicine is fundamentally about nursing support, medication delivery, and observation. Those services are portable.

An IV (intravenous) antibiotic does not care whether it hangs from a pole next to a hospital bed or from a hook in a living room. Oxygen behaves the same in either place. Daily physician assessment is equally effective whether done at the bedside or via telehealth.

I can’t be the only person who sees the possibilities….

What is less portable is the reimbursement.

Sidebar: “Sepsis” — Clinical Reality vs Payment Definition

Clinical sepsis (traditional bedside meaning)
Historically, sepsis implied physiologic instability and the potential for rapid deterioration — hypotension, rising lactate, altered mentation, organ dysfunction, and possible need for ICU-level monitoring, vasopressors, or ventilatory support. These patients require immediate access to true hospital or emergency resources because minutes matter and escalation must be available at the bedside.

Sepsis in modern Medicare claims (common payment-era usage)
Today, the term is frequently applied far more broadly. In practice it often captures stable infections that meet documentation or reimbursement thresholds — patients with normal blood pressure, intact mentation, modest or improving lactate, and a primary need for IV antibiotics and observation rather than invasive support. These are clinically “medical floor” patients, not ICU patients.

Why the distinction matters
Hospital-at-home programs simply apply the same stability filter hospitals already use: unstable patients stay in the hospital; stable infections are treated safely at home. The apparent contradiction resolves once you recognize that “sepsis” in payment data often reflects a coding and reimbursement category rather than the historic clinical emergency physicians were trained to treat. In effect, the diagnosis has been stretched to fit the payment model — while still being framed publicly as hospital-only care.

Under current rules, only hospitals are allowed to bill Medicare for these virtual inpatient stays. Even when the care occurs entirely in the home, the claim must still flow through a hospital provider number. Independent physician practices, community-based groups, and other care models are generally excluded from receiving equivalent payment for delivering the same services.The clinical services have been decentralized. The financial privilege has not.

That distinction matters more than it first appears.

Because once we accept that outcomes are comparable without the building, it becomes difficult to argue that the building itself is the therapeutic agent. The hospital is not what makes the antibiotic work. It is not what stabilizes the heart failure. It is not what resolves the infection.

What the hospital reliably provides is access to the billing system. Your Medicare and Insurance Card are dictating the point of care AND the reimbursement. In that sense, the hospital increasingly functions less as a clinical necessity and more as a financial gateway. It is the institutional structure through which reimbursement flows.

This does not mean hospitals are obsolete. They remain essential for surgery, trauma, intensive care, and highly specialized services. If a sick patient lacks the home support for safe ambulation or bathroom access, inpatient staff and services are need. The virtual hospital experience suggests that many routine medical admissions do not inherently depend on bricks and mortar. They depend on clinicians and treatment — both of which are mobile.

Once that becomes clear, the conclusion follows naturally.

The hospital isn’t the care. It’s the invoice.

And if acute care can be delivered safely wherever the patient happens to be, it becomes reasonable to ask why only hospitals are granted the privilege of providing — and billing for — that care. Perhaps the next evolution is not “hospital-at-home,” but something simpler: physician-directed care delivered at home, without the building serving as the mandatory middleman.

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References

1. Centers for Medicare & Medicaid Services. Acute Hospital Care at Home Initiative Evaluation Reports and Fact Sheets.

2. Medicare Payment Advisory Commission (MedPAC). Report to the Congress: Medicare and the Health Care Delivery System, Chapter on Hospital at Home programs.

3. CMS claims analyses (MedPAR/IPPS) summarized in national AHCAH evaluations showing LOS, DRG mix, and payments.

4. Adams et al. Outcomes of Hospital-at-Home Care vs Traditional Hospitalization, JAMA Health Forum.

5. Peer-reviewed and CMS-reported data on transfer rates, mortality, and geographic distribution of AHCAH participants.

There is a moment in every system when the story it tells about itself can no longer survive public scrutiny. American healthcare has entered that moment. For decades, policy, payment, and regulation quietly reshaped how illness is defined, documented, and reimbursed—creating the appearance of a nation growing relentlessly sicker, more fragile, and more dependent on medical intervention. But this portrait did not emerge organically. It was constructed.

Through payment multipliers, diagnostic inflation, and incentives that reward documentation over outcomes, institutions learned to prosper by describing disease rather than resolving it. What has changed is not the math. What has changed is the speed of exposure. Investigations into Medicare and Medicaid expenditures, fraud, and systemic waste have moved these realities out of back offices and into public view. The graveyard was always there. The lights simply came on faster than expected.

This is not a failure of medicine. It is a failure of the structures built around it. And it is futile to expect the government to reverse its course to correct things.

Policy Didn’t Just Pay for Care — It Shaped the Narrative of Illness

Modern healthcare policy did more than finance care; it shaped how sickness itself is recorded. Payment systems that reward higher acuity, more diagnoses, and greater complexity inevitably produce exactly that on paper. Residency training, clinical workflows, and documentation standards adapted to survive inside this regime—not because physicians abandoned ethics, but because the system required compliance to function. The following visual is a quote from the post linked above. MACRA stands for Medicare Access and CHIP Reauthorization Act. This was when the bureaucracy went on steroids and the real pummeling of doctors was placed into full view.

When reimbursement rises with documented sickness rather than restored health, institutions learn to document sickness more thoroughly. Over time, this creates a feedback loop: a population that appears progressively sicker on paper even when physiological reality is far more nuanced.

A population can look sicker without becoming sicker.

This distinction matters, because public health trends and billing trends are not the same thing—yet policy has blurred them until they are treated as interchangeable. I’ve written previously about how this opacity is sustained structurally, particularly through hospital billing practices and facility fees that exist largely because patients never see prices until after the fact:

Opaque Health Care Pricing
https://raymondkordonowy.substack.com/p/opaque-health-care-pricing

The “Payment Multiplier” and the Illusion of Decline

Government payment formulas—particularly within Medicare and its downstream commercial counterparts—use risk adjustment and relative value units (RVUs) to amplify reimbursement based on coded severity. These multipliers were designed to account for complexity. Instead, they became engines of distortion. This is not epidemiology. It is accounting.

The Affordable Care Act did not invent these incentives, but it scaled them nationally and embedded them into managed care. Diagnostic intensity became financially essential. Institutional survival grew dependent on portraying a sicker America—one that required constant intervention, expanding budgets, and permanent administrative oversight. MACRA was the follow-up and the lost opportunity that doctors en masse should have resisted.

I have addressed a direct example of the accounting manipulation in my recent post explaining the hoax of Medicare Part D, where “insurance” increasingly functions as a subsidy and transfer mechanism rather than true risk protection: SEE
When Insurance Stops Being Insurance
https://raymondkordonowy.substack.com/p/when-insurance-stops-being-insurance

Exposure Came Faster Than the System Could Adapt

Healthcare institutions assumed time—time to manage narratives, time to negotiate reforms, time to preserve opacity. Exposure removed that luxury. The obvious and more publicly aware lopsided payments given to hospital systems has politicians considering ending favored facility and institutional payments to hospitals. This is putting gasoline on the fire under hospital planning committees.

Media scrutiny, government audits, and budgetary alarms have made the economics visible to the public at a pace large systems cannot match. Structures that depend on obscurity are uniquely vulnerable once transparency accelerates. What once required specialized knowledge can now be understood intuitively by patients, employers, and voters.

This is why the present moment feels unstable. The system did not expect to be seen this clearly, this quickly.

A Political Signal, Not a Political Cause

Recent calls for healthcare reform—regardless of who voices them—are not the source of this disruption. They are signals that the disruption has already occurred. Politics reacts to economic fracture; it does not cause it.

Voter anger, employer fatigue, physician burnout, and unsustainable public spending converge when a system’s internal contradictions become impossible to ignore. Rhetoric follows reality.

The Pendulum Is Real — and It Can Swing Quickly

Healthcare’s defenders often assume change must be incremental. History suggests otherwise. Once buyers recognize themselves as buyers—and once physicians recognize their professional authority—the market corrects rapidly.

Newsflash folks, you are the buyer regardless if it is “Medicare for All”, your insurance payments or your payment at the point of service. I submit payment at the point of service is the most efficient way forward. Having your personal control in who you see creates infinite points of access. Or you can have Vanilla ice cream for life BUT wait longer and longer to get your cone.

Institutional healthcare did not expect this moment to arrive with such clarity. It did not expect patients to see prices, employers to question value, or physicians to openly question the ethics of administrative medicine. That miscalculation is its vulnerability.

When a profession withdraws moral consent, legitimacy erodes faster than revenue.

Physicians Are a Profession, Not a Workforce

Physicians are not interchangeable units of clinical labor. Medicine is a profession governed by an oath that predates modern payment systems, regulatory agencies, and insurance products. The Hippocratic tradition establishes a direct duty to the patient—independent of institutional convenience or political design.

Employment contracts can dictate schedules.
They cannot redefine ethical obligation.

Physicians did not create the distortions now under scrutiny. They were trained and required to practice within them. But they are uniquely positioned to correct them—by refusing dishonest narratives and choosing models aligned with professional ethics.

I’ve explored this restoration of the physician–patient relationship and the economic opportunities it creates here:
Opportunities, Let Me Count the Ways
https://raymondkordonowy.substack.com/i/176461165/opportunities-let-me-count-the-ways

Education Is Not the Solution — Structure Is

By now, the incentives are clear. Education alone does not correct distorted markets. Incentives do. There is plenty of information documenting the lack of fiscal restraint and dishonesty in the health care system. Heck, just look at your next medical bill generated at any hospital system and see what the “price” was and what Medicare paid. Who is lying and who is cheating who? Patients are caught in the crossfire and have no way of expressing their seeing of the obvious.

The path forward is not better messaging or tighter oversight. It is structural realignment. Let me offer these solutions.

End First-Dollar Health Insurance

Insurance that pays for everything ends up controlling everything. True insurance protects against catastrophic risk; it does not prepay routine care or dictate clinical judgment. Support Health Sharing and Cooperative Insurance pools.

Rescind Mandatory Participation Under PPACA/Obamacare

Mandated participation in distorted insurance markets is not access—it is compulsion dressed as compassion. It removes any need for competition in the insurance market.

Remove Medicare Relative Value Unit Price Controls

Centralized price setting suppresses honest valuation of medical work and distorts every downstream market. The RVU system and government engineered payment scheme is the exact cause and tool that has decimated private medical practices. Further this payment scheme falls prey to the hospital and corporate lobbies essentially guaranteeing a dying horse and buggy industry a monopoly on purchasing all competing and free market health delivery practices and surgical centers.

Universal Health Savings Accounts

HSAs should be available to all tax-paying citizens and function as true ownership vehicles—not carve-outs tied to insurance status. The requirement to attach high cost and high deductible insurance purchases to have access to and HSA is pretty much a designed “PBM” model of offloading even more costs and profit gouging on the beneficiaries. Conceding that virtually all people in the US engage in the health care system AND pay for the care, why would any tax-paying citizen not be allowed an HSA no strings attached.

Unwind CMS and Treasury Payments Into Individual Control

Public healthcare dollars should flow to individuals, not institutions—spent transparently through HSAs and documented for tax compliance, not to micromanage care. An even better concept would be for paid receipts from actual patients/individuals get submitted and “cleared” by CMS and the treasury. This might be my best idea yet!

Central payment systems were created to manage scarcity. They now manufacture it. When patients control the dollars and physicians control the care, excess collapses without coercion.

Stop Whistling

The graveyard American healthcare is passing is not merely financial—it is moral. A system that must exaggerate illness to sustain itself cannot survive sustained scrutiny. The public is beginning to understand that a “sicker America” was not simply discovered, but described—through incentives that rewarded complexity over clarity and documentation over healing.

Physicians did not create this distortion, but they hold the fulcrum for correction. Medicine has outlasted empires, bureaucracies, and payment schemes because it is rooted in oath, not optics. The exposure now underway is not a threat to that tradition. It is an invitation to reclaim it.

The whistling is understandable. But it is time to change direction. It is high time doctors accept the status quo is failing both the profession and patients. It is time to walk away and order our new office building shingle, post your services and let patients know you are there for them, not Uncle Sam and not corporate raiders. Patients can’t make the move to a better health care market and future until the doctors take back the moral high ground and return to their oath- all for the patient.

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While we were told that “vertical integration” in healthcare—the merger of insurers, hospitals, and pharmacies—would lead to better coordinated care, a bombshell Senate Judiciary Committee report released this week suggests it has instead built a perfect machine for systemic upcoding.

Based on 50,000 pages of internal documents, the investigation led by Senator Chuck Grassley (R-Iowa) reveals that healthcare giants like UnitedHealth Group (UHG) have turned Medicare Advantage (MA) risk adjustment from a clinical tool into a “profit-centered strategy”.

1. The Two Engines of Profit: Risk Adjustment and DRGs (Diagnosis- Related Group) billing

There exists a dual-incentive system where a single “trolled” diagnosis code pays out twice for the same vertically integrated entity:

• The Insurance Side (MA): Insurers mine records for high-value codes (like dementia or Peripheral Artery Disease) to inflate Risk Adjustment Factor (RAF) scores. This can net thousands of dollars in extra government payments per year, per patient—often with zero follow-up care. In other words, the government pays the insurance for more “costs of care” based upon reported diagnosis, even when they aren’t really ongoing medical problems requiring any actual medical care!

• The Hospital Side (Diagnosis-Related Group billing): The same diagnosis, if tagged as “Present on Admission,” can move a hospital stay into a higher-paying Diagnosis Related Group (DRG) tier. This creates an instant revenue boost of thousands of dollars for the hospital stay. Since President Nixon’s administration, in order to address detailed care invoicing (and fake pricing), Medicare pays hospitals based upon the diagnoses that requires/justifies hospitalization. Using the patient’s medical history (past/inactive plus real active problems), the hospital can get extra payment for a patient’s hospital stay.

2. Electronic Hospital Record “Trolling”: The AI (Artificial Intelligence) and Care Everywhere Problem

How is this done? It’s no longer just humans with highlighters. Hospitals are increasingly using AI-driven software that “trolls” the Epic Care Everywhere tab/function. This health record tab provides a portal of outside medical records from essentially any past clinic or health system a patient has had care from, nationwide. These tools identify outdated or inactive diagnoses that the current hospital physician hasn’t even seen, automatically adding them to the Epic record and coders to maximize the bill.

3. The Physician’s Liability Trap

Hospital employed (Hospitalists and employed specialist doctors) and contracted physicians (emergency room physicians are often independent but contracted by the hospital), agree by contract to let the hospital conduct all billing and collections on their behalf. This is a serious legal peril that so far doctors appear to either be ignorant of or are willingly looking the other way to garnish their salaries. Despite the hospitals being incentivized to code for dollars, it is actually the physicians that will go to jail once Uncle Sam decides to pursue action.

Here is the most dangerous finding for providers: while the hospital and insurer develop the algorithms and hire the “trollers,” the law only holds the physician responsible. If an automated system pulls an inactive code into your chart and you sign it, federal authorities like the Office of the Inspector General view it as “reckless disregard”.

The Cost of Business: While insurers and hospitals may face settlements—often viewed as a mere “1-2% tax” on their billions in extra revenue—physicians face criminal indictment, prison, and the loss of their license for fraudulent coding.

4. What Comes Next?

The “cost of doing business” for corporate healthcare is currently a winning bet. For every $100 in excessive payments generated by upcoding, the government currently recovers only $2 to $5.

As practitioners, we must realize that the unreconciled “Problem List” in your EHR is no longer just a clinical annoyance—it is the raw material for a multi-billion dollar gaming of the system.

The Provider’s Survival Guide: Protecting Yourself from Corporate Upcoding

While health systems and insurers profit from “trolling” your patients’ charts for inactive codes, the legal liability stops with you. If you are being pressured to sign off on suggested diagnoses that don’t reflect the current clinical reality, here are three steps to protect your license and your integrity:

1. Reconcile “Care Everywhere” Bloat Immediately

Don’t let the Electronic Health Record dictate the narrative. When Care Everywhere imports a laundry list of historical codes, use a standard clinical phrase to exclude them:

• Step one- reconcile the active medical history so obsolete and irrelevant past diagnosis are placed in the inactive or removed category.

• Consider a Defensive Move: Create a “SmartPhrase” or macro that states: “I have reviewed the historical problem list provided via outside records. The following diagnoses are currently inactive and did not contribute to the medical decision-making for this admission.” If you reconcile the medical problem list this step wouldn’t be necessary.

• The Goal: This creates a legal firewall by explicitly stating that these high-value codes were clinically irrelevant to the current stay.

2. Document Your “Refusal” to Upcode

If an auditor or automated prompt asks you to add a comorbidity (Complication/Comorbidity, Major Complication/Comorbidity) that you did not evaluate, do not ignore it—document your disagreement.

• The Action: If a coding query is sent to you, reply in writing through the hospital’s official portal: “Suggested code [X] is clinically unsupported for this encounter. Per my clinical assessment, the patient does not meet the criteria for this diagnosis at this time.”

• The Goal: This creates a paper trail proving you did not act with “reckless disregard” for billing accuracy.

3. Engage Your Compliance Department Early

If you notice a systemic pattern where non-physician staff are adding diagnoses to your charts without your knowledge, report it internally.

• The Action: Send an email to your Chief Medical Officer (CMO) and Compliance Officer: “I am concerned about the accuracy of DRG coding for my patients. It appears that diagnosis codes are being appended to the medical record without clinical validation by the treating physician. I request a review of this process to ensure it meets CMS standards.”

• The Goal: Reporting internally triggers whistleblower protections and signals that you are not part of a systemic upcoding scheme.

Noting just how prevalent and rampant billing fraud in Medicare is, physicians need to take action to protect themselves from legal peril AND the public from billing fraud and financial fleecing.

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It began with a U.S. Senate investigation.

A report led by Senator Chuck Grassley examining UnitedHealth Group’s role in Medicare Advantage risk adjustment documents how the current payment structure incentivizes aggressive disease documentation — making patients appear sicker on paper in order to drive higher payment multiples from Medicare.

The central allegation is not subtle: the structure of Medicare Advantage payments rewards coding intensity, not necessarily worse health. UnitedHealth is uniquely poised to run the bully pulpit in this paradigm. They are vertically integrated to acquire providers and data from the womb to the tomb. They not only harnessed their resources to perpetrate billing fraud, they even sell their tools to other Medicare Advantage insurance companies.

But as I worked through the report, something unexpected happened.

A single paragraph about Medicare Part D prescription drug spending forced me to re-examine an assumption I — like most physicians and patients — had never questioned.

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The assumption most of us get wrong

Most people believe that when a Medicare beneficiary pays a monthly premium for Medicare Advantage or Part D:

• That premium is paid to an insurance company

• The insurer then uses that money to pay for care and medications

That assumption is wrong.

In reality, Medicare Advantage and Part D premiums are not paid to insurers at all. Premiums are largely withheld from Social Security benefits, credited to the U.S. Treasury, and administered by CMS, which then pays private plans prospectively based on bids and risk adjustment.²

The Senate report makes this explicit in the Part D section:

“CMS (Centers For Medicare and Medicaid Services) generally provides MA-PDs (Medicare Advantage and Part D plan) and standalone Prescription Drug Plans with a risk-adjusted subsidy that aims to average 74.5 percent of basic benefit costs for all types of beneficiaries.”

This means that Medicare — not insurers — finances the majority of prescription drug spending, with private plans acting as administrators of public funds, not traditional risk-bearing insurers.

Because it changes the question from-
“Is UnitedHealth behaving badly?”
to
“What incentives does the system itself create?”

Why drug pricing became impossible to ignore

The Senate report further explains that Medicare Part D subsidies are adjusted using the RxHCC system, a diagnosis-based model derived from the same conceptual framework as Medicare Advantage risk adjustment. RxHCC stands for Prescription Drug Hierarchical Condition Categories.

What RxHCC Really Means (Plain English)

RxHCC stands for Prescription Drug Hierarchical Condition Categories.

It is Medicare’s diagnosis-based system for adjusting Part D prescription drug payments to private plans.

In simple terms:

• Doctors document diagnoses using ICD (International Classification of Diseases) codes

• Those diagnoses are grouped into RxHCC categories

• Each category increases a patient’s “risk score”

• Higher risk scores result in higher Medicare payments to plans

Crucially, RxHCC payment factors are calibrated using gross prescription drug spending — not actual drug acquisition costs or cash prices.

That means if drug prices are inflated today, those inflated prices become the baseline for future Medicare payments.

RxHCC does not just follow illness.
It locks in pricing structures, efficient or not.

For emphasis- RxHCC payment factors are calibrated using gross prescription drug expenditures, not acquisition cost or net prices. Nowhere can I find who or where these prices are generated. It appears this is “proprietary” between CMS and the insurance industry. What the heck??

“For each demographic group, the relative factor for each RxHCC is calculated based on diagnosis information from a base year and gross prescription drug expenditures from the following year.”

In other words:

• Whatever price exists at the point of claim submission

• Becomes embedded into future federal payments

Medicare does not ask:

• What did the drug cost to manufacture?

• What did the pharmacy pay to acquire it?

• Could the same drug have been dispensed more efficiently?

It simply finances the price that appears on paper.

That is where generic drugs become impossible to ignore.

The generic drug contradiction

Generic medications are:

• Off-patent

• Widely manufactured usually from multiple sources- commoditized.

• Highly competitive

• Inexpensive at wholesale

In real clinical practice — including my own — many generics can be purchased directly from wholesalers and dispensed to patients for pennies, nickels and dimes per pill.

Yet when routed through Medicare Part D:

• The same drugs are assigned “negotiated prices”

• Patients face copays or coinsurance based on those prices

• CMS subsidizes roughly three-quarters of the inflated amount

Independent drug-pricing analysts at 46Brooklyn Research have repeatedly shown that this inflation has little to do with drug cost and everything to do with intermediary pricing layers, including Prescription Benefit Managers spread pricing, administrative fees, and opaque contract structures.

Insurance does not lower the price of generics. It raises them.

This is not insurance — it is public finance with private branding

At this point, the pattern becomes clear:

• Medicare Advantage inflates payments through documentation incentives

• Medicare Part D inflates spending through price opacity

• Both are financed primarily by public funds

• Both rely on private companies whose revenues rise with higher gross spending, not efficiency

Generic drugs — predictable, low-cost commodities — do not belong in insurance pools.

They are not catastrophic risks.
They are not unpredictable events.
They do not require risk spreading.

They require price transparency and competition. The Medicare Part D Insurance scam totally contradicts this economic dynamic.

The obvious conclusion policymakers avoid

Using real-world dispensing experience, public Senate findings, and transparent pricing analysis from 46Brooklyn, the conclusion is unavoidable:

“Independent analyses by 46Brooklyn Research consistently show that multi-source generics have very low acquisition costs, while insured ‘negotiated prices’ are often an order of magnitude higher due to PBM pricing structures. These dynamics apply across commercial insurance, Medicare Part D, and cash markets.”

Generic prescriptions and Medicare Part D do not belong inside insurance structures.

A cost-plus pharmacy model — whether local, regional, or national — would:

• Deliver medications at near-acquisition cost

• Preserve fair, market-based profit for pharmacies

• Improve adherence

• Reduce federal spending

• Eliminate PBM rent extraction

• Restore insurance to its proper role: covering risk, not commodities

The infrastructure already exists.
Physicians and pharmacies already do this.
The only thing missing is policy permission.

What this review really uncovered

The UnitedHealth Senate investigation may have begun with diagnosis coding.

But it exposes something larger:

A Medicare system that no longer distinguishes between:

• Risk and routine

• Insurance and administration

• Cost and price

When insurance stops being insurance, inefficiency is no longer accidental — it is structural.

And generic drugs are the clearest place to start fixing it.

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Footnotes

1. U.S. Senate Judiciary Committee, Majority Staff Report, How UnitedHealth Group Puts the Risk in Medicare Advantage Risk Adjustment (2024).

   grassleyunh0112

2. Centers for Medicare & Medicaid Services, Medicare Prescription Drug Benefit Manual, Ch. 1 (premium collection and payment mechanics).

3. Senate Judiciary Committee Majority Staff Report, Medicare Part D subsidy discussion.

   grassleyunh0112

4. Senate Judiciary Committee Majority Staff Report, RxHCC calibration methodology.

   grassleyunh0112

5. 46Brooklyn Research, multiple analyses of generic pricing, PBM spread, and list-to-net distortions (2019–2024).

At the start of the New Year, the United States Department of Agriculture (USDA), in conjunction with U.S. Health and Human Services (HHS), provided us with updated dietary guidelines. I have reviewed these guidelines and believe they are a proper and balanced set of recommendations. The communication includes several excellent and reasonable points:

• Encourages prioritizing whole foods like proteins, dairy, vegetables, fruits, and healthy fats.

• Aims to reduce reliance on processed foods high in sugars and unhealthy fats.

• Calls for collaboration among various sectors to promote healthier eating habits.

The finer details include a consistent message focusing on nutrient density. For my entire professional career, physicians and dietitians have discussed protein, fat, and carbohydrates while ignoring nutrient quality. This has been a colossal error in patient discussions.

Another important point evident from the new food pyramid is the emphasis on portion control and protein quantification. We must not repeat past errors: eat enough consistent protein, but ensure your portions depend on whether your weight is excessive. There is no bashing of any specific food source; appropriately, the document educates people to stop falling for the myriad of processed additives and products that hide highly bioavailable, “nutrient-naked” calories, such as plant (sugar) syrups, artificial sweeteners, and food starches.

A Brief History

From looking at the history of U.S. diet recommendations, it wasn’t until 1989 that the Department of Agriculture was attached to dietary guidelines as an agency. Is it any wonder that things have “gone south” over these past many decades? This appears to be another case of regulatory capture—but this time, at the expense of our nation’s health. The first guidelines were produced in 1977, starting with the McGovern Report (”Dietary Goals for the United States”).

Nutritional Assessment in Our Medical Practice

My medical practice evolved over my first 10 years of patient care into a focus on wellness. This was a natural result of identifying a consistent cluster of diagnoses: essential hypertension, hypercholesterolemia, dyslipidemia, vascular disease, and diabetes. I eventually realized that “disease begat disease”; like a domino effect, one diagnosis led to the next. The underlying result of these conditions was often OBESITY. Clearly, we needed to address these facts, but the “how” has been a serious conundrum.

I started looking at nutrition when it wasn’t “cool”. Over time, I found tools to show patients visual, actionable data. It starts with a weight scale, which has evolved in our office into a body fat analysis system from an industry leader called SECA. This company has been weighing humans since the 1840s, and their equipment is used in most neonatal intensive care units due to its reliable precision.

Our health examinations also measure two of the most common nutritional deficiencies directly via blood analysis: Vitamin B12 and Vitamin D. As our understanding of genetics unfolds, we see that besides nutrients being stripped from food by the commercial industry, many people have genetic variants predisposing them to these deficiencies. Using raw genetic data from companies like 23andMe, it is possible to create genetic profiling via services like Pure Insight to help direct people toward customizable diets.

The Power of Metrics

One of the most innovative tools for looking at nutritional intake is the Biophotonic Scanner. This technology uses light physics (Raman Spectroscopy) to quantitatively measure carotenoids. This technology has been extensively validated with over 100 peer-reviewed articles.

After scanning patients for approximately 16 years, I can attest that this new food pyramid is desperately needed. By measuring antioxidant status, we can shift the conversation away from just “carbs and fats” and toward nutrient density.

The technology has now evolved into a handheld, portable unit called the Prysm iO, which can reliably quantify stored carotenoids in the tip of your finger. Our office transitioned to this technology just before Christmas. The price has dropped from thousands of dollars to approximately $350. I believe this tool will soon be a staple for health-conscious consumers, alongside smartwatches and rings.

Evidence for Diet and Health

Starting with the China Study and ongoing nutrition research, there is no disputing that consuming 8–12 half-cup servings of fresh vegetables and fruit leads to marked improvements in health outcomes. Antioxidants provide the necessary chemistry to counter cellular oxidative stress, which otherwise injures biological tissues and vascular integrity.

By my own practice experience, the vast majority of people are not near optimal nutrition. There is also recent data supporting multivitamin supplements for cognitive benefit. Notably, I have observed that tablet supplements are often inferior to capsules regarding bioavailability.

Metrics as the New Medicine

As I have discussed in past posts, our practice is striving to integrate your home metric data—from continuous glucose monitoring to sleep efficiency—into your medical chart as additional “vital signs”. It will be interesting to see if people achieve higher levels of fitness with this burgeoning access to real-time monitoring data.

The landscape of wellness is shifting from guesswork to precise, actionable data. If you are interested in being among the first to integrate antioxidant monitoring into your personal health toolkit, I am happy to help.

Follow this link to start an account and I can assist you in securing a Prysm iO unit for your home. As always, feel free to message me here on Substack with your questions or experiences as we navigate these new metrics together.

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A Turnkey Path for Small Businesses: Introducing the Hybrid ERISA Implementation Bundle

For months, readers have asked some version of the same question:

“This all makes sense — but how do I actually do it?”

Until now, my writing here has focused on explaining why the system behaves the way it does — the incentives, constraints, and tradeoffs facing small businesses trying to offer health benefits in the post-ACA world.

Implementation is harder.

Not because the ideas are complicated, but because the rules are layered, unforgiving, and poorly aligned with how small businesses actually operate.

Why “Turnkey” Matters — and Why It’s Rare

Most benefit resources fall into one of two categories:

1. High-level explanations with no implementation path

2. Fill-and-sign kits that quietly assume away legal reality

Neither is adequate.

Small employers need something different:

• Structured, not vague

• Flexible, not one-size-fits-all

• Actionable, but not reckless

That’s what this release is meant to provide.

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What’s New in the v1.2 Release

I’ve now published a turnkey, white-label ERISA implementation bundle designed specifically for small businesses.

It includes:

• A modular ERISA wrap plan

• Section 105 MER framework

• Direct Primary Care integration

• HSA compatibility guardrails

• Health care sharing treated correctly as non-insurance

• Employer adoption resolution

• Modular Summary Plan Description (SPD)

• Claims and appeals procedures

• Employee-facing overview

• A step-by-step “Getting Started” checklist

• Guidance on how to customize safely

This is not legal advice, and it is not a substitute for professional review.

It is a coherent, defensible architecture that reflects how the system actually works today.

Who This Is For

This bundle is designed for:

• Small business owners

• Professional practices

• Operators trying to control benefit costs without cutting care

• Advisors supporting multiple employers (under a commercial license)

It is not designed for:

• One-click adoption without review

• Employers seeking to bypass ERISA obligations

• People looking for loopholes

How Access Works

The materials are offered under license, not sold.

Two options are available:

• Licensed Implementation Access
  For employers/businesses adopting the framework within their own business. Requires Foundation Subscription

• Authorized Commercial License- $2,500 Annual Fee
  For professionals deploying the framework with clients- information available upon request. I will discount your Foundation Subscription toward the commercial license payment.

Access is provided via a private download, with clear versioning and update policies.

A Closing Thought

Health benefits have become one of the most distorted areas of small-business decision-making — not because employers don’t care, but because the system punishes clarity.

This framework won’t fix the system.

But it does give small businesses a way to operate honestly, deliberately, and defensibly within it.

More to come. I will provide a link to materials via email reply.

9th Inning and It’s a 3/2 Pitch

In July, I published a post titled “I Woke Up Surprised.”
It was written half in disbelief, half in relief.

The disbelief came from watching Congress finally do something meaningful for Health Savings Accounts — expanding eligibility and flexibility in a way many of us had argued for years was necessary. The relief came from realizing that, at least on paper, small businesses and families might finally have a tool that made economic sense again.

But paper reforms and real-world implementation are not the same thing.

Since that post, I’ve spent months trying to answer a much harder question:

How does a small business actually implement the implications of expanded HSAs — legally, sustainably, and without accidentally breaking half a dozen other rules?

What I learned surprised me.

The Promise of HSA Expansion — and the Wall You Immediately Hit

The HSA expansion in the so-called Big Beautiful Bill opened doors:

• Broader eligibility

• More flexibility

• Greater usefulness for families and employers

But almost immediately, anyone who tries to implement those ideas runs into a familiar obstacle:

Obamacare’s existing legal architecture.

Affordable Care Act (ACA)-era rules — particularly around employer-sponsored coverage, affordability testing, premium tax credits, and what “counts” as insurance — still dominate the terrain. They weren’t designed for flexibility. They were designed for standardization.

That matters.

Because once you’re a small business owner trying to help employees:

• Pay for care

• Preserve Health Savings Account (HSA) eligibility

• Control costs

• Avoid penalties

• And remain fair across different employee roles

…you discover that the system quietly funnels you toward a narrow set of viable options.

Why Small Businesses Drift Toward a Hybrid Model

After several iterations — some that worked on paper but failed legally, others that worked legally but failed economically — the conclusion became unavoidable:

For small businesses operating under current law, a hybrid model isn’t clever. It’s inevitable.

The model that consistently survives contact with reality looks like this:

• Direct Primary Care (DPC) for predictable, relationship-based care. It is documented that DPC patient care drops total health care expenditures 50% across the board for DPC users. This is critical to the fiduciary core premise for employers.

• Defined employer contributions, not open-ended promises

• Reimbursement structures that require receipts and preserve employer control- accountability and actual consumption documentation.

• HSA compatibility, where legitimately possible

• Optional insurance or health sharing, treated correctly under the law

• Clear class distinctions (owner/officer, manager, hourly staff), because pretending everyone is the same is neither honest nor compliant

This isn’t ideological. It’s structural.

When you trace the incentives, restrictions, and safe harbors, small employers are pushed — intelligently— into this kind of hybrid architecture.

“Small Business Benefit Paths Under ACA Rules”

The cafeteria model health benefits offering serves small businesses the best. You can budget your support and spend only what is used by employees who take you up on the offering. Emphasizing the long term relationship of primary care results in the best long term health care model for small business owners AND their employees.

What This Looks Like in Practice (High Level)

At a high level, the workable model has a few defining characteristics:

• Employers cap their exposure. Benefits are defined, not unlimited.

• Employees choose how to layer coverage (insurance, health sharing, HSA-qualified plans) within guardrails.

• Care delivery (DPC) is separated from catastrophic risk financing.

• Reimbursements are substantiated and documented — not stipends.

• Nothing relies on wishful interpretations of ACA or Internal Revenue Services (IRS) rules.

Importantly, this is not a loophole strategy.
It’s a compliance-aware design that accepts the rules as they are, not as we wish they were. I am convinced that over time, government legislation will open up more clear paths for individual ownership of health care dollars. This present framework allows small businesses to ACT AND BENEFIT immediately.

Why I Decided to Publish the Framework

Until now, my writing here has been explanatory and analytical — policy, economics, incentives, tradeoffs.

This is the first time I’ve decided to publish something actionable.

Not because I want to become a consultant or benefits broker (I don’t), but because enough readers — business owners, physicians, operators — kept asking the same question:

“Okay, but how would I actually do this?”

The honest answer is that doing this responsibly requires:

A coherent ERISA (Employee Retirement Income Security Act) framework

• Clear licensing boundaries

• Documentation discipline

• And an understanding of where the law ends, not just where we’d like it to go

So I’ve made that work available as a white-label, licensed framework for those who want to implement — not just read. The following is clarification of my offering.

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For Readers Who Want to Implement A Turnkey Path for Small Businesses: Introducing the Hybrid ERISA Implementation Bundle

I have put together a set of templated files to help small business owners with a tool kit to accomplish a formal health benefits plan and procedures to do this without additional staff or consultants.

“This all makes sense — but how do I actually do it?”

Until now, my writing here has focused on explaining why the system behaves the way it does — the incentives, constraints, and tradeoffs facing small businesses trying to offer health benefits in the post-ACA world.

Implementation is harder.

Not because the ideas are complicated, but because the rules are layered, unforgiving, and poorly aligned with how small businesses actually operate.

Why “Turnkey” Matters — and Why It’s Rare

Most benefit resources fall into one of two categories:

1. High-level explanations with no implementation path

2. Fill-and-sign kits that quietly assume away legal reality

Neither is adequate.

Small employers need something different:

• Structured, not vague

• Flexible, not one-size-fits-all

• Actionable, but not reckless

That’s what this materials file was put together.

I’ve now published a turnkey, white-label ERISA implementation bundle designed specifically for small businesses.

It includes:

• A modular ERISA wrap plan

• Section 105 MER framework

• Direct Primary Care integration

• HSA compatibility guardrails

• Health care sharing treated correctly as non-insurance

• Employer adoption resolution

• Modular Summary Plan Description (SPD)

• Claims and appeals procedures

• Employee-facing overview

• A step-by-step “Getting Started” checklist

• Guidance on how to customize safely

This is not legal advice, and it is not a substitute for professional review.

It is a coherent, defensible architecture that reflects how the system actually works today.

Who This Is For

This bundle is designed for:

• Small business owners

• Professional practices

• Operators trying to control benefit costs without cutting care

• Advisors supporting multiple employers (under a commercial license)

It is not designed for:

• One-click adoption without review

• Employers seeking to bypass ERISA obligations

• People looking for loopholes

How Access Works

The materials are offered under license, not sold.

Two options are available:

• Licensed Implementation Access
  For employers/businesses adopting the framework within their own business. Requires Foundation Subscription

• Authorized Commercial License
  For professionals deploying the framework with clients- information available upon request. I will discount your Foundation Subscription toward the commercial license payment.

Access is provided via a private download, with clear versioning and update policies.

A Physician’s Look at Hepatitis B Policies in Infants

By Raymond Kordonowy, MD

Every few months, someone online declares with great conviction that “If we stop vaccinating infants for Hepatitis B, millions of people will die.”

That kind of rhetoric may sound authoritative, but it collapses several different realities into one dramatic—and misleading—statement.

Doctors, as scientists and patient advocates, need to take an unpassionate, Spock-like view of health issues. As a physician who believes in evidence, risk‑stratification, and informed consent, I want to show readers what the data actually demonstrate about:

• Hepatitis B mortality in infants and children

• What universal newborn vaccination does—and does not—prevent

• The availability of highly effective adult Hepatitis B treatments

• What we know (and do not know) about serious adverse events in infancy

• A rational, targeted alternative strategy that respects both science and autonomy

This is not anti‑vaccine content. This is pro‑transparency. This should not be a political nor corporate lobby issue. This definitely falls in the wheelhouse of the medical profession.

The Claim: “If we stop Hepatitis B vaccination, millions will die.”

This claim is made frequently on social media—including by physicians who should know better.

Let’s be clear:

This is not true for U.S. infants. This is not true for U.S. children. This is not even true globally in the short or medium term.

It is only true if one:

1. Aggregates all global adult cirrhosis and liver cancer deaths for decades,

2. Assumes every country stops vaccinating,

3. And then sums those adult deaths into a single dramatic figure.

That is a global adult epidemiology argument—not a pediatric risk argument.

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The Actual U.S. Pediatric Mortality Data (0–18 Years)

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Pre‑vaccine era (U.S., before 1991):

• Estimated infant Hepatitis B Virus deaths per year: ~7–11 (these appear to be absolute cases (the entire US population).

• Childhood HBV deaths (ages 1–18): 0–2 (these appear to be absolute cases (the entire US population).

• Many years recorded zero deaths

Post‑vaccine era (today):

• Infant HBV deaths: 0–1 per year

• Childhood HBV deaths: 0 per year

• Essentially no measurable pediatric mortality signal

Stated plainly:

Hepatitis B was not a significant cause of death in American children before vaccination, and it is not a cause of death now.

Universal vaccination took “very rare” and made it “almost zero.”

The Natural History Of Hepatitis B In Humans- Who Remains Infection Positive Beyond 6 months After Initial DX (chronic).

We Can Intervene With Efficacy In Infant Hepatitis B Exposure/Infection

Hepatitis B Immune Globulin (infused antibodies against the Hep B virus) works in creating seronegative status in infants. It works even better when combined with Hep B vaccination series in conjunction with the passive immunity infusion.

Why Do Public Health Authorities (and Politicians) Still Push Universal Infant Vaccination?

Because for public health authorities the goal is not protecting infants from death.

Infants infected with hepatitis at birth have a 70–90% risk of chronic infection. By definition they contracted it from their mothers.

Chronic infection carries a ~25% lifetime risk of death from cirrhosis or liver cancer.

Those deaths occur in middle or later age—not childhood.

So the public health argument is:

“By vaccinating newborns today, we lower adult liver cancer 40–60 years from now.”

Parents are rarely told this plainly.

An Important Point In The Vaccine Debate. Having Effective Treatments Temporizes The Importance and Relevance of Vaccination As Policy. Modern Adult Hepatitis B Treatments Are Highly Effective

Today we have Tenofovir and Entecavir: These Drugs

• Suppress viral replication to undetectable levels

• Prevent disease progression

• Dramatically reduce risk of cirrhosis and hepatocellular carcinoma

• Achieve viral suppression rates above 90%

• Are extremely safe and well‑tolerated

The idea that chronic infant infection leads inevitably to death is no longer consistent with modern antiviral therapy.

What About Serious Adverse Events in Infancy?

The Hepatitis B vaccine is generally considered safe, but several concerns deserve honest exploration:

1. Temporal association with SIDS (Sudden Infant Death Syndrome).

– Some studies show no link, others show clustering after well‑child visits.

– By definition, SIDS has no identified cause, making subtle causal signals difficult to detect. I find it strange that we never attribute sudden death in infants to “rhythm or heart attack”.

2. Combination vaccine adverse events

– Infants receive multiple vaccines simultaneously. Their body mass is a fraction of that of an adult. That is a relevant point. Further their immune system and all other organs are in no way fully developed as an adult.

– Trials rarely evaluate real‑world combinations given in a single session. Yet the list of recommended and coerced vaccines is ever increasing.

3. Underreporting in passive surveillance systems

– CDC and FDA acknowledge these systems miss most events unless extremely common.

4. Autoimmune and neurologic events. It is important to note that there is evidence (suppressed) that stacked vaccination and potentially carrier molecules/adjuvants (especially aluminum) combined with single nucleotide polymorphisms in individuals genetics is a plausible explanation for the unprecedented incidence of US modern day autism rates.

– Rare but documented. Causality often debated.

The correct stance is humility: absence of evidence does not equal evidence of absence.

FACT: Vaccinating Children For The Claim of Saving Childhood Lives Is Not Nearly Cost Effective.

If we evaluate only pediatric mortality (0–18 years), the program costs tens of millions per life saved.

Using the U.S. cost of vaccinating one annual birth cohort (~$444 million):

• If the pre-vaccine U.S. saw 10 infant deaths per year,
  → $44 million per pediatric life saved

• If the true number was closer to 5 deaths,
  → $88 million per pediatric life saved

These numbers come directly from the extremely low baseline mortality.

This has nothing to do with whether the vaccine “works.”
It has everything to do with what risk the newborn population actually faces.

Let’s Consider A Rational, Targeted Alternative Strategy

Today, with prenatal screening and modern technology, we can implement a targeted strategy:

1. Screen all pregnant women for active Hepatitis B.

2. Confirm maternal status at delivery with rapid testing.

3. If mother is positive:

• Give HBIG + Hepatitis B vaccine to infant affected.

• Treat the mother when indicated

4. If mother is negative:

• Defer vaccination until childhood or adolescence, or offer optional vaccination

This respects proportionality, risk‑based medicine, and parental autonomy and the best interest of the infant. Society owes a balanced protection of those unable to defend themselves.

Does Infant Vaccination Hold?

Yes is the answer.

Honest Takeaways

• Hepatitis B vaccination in infancy does not prevent pediatric deaths.

• Pediatric HBV mortality in the U.S. has always been near zero.

• The vaccine prevents adult deaths decades later—not childhood deaths today.

• Modern antivirals dramatically reduce adult HBV mortality.

• Serious adverse events in infancy are understudied due to passive surveillance.

• A targeted maternal screening + HBIG strategy is scientifically rational in low‑prevalence nations.

And the claim that “millions will die if we don’t vaccinate infants for Hepatitis B” is not supported by U.S. data, pediatric data, or therapeutic reality.

Parents deserve informed consent—not fear‑driven slogans.

References:

[1] WHO Global Hepatitis Report; GBD Hepatitis B Mortality Estimates.

[2] CDC Viral Hepatitis Surveillance (1982–1989); Mast EE et al. MMWR 2005.

[3] CDC NNDSS Hepatitis B annual reports (2000–2023).

[4] Beasley RP; Chang MH et al. NEJM; WHO Hepatitis B Fact Sheet.

[5] Marcellin P et al. NEJM; Chang TT et al. NEJM; AASLD HBV Guidelines.

[6] Institute of Medicine (IOM). Adverse Effects of Vaccines; CDC VAERS Limitations.

[7] Altman & Bland. BMJ: “Absence of evidence is not evidence of absence.”

[8] Beasley RP et al. Lancet; Lee C et al. Vaccine; CDC Perinatal HBV Guidelines.

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An update on premium subsidies, catastrophic plans, and what you need to know before open enrollment begins on November 1st.

The last vote on a stopgap bill to fund the government through Nov. 21 failed after a 54-46 vote on Oct. 23. While three senators who caucus with Democrats, including Maine Independent Sen. Angus King, have joined Republicans to support the bill, they need another five to reach the 60-vote threshold needed to pass. The pundits and politicians are promising various rate hikes yet we truly won’t know the actual quotes until enrollment actually begins.

Open enrollment details and dates

For most Americans, the critical dates for securing 2026 health insurance coverage are:

• November 1, 2025: The official start of the 2026 open enrollment period.

• December 15, 2025: The deadline to enroll or change plans for coverage to begin on January 1, 2026.

• January 15, 2026: The final day to enroll in a 2026 health plan.

Even if you are currently enrolled, it is crucial to re-evaluate your options during this period. Your current plan’s costs and benefits may change drastically next year, and you need to shop around to find the best fit for your situation.

The end of enhanced premium subsidies is coming

The most significant financial factor for 2026 is the expiration of the enhanced premium tax credits, which were established during the COVID-19 pandemic and extended through 2025. A local health insurance broker has shared that he feels most individuals and small businesses will be looking to go with minimal/catastrophic coverage as the proposed quotes of $22,400 per year for an individual. Family plans could be north of $50,000 with deductibles of 7 thousand (word in the street).

• The subsidy cliff returns: Previously, federal subsidies were unavailable to households with incomes above 400% of the federal poverty level (FPL). The enhanced subsidies removed this “subsidy cliff,” but it is scheduled to return in 2026. This means many middle-income families could see a major jump in their out-of-pocket premium costs.

• Projected cost examples: While actual quotes will not be available until November 1, analysts forecast significant rate increases, especially for those receiving subsidies.

  • Average ACA enrollees receiving subsidies could see their out-of-pocket premium more than double, with an average annual increase from roughly $888 to over $1,900.

  • A 60-year-old earning just above the 400% FPL threshold might face an annual premium hike of nearly $9,600.

Catastrophic health insurance policies are more accessible

There is one piece of good news for those anticipating high costs: the federal government is expanding access to catastrophic health plans for 2026.

• Eligibility expansion: Historically, these plans were limited to people under 30 or those who qualified for a hardship exemption. As of November 1, 2025, a new hardship exemption will be available for consumers who expect to be ineligible for premium tax credits based on their income.

• Coverage and cost: Catastrophic plans cover the same essential health benefits as other marketplace plans and provide free preventive services.

• High deductible: It’s important to understand the trade-off with these plans: they have lower premiums but come with a very high deductible. For 2026, the deductible is set at $10,600 for individuals and $21,200 for families. Subsidies cannot be used to pay for a catastrophic plan.

What should you do now? It makes NO SENSE to pay a mother or father’s entire year’s salary on a family health insurance policy. BEFORE ENGAGING IN HEALTH CARE CONSUMPTION.

To prepare for open enrollment, consider these steps:

1. Assess your needs: Review your family’s health usage over the last year. How many doctor’s visits did you have? What were your prescription costs? Use this information to estimate your healthcare needs for the coming year.

2. Estimate your costs: Use online calculators (search for “ACA subsidy calculator 2026”) to get a preliminary idea of what your costs might look like without the enhanced subsidies.

3. Review plan options: Be prepared to compare plans carefully once open enrollment begins. Don’t assume your current plan is still the best or most affordable option.

4. Consider all options: For those facing the subsidy cliff, look at all plan tiers, including catastrophic, to find the right balance of premium cost and out-of-pocket risk.

In 2017 I warned the public that the puck was taking the game into a new direction.

And here we find ourselves. The Direct Primary Care (primary care membership health care service) is looking like the inevitable fiscally prudent family health care access point. There are a total of nine confirmed DPC practices in Lee and Collier County. These are physicians in Internal Medicine, Family Medicine and Pediatrics. I believe there are at least 16 doctors within these options. Given the dynamics, more are sure to develop.

Business Owners TAKE HEED: And Now Enter The Brave New World. This Is What The Democratic Party Is So Fearful Of. And Why The Republicans Refuse To Negotiate Until The ShutDown Ends

How small businesses can pay for catastrophic coverage

A small business generally cannot directly pay for catastrophic insurance premiums for employees, as these plans are typically purchased by individuals through the ACA Marketplace. However, small businesses can provide tax-advantaged funds for employees to purchase their own coverage using a Health Reimbursement Arrangement (HRA).

• Individual Coverage HRA (ICHRA): This arrangement allows businesses of any size to provide tax-free reimbursements to employees for individual health insurance premiums and other medical expenses.

  • How it works: An employer sets a monthly budget, and employees purchase an ACA-compliant plan (including a catastrophic plan, if eligible) on their own. The business then reimburses the employee for the premium.

  • Catastrophic plan compatibility: For 2026, eligibility for catastrophic plans has been expanded. Employees who are not eligible for premium tax credits can apply for a hardship exemption to purchase one.

  • Important note: Employees who accept the ICHRA offer cannot also receive ACA premium tax credits, unless the ICHRA is deemed unaffordable.

• Qualified Small Employer HRA (QSEHRA): Designed for businesses with fewer than 50 employees that do not offer a group health plan, a QSEHRA functions similarly to an ICHRA but has specific annual maximum contribution limits set by the IRS.

AND FURTHER:

How small businesses can pay for DPC membership

Paying for employee DPC memberships is simpler, especially with new regulations that take effect in 2026.

• Compatibility with HSAs starting in 2026: New legislation clarifies that DPC memberships are no longer considered a disqualifying health plan. This means employees can contribute to and use a Health Savings Account (HSA) while also having a DPC membership, as long as the DPC fee does not exceed a monthly cap ($150 for individuals, $300 for families in 2025).

• Paying with an HRA: Under an ICHRA or QSEHRA, the employer can also reimburse employees for DPC membership fees, which are now considered a qualified medical expense under tax law, as long as they are billed correctly.

• Direct employer payment: An employer can also pay for DPC memberships directly. This is a simple arrangement where the business contracts with a DPC practice.

Key advantages of this approach for small businesses

• Cost control: DPC memberships typically have predictable, flat monthly fees, which helps small businesses manage their budget. By pairing it with a high-deductible catastrophic plan, the business insulates itself from the high, unpredictable premium costs associated with traditional group plans.

• Employee choice: Using an ICHRA empowers employees to select the catastrophic plan that best fits their needs, while the DPC benefit provides access to high-quality, continuous primary care.

• Enhanced access: The DPC model’s smaller patient panels allow for same-day or next-day appointments, longer visits, and direct communication with a doctor. This improves employee health, reduces absenteeism, and can prevent more serious health issues from developing.

• Tax benefits: Both the HRA reimbursements and the cost of the DPC memberships can be tax-advantaged for the business and tax-free for the employee.

The present overly subsidized health insurance government policies are simply not sustainable nor affordable. Policies have shielded market participants from directly engaging in health care price discovery. All of this has been to the benefit of Hospitals and their 15-year consolidation business wrap-up model. Insurance companies and Medicare have provided preferential and much higher payments for services that can and could be offered in independent physician owned offices and facilities.