The Healthcare Middlemen Most Doctors Never Knew Existed

When a hurricane knocked out one factory… hospitals across the country suddenly ran short on IV bags.

Surgeries were delayed.

Treatments were canceled.

And hospitals were scrambling.

But the real question is this:

Why was the entire healthcare system depending on one single plant?

In this episode, I break down a part of healthcare most people have never heard of — group purchasing organizations.

These middlemen control the flow of medical supplies into hospitals across the country. And the rules around them created a system where a few companies can quietly shape the entire medical supply chain.

Once you understand how this system works, a lot of the strange shortages in healthcare start to make more sense.

In this episode, you’ll learn:

• Why one factory failure caused a nationwide shortage of IV bags
• The little-known organizations that control most hospital supply contracts
• How certain healthcare rules quietly changed the entire medical supply chain

Learn more about Dr. Marion Mass:

• https://free2care.org/wp-content/uploads/2025/01/report.pdf
• https://www.bucksindependence.com/author/marion-mass/

Chapters:

00:00 – The IV Bag Shortage That Shocked Hospitals

00:11 – How One Factory Disrupted the Entire System

02:05 – What Group Purchasing Organizations Actually Do

04:23 – Why Medical Shortages Keep Happening

06:01 – The Growing Problem With Drug Supply Chains

08:29 – The Conflict Built Into Medical Purchasing

11:13 – Why No One Is Looking at the Contracts

12:53 – The Hidden Costs Inside Hospital Supplies

14:58 – How One Company Controls Huge Parts of the Market

17:21 – The Rise of Hospital Care at Home

21:17 – Why Hospitals May Not Be Needed for Some Care

27:00 – The Direct Care Model Changing Healthcare

36:43 – How Electronic Records Changed Doctor Workflows

Transcript

SPEAKER_01 0:00

The United States is the most technologically advanced country in the history of the world. Except, we can't seem to make salt water in a bag. That's too difficult for us. In September of 24, Hurricane Helene tore to North Carolina and took offline the Baxter International saline plant. It was a disaster. All of a sudden, hospitals are getting 40% of what they usually would get in terms of their supplies. All of a sudden, surgeries are canceled, moms couldn't come in for inductions of labor. Everybody was panicking. And I started wondering why is this? This makes no sense. And it turns out in 2017, a similar thing happened at a hurricane in Puerto Rico, the same company. And all of a sudden, those are small IV bags that time. But none of this makes sense. But we're going to go ahead in this episode, and we're going to give you the real answer of why that happened. And it is more of a storm than actually that hurricane. And this podcast is for educational purposes only, non medical advice. And you should always take the advice of a physician for your specific areas or questions. And today I've got a great guest, Dr. Marion Moss, who is an expert on what I call murky middlemen. And one of the murkiest middlemen is the hospital group purchasing organizations. And I had no idea who they were up to a couple of years, never heard of them. I've been in healthcare forever. No idea. The only thing I knew is every time I wanted something in the hospital, a piece of equipment, they'd call me back and go, yeah, we actually don't have that. I'm like, really? Why not? It's a good idea. It's great for patients, not interested. But Mary, could you please tell us about group purchasing organizations and how they distort the supply chain?

SPEAKER_00 1:52

We always have to look at history, right? The group purchasing organizations were created in the wake of the 1918 Spanish flu epidemic because a lot of hospitals needed to have someone that was helping them procure all of their equipment. And so they at first they worked kind of like a Costco, right? So the hospital could call up the GPO and say, hey, we're a hospital over here. We'd like to, you know, what's your best deal in getting a whole bunch of IVs? What's your best deal in getting a whole bunch of bags of saline, you know, all that other stuff. And this actually worked well for quite a while. Um, and then in 1987, uh, under the Medicare, Medicaid, Patient Protection Act, um, which was signed by Ronald Reagan, these group purchasing organizations got an exemption from the anti-kickback statutes. That means all of a sudden they could collect kickbacks. Well, what does that mean? That means that the supply the manufacturers of the salines, of the IVs, of the various medications could pay the GPOs in order that the GPOs would get their product into the hospitals. Well, that's setting up a huge conflict of interest because you could functionally you could pay to get market share. And so that was signed in 1987, and I believe we started to see the first drug shortages in the early 2000s, and we've had problems with drug shortages in the United States for decades. The patients don't know about this, they don't see it because who's left to MacGyver their way out of it? Well, you know, it's the doctors. You know, so I have anesthesiologists who call me and tell me, um, I want to be able to use a certain tray so that I can put the epidural into my patient that's in labor, but they don't have that tray anymore. They've given me a substandard tray. Um, we have situations where the OB needs to be able to get Pitocin, but there's a shortage of Pitocin, so you can't put the woman to labor. That's actually kind of like emergent.

SPEAKER_01 3:48

Yes.

SPEAKER_00 3:48

Um, you mentioned the two saline shortages. There was one that even predated that back to 2012. And whenever you hear about these, they blame it on the hurricane or they blame it on the natural disaster that led to it. But the first question should be well, wait a second, if the hurricane wiped out the plant that was producing most of the saline that American hospitals use, why is there one major plant that's supplying most of the saline? That creates the brittle supply chain, right?

SPEAKER_01 4:16

Absolutely.

SPEAKER_00 4:17

And the answer, although I can't see the contracts for they call them rebates, just like they do for PBMs. The answer is like we should be able to see the kickback contracts for the various um major supplies that have been in shortage over the years, but we can't see those. So if you have one major supplier that's manufacturing, you know, a bag of saline should cost $10 to manufacture, and then all of a sudden you have a shortage. Well, when you have the shortage, what's gonna happen to the cost of the supply? Well, we know what it's gonna do. You know, it's gonna go up, right? And so, like maybe they're charging more in the first place before you even have the shortage, but then there's certainly going to be a bigger problem later if you can even get the supply. And this is not just an isolated one-off. At times there have been 300 active shortages on the shortage list. You know, currently uh it's going around, and I I um exposted about this recently. We have a shortage of IM bicillin. Well, that's a real problem now because we also have a really uh much higher rate than we did five years ago of syphilis and pregnant women and then the babies that they deliver. And you need that IM bicillin. It's penicillin. We had a shortage of penicillin. It's a craziest thing. Yeah, we thought, my gosh, thank goodness we live in America. We'll never have a shortage of penicillin here. But yet, here we are shortage of penicillin.

SPEAKER_01 5:44

And with shortage of eupin, epinephrine, I mean, the the when you look at these lists of these meds are all simple ones that have been around for decades. And I know in your free to care, you talked about the China problem where the active pharmaceutical ingredients, which used to be produced in the United States, Europe, Japan up to the 90s, have now migrated to China and also now India. And a lot of these companies kind of get beat down on the price by these middlemen, these group purchasing organizations. And then what they do, which is very sneaky, is they basically offshore the regulatory burden. Because if you have a factory in the United States, the FDA can pop by anytime, unannounced visits. All of a sudden, you move it to China or to India. During COVID, there was no inspections at all. But on a regular time, shut down shut down. And a regular time, you have to let them know before you're going to come in and inspect. You can't just show up. So that changes the whole game. So essentially, there's no regulation. And that's pretty scary. All Americans need to know that. We need to bring, if COVID taught us anything, and it taught us a lot of things, but one thing should be we should never depend on China for crucial supplies, like the personal protection equipment, the mask, everything. And crucial drugs like the antibiotics that you talked about, like penicillin G, benzethene, which we use for syphilis. And it's crazy. And a lot of these GPOs will do the sole source contract. And I think that's what happened with Baxter, is they had the sole source contract for a lot of hospitals. And that means that you, if you pay high enough of a rebate or kickback to the GPO, they'll say you're the only player in town. So all the hospitals in that network have to do, they have to use your product. If they don't use their product, they're going to be penalized financially. And then they also do some other sneaky things in there where if you're a big distributor or a big manufacturer of lots of products, you could demand that they use all your products. Maybe there's competitors who have better products, but now they're forced out. So it really limits innovation. And I know initially when this started out, the hospitals were paying the group purchasing organization because it was working for the hospitals. And that makes sense.

SPEAKER_00 8:03

It's like a cost bill. It's like a method.

SPEAKER_01 8:05

Exactly. But now it's now all of a sudden they're getting paid by the vendor, which is a huge conflict of interest. And if a physician in a federal health program took a kickback, we would be in lots of trouble. We can go to prison, we can get fined, we get kicked out of federal health care programs. But due to this, what I call the hall pass from or the safe harbor, they get to PBMs and GPOs get to get around this, which makes no sense. That needs to go away.

SPEAKER_00 8:36

Oh, well, I mean, the simple question that everyone should be asking is why do and keep in mind, there's three GPOs that are controlling, I think, 90 or 95% of all the flow of all of the um uh equipment and medications and solutions into hospitals and nursing homes. You know, and this is like no small amount of money. I mean, you know, we know our Medicaid program is 10% of the spend of all of the United States, and nursing homes account for 30% of the Medicaid spend. So if the GPOs are controlling the supplies going into the hospitals, and there's three of them that are controlling most of the supply, then because they'd consolidate it just like everything else, um, then it it can be a a real issue. Um, I wrote an article uh that talked about the ways that nonprofit hospitals uh make money, and one of the things that it pointed out was you know the purchasing organizations. There is a record that the hospitals often receive something called a share back. So, you know, because like a lot of people have said to me, well, why are the hospitals for this? Because wouldn't they be paying more in supplies? Well, I at one point someone kind of spilled that, hey, look, I get a share back um as part of the deal for working with the particular GPO, and that share back is uh half of my salary. Now, this goes back many years, but I can't find any oversight where our government who gave the GPOs the right to receive the kickbacks and not get prosecuted, they're supposed to be looking at the kickback contracts. I don't think they've ever looked. I have found no evidence of that. As of 2018, when I went to a conference where the head lobbyist for the GPO was on stage, and you know, he he said, We're fully willing to be transparent, but HHS OIG has never asked. So the government gives them the right, we can see the hospital costs are rising. We know that in some hospitals, 40% of the overhead of the hospital is the supplies, but if you've given them the right to kickbacks, and there's examples and there are of like a $1 screw that you know the GPO, the hospital ends up charging $800 for, presumably because of the costs that the GPO added on. If that's our situation for a $1 screw going up to $800, and these middlemen for the hospitals that no one has ever heard of have the right to kickbacks, why is no one looking at those contracts? And furthermore, why are they not looking at the money flow that happens between the hospital and the GPO itself? Because if there's money flow in there, then we ought to know about it.

SPEAKER_01 11:10

And the interesting interesting thing is when they gave them that safe harbor, they said they're gonna limit it to the the GPOs could only get 3% of the list price for fees. But as you said, and this is what happens all the time in healthcare. If nobody enforces it or looks at it, it's meaningless. And then the other thing you can do, you can say I'll take 3% of fees, but then I add on an administrative fee, a marketing fee, a placement fee, a whatever fee. And the interesting thing with the GPOs is they're not really touching these supplies. They're like exactly like the PBMs. They're a middleman that you really aren't doing anything unique or that's necessary for the whole system to work. So that's the other thing. And there's the other thing is I know on the medical boards of these GPOs, they have hospital executives, they have physician executives on there as well. So that's another conflict of interest. So this is yeah. So I mean, there's so many conflicts of interest there. And I was reading a story this morning. The highest cost I could find for a IV, a bag of salt water, was $26,000. I mean, it's insane.

SPEAKER_00 12:22

You know, about $10 to make.

SPEAKER_01 12:24

Yeah, and you get $26,000. But I think 100%, you know, this is the stuff that most people don't know about. And we have to look at every expense of the hospitals. And like you said, we desperately need hospitals and we need all the advanced equipment, but we don't need to overpay the C-suite. We don't need to overpay supplies so there can be kickbacks. And these are things that I think we really need to let the public know about. And you've done a great job writing about this and talking about this. So I appreciate you addressing that.

SPEAKER_00 12:57

And you know, it's really interesting because you know, everyone talks about how convoluted and um hard it is to understand. You know, I learn new things all the time. I think it was about two years ago I was reading an article and I discovered um when I was writing about the 340B program, actually, maybe it goes back to 2022 or so, but what I discovered was one of the very big GPOs named Visiant, they own a company called Apexis, and Apexis for 22 years has had the sole contract to do the negotiations. I'm not quite sure exactly what they're doing because nothing's transparent, but they're doing the 340B negotiations. So if Visiant is collecting money from manufacturers to get products into hospitals, if Visiant owns the company that's maybe helping to set the prices for 340B, maybe they could set them even lower, and then Visiant themselves could help pick a more expensive product to go on to the hospital formulary. You know, we're right back to formularies and networks as far as I'm concerned. And then are you really getting the best product for the patient? Or are you getting the best product that if the kickback is paying to the GPO, you know, and then the hospital is able to make more off of it because the 340B program is uh is able to set the price. I mean, I I can't even tell what's going on there, right? No, I'm not sure. I'm not saying I know. I'm just saying that it's really concerning that Visiant, one of the three major GPOs, owns the company that has the sole source contract that was given by our government. It's a HRSA contract. It's it's a real big concern for me.

SPEAKER_01 14:40

I agree with that. And Visiant owns about controls about 60%. I think they control a huge amount of the market share, and they control a lot of the academic medical centers. So that's even more disturbing. These are our top medical centers. And I love the top medical centers, but you know, they have so many special fees and ways of overcharging people. And we need to really look at the hospitals in detail and get this under control.

SPEAKER_00 15:07

Well, I think um I believe, and I'm not sure which hospitals, but I I think there's often a situation where, and I'm not naming any particular hospitals where they're actually shareholders in the GPOs in some of these nonprofit academic hospitals. Um and then if you look carefully, uh the HCA, which is a for-profit hospital system, HCA wholly owns one of the GPOs. Uh I believe it's called Health Trust. Health Trust, yeah. Um, yeah. So it's that's it's another big conflict of interest. So if you own the GPO and then you're the big hospital center, and HCA goes across, I don't even know how many states, and there's dozens of hospitals that they own, it speaks for more conflicts of interest. And if you're the government and now you are granting um, for at least the nonprofit hospitals, the right to pay no taxes, and you know, the you know, you're collecting more on Medicare and um your Medicare fee schedule is going up and up, and then now there's a connection between uh academic hospitals potentially and GPOs and no oversight for the kickback contracts. I mean, this is just like there's just money flying all over the place that we as Americans are paying for. There is. And are we really getting the best product? And why should we have to deal with the shortages if the uh contracts are potentially part of the problem?

SPEAKER_01 16:33

And one of the interesting things is when you look at the expense of a staying in the hospital overnight, that the nonprofit hospitals charge more than the for-profit hospitals, which is interesting to me because the nonprofit hospitals get all the tax breaks that the for-profit ones don't. And you would think that they would say, okay, we're getting all this benefit from not paying these taxes, that we would lower our cost. So it's just a fascinating part of how that works out. The other thing I want to talk about is a fairly new program, which is called the Acute Care at Home or Hospital Home Program. And that was a program that started during 2020. And CMS gave a Center for Medicare and Medicaid Services, gave a waiver to hospitals because people, rightly so, were afraid to go into the hospital. If you had pneumonia, you said, I don't want to go in the hospital, I don't want to get COVID, I think I'm gonna die if I get COVID. And they said, we're gonna give you a waiver so you don't have to have nurses in the setting 24-7, like you do in a hospital. And hospitals also have to have an open emergency room. And they started doing treatment at home. And what they found for the selected medical patients, they did very well at home. There was no difference in mortality, no difference, and they actually saved money in the 30 days after they left the hot after they left home, once they were like discharged from home. So it was a fascinating program. Most of the things were things that we've all treated as medical students or residents, uh COPD, people with congested heart failure, cellulitis, and there's many things that because now you have all this remote monitoring that you could watch people very carefully at home. So it's an interesting program. So it involved you know, physician visit daily, you would have nurses coming, and you would have 24-7 monitoring of the patients. And it worked out very well. The patients loved it. And the one thing that was really strange with it, though, the hospitals were paid on the same DRG or diagnostic related group as they were for inpatient care. So now the care is in your house and the hospital is getting paid as if it's in their house. I'm like, okay, this makes no sense. Only the government would think this is a good idea. And we don't know how to spend our money going on. They know how to spend our money poorly. And there was a study by Milliman, I think it was 22, that looked at this and said uh they really should be charging it for home health care, not hospital care. It's not a hospital. There's no ICU in your house. And they said if they did that, it would cost about 50 percent of what it would. But I really think this is a point where the physician should be directing this. This should be physician-directed care at home. I think the ideal thing, you would see your intern is a direct patient care doctor, and it'd say, you know what, I think you're gonna need more intensive care for, you know, maybe you need diuresis for CHF, and then have them kind of run this care at home. Because I think that's what we need. Just like with surgeries used to all be done in the hospital. When I was in medical school, people had their gallbladder out, it was a big right upper quadrant scar. They were in a hospital for five to seven days. And then all of a sudden, 1991, the general surgeon said, Hey, we can do this laparoscopically. And then it moved from there into the freestanding ambulatory surgery centers that the physicians are running at a much lower price. So I think we have to look for where we can get value for our money in healthcare. And I think that would be a great thing to start having physicians do that. And I think we have to support our primary care physicians. I feel really bad for the internist and the family docs. I feel that the systems just want to hire them and just have them be referral machines for expensive referrals. But I think this is a really fascinating thing that can come out. And I and I think this will expand over time. But then you start thinking, what do you really need the hospital for acutely? I mean, you need the emergency.

SPEAKER_00 20:36

What are they doing there in the first place?

SPEAKER_01 20:38

What were they doing there in the first place? So then you kind of say, okay, if you need surgery or you need an ICU, you need to be in the hospital. If you need an emergency room, you need to be there. But for a lot of the chronic medical conditions, you know, cellulitis, other things like that, there's really no need anymore.

SPEAKER_00 20:55

Right. You know, actually, it's it, I actually think it brings up a really good opportunity. Um, I'm I'm gonna backtrack to through some of what you were talking about there. So if if it's being done through the hospitals that and they're collecting the full hospital fee, you know, like what whatever the average costs. So like the first thing we need to say is if it's being done at home, we don't think the hospital should be in charge of the collecting here. So I mean, we might want to split it acros uh apart from the hospitals, right? Because we can already see if they're collecting money for something that they're not actually giving, then we shouldn't be trusting them to do it in the first place. Correct. Um, you know, the other thing too is is it really brings up um an important point, which is you know, so much of what we do as doctors, it really matters like what our what our patient is is able to do and what their circumstances are. Um and so when you're in someone's home, you're gonna figure out their circumstances a lot faster than if they're in the hospital bed. And you know, like so it actually gives you a touch point to be able to. know what's really going on with that patient and to be able to tailor and to give personal care. I mean so many times we um I'm gonna get back to that uh that shortage of IM penicillin right because as physicians we might write a prescription but then the patient tells us something about themselves that lets them know that this is not the right choice for me, right? You know, so for instance, I deal with strep throat frequently as an urgent care pediatrician. And you know I had a patient that came in that was you know severely autistic and had strep throat and this was back when we had a penicillin shortage maybe five years ago because we've had them before and that patient who's severely autistic you know I said to the um to the father you know I'm gonna write you a uh the prescription for your 10 days worth of you know taking amoxicillin and the dad's like no can do because my son can't take oral meds. I want the shot and I'm like no can do because I don't have the shot. But like you know we we get so used to reflexively doing something but our patients may have circumstances that prevent them from being able to follow through. When you're doing at-home care, you may be able to see what some of those barriers are and you know I think you're right and you know you mentioned we should have the physicians lead here. You know I'll point out that we have really tremendous nurses that are probably going to be a big part of the leadership in home care as well.

SPEAKER_01 23:19

Absolutely and that's exactly what you would would suspect. You know you'd want to have physicians working along with the nurses and you know we've always depended Scrubs let's hear scrubs yes I mean we've always in the hospital especially before the electronic health records the nurses were always in a room with the patient they would be the ones to call you they'd say you know what I'm noticing a subtle shift in this patient. Could you just come by and take a look? But now they're on the computers they're like us they're not in the rooms as much as they used to be and I love this getting them back in the home they can have that contact with them. And then you talk about continuity of care. You know if you have your intern is treating you at home that's perfect. You don't have to worry you don't have to worry about follow-up because he knows exactly she knows exactly how the treatment went, what worked for you to your point what didn't work for you. And then your family knows they're there. You know they're talking they don't have to worry about catching you on your rounds and you know they're trying to get there at five in the morning catch you round at five in the morning you're there and you could talk to them, do some great education, say this is when you would need to call me. So I think there's so many benefits with this and I think if we can intelligently limit our use of the hospital is always a good thing. As well as intelligently pay the hospital. I'd say those are kind of the the two things but I love this idea of this system. I just wish CMS wasn't in charge of it because you know they're incentivized to just you know play ball with the hospitals. But I would love to have the I think patients will love it if physicians were running it.

SPEAKER_00 24:52

I'm just going to get back to what we said before where if if the hospitals are charging the hospital fee because they're running it, then we've we've already defined who maybe shouldn't be running it.

SPEAKER_01 25:01

How about we say that well it's kind of ironic so if the hospital's running it the hospital is hiring a physician to actually go in and do the work.

SPEAKER_00 25:08

You're like okay well then what do we need the hospital for a hundred percent yeah in that case they're serving they're serving as a middleman in that case, right? Absolutely. Yeah. And whenever you have a middleman they're extracting some kind of fee from the system.

SPEAKER_01 25:22

It'd be the same thing if you had the hospital in charge of you have a freestanding surgery center that a physician owns but then you have to pay the hospital to give you permission to operate on so it would it wouldn't make any sense. You're like, well that's silly. You know why do you need this middleman over here? And I think that's what you have to start doing in healthcare is really look at the role of every middleman and say are you absolutely necessary and one of the things I love I love with direct patient care is you pay the physician directly. I heard on a show that you you were on a great news show what was that last week in Philadelphia with uh Drs Deek Emanuel and Wendell Potter and they were and Zeke manual was talking about using AI for all these you know figuring out the dealings the uh the payment flow I thought you know what you don't need that if you just pay a doctor in cash there's no AI you're gonna save so much more money you're gonna save 30 40 percent if you're just paying physician visits in cash same thing for labs x-rays we don't need to make it complicated so I think we have to look back and say how do we simplify this system?

SPEAKER_00 26:30

Well we're already back to shopping right yes because like what when when you look at direct care or like a physician led care you can see examples of the patients are paying directly they're cutting out their insurance sometimes they're cutting out Medicare, Medicaid, all those things. So like when you look at uh direct primary care physicians um direct primary care physicians this is not concierge medicine so I want your audience to understand this. So concierge medicine they accept insurance and they usually charge pretty beefed up fees. Correct um direct primary care um I don't know what the average is now I I want to say it's something like if you're a um an adult it's $70 per month to belong it's like a membership fee right I think that's about right depending where you live and such exactly 75 to 100 maybe yeah right what are you getting for your you know $75 to $100 per month you're getting access usually you get the cell phone of your physicians you get to call them um you know we've all talked about how telehealth has been this revolutionary thing because during the pandemic we started doing more of it. Those DPC doctors they've been doing it for a decade they just pop their patient on their FaceTime on their phone. You know and like I've seen these DPC doctors they come in they stitch up their patient they keep them out of the ER they contract with local radiology groups they're the ones that are contracting for the $70 x-ray so that you're not paying the $700 x-ray. There are instances where these DPC docs are able to dispense medications in their practices and if they're able to dispense medications then they're saving the patient off of the exorbitant fee of some of these they're they're cutting out the PDMs right there. Right? You know and then they're serving as a transparent model for care. They're spending more time with their patients the patients are getting good solid care even if we don't have enough doctors to all go into DPC they're proving that the costs are not as high as they have to be getting lab work done for $10 a a clip instead of $800 for a panel. And then if you're thinking about it, if you're not paying that into the system then the premiums are not going to go up and we have an example of transparency. And we can see the example of transparency with the DPC docs. We can see it with what um Mark Cuban has done with generic with cutting out the middlemen and really driving the costs down when he cuts out the middlemen. I know now like with Trump RX is actually doing non-generic drugs not that many of them 40 of them but using similar models and at least showing that you can drive the cost of these very expensive drugs down. And you and I both know about um physician owned hospitals that were grandfathered in because they were created before the ACA banned them that are able to provide care. They're very fully transparent hospitals and they're providing care at a fraction of the price that hospitals are charging. So now we're right back to the whole idea of shopping because we can see that we have innovative models of direct care where the patient is paying we should be able to demand hey look I want that price over there. If that guy's able to give that price why can't you? Now not in all cases are we going to be able to get that because I certainly do understand if you're a hospital and you're taking care of a very complex case you know you're you're taking care of a lot of people that are allowing the inflow into the hospital the people who are working in the hospital things are going to cost more but as much more as we're paying I I think things are a little skewed here.

SPEAKER_01 30:13

Well you wouldn't be getting these huge CEO salaries if you're running your hospital lean you know just like you know and we were talking earlier about Surgery Center of Oklahoma when we're offline and in that Senate hearing Dr. Keith Smith was saying that he was charging between one sixth and one tenth of what the hospitals were for this same procedure. And he can do that because he doesn't have a big administrative staff. He doesn't have a C suite. He doesn't have a whole wing of administrators hanging out, you know, doing whatever administrators do. And I don't think people realize when you have a bunch of administrators in a hospital they always look for something to do. And what they always end up doing is harassing physicians and they slow us down. And I've worked in freestanding surgery centers that are physician owned it's like a breath of fresh air you get in you can do your cases it's when you have a hospital try to do the same model it doesn't work because they want to treat everything as very complex. They want lots of extra steps and it's just fascinating to see the difference. They can only think one way and they come up with all these protocols that don't match like there was a a protocol that they were talking about in the order like okay and it comes back to orthopedic surgery. So if you're going to have a hip or knee done you need to know which side you need to have done. So you have to mark it be very careful. And then they would say that for GYN surgery I'm like okay well if I'm doing laparoscopy I can see where the ovarian cyst is the laterality doesn't matter. What matters for me is I want to make sure the patients aren't pregnant. So why don't you make sure but you know they couldn't do that. They're like no we can't change this. We have to have one protocol. I'm like it makes no sense. So you're enforcing things that are nonsensical and then you don't get buy-in by physicians.

SPEAKER_00 32:10

I'm sorry to interrupt no no it's great I I bet a lot of the listeners that are watching the pit. There was an early episode where the head administrator of the hospital came down and she started complaining about the press gaining scores. This is like the patient satisfaction scores, right? Well so we have the C-suite of suits plus the CEO who's making decisions for the hospital trying to make everyone work faster, see more patients, all those things. And then of course it's gonna drive the scores lower right and then you're gonna come down and complain to the staff. I mean every doctor in America was probably laughing when they watched the suit come down to a busy OR and say the satisfaction scores aren't high. Now let's take a look out in Oregon right so there's I'm I'm not gonna remember the name of the hospital but there's a hosp um hospital system in Oregon where they owned several hospitals they shut one of them down causing the other hospital to get an influx of patients and then they claimed that they were going to fire the ER doc at the hospital that remained open because the patients were unhappy because the waiting times were too long and the care wasn't as good. But it was the it was the administrators that made the decision to shut down the other hospital driving more patients in and then they're firing all of these doctors that actually have lived and worked in the community they have families there. These are the people that know the people that they're taking care of and then they announced that they were going to hire a group out of you know so this is in Oregon I think they hired someone out of Georgia to come and staff the hospital how is this helping who is like how are we allowing such a place to make such obscene absurd decisions and then and what are they getting paid to do it? It's a complete disaster.

SPEAKER_01 33:51

Yeah. And the thing is you know being as you know like you said OBs are kind of a hybrid between primary care and surgery. We're in the ER all the time for either obstetric things or gynecologic issues. And we get to know the ER docs really well and you work with them over years. I mean it's great to have those relationships when I first came they had always the same guys they got to know you they got to know when you wanted to be called because some docs don't want to be called at all and I was like you know if there's a problem my patient's here just call me I'll come and I'll see them. I'd rather see them and they love that. They're like oh great no problem at all or I'd call them up ahead and say I'm sending this patient in could you get a CBC, uh you know, a couple other UA and then I'll come in and see them. But you develop those relationships and it's it's great for both sides. And when you add people in like that who don't know the system and the culture it's a huge problem and patient care suffers. And I've seen that with an OB hospitals group that I was working on. We got our group kind of got fired by the hospital and they kind of forced another group of employee docs to do it who didn't want to do it. And it was a disaster they didn't want to do it. The docs didn't want to do it. But it was the administrators for that group forced them into it. And it doesn't work. That's why really physicians should for the most part be independent and there's plenty of great employee docs. I'm not saying they're they're bad people by any means great people but you're talking to one I know you are you know and I and I did both I was you know independent most of my career was employed towards the end but you know you really need those long-term relationships. When I first started you know we had a group of radiologists and I love you know we didn't order that many CAT scans so I ordered one I would go down to the reading room and I would talk to them I'd have them review it with me I'd give them the clinical party said listen here's what I'm really worried about. And then they could write a report that made sense. Otherwise if they don't have that input they're just gonna write a report and you're like well I don't they missed why I'm getting the darn test. But you know that is what we're losing in healthcare. And they said ironically when we had electronic health records that was going to enable physicians to communicate better with each other. And nothing could be further from the truth because now you don't have time. Now the radiologists aren't in the reading room in your hospital because now they're centralized and they cover five hospitals and they don't have time to take your call to go through it. And that's what happens.

SPEAKER_00 36:13

It's really interesting you brought up the electronic health records because like it's it's funny. I think another thing that it's done is the patients were sort of sold the bill of goods that oh all of the information will be there. You don't have to remember it. You don't have to worry about it. You know and and I I'm not blaming parents for what I'm about to say because that's what they were told. Right. But the parent comes in and they'll say to me oh yeah like um I can't remember when we were on antibiotics. I can't remember the last antibiotic it's in the record it's in the record. And you know even though I'm doing a supposedly short visit I have to go back and click through the record. The real one of the real problems is the patient doesn't have easy access to their own record. The records are complicated even though the sometimes if they cross over between systems are complete then we have to dig through a big voluminous record to find what's needed. And so the records weren't created for the patient or for the physician's ease. They could they were created for the billing ease. And you know that that's created a huge problem and though even though we think that everything's going to be automated and there's some very good things about the records right like when it is complete and so when you have a complicated patient you can at least get to it although it takes time um there's some good things about it. I I feel like it it's really created a lot of a time suck for us. A very simple visit you know seeing a simple ear infection which you know could have been a write up before now takes probably like you know 45 clicks to get through click click click death by a thousand clicks in the Wall Street Journal in 2018.

SPEAKER_01 37:52

I remember in when I was back in Wisconsin Epic changed you know they did an upgrade and all of a sudden no one in the hospital knew how to order blood. So there's people sitting in the ICU who needed blood and everybody's in a panic and I'm like well this isn't good.

SPEAKER_00 38:07

And that's like the real world effects that people don't think about and a hundred percent and then if a hospital buys another hospital and you're an employed physician or even if you're not employed and you're independent then you all of a sudden have to learn the new system correct for the the hospital that did the buyout so that you know like now you're taking more of your time. And it was a decision that suits made and not scrubs made.

SPEAKER_01 38:30

And there's different versions of Epic Epic some versions if you have an external CAT scan say it'll show up in the flow of x-rays. Other ones it doesn't you have to then really go back and search it through other documents. So even if you use the Epic, it depends on which Epic you have how much money your hospital spent on it. So there's so many nuances with it and it is crazy. But I think you've done a great job and I'm so honored you're here today. Thank you so much, Mary you're always one of my favorites and I always appreciate the great work you do with your writing. I don't know how you've time to be a mom work and do all this great writing and advocation but thank you for everything you do.

SPEAKER_00 39:11

Oh it's a pleasure you know what honestly I think more of us need to speak up for our patients and for the sustainability of our profession and the other scrubs that work alongside us. I love that when we do that we get together and we think about what the patient needs and then pare it down to the bare bones and remove all the middlemen that are not giving care to the patient and not giving value well then I think we'll get somewhere in the American medical landscape.

SPEAKER_01 39:39

Great day that's a great way to end thank you so much. Please like and follow for more let me know in the comments what your thoughts are and I'm gonna go ahead and I'm gonna put the free to care would you call it the um plan position paper. Physician paper thank you paper position paper. I'm gonna link that to the show notes because I think everybody should look through that it was really really well done. So everybody look through that kind of view.

SPEAKER_00 40:05

Oh absolutely you could also if you wanted to instead because it's newer you could take the um if you look up Marion Mass's author at the Bucks Independence that's the series that I've done since the fall sort of like newer stuff. Sure. I I just like it'd be nice to like get to all the pieces that I want to write but then something keeps happening you know someone's the pyramid you know like whatever absolutely you feel compelled to write about that.

SPEAKER_01 40:29

No you're such a great writer I want everybody to look at your great work and I think they'll enjoy it. And it uh so you have a real gift for that. So please keep doing that. And and thanks again for showing up and thanks to my listeners and please like and follow for more thank you all