Patients at Risk
Patients at Risk
If you are hospitalized, will your care be overseen by a physician?
Hospital organizations are increasingly replacing physicians with nurse practitioners and physician assistants who act as "hospitalists." John Chamberlain, the board chairman of Citizen Health and a former hospital CEO, discusses his wife's hospital stay, during which her care was supervised by a nurse practitioner.
We also discuss the increasing corportization of health care and the importance in transparency among health care practitioners and hospital pricing.
Citizen Health aims to redesign healthcare by putting patients and physicians in control. Learn more at https://citizenhealth.io/.
Get the book! https://www.amazon.com/Patients-Risk-Practitioner-Physician-Healthcare/dp/1627343164/
PhysiciansForPatientProtection.org
Welcome to'patients at risk' a discussion of the dangers that patients face when physicians are replaced with non physician practitioners. I'm your host, Dr. Rebekah Bernard, and I'm joined by my co host and the co author of our book, patients at risk the rise of the nurse practitioner and physician assistant in healthcare, Dr. Niran Al-Agba. Most of us assume that if we have to be hospitalized, that our care will be overseen by a physician, but more than ever, patients are finding out that even if they have to be admitted to the hospital, that the care that they are receiving is not by a medical doctor, but often by a nurse practitioner or a physician assistant. Today we'll hear the story of a patient who had such an experience, John Chamberlain's wife required hospitalization, and during her entire stay, her care was managed by a nurse practitioner hospitalist rather than a physician. John, welcome to the podcast.
John Chamberlain:Thank you very much. Nice to be here and appreciate seeing both of you.
Rebekah Bernard MD:John, you're the board chairman of citizen health, which is a health care cooperative working to redesign health care. And you also were a former hospital executive. So you know, a thing or two about the health care system. So can you tell tell us about your wife's experience and what you saw,
John Chamberlain:my wife has Parkinson's and one night, right but is the night before Thanksgiving she fell, lost her balance and fell and fractured neck of her right femur, which necessitated a trip to the hospital ER, and subsequent pinning of that particular injury. And we were admitted through the ER. And our first visit from the hospitalist was from a nurse practitioner, a very pleasant young lady, I was surprised to some degree in that two years prior, I went in for a hot gallbladder and I saw a physician hospitalist. And I happen to know the doctor or group of doctors that owns the hospital, his practice at the hospital contracts with. So again, I was surprised when we had a a nurse practitioner, hospitalist at the time we were there. And it wasn't a complicated hospital admission. I wasn't particularly upset by it. But more concerned, she seemed to be knowledgeable to the point. And I think where I would have gotten upset if there had been any complications, I did not ask to see the physician, because we didn't have those complications. But I think it's a I think it's a dangerous step. And it's happening more and more in hospitals across the country. Had I requested a physician, I would have been very upset if one wasn't provided. Now again, I know the doctor that owns the hospitalist practice, I'm sure I could have requested through him to see a physician, I came to found out later that the doctor that was my hospitalist wasn't along with them that's neither here nor there, except that it tells me that they're like everybody else, replacing physicians with lower cost, quote, unquote, mid level practitioners. And I don't find that to be a very pleasant trend. I think it's a dangerous trend.
Niran Al-Agba MD:I guess my question is, of course, you know, you were once in that system, right? You were once involved with the hospital and an administrator. So from your perspective, I would love to hear because it's one thing when we talk about it when we own our own clinics, both Dr. Bernard and I but I would love to hear about how or why you think really hospitals are replacing physicians. What are they getting out of this?
John Chamberlain:I think they're doing it primarily for a cost standpoint, their hospitals, both not for profit and for profit have become more and more lack of a better term greedy, they have a lot of regulatory pressures, they're looking for ways to continue to put money to their bottom line. And that's why they're using lower cost practitioners, if you will. I think that's primarily it. I think they don't see anything wrong with that. And I have a big issue with that. I think, again, just so for general purposes, I think there's certainly a place for mid levels as a part of a team. And I think had the mid level that was over my wife's care from a hospitalist standpoint had said well, I'm going to go back and speak to Dr. So and So about this, if you have any questions that was never offered, hospitals are doing it for from a purely financial standpoint. I think there's also pressure from legislative bodies, they're getting pressure from lobbyist, AANP, APA, you name it now even got optometrists wanting to do eye surgery, which is just bizarre, beyond the pale, but I think it's strictly financial. And again, I think there's some legislative pressure as well.
Niran Al-Agba MD:My second question then is something we've talked about a lot on this podcast is that the studies really show that non physician practitioners or nurse practitioners and PDAs tend to order more studies, more labs, more imaging and in fact 400% More imaging studies than physicians do. And so can you talk to me a little more about how that's also benefiting hospitals? Because
John Chamberlain:I think it is, obviously, from a financial standpoint, if you're working for the hospital, as a nurse practitioner or a PA, where are you going to refer those patients for imaging and diagnostic labs? Well, to the hospital, of course. And while you and I and Dr. Bernard may think, Well, you know, that's not good that they're doing 400% More imaging ordering. Well, the hospital CEO think that's great, because it's revenue in the door, and they're revenue driven, whether you're for profit, or as we're coming to find out more and more than opera profits are even worse. Not only do they have a tax advantage, but they are able to get away with these things because of quote, community benefit. In reality. I just saw an article today that blew my mind, there's a hospital group, I think they're in Illinois, that has invested some of their largest into basically an innovations or an acquisition unit as part of their hospitals system, investment funds. So they're looking to go out and buy companies to drive revenue for the hospital system. And and I've worked in both I've been both a not for profit CEO and a for profit CEO, and the not for profits have been getting away with murder for decades. And it's high time that it comes to a screeching halt. But long answer to a short question. Of course, they're happy with them because they're generating more revenue. And if you know what hospitals bill for imaging and labs compared to what a freestanding Senator would bill, it's understandable from that standpoint.
Rebekah Bernard MD:Absolutely. Now, John, when your wife was in the hospital, this was in the state of Alabama, is that correct? And if I'm not mistaken, I thought Alabama, is that an independent practice state? I don't. So it's not so technically nurse practitioners must be practicing under supervision or under a collaborative agreement with a physician. And yet, as far as you knew there was never any physician involvement, or at least no one mentioned it to you at all.
John Chamberlain:That's correct. I take what would have been appropriate if it had been my employ as a hospital CEO, and my nurse practitioner did not tell the patient, I am so and so I work with such and such company. And it's Dr. So and so is our CEO, and I will be getting back to the physician overseer for lack of a better term, and bring him up to speed him or her up to speed on your wife's progress. Now, of course, because it was surgical case, we had the surgeon came in and checked it. Like I said, it wasn't a complicated medical admission. And if I felt like I wanted to reach out to this physician owner and tell him that, I probably would and just say look, just a bit of friendly advice. You know, some people are not going to understand why they're not seeing a doctor as part of their hospitalist routine.
Rebekah Bernard MD:And you know, the other question that I have is I know that when a nurse practitioner or a physician assistant is evaluating a patient and they're practicing under the license of a physician, they call that incident to when you do the billing, and if you're practicing under a physician, and you're kind of filling the physician's plan, let's say you're allowed to bill at 100%, the exact same charge as the physician because you're acting as the physicians quote extender. Now, NPs did not like this term position extender these days, but that's the way the billing is set up. So that's called incident to billing. Now, if they are not working under supervision, or they're not being directed by a physician, then they're supposed to bill under their own licensing number at which they get paid 85% of the billing. So I also wonder if did you ever find out about any of the billing that happened was Were you being billed for physician level services, even though you only saw a nurse practitioner?
John Chamberlain:Well, interestingly enough, she was discharged on November 29. And I've yet to receive the itemized statement from the hospital. So I don't know how exactly how it was built. Of course, I got my EOB from the insurance company. It wasn't detailed. I still haven't received an itemized statement. I was to the point where I wasn't gonna pay until I received it. But you know how that goes. Anyway, right? No, I don't know how exactly how that was built out. I do know that there's an increasing prevalence of nurse practitioners outside the hospital as well. The last probably four visits my wife and I've had with our PCP have all been the nurse practitioner. We haven't seen the PCP in probably six months, eight months, maybe?
Niran Al-Agba MD:Well, you told when you schedule the appointments that you weren't gonna see your regular physician.
John Chamberlain:It kind of became automatic, you know, I'll see you back nurse pay and we've been again, nothing serious routine stuff. That would be a different story. If it was my wife's neurologist, and we were seeing a nurse practitioner neurology. There's practitioner, that's a different story, but no, we were not told up front that you would be seeing so and so you know, Dr. So and so's nurse practitioner, but Again, we're happy with the one we've got so far is what we what our needs have been. But I happen to know the PCP I wouldn't be afraid to stop her in the hall and say, hey, look, we'd really like to see you next time for this particular reason. And I'm sure Honestly, if I asked, I would probably be allowed to schedule with with Dr. Baraka now,
Rebekah Bernard MD:you shouldn't have to ask and no should you know, it's sort of like putting the onus on the patient to determine whether or not you need to be seen by a physician and savvy and you know, you probably do know, but let's take the average person that maybe doesn't have that level of acumen. And they're supposed to know like, well, this doesn't seem right, or I'm not getting better. I wonder if I should maybe see the doctor. I mean, that seems kind of, you know, just not right, that the patient has to be the one to take that responsibility.
John Chamberlain:Yeah, it's very standoffish. And I think, again, my dad was a an internist, diagnostic cardiologist, five generations of physicians. He would it was he passed a long time ago, but he was the kind of physician that would if he wasn't seeing somebody, and of course, he didn't have nurse practitioners when he was practicing. But if he had any questions, he just stick his head in. And again, if I were my PCP, if I saw you in the hallway, or just knew you were in the clinic, and she's busy, I understand that she's a fee for service practitioner. So that's why she has two or three nurse practitioners working for, but just to stick her head and say, hey, I want to say hi, see how you're doing? You know, not to make her nurse practitioner feel uncomfortable. But I mean, that's part of business, you know, you out is being direct primary care. And I'm sure Iran does in her business. It's more than just the clinical. It's the patient relationship. And I don't hold that against Dr. B. I know her but there's gonna be some point I'm going to say, All right, look, how do you have a schedule? We really think it's time to see the doctor, and I'll be insistent about it. It's Dr. B
Niran Al-Agba MD:in a free standing independent clinic or is she part of a hospital and employed?
Unknown:She is staunchly independent. I've tried to talk her into going DPC get out of the insurance game for five or six years, and she's got it down to a system. She's happy doing what she's doing. She would do fabulous in a DPC practice, because she has that personality if and when you get to see her.
Niran Al-Agba MD:So and again, not even talking about Dr. B per se, but what do you think? I mean, Dr. Barnard, of course, has a great DPC practice and being pediatrics, you know, I'm still a old fashioned classic, essentially a micro practice who still takes insurance and I do fine. But I guess what do you think the holdup is for physicians? Why do you think they're I mean, you're a business guy. What do you think is the hold up for people who really wouldn't be successful at DPC practices?
John Chamberlain:I think it's a fear of the unknown for one. I think it's also huge medical school debt. If you're trying to catch young doctors coming out of residency, I take it you know, how am I going to pay I actually had a young man that I was working with here three years ago, had had an unsuccessful tried a for profit hospital working for them as an employee over in Northwest Florida. And he called me up we talked and it came down to the fact I said, Look, you can open a DPC practice for next to nothing. Let's look for some real estate, I know where you want to be. You don't have to have near the space that you do as a as a fee for service practitioner because you're not taking insurance. You don't have the overhead pure and simple. And his number one problem concern was he had massive medical school debt. He took a two year contract with a another freestanding family practice doc near here. And I've been reaching out to him because it was coming up on the end of his contract to see if he's still interested. We did put our first DPC doctor in place about 45 minutes from here. I didn't participate in it directly. But I know the people that did and I think he's doing very well, it's my philosophy is five become successful in placing one DPC doc in this market. I'll have five in less than a year. Because that model is that good. Yeah, there are a lot of people in this market that don't have access to insurance. This is a tourist area Mom and Pop small employer groups. It can't really afford to provide insurance.
Rebekah Bernard MD:Yeah, that's exactly my niche is I'm here in southwest Florida. We have a very large group of patients that can't afford health insurance they have like I said, mom and pop businesses, a lot of roofers and tilers and cleaning people good hard working people just can't afford health insurance and DPC really affordable model. And like you said, it's super cheap to set up a practice I opened a practice in less than a month. And you know, it doesn't take much it doesn't take a lot of capital at all. I didn't even put anything into it. And five years in, I'm making more money than I made even when I worked for a for profit hospitals so it can be done and that we have to get past that fear and realize that DPC gives you that control and you can make a very good living doing it and you build it as you go.
John Chamberlain:It's not like you have to walk in and have 2500 patients in your panel as a piece. Service talk or be an employee that to me would be that would be hell on earth, being an employee of the hospital that's going to drive their revenue from my work, and I'm going to get a flat salary. And they're going to make all these facility fees and all this money from my referrals. And I'm still stuck at 200,000 a year as a family practitioner.
Niran Al-Agba MD:I think that's the biggest problem that we've spent a lot of time trying to educate patients as much as possible. You talked about a freestanding imaging versus a hospital imaging and just as a reference, at least where I'm at in Washington state, it's five times the cost. So an abdominal CT cost 10 grand at a hospital, and it's at 100 at our freestanding radiology center. And what's amazing to me is patients will say, Well, I got this X ray, this chiropractor, order this X ray over at this hospital, and it's so expensive. And I'm like, gosh, you know what, X ray cost 60 bucks. I don't know what you're talking about $350. And they're like, well, that's the bill I got. And I always think to myself, you know, that's the problem here. You have so many cooks in the kitchen, you know, even as a regular insurance. I mean, I couldn't be employed either. That honestly would be like hell on earth. I completely agree with you. But what kills me is we're really cheap. Like, we're really not that expensive. I mean, yes, there's a copay. But beyond that, I mean, we do almost everything without having to do labs and referrals and all this other stuff. And I always say Nordstrom service at Walmart prices. That's kind of what my, my stick is it whether you know you like Nordstrom or not. It's kind of a Northwest thing. But, you know, in a nutshell, it makes a difference. And people don't really realize how expensive these hospitals are.
John Chamberlain:Now, four years ago, I got, I got a new conversation with folks at Walmart corporate about opening a DPC clinic in one of their stores here. And we were this close, they said you go out and find me 600 People, employers that sponsor 600 people because I tell them that was kind of a really good average DPC panel, they said, you go out and find me that many employers that would be willing to commit not necessarily sign on the bottom line, but present a letter of interest. And we'll look at just putting one of these clinics in our one of our stores and there's three in the area. Well, you know, push came to shove and they went a different direction. They're now doing Walmart Hill. And I just saw today where nine of their senior executive in health care left the company so that things have like is blowing up.
Rebekah Bernard MD:I just saw that too. I thought that was really interesting. They had this idea of of offering comprehensive primary care, but not in a DPC model more in a traditional model, right. No, is just has too many middlemen, it has too many additional fees associated with it. The margins are so narrow when you operate like that. I think they realized that they were not going to make money even off of what they were going to sell to people shopping at Walmart after going to their doctor visit.
John Chamberlain:And I believe in some of their demonstration clinics, they got about six open I think they had an office X ray in the clinic. So at least they had some of that cover. They obviously have a good pharmacy program in the store. And yes there depending on that drive by shopping while people are waiting for results or waiting to get into see the provider. Now they said they were going to have physicians in all these locations. I don't know if that means literally on site for in a collaborative supervision role. I guess it depends on the state. But I think they saw what happened to Haven and Haven crashed and burned because healthcare is difficult. It's very difficult.
Rebekah Bernard MD:what is haven for those that don't know about that.
John Chamberlain:Haven is the joint venture between Berkshire Hathaway, Amazon, I forget who else they had a big powerful name. Dr. Atul Gawande is their CEO, Jeff Bezos. And you know, it was really a lot to do and Wall Street was ecstatic about it. It didn't, didn't get off the ground. Basically, they can do it within a year announcing healthcare is difficult to do.
Rebekah Bernard MD:Because they always talk about how we need to scale DPC, we need to scale it make it bigger, but I don't think so I think that's where it fails. It becomes too big. There's too many managers. There's too many people getting between the physician and the patient. And it drives up costs and it decreases the quality of care.
John Chamberlain:Oh, that I learned a long time ago. Healthcare is local. I don't care how big your hospital system is. Healthcare is local. I don't care what kind of brand you try to put on it. I had a very interesting discussion this afternoon. But we're doing it citizen health is trying to bring that back down to the physician patient relationship. Everything else is third party middleman intermediary and that's insurance as PBM that's big pharma, big tech, you name it all the digital health stuff is flying around. It's all mumble mumble the junk and all it does this add cost and subtract value?
Niran Al-Agba MD:I've often said when and of course I'm only a third generation primary care doc I know you're five generations back and you're broke them all. You broke them all. I'm hoping we get They're eventually but anyway, my grandfather was a family doc, about 45 minutes from here and his own practice back when GPS did surgery, they did teenage they did a raise, and it says, Yep, you got it. He even did a C section to deliver his eighth child on his wife. So, again, this, those were those days where it was local. And you know, my dad, obviously then was a pediatrician. And then here I am in the same practice. And what's crazy is, every time they add a computer, they add a scribe, they add an extra person in sure whatever it is, it's another person in between me and my patient. What's been fascinating to me is you're absolutely onto something when you say citizen health is looking at making health care or concentrating on the packets local, I have third and fourth generation families, I've 1/4 generation I probably close to 100/3 generation, they have for three generations been taken care of by a doctor Elijah, maybe not me, but the same name underneath it all related to the original. And it's so different, because you know, I had a new resident today, I'm telling the stories of these moms that I took care of as kids, I have tons of second generation patients, and you're you're dead on you're right on when you talk about local because the whole point is that healthcare isn't about, do this test and get this answer. It's knowing the entire life story of the patient and having it right here in your head, not in a computer, not over here. And that's what we're missing. And I guess my question for you is you brought up the word provider, which has been, gosh, about every six months, it comes back on Twitter, and everybody wants to jabber and jabber about it. And in a nutshell, what is your take on the word provider as far as what it does with corporatization of healthcare?
John Chamberlain:I think it accelerates it. I think it demeans physicians that have more extensive training than is imaginable compared to a nurse practitioner or a PA. Not only that, I think the recent trend in in BS taking somebody off the street who has no nursing background, putting him in an accelerated program, they may have been an engineer and said, Hey, you can make a lot of money as a nurse practitioner, I think I'll go do that. Well, I can tell you from experience, not everyone is cut out to be a nurse practitioner. And the ones that I know that have a nursing background, extensive nursing background, make the best nurse practitioners. And I'm not going to say they know their place, but they know where their heart is where their experience is. And they know where they can be helpful. And they know where they just back off and take direction from the leader of the team. I think it's cheapened health care. Overall. You know, we talked a minute ago about scaling DPC, there have been a lot of attempts at that. And there's still some that are going on, the ones that come to mind that are abject failures for two lions out in your neck of the woods, and turntable health in Las Vegas. Now, there are regional DPC companies, quote unquote, guess what they're doing. adding layers, adding costs to just doesn't make sense to me. Now, is there a way to to get all the independent DPC physicians to collaborate on data sharing? Yes. And you don't have to be in the same network. You can do that. We can do anything. We can put a vehicle on Mars, I think we could maybe one day get rid of fax machines in healthcare. But I think back to your original question, I think the word provider and you see all the means with a pilot in an airplane and stewardess saying and I'd like to introduce you to your provider today. Who's flying the plane? Well, that's kind of the same scenario. It's sad is what it is. But again, a lot of that's coming from lobbying pressure, that's probably the number one thing I would remove is lobbyist. You think about lobbyists and their impact on health care while they're having an on mid levels, this interesting battle, if you will, but I think provider does nothing but cheap, and it really cheapens it for everybody. Because I think the good nurse practitioners are cheapened by it. And the physicians, of course, are cheapened by when you have somebody coming out of a 500 hour DNP program that was, I don't know, maybe they were flipping burgers. They're accepting anybody, a lot of programs except anybody off the street, you pays your money, you get your chances, you know, you too, could be a nurse practitioner. And like many of you have, you know, you don't have to pass the first few years, he will give you another year pay for it. That's not right, the way
Rebekah Bernard MD:it is. And it seems to me like corporations would like to lump us all into the same basket so that they can make equivalency between us. They can say, Oh, well, you're gonna see the provider. And so patients don't ask, well, is that a physician is that a nurse practitioner, you know, we're all kind of lumped together in that same category. And so we don't, there's not as much transparency when you use that term.
John Chamberlain:And that's another word that I'm pretty much passionate about is transparency not only in that setting, but in pricing. I mean, you know, you talk about 1800 for abdominal CT. I can go to one of the great imaging locations anywhere in the country and get that At with or without contrast for less than 1800 You know I mean it's there are options out there but people don't know. And healthcare corporatocracy doesn't want them to know that there are alternatives.
Rebekah Bernard MD:John, when you think back to your days working in the hospital, did you ever see any of this coming down the pipeline? Or was this really a surprise, this rapid increase in non physician practitioners,
John Chamberlain:it was really a surprise to me my my most recent experience with nurse practitioners within an urgent care setting, I left a hospital CEO job came to the Gulf Coast because my wife's mom was experiencing health issues. And that kind of started over I didn't look for another hospital job, because it's limited availability here. But I went to work and work for a couple of different urgent care companies. And I we were just this was back in 2010. So 11 years ago, and we were just really starting to see nurse practitioners come into the urgent care setting. And everyone I worked with in both events was an RN, who went back and got their nurse practitioners. And they were in a collaborative arrangement. The relationship with their collaborating physician was on site. It wasn't somebody from afar. So that dialogue, that exchange of information from NP to physician says immediate, even if if they're collaborating physician when they're the physician on on duty was, so there was no barrier between NP and the physician, regardless of collaborating arrangement. And what that translated to was really good patient care. So instead of taking a guess, as a nurse practitioner, of course, again, the ones I had experience with were knowledgeable in from experience as well as training. You know, there's no guessing if you don't know, don't do it, get an answer. Because the the person is in the middle of anticipation. And that's food. That's what we lose sight of all the time, the corporate, the corporate autocracy doesn't care about patients. The PBM doesn't care about patients. The GPO could care less about patients, physicians still care about patients. And that's another reason I couldn't work as a physician employed, because you're pretty much told, don't worry about it. Right? Well, yeah, this is my patient, and my name's on the chart, and I am going to worry about it. But then again, you know, you can only beat your head against the wall so many times until you quit doing it.
Rebekah Bernard MD:Exactly. So you mentioned that fortunately, your wife had a relatively straightforward hospital stay, so no complication. So you were okay with having the management with a nurse practitioner? Because you did have physician involvement, that orthopedic surgeon, but what would you advise to patients, if they were in a hospital situation, or any clinical situation in which they weren't sure about whether they were getting the right care, or there were complications, and they were being cared for by a non physician? What advice would you give them?
John Chamberlain:I would, I would tell them, if you're seeing, you know, your only exposure to a hospitalist and you're required by you know, virtue of your admission to this facility. And you're only seeing a nurse practitioner and you have questions about what you're hearing, especially if you have questions about what you're hearing asked to see a physician, I would say that in general, asked to see a physician at some point during your stay, especially again, with a complicated medical admission. I mean, my wife's mom was in the hospital several times since we moved down here several years ago, she passed a few years back, but there was one of us in the hospital 24/7 - one of the family, we were there 24/7. And there were at that time physician hospitalist in addition to her specialist, but that's changing, that's changing so rapidly, I would I would advise anybody going into the hospital today, if you don't have a physician hospitalist that you've seen within the first 24 hours of admission, ask for one.
Niran Al-Agba MD:And then in the same token, what would you what would citizen health and really you like to see out of transparency? I mean, what would be the ideal kind of future transparency in the clinic,
John Chamberlain:I think what we're looking to do is restore the physician patient relationship. And if that's if that involves does say, for instance, it's a fee for service practice, and it's an independent practice and there's a nurse practitioner employ. We would like to see the relationship extended to certainly the nurse practitioner to be basically three people involved the patient, the physician and the nurse practitioner where appropriate. From a transparency standpoint, I think it's really incumbent upon the physician who is the leader, to be transparent. And if you know for some reason, they're not going to be there at the appointed time. They're going to they're going to need to let you know need to let the patient know. I'm going to have Becky see you today. I'm not going to be there but I'll be available to you after your visit if you have any questions. So transparency is important. Now that's a that's a big word. Covered A lot of ground. And we're seeing a lot of issues now around pricing transparency for services. And hospitals are by and large, saying, we're not telling you, we don't care if it is a federal law, it's going to cost us $109,500 To be non compliant. And so poof, we will write you a check today. Well, that's not the point. And the point is, they're going to be people, they're going to be hospitals in markets that are going to say, hey, we're going to take this bull by the horns, and we are going to be transparent. We're going to show you we're going to shame you into being transparent, because we're going to show you how long our prices are, or can be, I had that word. 25 years ago, in Louisiana, we had one hospital in the entire state that didn't want to participate in a statewide data gathering. So I just call the CEO and I said, You know what, you're the only one and we're just gonna back into your numbers. How's that? Immediately, that same day, they decided to join in. So it's doable. But they've gone so far as to put coding into their software that blocks that transparency information, some hospitals have done that. And they're getting found out and Congress is not happy about it. There was a letter written by a group of congressmen to Secretary viscera, the new HHS Secretary said, you know, you need to fix this, this is not right. But what will happen is the ones that don't want to do it will just pay the fine.
Rebekah Bernard MD:Well, we're so glad for people like you that are holding these corporations feet to the fire and also speaking out so that patients know what's going on. And so I'd like to thank John Chamberlin, the chairman of citizen health, and you can find him as at his website, citizen health.io. So thank you so much for being with us. And of course, to learn more about this topic, we encourage you to get our book. It's called patients at risk the rise of the nurse practitioner and physician assistant in healthcare. It's available at Amazon and at Barnes and noble.com. And of course, we'd encourage you to subscribe to our podcast and our YouTube channel. It's called patients at risk. And if you're a physician, and you'd like to learn more about how to promote physician led care and truth and transparency, we encourage you to join us physicians for patient protection.org Thank you so much, and we'll see you on the next podcast. Thank you all