The Cost Conundrum was an article written in 2007 in the New Yorker by famed surgeon and author, Atul Gawande that sought to explain the high cost of American medical care.

It was inspired by data from a health policy researcher from Dartmouth named Eliot Fisher. Fisher’s group had mapped Medicare spending of every county in the U.S.

McAllen, Texas had the distinction of having the second highest per capita Medicare spending in the country, and it was this town Gawande traveled to, to write his article.

Gawande, an academic surgeon from one of the elite medical centers in America wrote with some distaste of a two filled with strip malls with small independent private practices dotting the landscape that were making handsome profits by billing fee for service Medicare to the max.

Gawande provided a stark contrast to this low value, profit driven care by traveling to a high value, low cost county — the Mayo Clinic.

 A visit to a surgeon’s clinic at the Mayo Clinic told the story of an hour long discussion with a patient followed by a cardiologist materializing within 15minutes from another floor to help ready a patient for surgery the next day. 

 How did they do this?

Gawande’s words :

“..decades ago Mayo recognized that the first thing it needed to do was eliminate the financial barriers. It pooled all the money the doctors and the hospital system received and began paying everyone a salary, so that the doctors’ goal in patient care couldn’t be increasing their income. Mayo promoted leaders who focused first on what was best for patients, and then on how to make this financially possible.
No one there actually intends to do fewer expensive scans and procedures than is done elsewhere in the country. The aim is to raise quality and to help doctors and other staff members work as a team. But, almost by happenstance, the result has been lower costs.”

The answer to the health care cost problem lay in this elegant article.  The plan as initially forwarded by Eliot Fisher from Dartmouth and now gracing the pages of the New Yorker was to create “Accountable Care Organizations” in the image of the Mayo Clinic. 

Convert McAllen, Tx to Rochester, MN and the nations problems would be solved.

As a young medical trainee reading his article, I was sold.

But I never stopped to think of how Mayo was operating in this manner.  How could a surgeon at Mayo afford to spend a whole hour with a patient?  How exactly does a cardiologist have time to run down in the middle of the day to discuss a complicated patient?  If the cardiologist doesn’t bill the consultation, how is the cardiologist being paid?

1/x Gawande never provided these details, and more importantly no one of any importance asked these questions.

“The Cost Conundrum” was required reading for the framers of the ACA, and so health care was reimagined and jiggered to make winners out of large health care systems.  Cuts from CMS targeted private practice reimbursement.  Regulations that required reporting of practices through an electronic health record were applied.  The incentives quickly melted away to become penalties.  Private practitioners faced a choice : accept the lump of coal or join a hospital.  Most fled to hospitals, dotting the landscape with soup to nuts health care systems and realizing the dream Gawande had written about.

Except, Gawande and his adoring readers (that would include me) had been hoodwinked.  The secret sauce for this high value care being provided to patients by the very best in the field wasn’t in the Medicare data that Eliot Fisher’s group in Dartmouth had put out.  The drunk looking for keys under the lamp post doesn’t find his keys for a reason.  The keys in this case was where no one was looking – payments from private insurers.

2/x

Thread on Medicare Advantage denials

1. MA denies an MRI to follow up / characterize a suspicious adrenal mass seen on a CT 2. MA denies a walker to a 76 year old polio survivor because he received a cane in the past 5 years

Comments / summary on Pfizer subclinical myocarditis study

Overall really confusing

Group 1: 1487 total randomized to Pfizer vs placebo, troponin done at baseline, post usual dose (30mg)

Group 2 : Broken into 2 bc EUA for 12-15 arrived during trial, so majority of 12-15 unblinded and took Pfizer vaccine
🧵 Troponin tested pre and post vaccine dose.

Rather than show individual baseline troponin and rise after placebo vs drug , results shown in summary format, so cannot track individual rise In tn

Ok. So my summary on the @Change_HC @Optum @UHC cyberattack debacle.

TL,DR : Govt. regulation creates billion dollar revenue streams for large corporations. Regulatory capture by large organizations means a healthcare system that is incredibly susceptible to single points of failure, and most of the players in the space have no clue/ don't really care!

🧵 Feb 21, 2024, cyberhackers compromise @Change_HC (formerly Emdeon, acquired a few years prior by @UHC for $13billion).

@Change_HC is the largest medical clearing house that takes electronic claims generated by hospitals and doctors offices , scrubs them, and puts them in a format that insurance companies accept. Insurance companies process claims, and make payments to hospitals and doctors.

If you have a deep seated fear of COVID you will instinctually seize on any study that confirms that bias.

If you fear the vaccines, you instinctually will want to believe data that confirms that bias.

Neither approach will get you close to the truth

🧵

https://twitter.com/ichudov/status/1708534667261972962

If the goal is truth, then the real bias everyone should lean into is against the academic-peer-review industrial complex that spends most of its time generating data that doesn’t replicate and then exacerbates the problem with hyperbolic conclusions

The coverage of this wildly speculative paper linking sars-cov2 is much worse than the actual paper is.

To give you a flavor.

The study is based on 8 autopsies of patients with a diagnosis of COVID.

Let’s take Patient 1.

🧵

59 year old black man with a history of CAD.

He was admitted to the hospital 3 times before dying.

Hospitalizations 1 was with a clot in his lungs. His only treatment was heparin and xarelto. This means he didn’t present with a COVID pneumonia.

Hospitalization 2 was listed for heart failure. His ejection fraction was 40-45%. He spent 5 days in the hospital. He was still COVID positive.

Hospitalization 3 was with an acute heart attack. A circumflex artery occlusion associated with rupture of a component of the mitral valve — the papillary muscle. He was now COVID negative. He died of the heart attack and resultant heart failure, I assume.

One of the major issues of the last 3 years has been a seeming inability of US institutions to seek to answer basic questions like how extensive and how long a novel vaccine administered to humans lasts.

Well, these researchers tried to answer this question, and the results are really interesting!
Human bio-distribution studies are hard by nature.. it requires specimens of a variety of organs at various time point after administration of a therapeutic.

Preclinical animal studies of the mrna/LNP construct suggested a short duration (days)

The few human studies have suggested a much longer duration of action.

“Using human axillary lymph node biopsies, spike protein and vaccine mRNA were reported to persist up to 60 days from vaccination with either BNT162b2 or mRNA-1273 as detected by immunohistochem- istry and in-situ hybridization. In that study spike protein was also detected in the plasma up to 7 days from vaccination. BNT162b2 mRNA was detected in patients by PCR in circulating leukocytes up to 6 days from vaccination and in the plasma up to 15 days from vaccination. Using highly sensitive single-molecule array assays, spike protein derived from mRNA-1273 was detected in the plasma of patients up to 28 days from most recent vaccination20. Circulating exosomes containing spike protein derived from BNT162b2 were detected in patients 4 months after vaccination”

Study from Basel, Switzerland that looks at myocardial injury as measured by routine measurements of cardiac biomarker (HsTn) after healthcare employees received a booster.

Obvious big limitations :

https://t.co/Gdffqn93jSonlinelibrary.wiley.com/doi/epdf/10.10…
1. Excludes anyone who had myocarditis after dose 1 or dose 2
2. No baseline troponin checked prior to booster administration
3. 1871 Screened ---> 777 evaluated in trial
4. Average age 37, only 30% male

(Peak clinical myocarditis to date has been seen in 16-17 year old boys)

The @nytimes & @propublica both have stories out focused on outpatient vascular care that leave the impression doctors who own vascular centers are harming patients while chasing profits.





Not quite..

🧵 nytimes.com/2023/07/15/hea…
propublica.org/article/maryla…


The context missing from both articles is that severe PAD is a major problem impacting a large number of patients that results in amputations.

Every 4 minutes in the US, a diabetic patient undergoes an amputation.

Poor patients, and black/hispanic patients have ⏫ rates

Dr. Wang had distinguished himself as a scholar who published frequently in his specialized field of electrophysiology as well as an excellent teacher (hence his role as director of the electrophysiology fellowship program)

His mistake in 2020 was having a paper accepted for… twitter.com/i/web/status/1… The Abstract:

“Since 1969, racial and ethnic preferences have existed throughout the American medical academy. The primary purpose has been to increase the number of blacks and Hispanics within the physician workforce as they were deemed to be “underrepresented in medicine.” To… twitter.com/i/web/status/1…

Want proof that we do not have adequate mechanisms in place to assess safety of a novel therapeutic given to millions?

See this autopsy study from Japan on post COVID vaccine deaths 🧵 sciencedirect.com/science/articl… “Tokyo Metropolis is a metropolitan prefecture, and the medical examiner system has been implemented in the special wards of Tokyo Metropolis. All medicolegal deaths including natural, non-natural and undetermined manner of death occurred in the special wards of Tokyo Metropolis… twitter.com/i/web/status/1…

Comprehensive Korean study on mrna vaccine myocarditis (VRM) should raise serious concerns:

- COVID-19 VRM was confirmed in 480 cases (1.08 cases per 100 000 persons)
- VRM incidence was highest in males between the ages of 12 and 17 years (5.29 cases per 100 000 persons)
-… twitter.com/i/web/status/1… The severe events reported here are occurring at a much greater rate than what’s been seen to date, especially in the US.. and this points to potential under reporting in the US mechanism for picking up vaccine adverse events..

The US uses VAERS, which is a passive reporting… twitter.com/i/web/status/1…

Let's see how this Ioannidis Stat News article from March 17,2020 aged..

statnews.com/2020/03/17/a-f… "The current coronavirus disease, Covid-19, has been called a once-in-a-century pandemic. But it may also be a once-in-a-century evidence fiasco."

"Better information is needed to guide decisions and actions of monumental significance and to monitor their impact."

Was just sent this from @Medscape featuring Eric Topol, Bob Harrington & Abraham Verghese on rogue faculty in medicine at elite institutions and free speech. 3 academic medical leaders get together & define academic freedom that is worthy of being defended as anything that disagrees with their clearly politically shaded views

They complain more wasn't done to shut down @DrJBhattacharya @VPrasadMDMPH , Ioannidis, Scott Atlas

Helps to better define COVID myocarditis.

Cardiologists that have been rounding in hospitals through the pandemic (🙋‍♂️) generally feel what's labeled as C19 myocarditis is ill patients in the hospital with C19 who spill troponins (a biomarker of cardiac cell damage) 🧵

https://twitter.com/TracyBethHoeg/status/1621734467667906561

This is very different than what myocarditis has classically been described as - usually a viral illness that results in cardiac abnormalities (chest pain/heart failure) that is THE reason patients present to doctors offices/hospitals

2/

The elite (Harvard/Yale/etc) face irrelevance bc they r incompetent. Their response:

“In 2022, US Food and Drug Administration (FDA) Commissioner Robert Califf announced that a core plank of the agency’s agenda would be “countering misinformation about science and the FDA” “Health misinformation, which Commissioner Califf characterized as the leading cause of death in the USA, has attracted substantial attention during the COVID-19 pandemic”

It's unfortunate this space wasn't recorded.

The space was billed as a reality check on covid/vaccines and specifically myocarditis.

For context, in September 2021, Dr. Han, a pediatric cardiologist wrote this blog on sciencebased medicine blog" sciencebasedmedicine.org/myocarditis-an…

https://twitter.com/han_francis/status/1618122776656891906

I believe the editors chose to this sub-heading : "In response to the dumpster diving VAERS study published earlier this month... pediatric cardiologist and guest blogger Dr. Han adds context"

The study in question was from @TracyBethHoeg et al: onlinelibrary.wiley.com/doi/10.1111/ec…

Italian retrospective study of vaccine effectiveness against omicron in 5-11 yo

“On April 13, 2022, 1063035 (35·8%) children had completed the primary cycle of two doses, 134 386 (4·5%) had received one dose, and 1768497 (59·6%) were unvaccinated.”

ncbi.nlm.nih.gov/pmc/articles/P… “Overall, 644 children had severe COVID-19 and required hospitalisation (15 of whom were admitted to an ICU; two died; all were unvaccinated). “

Classic example of problems with this topic.

Odds ratio for C19 & COVID myocarditis is found to be 8!

But paper is looking for complications in hospitalized COVID patients.

Complications are “found” if an ICD10 code is placed in EMR

cmaj.ca/content/cmaj/1…

https://twitter.com/MartinFierro769/status/1617106303532556292

So in the universe of sars-cov2 COVID infections this study’s denominator is hospitalized patients only.

The ppl that get c19 and don’t get hospitalized? Not included ..

“Vaccine myocarditis is less severe than myocarditis from the virus”

What is this assertion based on? Maybe MIS-C ? Which afflicted young children earlier in the pandemic (risk of mis-c seemed to drop with successive waves)

Also need a machine learning model to differentiate kawasakis from mis-c 🤔

Going to attempt a twitter space tomorrow with some cardiologists at noon to discuss a non-COVID cardiology topic.
#twitterheartspaces

We'll be discussing re-analysis of the data used to approve a common injectable medicine to lower cholesterol levels -- Evolucumab Evolucumab was shown to markedly lower LDL in patients who already had very low LDL levels to begin with.

The real question is whether it also lowered an endpoint that matters to patients like fewer heart attacks, fewer stents, or dying less..