Somewhere Wyoming, USA
Joined May 2022
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SagebrushPhntm retweeted
I get tired of Democrats claiming to be on the “right side of history” when both their past and their present are so utterly sordid and destructive. So, if you are a Democrat, let me tell you about MY side of history and YOUR side of history.
My side of history is Cato the Elder, John Locke, Thomas Jefferson, James Madison, Irving Babbitt and William F. Buckley. Your side of history is Thomas Hobbes, Karl Marx, Josef Stalin, Mao’s Little Red Book and Noam Chomsky.
My side of history is George Washington, Abraham Lincoln, Teddy Roosevelt, Martin Luther King, Ronald Reagan and Donald Trump. Your side of history is Tories who fled to Canada, Jefferson Davis, Woodrow Wilson, Bull Connor, George Wallace and Nancy Pelosi.
My side of history is freedom of thought, freedom of speech, freedom of religion and spirited debate. Your side of history is ThoughtCrime, Speech Codes, religious persecution and Cancel Culture.
My side of history is Brown v. Board of Ed., Loving v. VA, Gitlow v. NY, and Heller v. DC. Your side of history is Dred Scott, Korematsu and Roe v. Wade.
My side of history is Jackie Robinson. Your side of history is Colin Kaepernick.
My side of history is head held high, standing straight, hand over heart. Your side of history is sullen glances at the ground, kneeling.
My side of history is the family as the foundation of society. Your side of history is mutilating confused children.
My side of history is the rockets’ red glare. Your side of history is imagine no religion.
My side of history is firefighters going up the stairs into the Twin Towers. Your side of history is 28-year-old men playing Call of Duty in their mothers’ basements.
My side of history is smoked brisket. Your side of history is a no-foam, no-sugar, soy latte.
My side of history is Lincoln freeing the slaves and General Patton liberating Buchenwald. Your side of history is Fort Sumter, the Gulag and Pol Pot’s killing fields.
My side of history is Mel Brooks. Your side of history is Amy Schumer.
My side of history is all men and women are created equal and endowed by their Creator with certain inalienable rights. Your side of history is critical theory and only some lives matter.
My side of history is 20-year-olds storming Omaha Beach. Your side of history is 20-year-olds in their safe spaces with adult coloring books.
My side of history is American men and women disabled by an IED. Your side of history is American men and women disabled by anxiety.
My side of history is the Kentucky Rifle, the Springfield 1861, the M1911, the M1 Garand, the M14 and the AR15. Your side of history is whimpering submission.
My side of history is Thomas Edison, the Wright Brothers, Apollo 11 and Jonas Salk. Your side of history is “global warming,” 100+ genders and porous cloth masks stopping viruses.
My side is of history is laughing babies. Your side of history is selling aborted baby parts on the open market.
My side of history is the Sistine Chapel and Monet’s water lilies. Your side of history is an inverted crucifix in a bottle of urine.
My side of history is construction. Your side of history is deconstruction.
My side of history is civilization. Your side of history is nihilism.
And, MOST OF ALL:
My side of history is liberty. Your side of history is tyranny.
*finis*
SagebrushPhntm retweeted
For all of physician twitter
Respectfully
Medicare isn’t going to save us. Neither is Congress.
Medicare just told us. Another pay cut is in the works.
I’ve listened to this same conversation in physicians’ lounges every Wednesday since 1999. It has expanded to X and other social media platforms. It’s the same conversation. Physicians lament their loss of autonomy, yet year after year, the exact opposite of what we want continues to happen. Consolidation accelerates. Administrative control expands. Reimbursement erodes. And we continue to accept it.
There is no gentle solution. No legislative rescue. No negotiation that will restore what we’ve surrendered over decades.
Physicians must be willing to walk away, say no, and reclaim control of our profession. Not another committee. Not another appeal to Congress. Not another round of complaints while we continue participating in the very system stripping us of our independence.
Until physicians collectively decide that enough is enough, every discussion about autonomy, reimbursement, and the future of medicine is moot.
The solution isn’t coming from Washington, hospital administrators, or insurance companies.
Politicians, pundits, influencers, insurers, and bureaucrats all seem to believe they should have a say in how physicians practice medicine, how we’re compensated, and under what conditions we’re allowed to work. Everyone has an opinion, and everyone feels entitled to impose it on our profession.
At what point did we surrender that much control to people who have never practiced medicine?
And the more important question is, why do we continue to allow it?
It has to come from us. And it begins with the willingness to walk away
There is no other solution. Challenge me all you want. I’ll visit you in a decade in the lounge.
@DutchRojas
@DrDiGiorgio
@anish_koka
@real_doc_speaks
@HeathVeuleman
@JahangirAsgha10
Medicare for All still has to pay enough to cover practice overhead and compensate physicians.
If its rates cannot sustain independent practices, expect more consolidation, more subsidies for already subsidized health systems, and less access to care.
Calling it “one simple insurer” does not make the cost of delivering care disappear.
But keep believing in fairies.
SagebrushPhntm retweeted
A society that disrespects its physicians and devalues their care, is a society in decline.
The NYT's attack on Sen. Roger Marshall is outrageous.
Why are doctors the only people in the country who don't deserve to be paid? How about editors and reporters - why don’t they give their salaries to these layabouts on "disability" who demand medical services, and then refuse to pay?
The average OB/GYN sees a thousand patients a year. That means Dr. Marshall probably saw 25,000 patients and THE NEW YORK TIMES IS DISGUSTED that he submitted 700 unpaid bills to his lawyers.
SEVEN HUNDRED out of 25,000 - that means he pursued unpaid bills from LESS THAN 3% OF HIS PATIENTS.
I like the woman who refuses to pay for her C-section and complains she got served by a lawyer two years later WHEN SHE WAS PREGNANT AGAIN. Uh, miss — if you can’t afford to pay for the delivery of your first child, how about learning to use birth control?
Not only that, but she irresponsibly failed to sign up for Medicaid which would have paid all medical bills related to her pregnancy FREE. ("Free” meaning: "Ann Pays More.”)
Oops, she f-ed up, so the doctor doesn't get paid.
And this arrogant, entitled narcissist complains about having to pay for the birth of her child: "I had to choose whether I’d pay my electricity or pay $50 to a doctor who didn’t need it.”
After practicing obstetrics for a quarter century and being part owner of the hospital, Dr. Marshall’s combined salary was $780,000. What's Pinch Sulzberger’s salary? How about Maureen Dowd?
Why don't you guys pay for these slackers, instead of a rural doctor who delivered thousands of babies and -- unlike a lot of doctors -- accepted Medicaid patients.
Or Sarah Kliff -- who can't deliver babies, but DID review "thousands of pages of court records and interviewed eight people whom Roger Marshall sued over medical debt."
The Times should refuse to pay you for your work, Sarah.
It's bad enough that these layabouts think they have a God-given right not to pay doctors, but appalling that overpaid journalists think it's a moral crusade to back them IN NOT PAYING FOR SERVICES THEY ACCEPTED.
Explore this gift article from The New York Times. You can read it for free without a subscription. nytimes.com/2026/09/08/us/po…
SagebrushPhntm retweeted
In 2024, we spent $5.3 Trillion on healthcare. 2025 is projected to be $5.7 Trillion. This year it’s projected to cross $6.0 Trillion dollars. Note here that our national debt just crossed the $40 Trillion dollars mark.
Healthcare is ~20% of our GDP.
The largest beneficiary of American health spending is a sector that sues its patients - with their own tax dollars - and calls the arrangement philanthropy.
The not-for-profit hospital cabal. Also known as “charity” hospitals.
Methodist Le Bonheur, a nonprofit, sued more than 8,000 patients in five years, including its own housekeepers, whom it paid so little that some qualified for the hospital's own financial assistance policy. Nobody told them.
Providence, a nonprofit, paid McKinsey to design a collections program that trained staff to extract payment from patients who qualified for free care under state law. Washington's attorney general eventually persuaded them to return $158 million.
Ballad Health, a nonprofit holding a state-sanctioned monopoly, filed thousands of lawsuits against its own patients.
Each of these institutions is exempt from taxation because it is, in the eyes of the law, a charity.
The dysfunction is not a scandal. It is the operating model.
A nonprofit cannot distribute profit, so surplus has three exits. Reserves, executive compensation, and expansion. Aggressive collections feed all three, and the exemption lets the proceeds compound untaxed.
The family being garnished already subsidized the hospital once - through their tax dollars. And tens of thousands of families are forced into bankruptcy each year due to these hospital bills.
@DutchRojas has written extensively about the not-for-profit pox upon our houses.
Today, 82% of physicians are employed. (mainly by not-for-profit health systems). They average about 50 hours per week, for an average salary of ~$373K.
Hospital CEOs average $1.1MM. The large system CEOs run $8-10MM, and the largest have cleared $30MM in a single year. Most of them work ~216 days a year.
Follow the money and you'll find the mission.
SagebrushPhntm retweeted
The Marines taught me one rule: the man at the top owns everything that happens below him. No exceptions.
Then I got into healthcare.
Where a CEO can gut a town's only maternity ward, miss every quality metric, and collect a retention bonus.
Two different definitions of leadership.
One of them I'd let near my kids.
SagebrushPhntm retweeted
The core of the discussion about physicians today is less about money and more about the loss of autonomy. Laws have shifted the balance of control of medicine toward insurers, administrators, and government, and completely away from doctors. Physician “Burn Out” occurs from a loss of control and all the new demands that must be met while lacking the ability to protest or change. The doctor no longer has control or leverage and that is first frustrating and ultimately infuriating.
SagebrushPhntm retweeted
Healthcare is the only sector where the customer doesn’t pick it, doesn’t price it, and doesn’t pay for it and we’re all shocked it costs what a war costs.
Friday economics.
SagebrushPhntm retweeted
If insurance companies can deny care and call it "medically unnecessary", why aren't they required to have malpractice insurance doe when they get it wrong and someone gets sicker or tragically dies ?
SagebrushPhntm retweeted
Medicaid pays hospitals more than my online, posted pricing, fyi. Spoiler…I’m profitable. GKS
SagebrushPhntm retweeted
Here's how your tax dollars get spent.
1. CMS lets random frauds spend your money on fake bullshit
2. The DOJ prosecutes frauds for spending your money on fake bullshit
3. CMS expands funding for fake bullshit
4. The DOJ expands prosecution of fake bullshit
Rinse, repeat.
SagebrushPhntm retweeted
The failing @nytimes write a 3,000 word article on Jackson, Wyoming. I’ve suffered through it so you don’t have to (TMFMS)
1) this is going to surprise you but the authors really don’t like Donald Trump! Especially Donald Trump’s tax policies which they sort of claim created and entrenched a new wave of Jackson’s billionaires (lol!).
2) They have sour faced soylennial NGO person in there to tell you more money should go to immigrants. No mention of 7th gen ranching families who also can’t afford the area. This is about the NGOs and their immigrants! :(
2) the reporters really don’t like that billionaires exist at all, anywhere in America, and they really don’t like Elon Musk! They take about 1000 words to tell you all that before returning to Wyoming.
3) they attack @daily_cowboy as a “right wing paper” even though it’s arguably the best wildlife reporting in the entire Mountain West. This was the most surprising part of the article, I howled.
4) they mention Joe Rickett’s (of TD Ameritrade and Chicago Cubs fame) proposed luxury ranch resort that was planned in the middle of one of the most important mule deer/elk/pronghorn migration corridors in the entire Greater Yellowstone near Bondurant (pop 59).
This is a super interesting case study but they sort of gloss over the most interesting parts. The county commission was going to let him build, but he wanted *all seasonal wildlife* restrictions lifted (eg allowing construction during peak migration). He was miffed he couldn’t get this and cancelled the project.
What’s currently interesting about “billionaires in the west” isn’t any of the vignettes told by the NYT. Rather it’s shadowy donor advised funds and philanthropic networks pouring tons of campaign money into activist extremist pet projects ranging from American Prairie to this week’s ban on fur sales in Colorado. Billionaires are undermining local values, culture, and preferences, and funding campaigns that release wolves in the heart of ranch country, while facing zero accountability by the press.
These impacts go against public wishes of the rural communities that wildlife commissions of the western states used to serve. State by state, restrictions on hunting and fishing and wildlife stewardship are being pushed by the same unelected (often opaque) networks of billionaires named in this very article (most notably the Swiss billionaire Wyss family) but the NYT spends all its ammo on Trump and Elon derangement, missing what’s happening on the ground and making the article boring and irrelevant.
Missed opportunity to call out Millionaire Cowboy Bar for not having beer on draft. And they call themselves the paper of record.
SagebrushPhntm retweeted
Black Americans in a church.
Mexican Americans in a store.
Asian Americans in a spa.
Radicalized white men are the greatest domestic terrorist threat in our country.
SagebrushPhntm retweeted
This “neurosurgeons as bullies” fairy tale is historically illiterate.
Congress created RBRVS. In 1989, Congress scrapped UCR and imposed a budget neutral fee schedule because they believed physicians were overpaid. They mandated that physician work be valued based on time, intensity, technical skill, mental effort, and risk.
The early 1990s implementation actually cut many surgical payments relative to UCR and raised evaluation and management codes. The political selling point of RBRVS was that it would boost primary care and rein in procedural excess.
The original valuation work was done by researchers at Harvard under William Hsiao. They surveyed specialties and modeled physician work. Neurosurgeons did not design the system. It was federal statute.
After that, every specialty went through the same process. Every specialty argued for its codes. The RUC does not print money. It reallocates within a budget neutral framework set by Congress. Neurosurgeons are outnumbered by primary care on the RUC panel.
And what has been cut for decades? The conversion factor.
If you want to talk about structural underpayment of primary care, start with:
– Budget neutrality
– The SGR era
– Repeated congressional failure to update the conversion factor for inflation
– The migration of dollars into facility fees and hospital systems
– Laws that hollowed out independent practice
The idea that organized neurosurgery should have heroically refused third party payments in the 1990s to save primary care is fantasy. We cover trauma centers. We take call. We treat Medicaid and uninsured patients. You do not run a Level 1 trauma service on moral theater.
Private pay? I’m all for it. I’ve hosted @AtlasMD on @DRsLoungePod. Many of my reform proposals revolve around empowering patients with real dollars so they can choose cash primary care (thedoctorslounge.substack.co…).
But I cover a county hospital and my practice is roughly 80 percent Medicaid. Should I inform those patients I am exiting in solidarity? What is your Medicaid mix? Or is this advice coming from a cash pay practice insulated from public coverage?
Primary care’s problem is not that neurosurgeons stole lunch money.
Primary care’s problem is that Congress froze the physician fee schedule in real terms while administrative overhead exploded, shifted power to hospitals, inflated facility payments, and locked everything into budget neutrality.
Meanwhile specialists have absorbed repeated conversion factor cuts, site of service distortions, prior authorization expansion, and regulatory creep that drove many of us into employment.
No one is sitting on piles of stolen treasure. The real extraction has happened at the facility level and in administrative bloat.
And the “age of influence peddling is over” line is misplaced. The dominant lobbying force in American healthcare is hospital systems, not neurosurgery. Independent physicians of all types have been losing leverage for two decades.
If the argument is that we should rebuild medicine around patient directed payment and real price signals, I agree.
If the argument is that neurosurgeons are morally responsible for Congress designing a budget neutral price control regime, that is unserious.