Anish Koka: Hello, we are back at the doctor's lounge after a week off a much needed break for the in the fatigable Dr. DiGiorgio who is crisscrossing the country seemingly everything. He's single-handedly trying to ⁓ the ship in terms of healthcare policy in America. So were partly needed break because ⁓ you were in Congress. So congrats. Anthony DiGiorgio: Thank you. Anish Koka: for doing that and for making your voice heard. The testimony is fantastic. I am 100 % gonna link to both the YouTube link to it. We're also gonna link to the written testimony that apparently I found out is a little shorter than your actual verbal testimony to Congress. But how did that go? I mean, this is not your first time. This is not your first rodeo. This is your like old hat. You're doing this, right? So, but tell me how, what was the experience like? Anthony DiGiorgio: Yeah, old news, right? It's great. So I really want to give credit to the energy and commerce committee, subcommittee on health for having this series of hearings. So this their third in the series, the first all around ⁓ health care costs for Americans. So the first featured the insurance companies, ⁓ the second featured And now this, they're looking at what they call the provider landscape, which I know a lot of doctors don't like that word, but that encompasses hospitals, physical therapy. and all that. So I was a independent witness speaking on my own behalf, ⁓ not any institution. The other there, David Aziz from the American Medical Association, ⁓ Sean Martin for Association for Family Practitioners. There was a ⁓ representative for the ⁓ American Hospital Association, AHA. and then a representative from the healthcare buyers. So essentially the ERISA plans. And then ⁓ Democratic witness was speaking about behavioral health, ⁓ largely to talk about the cuts to Medicaid, which is sort of tangentially related to whole topic. I thought it went very well. ⁓ It gave a chance to speak about hospital consolidation. We talked a about physician owned hospitals. seems like a lot of the, ⁓ at least Republican maybe even some of the Democrat members a little skeptical of the continued ban ⁓ physician-owned hospitals. There was a ⁓ of discussion on that and ⁓ all other things that, ⁓ you things we routinely mention on here we discussed. So Stark Law, 340B, Certificate of Need We talked about ⁓ physician non-competes. We talked about the bureaucratic overload that independent physicians face, such as MIPS. and all the other ⁓ Medicare conditions of participation, ⁓ fact that Medicare prohibits cash-based contracting and independent contracting, of that came up. So very productive hearing. I'm happy to talk about any part of it. ⁓ There's suggestions I gave, both in the written form and verbally. ⁓ But I thought it was great. And again, really appreciate them having me. Anish Koka: Yeah, no, ⁓ sure, you extremely articulate discussing health policy and obviously you have ⁓ a deep well of so it comes out and so you're like the perfect person to kind of represent for physicians. And ⁓ by way, please, your testimony is... Anthony DiGiorgio: except for you. Anish Koka: extremely broad. am embarrassed to say that I read it. I didn't realize that the video was actually going to be that much different than this. I'm going to ⁓ to watch the video now. But the written testimony was awesome. talking about your blueprint for what to to directionally move us a more positive direction. ⁓ You discussed ⁓ neutral payment, idea that... ⁓ it's not like Anthony DiGiorgio... an extremely ⁓ individual, but my goodness, MedPAC has literally been saying site neutral payment forever. MedPAC is the committee that exists to advise Medicare on payment whatnot. And they've said ⁓ site neutral over and over and over again. This idea that hospitals, ⁓ once you a hospital, you suddenly get paid much more. ⁓ The problem, ⁓ is that little funding becomes a... threat if you cut that funding line, right? So, God, mean, and the problem is that the health systems in ⁓ all economies, whether, I mean, if you're talking about a small city, my goodness, it's like 80 % of the health economy, 80 % of the economy, right? ⁓ Even a place like Philadelphia, which is, know, the sixth largest city in the, ⁓ in United States, you know, if you, if you ⁓ went health system revenues by just, you know, one day tomorrow telling all the major health systems in Philadelphia that you know what, the work you're doing right now, it's not gonna be valued 30 % less. It would be absolute pandemonium. And I think that probably is why there's such a, I mean, it's like untouchable despite the fact that everyone knows that it's completely, know, completely ridiculous. Do you get that sense is that, do you get the sense that that's the big, it's not that people don't understand it, it's that touching that would just create chaos, chaos. Anthony DiGiorgio: Yeah, and you've mentioned the sort of soft landing before and I tend to agree with you, but counter that point, if we increase competition in the healthcare space, if the big academic centers and the big consolidated hospitals don't get these largesse from the government, there's going to be more healthcare facilities popping up. So yes, some people may lose jobs. ⁓ Some I think will have to take a pay cut or learn how to ⁓ operate private practice again, which I think in the end would come out neutral. I think the point that that's worth making is that in most congressional members districts, the largest employer is the hospital. And it's really hard for a congressperson to go against such a huge constituent, such a sympathetic constituent too. Anish Koka: Right, and so have to do, ⁓ cannot do just one thing on its own. You can't just do sight and hearing impairment. You must create an avenue for alternative of healthcare delivery to come up. Because ⁓ yes, you're to create a lot, you're going to do, you're going to create a lot of displacement, but if you don't ⁓ also sight and hearing impairment also allow physician-owned hospitals to come If you don't also allow the thing that, Anthony DiGiorgio: Right. Anish Koka: doesn't get a lot of mention and I'm so glad you mentioned it. If you don't have star claw reform also happening, then you are not gonna just solve the problem here, right? You cannot do site neutral payment on its own. You must have site neutral payment and allow other places come up. And honestly, I would suggest since, you it's not like you get rid of site neutral payment and tomorrow there's a hospital, right? I mean, there are some abandoned hospitals that maybe you could. you capital would come in, take over and do something with, perhaps there's those. But I would suggest the first thing you need to do is to massively increase the amount of competition there is in the current landscape, right? Though ⁓ presents problems, right? Because if you bring physician-owned hospitals that then become reliant on the gap in payment between ASCs and whatever, now all of a sudden ⁓ you you know, you have... Now you're going to have the physician-owned hospitals that are going to be lobbying hard to keep a site differential payment system. a compromise, again, sorry, my physician colleagues, don't throw tomatoes at me when you see me next time. But a great compromise I think would be, look, we're going to allow physician-owned hospitals, we're going to pay those physician-owned hospitals at the rates of ASCs or whatnot. Anthony DiGiorgio: So MedPak in their report actually has a methodology for site neutrality that doesn't involve just bringing everything down to the physician fee schedule, facility fee rates. It basically, you take where the service most commonly is performed and bringing the facility fee to around there. So one example they give, and this is all in my testimony, but a echocardiogram, this is up your lane, is 194 % more in a hospital than a freestanding office. Anish Koka: What do think of that? Right, it's a... Right. Anthony DiGiorgio: So if you implement site neutrality tomorrow and don't even, know, say you bring it close to what the physician fee schedule facility fee is now coca cardiology can expand, right? You're probably going to hire an echo tech because there's going to be this need. People are going to want to be getting echocardiograms. The hospital is no longer going to want to siphon all of them into their inpatient facility because they're, they're not getting that huge largesse anymore. So I think it'll all come out in the wash in terms of job creation. But overall, the patient is going to have and the employer that's paying the bill is going to have more money to do other things with. So the economy will grow in other ways. There's a great paper by, believe, Brock Goldberg is the first author that shows that consolidation decreases ⁓ ⁓ local economy, the strength of the local economy and leads to job loss because businesses are the ones that ultimately have to pay for these higher prices with consolidation. Anish Koka: No to pay. Anthony DiGiorgio: give some percentages, ⁓ get ⁓ job loss, get economic stagnation, and you actually get a decrease in tax revenue because you have a nonprofit that's ⁓ and charging ⁓ prices. You don't get to tax those higher prices on the nonprofit, but the lack of economic activity decreases local tax revenue. So I think economically, this would be a painful bandaid to tear off. I agree with you there, but ultimately it will be more successful for the local economy. There will be more jobs. There will be plenty of jobs still in healthcare. There'll be more competition and there'll be more money for non-healthcare entities to then use to expand their businesses. Anish Koka: Yeah, yeah, no, absolutely. that's great point that, like you said, you did bring up in your testimony in terms of this. know, the folks in MedPak are not, know, having read some of those MedPak reports, they're pretty bright individuals that have a deep understanding of what's going on. you know, it seems over and over again, the problem with our government is not that there are not people there that understand, there are people that understand what the real problems are. It's that so much, there's so much of Anthony DiGiorgio: Yes. Anish Koka: people's income that's tied into creeping things this way. And that's what creates this massive amount of paralysis. getting citizens to be more informed and understanding some of these issues, think you're not gonna get, I think it's gonna be hard to break through this kind of impasse that's created. other, so we talked about psychonautic impairment, we talked about physician-owned hospitals, obviously we want more competition. talk to me about Starklaw I mean this is my favorite one that's often ignored but anyone who goes in private practice ⁓ automatically this right? But ⁓ I interestingly enough ⁓ I see lot of physicians who are like-minded us independent ⁓ who actually want implementation to applied to the hospital systems and I actually think the opposite. Tell me, tell me Dr. George, your thoughts. Anthony DiGiorgio: I agree. And so for our ⁓ listeners who don't know, Starklaw is essentially a self-referral ban in Medicare. the reason it's implemented is when was Medicare fee for service, there was essentially no utilization control, right? So I, as a neurosurgeon, if I was in private practice, could purchase my own MRI machine, send all my patients for weekly MRIs because I think that now that I own this machine, I want to bill Medicare for a weekly MRI on this brain tumor patient, which is completely unindicated. So there was a good reason for this initially. In Medicare fee for service, there's no utilization control. So Stark law essentially made it so that you cannot refer as a physician to things that you own and get a volume as the, the way I think of it is you can't get a volume based reimbursement for that. And correct me if I'm wrong, because I know there are ways that physicians can as groups own things like MRI scanners, physical therapy, but it's a lot more complicated. And then one of our colleagues has mentioned that he was trying to expand his, his independent ⁓ spine practice and purchase an MRI. He got three lawyers to come together and they gave him five different opinions on how to go about Stark Law. So it's really, it's one of those things that if a hospital system wants to come after you, if the government wants to come after you, they'll probably find some way that you've violated Stark Law and had referred to yourself. So of just eliminating Stark Law, because I think that, you know, with all the fraud that we're seeing, there is clearly ⁓ a for fraud in Medicare and Medicaid. So we do need some fraud protections. especially in fee for service billing. And it's really important to note the lack of utilization control in fee for service. I bring it up a couple of times because it's important that in fee for service, if you're billing the government, you can just submit a bill and they're supposed to pay you for it. Right? So you get an MRI, the government's just supposed to pay you for it. And this is where I think we may disagree a little bit because I know you hate managed care, but if you could carve out Stark from managed care, there's no reason that you need Stark protections for things like Medicaid managed care or Medicare Advantage. And this is where I think we may disagree a little bit because I know you hate managed care, but if you could carve out Stark from managed care, there's no reason that you need Stark protections for things like Medicaid managed care or Medicare Advantage. Stark law does not apply to private insurance. So if you have commercial insurance, there is no Stark law because the commercial insurance has utilization control, right? You need a prior off to get that MRI. And so the same thing happens in Medicare Advantage and Medicare MCOs. So there's really no reason for Stark law. So one of the ways that I think you could actually legitimately reform Stark law and not open the door to a ton of fraud is just carving it out of managed care. Over 50 % of Medicare beneficiaries have Medicare Advantage. Stark law does not apply to private insurance. So if you have commercial insurance, there is no Stark law because the commercial insurance has utilization control, right? You need a prior off to get that MRI. And so the same thing happens in Medicare Advantage and Medicare MCOs. So there's really no reason for Stark law. So one of the ways that I think you could actually legitimately reform Stark law and not open the door to a ton of fraud is just carving it out of managed care. Over 50 % of Medicare beneficiaries have Medicare Advantage. Over 80 % of Medicaid beneficiaries have Medicaid managed care. So you could just carve out and say Stark doesn't apply if there is a private insurance intermediary. And I think that's a really good way to do it and still maintaining some sort of bulwark against fraud. ⁓ Over 80 % of Medicaid beneficiaries have Medicaid managed care. So you could just carve out and say Stark doesn't apply if there is a private insurance intermediary. And I think that's a really good way to do it and still maintaining some sort of bulwark against fraud. Anish Koka: Yeah, right. all the stuff that we've seen recently with Medicaid fraud and the intrepid Nick Shirley that has now made his way over to the People's Republic of California, ⁓ your neck the woods, did you watch that video of his recently? Anthony DiGiorgio: Right. The Los Angeles hospice one? Yeah. so part of the reason, so I think that's worth talking about in this discussion because those hospices are not, they're not subject to any of the same rules that we as doctors have, right? So there was this huge thing when doctors were billing Medicare fee for service that all the doctors were greedy and inherently suspect. And so they created this star claw, which puts these handcuffs on doctors, but apparently anyone can go to Los Angeles and open a hospice facility and just self-refer. And there's no restrictions on that. Anish Koka: Yeah, that one. Yeah, this kid, Nick Shirley, I don't know, he's like 15 or 16 years old or something. He shows up in this parking lot motel and the parking lot is full of like, Maybacks and... Is that a car? Mayback? Apparently it's a nice car. like, okay, 23, sorry, sorry. High end, high end beamers and whatnot. And he starts knocking on these doors that have like... Anthony DiGiorgio: He's 23, by the way. I just looked it up. Anish Koka: names of hospice motel like motel like it's a motel and he goes to each motel and he's like hello is anyone there i'm looking for this hospice thing and then suddenly out of nowhere some i'm gonna get the nationality wrong and i don't know i don't want i mean armenian i think armenian armenian person heavily accented ⁓ individual comes out and starts following him around i don't know why and then essentially tries to chase him away Anthony DiGiorgio: Yes. Anish Koka: And of course this is on the heels of Oz showing up at some point in California and claiming that there's a bunch of Armenian gangs that are hospice fraud and ⁓ money. ⁓ my God. mean, ⁓ think, I mean, this is ⁓ yeah, you're completely right about the fact that clearly we need some type of ⁓ on the system, ⁓ it also makes the, it does make the point, right? That why the system so focused on physicians defrauding the system because you know, of course have defrauded the system and physicians are ⁓ course have been responsible for waste abuse. But ⁓ you the thing that is somewhat stopping physicians beyond our oath that we take and we're supposedly a highly filtered class of people that get through whatever hurdles to ⁓ get MD. ⁓ But that, like, you know, we ⁓ have license that we have to maintain, right? And like, Anthony DiGiorgio: Of course. Anish Koka: I mean, every physician I know is terrified of like, you know, something happening to their license, right? And so there is that kind of, you number one, you know, ⁓ the physician is not excited to lose their medical license because the medical license is literally what allows you to, you know, be in and do what you do. You cannot really practice medicine without a medical license. And then, you on top of that, a healthy fear because... Doctors live relatively comfortable lives in know whatever suburbs and live in of going to jail right? Meaning you want to get on the wrong side. ⁓ Now ⁓ imagine know somebody a criminal you know who doesn't have a license who ⁓ has been in and out of jail for, I don't know, some number of years for some variety of things. There's, you know, like, what's to stop him from being like, ⁓ there's this game where I can get a hospice and I can set it up and then buy a bunch of Medicare numbers and then start billing and getting paid. Like, okay, so they catch me and I go to jail. I mean, know, the whole thing ⁓ me as like hilarious. It's like, they're worried about physicians and the fraud that we're going to commit because we're conflicted. And they're not, it's like, okay, you're not at all worried about, you know, of course we talk all the time about nonprofit health systems and the CEOs and you know, in citizens bank park or whatever, you know, major ballpark you have, right? And ⁓ literally just serving as these, ⁓ know, ⁓ corporatized versions of, know, where profit is the key thing. There's that. ⁓ there's, course, there's the other end of the spectrum, which is being exposed now by kids like Nick Shirley ⁓ like, well, yeah, what, How are you preventing fraud from like the other rungs of society beyond physicians? And arguably again, I'm going to say it again, that there's a bunch of things that are kind of beyond the ethics of supposedly physicians, say all physicians say no ethics. Beyond that, like most physicians are terrified of losing their license. Like what is preventing Armenian gang member, like what is preventing him from doing that? mean, right? ⁓ Anthony DiGiorgio: Yeah, it's worth noting that Nick Shirley was the one who also uncovered the Medicaid ⁓ autism fraud in Minnesota. And it really is the fact that you ⁓ ⁓ the government for these services with very little utilization management is what it comes down to. And that's what was happening in these autism centers. You saw some places don't have a cap on how much you can bill Medicaid for teaching facilities. you learning facilities for autism patients in Medicaid. And so you could sign up 20 kids, charge them $800 an hour each and just bill Medicaid for that. And there was no utilization control because again, when you're in this fee for service environment, all you do is submit the bill, the ICD code matches the bill, the CPT code, they send you a check. There's no third party intermediary. And that's where I... I don't like lot about Medicare Advantage and Medicaid managed care, but that is one thing I think that they can provide as a bulwark against some of this fraud. Anish Koka: Yeah, no, absolutely. yeah, so I guess it's always such a struggle. How do you, you know, that's why I get you gets, it gets back to this original, what's the original sin thing. We always talk about this and you know, the original sin is of course third party payment. And, but yeah, you're, you're 100 % right. I can't disagree with you. I if you have a third party payment system, like we have now with Medicaid, Medicare, that's just, you know, sending, money for claims they receive, then ⁓ of course you're going to need some type of check utilization. Right? So whether that be, I'm sorry, whether that be prior authorization, Anthony DiGiorgio: Right. Right. Anish Koka: or something smarter than that. I'm not sure what it is. mean, know, Dutch has talked about, you know, different systems where you don't have prior authorization. I mean, I struggled to quite understand how exactly one implements things where when you have this Anthony DiGiorgio: narrow network with gold carding. I think there's other ways that payers can ensure they're getting quality. But yeah, there's multiple ways to do it without the onerous prior Roth method. Anish Koka: Yeah, right. Right, right, right, right. Yeah. Correct. anyway, so, so again, but I think the point, sorry, the point to come back to here is, is that star clause, you know, it does is, is prevents referrals, right? And so a physician can't own, you know, it's to prevent exactly what you're talking about in terms of MRI and it applies to everything like physician in terms of owning their own physical therapy or owning, you know, you can't have relationships with other where you're getting any type of monetary, or amount back it for making that referral which which again one understands but by the same you know ⁓ by the token there are ways around it was systems are figured out how system simply employ people and they pay folks you know some type of overage over whatever ⁓ and and some of is dependent on on what their type of downstream revenue referral is. And if you're too explicit about it, right, if you do it in a way that's not explicit, everything's okay, everything's kosher, right? But if you're too explicit about it, and you upset somebody, know, ⁓ somebody goes and ⁓ blows to the government, you know, people get in trouble because that is what is fundamentally happening, you know, health systems are not paying ⁓ premium for you ⁓ whoever is, unless you are doing something of value. And that value frequently is the amount of procedures you do, the amount of referrals you generate. we have a very asymmetric system that ⁓ I ⁓ one approach to, we talking about soft landings, at least I do, is ⁓ approach trying to come after these large academic health systems really is to allow that increased competition with physician-owned hospitals by taking out star clause to allow kind of integrated networks to exist. Yes, sorry, the physicians may profit off of that, that is ⁓ fantastic bulwark against what's happening right now, which is basically handing over monopoly power to a large health system, right? So ⁓ ⁓ independent physician groups that are scattered surrounding these health systems to kind of get together to be able ⁓ to of push back even more effectively against ⁓ the systems, which right now are like the only place to get. certain types of certain certain, you know, levels of care or whatnot. So if you allowed physician hospitals, you allowed independent physicians to kind of string together, to do, to, ⁓ to do stuff and have not be forced ⁓ to under one EIN number, right? That, because that's right now, that's what has happened in order for me to get together with seven of my physician colleagues around the Philadelphia area, right. ⁓ And, and you know, send patients to an ambulatory surgical center that we, that we perhaps co-owner something or have some type of financial relation to right now, that would be illegal. Cannot do that. Right. And so it doesn't happen. Right. The health system has no problem with any of that. They just own everything and everything, everything, and that's what happens. And so there are the only game in town. So, so if you want to get procedure X, Y, and Z, and you end up at some health system, you are going to get some massive charge. Right. So the only way to push back against that, my fellow Americans, is to allow competing interests to come up. And if you have the type of competition, will, in the way that Dr. DeGeorge and the way Anthony that you're kind of framing it, I think you will not have costs that just keep skyrocketing and you will have a better kind of solution here that works for patients and employers who are ultimately footing these insane bills. Anthony DiGiorgio: Yeah, and I spoke specifically on this in my testimony. If you allow me to quote myself, six years or one, which the physician or hospital ban is start creating an untenable double standard where corporate health systems are granted broad safe harbors that allow them to functionally pay primary care doctors for lucrative downstream referrals simply by employing them. then I cite a study that shows that when ⁓ acquire independent care doctors, Anish Koka: Yeah. Anthony DiGiorgio: anti-competitively steer referrals within their own system. Ironically, ⁓ paper was written by David Cutler, ⁓ was one of the architects of the Affordable Care Act. So ⁓ the physician, especially the primary care doctor, is more valuable to the health system than they are to themselves. If you're an owner of a primary care practice, a health system can extract more value because if they were to purchase your practice, A, all of a sudden all the clinic visits now carry a facility fee. So just the simple arbitrage on billing all your clinic visits goes up about a hundred percent. So you double the revenue just from there. now the health system captures all the referrals from that practice, all the specialists, all the surgeries, all the MRIs, all the physical therapy, all the labs, everything goes through the health system. So independent practice, that is why the big hospitals can buy these independent practices. If that independent practice starts, tries to stay independent, they don't get any of that financial arbitrage that comes with the facility fees and the referrals. And they get beat down with more Medicare ⁓ less Medicare payments on the fee for service side. And it really creates this imbalance that is impossible for these independent practices to overcome. And that's why we see all this consolidation. Anish Koka: Right, right, no, that is 100 % correct. Anthony DiGiorgio: Just ironically, the Federation of American Hospitals had a fantastic tweet after that hearing they said, there's no issue with physician-led hospitals. The issue is about the conflict of interest when physicians self-refer patients to their own hospitals. Data is clear. POHs tend to treat more commercially insured and healthier patients in full-service hospitals. ⁓ got ratioed so hard on that. It's currently sitting at 95,000 views and only 20 people have liked it. Anish Koka: ⁓ yeah. Anthony DiGiorgio: Because everyone knows every physician that works in a hospital knows that hospitals are guilty of the exact same thing yet the hospitals are allowed to self-refer and physicians are not some of the hospitals are immune to this corporate greed that physicians have and their self referrals must always be altruistic whereas a physician only do it out of you know financial self-interest and to harm their patients It's just ridiculous that the Federation would would come out and say this because any doctor I think even most patients probably realize that this is happening on the hospital side. Anish Koka: Yeah, no, it's really, it's really ridiculous. There must not be enough hospital administrators on Twitter or something. I don't even know. Yeah. Yeah. Anthony DiGiorgio: And just a nice historical fact is the lobbyist for the Federation of American Hospitals, it was the main architect of Section 6001 of the Affordable Care Act, which banned physician-owned hospitals. So was actually, it was called the whole hospital exemption within Stark law, where if the physicians owned the hospital, the ⁓ hospital was exempt from Stark because otherwise it would have been self-referral. And so really what Section 6001 did was just expand Stark to prevent self-referral to the whole hospital. And again, the architect of that was one of the lobbyists for the Federation of American Hospitals. Anish Koka: Yeah, it's just, you know, it goes to show you how important it is for physicians to be involved in this type of stuff. Because if you're not involved and you just blindly trust like me, blindly trust, you know, our health policy elite to come up with beautiful solutions, you get stuff like this, which it's like, I cannot believe. I mean, I, yeah, I can't believe, mean, I can't believe that that, that, that, was in and it passed and Everyone cheered and it's because most people just didn't know and most people still don't know. I would love to hear physicians tell me, explain to me, go ahead, tell me why physicians are banned from owning hospitals. That is the most insane thing. I one of the most insane pieces of health policy legislation that has come across. All right. We're going to talk about your testimony for many Doctors' Knowledge episodes to come. We should probably spend one whole episode talking about your It's so good. Anthony DiGiorgio: ⁓ It wasn't that good. We'll link to it. People can judge for themselves. Anish Koka: Yeah, no, yeah, no, no, was extremely good. I'm gonna actually link to it right now on one of our tweets while we're talking. So at AHHS, ⁓ and Dr. Oz announced today a new healthcare advisory committee, top experts across the country coming together to provide insight on how to cut costs, reduce red tape and put patients first. Dr. DiGiorgio, ⁓ I was... Anthony DiGiorgio: Hehehe. Anish Koka: Sad to see your name was not there. What the heck? Who is on this thing if it's not you? Anthony DiGiorgio: That's okay. I've got enough other things going on. There are some good names on there. I had the announcement pulled up. don't know, ⁓ are your thoughts? Do you think this will move the needle at all or is it just gonna come out with some recommendations? Anish Koka: Yeah. I mean... Yeah, I don't know. don't know. Is that a play? Look, I don't understand the political game. mean, you know, like Donald and Kamala Harris, well, maybe not Kamala Harris, but folks Donald Trump are ⁓ extremely savvy politics, right? And things that seem completely wacky and, you know, he ends up, mean, whatever you want to say about President Trump. mean, man is president ⁓ after, you know. playing politics and so the political game is always so difficult to kind of read and figure out. I think this idea that you can go to Washington DC and just do the right thing and everything will be fine, like it just doesn't work. Like, you know, as we saw with our, you know, our buddy Vinay Prasad, you know, the guy was like, you know, he was a Tomahawk cruise missile doing the right thing, I thought, but, you know, you to like... pay attention to all the politics of how things look and stuff. anyway, long story short, long answer, long-winded answer, but it's play to get a bunch of like good people ⁓ real good and that somehow improves the chances of getting good legislation through. Great. But I think everyone knows what the problem is and how to, how to reduce costs. Right. I mean, we talk about it every day. I mean, it's almost like, what is the point of having this show? We could finish it in five, five episodes because we just repeat the same thing over and over and over again. knows what the problem is. The question is like Tony Robbins, Tony is on there. I mean, apparently he's a tremendous motivational speaker and Hey, If you can get, maybe if Tony Robbins was saying we should repeal physician hospital bands, maybe then we'll get legislation. So Maybe... Anthony DiGiorgio: How much do you think Tony Robbins Anish Koka: You know, I hear that he is an avid listener of Dr. DiGiorgio. I think, yeah, he apparently follows you or something. No, no, I'm kidding. I don't know if he you. Yeah. Anthony DiGiorgio: That would be surprising. I mean, the charge of this committee is admirable. ⁓ Defend action policy solutions to better manage chronic disease. Who doesn't like that? Advance accountability for safety and outcomes. the use of real-time data to support higher quality of care, speed up claims processing and improve quality measurement. ⁓ Enhance care for Medicaid patients and strengthen Medicare advantage sustainability, including risk adjustment and quality measurement. I mean, those are all... Anish Koka: Yeah. Yeah. Anthony DiGiorgio: admirable tasks. will be hopeful. Maybe I'm insane because I remain hopeful. Anish Koka: Yeah, I don't know. ⁓ When I hear Medicare improving, Medicare adjustment risk, I'm like, ⁓ man, like you're trying to like, this is like the sunk cost policy. Look, I get it. You need some type of utilization review for Medicare traditional FFS, traditional fee for service. much as I like traditional for service with a supplemental G plan. mean, I love it. It's great. you ⁓ ⁓ it's, there's, there's not a lot of back and forth, right? ⁓ ⁓ right? Correct. Correct. Correct. No, no, no, it's not. right. So, know, well, I, know, my MIPS score, my MIPS score, I'm more candid, making sure I'm checking all my boxes ⁓ make sure I don't get these, these cuts. ⁓ I that's the other thing with this whole MIPS score BS, right? Sorry, as an aside, like this MIPS score, like, ⁓ Anthony DiGiorgio: You didn't get the efficiency cut this year. Anish Koka: Like what, just any independent physician who's working for like one fourth the amount of my employed colleague down the block. I'm like automatically more efficient. I would have to do ⁓ X number of echoes in to like be like, know, be, be, be less cost efficient than my guy down the street. So look, I can make MIPS ⁓ MIPS thing really easy. you're an independent physician, you just automatically get a bonus. All right. How about that? Anthony DiGiorgio: Hehehe. Anish Koka: That would be my thing. No, anyway, look, to me, sometimes it feels like we're just throwing good money after bad in some sense, like improving Medicare Advantage risk readjustment. how do we improve Medicare Advantage? How do we, yeah, as you said, there are different ways of doing it, but mean, it's so complicated, Anthony. Then you have to like... Mandate Medicare Advantage do something a certain way in terms of like say you have a gold card for like, know prior author stuff or you know ⁓ instead of that right or mean ⁓ are smart ways to do it but it makes my head hurt to think about how to do it and then you're like ⁓ on some bureaucrat to get some ⁓ correct, you know, and it's like every system is gonna be game so that some insurance company is gonna be making ⁓ bajillion dollars So I know ⁓ Yeah Anthony DiGiorgio: I think there might be some good points there. both agree from first principles that it's hard for the government to run operate a health plan. ⁓ But in a world where the government is insisting on running and operating a health plan. ⁓ And if it's going to do that, ⁓ I that having a third party intermediary is probably better for waste, fraud and abuse. Anish Koka: Yeah. Anthony DiGiorgio: So how can you do that? And are there ways to modernize Medicare so it at least is not as bad as it was before? And I think, know, so right now for those that don't know, Medicare gets paid based on how sick their patients are, right? And so it determines how sick their patients are because you want these plans to get more money for signing up sicker patients or else they're gonna just cherry pick healthy patients. ⁓ now there is a financial incentive for these companies to make their patients seem as sick as possible. And so what they'll do is there's actually these insurance companies will send people to nurses and doctors to people's homes ⁓ every last diagnosis that they could put in the chart to ⁓ up their risk score and get more money. And there's actually a large return on investment in that. And so I think, again, if we're going to insist on having ⁓ run its own health plan, you can make that process not as bad. I don't think you can ever make it perfect from a first principle standpoint that you and I would agree with, but you can at least make it so The hospitals don't, or the insurance companies don't have this huge ROI on just sending people out to diabetic retinopathy in the chart so they get paid more. ⁓ can make it auto extract from objective data using AI. I think you could do a lot of different ways to better the grounds truth of how unhealthy the patients are. You'll never get, again, ⁓ concede the that it will not get to something that you and I think is perfect, but it could be a little less bad than it is now. Anish Koka: Yeah. Yeah. Yeah, no question. Anything that's less bad is a good thing. And I think we need to kind of, know, we need to understand that, that, you know, and Friedman, I say this all the time, Milton Friedman, when you listen to him enough, ⁓ he the time, ⁓ when have these conversations talk about ⁓ you know, okay, this is where we need to get to and what is pragmatic. And he would look to the politicians, like the folks, well versed politicians, you know, and he's such a brilliant guy. And he would pause and say, wouldn't that, wouldn't that in that, in that friendly voice, that big smile, wouldn't that be possible? And, know, as if he's asking, he's like, you know, this is what we should do, but is that possible from a political standpoint or where we are in politics say. Anthony DiGiorgio: Right. Anish Koka: What? Okay, next topic. Not to get spicy, but you know, there's this issue. There's an issue that's raised over and over again. We're gonna skirt, we're gonna beat around the bush a little bit. There's an issue that's raised all the time, right? The rural access gap. What do you think about the difficulty are... Anthony DiGiorgio: You wanna get spicy. Anish Koka: rural, ⁓ ⁓ the United States. ⁓ what is the scope of that problem? And what should we do about it? Anthony DiGiorgio: I mean, I don't know because part of it is what do you define as rural, right? I think that's one of the main issues is Stinson Beach, California down the street from me is considered rural. It's a 30 minute drive from San Francisco. So I that's part of it is you end up, you lump a lot of these hospitals in and they get classified as rural and maybe they're not. There's no question that if you're living out in the of, I don't know, Texas, ⁓ four hours from the nearest town, you're probably not gonna have great access to healthcare. If you're living in Houston, you're probably gonna have better access to healthcare than anyone else. There's comfortable medium there where you ⁓ get people, not everyone's gonna have the best open aneurysm surgeon on the planet within a drive away. ⁓ 99 % the country doesn't have that. So I don't know, I think ⁓ you probably set some sort of baseline, and this is where I actually think that that it is more of a community good, healthcare readiness is a community good, like the way we treat firefighter readiness, right? So you would pay, a local community could pay to have 24 seven trauma coverage, heart attack coverage, stroke coverage, OB coverage, just the way that they pay for 24 seven fire and police. I think that that is a totally legitimate use of a community good and public funding. think it's silly that we pay for trauma and stroke. on a fee for service basis when you really should be funding it for a readiness basis. You don't pay firefighters depending on how many fires they put out. So that's how I would encourage localities to do it. If you ask the federal government to make these large programs, you end up losing local control. I would do grants to local communities so they could do it locally. And that way you can have more focused services. But I don't know, what are your thoughts? Anish Koka: Well, yeah, I I guess I'm going to ⁓ up is that I like the plight ⁓ of rural poor, as you very said, and I'm glad you brought it up because I was going to bring it up if you didn't bring it up, was the fact that there's ⁓ way too folks are labeled. If you're 30 minutes away from a major teaching hospital, OK, ⁓ I'm sorry. You may be defined as rural poor, but that is probably as good as you're to get. That's probably like, that's probably the best you get in the world. Okay. I don't know that we're going to get too much better than being 30 miles or 30 minutes or something like that from there. 30 miles. Okay. And in rush hour, it's an hour. Look, that is not bad. Okay. So if you define, if you, if you do have some baseline things in terms of defining and then go about saying, okay, what percentage of the population is truly rural poor? I think you're talking about a very, very small percentage of the population. All right. If you define it that way, right. This idea, like you said, that's completely inane, utopic, you know, I'll go as far to say asinine that, you know, you need like a UCSF style center in like, know, Topeka, Kansas is Topeka a big city? I don't know. Maybe Topeka has some, has some great thing. don't know. But anyway, my, my point is some Tubalook Montana, I'll make up some name. So that's not to get anyone in trouble, I'll get myself in trouble. But the point is you can't have that in every single place. You may have to drive to that. It just doesn't work. It's not reality. Okay, all right. So relatively small. It's okay. So they probably don't have the most. Anyway, stop there. yeah, ⁓ all of Topeka listeners, yes. I love Topeka. I've never been, but I hear they have great stakes. Anthony DiGiorgio: The Pica Kansas has 125,000 people. We just lost all our Topeka listeners. Anish Koka: But the, where was I? Yeah, so right. if you, so, then that tiny percentage of the population that actually is, you know, difficult to get to, difficult access and stuff, ⁓ are being weaponized for all sorts of policy proposals ⁓ I don't think are in the best interests of everyone. I really don't. Anthony DiGiorgio: So just quick stats that I looked up, to add some of the handy. 81 % of the US population lives within one hour of a level one or two trauma center. That is almost the entire population. it's hard, given the geographic breadth of this country, it's probably hard to do much better than that. And I'm sure if you include level threes, you're probably getting close to 99 % Anish Koka: Yeah. I mean, that's pretty good. Right. 90%. Yeah, exactly. So, you know, it's weaponized all the time. So was weaponized in the 1980 whatever bill that Bill Clinton passed. And that's kind of why, that was the big push for why nurse practitioners were given independent practice, right? Again, I'm not ⁓ opposed to anyone wanting to practice medicine if they want. I think physicians have a ton of training. You to open up a practice and start trying to practice, you know, neurosurgery or oncology or cardiology next door to me. please be my guest. suspect I'm going to do okay and you know, ⁓ be fine. ⁓ ⁓ idea that ⁓ practitioners becoming, giving them the ability to practice independently, that was going to be the solution solving the rural shortage problem. ⁓ That happen. That didn't happen. That's been 20 some years because all the nurse practitioners, I mean, there are some, there are some... wonderful, lovely nurse practitioners who do set up shop in areas that nobody wants to go to, no physicians want to go to, that happens. But that is rare. The vast majority of folks that are becoming nurse practitioners are doing because they want to do ⁓ X, and Z in some major city, which is just a natural human thing. Most people want to be in cities, which is why most people are in cities. And so, you you of this NP path allow NPs to practice independently so that you would solve the rural short of the rural poor problem in terms of access to medicine and you have not solved that at all. All right. And by the way, you've probably devalued, know, devalued family medicine, ⁓ cetera. You've probably allowed, you the widget of the American physician, right? Where ⁓ now health are like, ⁓ look at that. ⁓ We can we just have somebody else that can refer for 10. downstream revenue producing procedures. I don't care what type of provider it is. It could be an NP, could be an MD, could be a PA, could be a ND, whatever, right? Like tomorrow, if they allowed, if the government said, we're gonna allow naturopaths and crystal healers to bill Medicare, 100%, the next week there would be naturopaths and crystal healers. in health systems, because hey, they're much cheaper and they can do kind of the same job, because all the health systems care about is that downstream referral. They don't really care about quality as much as they say they care about quality. So that this whole, ⁓ Anthony DiGiorgio: Well, to push back on that point though, if you could charge Medicare for crystal healing, the crystal healing industry probably would hate that because then you can no longer charge cash. And right now they would rather take cash with no third party intermediary. Just that's why the dentists have held out from being in Medicare. Anish Koka: Mmm. Yeah, that's very good point. But of course, Medicare would for crystal healing would pay so little that nobody would participate. They would still be out network. But yeah, right. Anthony DiGiorgio: Right, that's true. It's like acupuncture is covered here in California for Medicaid. You can't find a ⁓ Medicaid participating acupuncture provider. It's very difficult. Anish Koka: Right, Yeah, that would be, it's like psychiatry. like good luck fighting it. ⁓ we're just doing psychiatry. ⁓ ⁓ course, you know, the latest round of folks to that constantly bring up ⁓ the poor is, you know, is international, ⁓ is debate on international medical graduates, which I think is. a nuanced debate that we should probably spend some time on and maybe get a guest in on. I'll just say, the only thing I'm going to say about the IMG thing is that this idea that we're going to solve the rural poor problem a constant inflow of ⁓ metal grads or importing even more national metal grads ⁓ complete fiction. I mean, the vast majority of international metal grads have no interest. Like ⁓ the who who trained in Delhi little interest in ⁓ to practice in some rural place in Montana for the rest of his career. Now he may end up practicing there for the rest of his career because he ends up being forced to because he ⁓ get somewhere for whatever reason. But the vast majority of international grads have no interest in practicing in rural poor America. so, so they're maxing the stay for their J-1 visa, you know, they're going to stay for the three to five year ⁓ of time they have to do there and then they're going to move on. So is not a good long term solution if that's what the problem is. ⁓ And don't know that the problem is so massive that we have to ⁓ necessarily a bunch of different things. So my bigger which jives with what we talk about all the time, is the fact that there are members of the local community in many of these places that would absolutely serve as practitioners, right? And we should have accelerated pathways. Like, if you are a bright kid in a rural part of the country, okay? Like, we should bend over backwards to get you to be able to practice medicine. Yeah? Like, 150 % because that kid is gonna be 90 times more likely to want to practice there. Now, of course, there's going to be some of those kids that are going to be like, get me the hell out of wherever I am. I want to get to the big city and stuff. That's fine. But like what the percentage chance that like a kid that grew up in some community wants to practice in that area is much, much higher. And I think the really interesting parallel is to what happened with PCOM, which is the Physicians College of Osteopathic Medicine in Philadelphia. Right. It was, you know, this is the whole, you know, we're well past that now. Right. ⁓ where you know this whole DO versus MD and DO schools were coming up and they were alternative and they were outside the system and whatnot and they were gaining legitimacy and the DO track was a very different track especially for family medicine. was you know four years of med school it was slightly different though you first few years I think are very very very similar and slightly different in terms of the clinical years some osteopathic manipulation and stuff but at end of the day then they had a one-year track where you could could do like a residency type training and then you were, you you're, you're out, you could do, you could do family medicine, right? ⁓ and what do you know? Like if you look in South Philadelphia, like that South Philadelphia landscape to this day is dotted with a tremendous number of DOs who were local, members, boys and girls from the community that went to PCOM did their thing and came back to South Philly, ⁓ set up You know, they're in one of those raw homes, right? I go to one of those raw homes ⁓ on a once a month. to see some cardiology patients there in one of those offices. And that's what happened. And so I think that's a much, much better solution than expecting a kid from Hyderabad or Gurgaon, India to come to whatever town in the US. yeah, he's going to set up shop and practice there for the next 40, 50 years. I just think it's silly that that's the reason given. Anthony DiGiorgio: Well, I think there's two issues. One is, when I spoke earlier, is access to emergency services, which needs to be, I think, ideally funded like we fund firefighters. I think what you're talking about is access to a lot of elective services, first principles, we should just allow the prices to rise. The problem is you can't charge more if you're the only physician in town if you're taking all Medicaid patients. If we allow charges, Anish Koka: Yeah. Anthony DiGiorgio: prices to rise, costs more in rural areas. Your broadband internet costs more, your groceries probably cost more because they have to ship them farther. Things just cost more when it's isolated. And so it's not that you want to charge the rural poor more because you don't like them, but allowing the prices to rise signals a lack of supply. And so some kid from that community would say, hey, ⁓ could be the only doctor in this town. I could have a complete capture of everyone in this town for elective care. and go and make a killing if I'm allowed to charge what I want. The problem is you're not, you have to abide by Medicaid and Medicare conditions of participation and you have to bill E ⁓ codes and you only get reimbursed what you get reimbursed. But if you went, if you allowed the prices to rise, then people would be happy to go do that. And probably a lot of them would see a fair number of charity care because they would carve out like you do, go one day a month and go to just see people who can't afford care and give free care. But we don't allow that anymore. make it so the only way you can survive is going and billing Medicaid and Medicare, which doesn't cover your overhead. And so why would you want to do that? So you, like you said, people try to get international graduates to go there. They don't want to go there. Nurse practitioners don't want to go there. There's a great study showing that when they've given nurse practitioners independent, independent rights, what they do is they end up practicing like dermatology in large cities. They go to the rural areas and practice family care. So Anish Koka: Yeah. Anthony DiGiorgio: I really think if you just allow prices to rise, you would get, market would sort itself out and you would get people establishing clinics and stuff in these areas. The trauma care, the OB, stuff like that, you're gonna have to fund that as a community good. There's no question there. But I think you could get primary care clinics in a lot of these areas. Anish Koka: Yeah, and these places, wouldn't even have to say that, Anthony, obviously. think, in some of these places, I Medicaid rates are so, I mean, absurdly ridiculous. think you would have these folks would just open up a practice and do it the old way as when you didn't have it. They would just collect money from folks, right? And then they would live outside of the insurance network because that would probably be an easier subscription model or something. Like ⁓ those type of things to happen. And if anything, ⁓ should Anthony DiGiorgio: Right, you can never meet overhead. Anish Koka: you know, from a public policy standpoint, as you said frequently in the past, is allow Medicaid, Medicare to kind of feed into some of those subscription ⁓ certain that really do, certainly for once you fall below a whatever level, okay, we should feed that. But then yes, ⁓ everything else, there's reason that you... those things would help, right? If you allowed a physician to practice in rural, ⁓ poor of the country ⁓ and him to both ⁓ take type subscription services on a monthly basis, plus ⁓ allowed him for folks that cash pay as then would automatically help that in more so ⁓ than the current system. ⁓ Anthony DiGiorgio: Right. And don't make them do MIPS and don't make them do Medicare because of their participation. Don't make them abide by Starklaw. Let them buy his own x-ray machine, his own MRI. then also, I mean, local governments are creative. They could give tax incentives for local physicians to set up shop. They could even, you you could probably get a local community to fund a subscription type service where, you know, $2 for every person per month, you know, in the community, as long as you see them when they want. Anish Koka: Yep. Anthony DiGiorgio: And there's so many different ways that you can do these creative finance. this is, know, going back to my testimony is that I brought up is that Medicare conditions of participation restrict physicians from coming up with these creative ways to finance care because you can't charge cash prices. You can't enter independent value-based contracts with local businesses, right? You have to by the E ⁓ the physician fee schedules with E ⁓ codes, the CPTs and ⁓ So you can't enter all these creative ways to pay for it. that I think would really unleash competition in the free market if you allowed physicians to do that. Anish Koka: Right, no, absolutely, Yeah, we have to think about who we can bring on ⁓ to talk about it. ⁓ friend, ⁓ Bowden has been in the news quite, ⁓ know, she's been making many, waves on this front. So let's think about who to bring on. ⁓ Anthony DiGiorgio: Well, think mean, Josh Umber with with Atlas MD, mean, I'm sure he's got a large rural footprint. And again, a lot of this is going to be regulated on a state by state basis. The way some states try to address this is with their state directed payment permit programs where you can essentially give a supplement through Medicaid payments if you go to certain communities. But again, it's a lot of central planning. It's it's on a state based level, not on the community level. Anish Koka: ⁓ yeah. Anthony DiGiorgio: And it just ends up being manipulated by a lot of these large health systems. I think the FQHCs and critical access hospitals are kind of a good example of what can go wrong there. Anish Koka: Right. Yeah, absolutely. Well, we're nearing an hour, sir. Anything else that you want to talk about? Anthony DiGiorgio: One of the last things I did bring up in my testimony that I think is worth talking about is something we came up with about an adjustment to the federal matching rate for Medicaid based on a state's competitiveness. so this, going back to the Medicaid talk, is the federal government reimburses 60 and 90 % of the Medicaid costs for the states. But a lot of these states are driving up the costs with things like certificate of need laws. Anish Koka: Hmm. Hmm. Anthony DiGiorgio: or restrictive covenants for physicians. And so the federal government, if they're footing a lot of the bill, I think should be able to tell the state, like, look, if you have certificate of need laws, we're gonna drop how much we're reimbursing you because you're artificially inflating the cost of care in your state. And we're not gonna, you know, it's not fair for a competitive state to fund a non-competitive state that's driving up the cost of care. So think that was just one other thing that is worth mentioning. ⁓ There seemed to be some buy-in from some of the members there, which I think would be a good project to undertake. Anish Koka: What was the, I mean, obviously you're testifying in front of Republicans and Democrats. ⁓ Can you, what was the, how was the, how did that go? Like, would you get a lot of questions from both sides or what can you talk about? I should have, I'm sorry, I'm a bad interviewer. I should have talked more about the. Anthony DiGiorgio: This is true. No, no, it's okay. the Democrats didn't want to talk to me. they ⁓ used of their time just to, basically do speeches. ⁓ they used it as grandstanding time to talk about the one big, beautiful bill, and the lack of, ⁓ extension of the supplemental ACA payments. Those were the two things that they brought up over and over again. they really didn't ask that many questions. They, they direct a lot of the questions at, the Anish Koka: ⁓ really? Anthony DiGiorgio: Democrat witness and the AHA just asking them what lines, what service lines are going to be closed with fewer Medicaid funds. so the Democrats really didn't ⁓ to engage that much with me. I don't think I got ⁓ single question from them. They listening though. AOC was there ⁓ for part the hearing. She listened intently to my opening statement and then, ⁓ but did stay around for questions. was looking forward to getting a question or two from her, but it did not happen. But think the Republicans were very engaged. was ⁓ impressed. There's a lot of physicians ⁓ that, in that committee. So, Representative Miller Meeks, Representative Joyce, to name few, their physicians had very good questions, ⁓ very much in physician-owned hospitals. So a lot of good engagement from that side. Anish Koka: Hmm, that's disappointing. It's too bad we Yeah, is there anything that you think that would get Democrats ⁓ interested ⁓ some the proposals? Like, why wouldn't they be interested in breaking ⁓ ⁓ system of monopoly? Like, they seem very intent on... What are they... ⁓ Yeah, what you think the political game is from their side? ⁓ Anthony DiGiorgio: think they are sympathetic to the monopoly idea. one of the points I did bring up is there's good data showing that the allied health and nurses wages go down when systems consolidate. you have a labor force issue as well, right? If you're a monopsisy buyer of labor, then you're going to charge less for something like 7 % when hospitals merge. It's like a 7 % drop in nursing wages. So it's not insignificant. Anish Koka: Yeah. Yeah. Anthony DiGiorgio: So I think they could be sympathetic to that, I think it, you know, politics is politics. ⁓ are coming up that think that they can win on the ACA subsidies and they can win on Medicaid cuts. And that's the point they're going to keep driving home. And I don't think anything, they're not to get any support from the, the Republicans aren't going to get much support from the Dems on any sort of healthcare reform, as long as they can keep hammering on those points. They certainly don't want to give the Republicans a win ⁓ before the midterms. Anish Koka: Yeah, it seems it seems like things are it doesn't seem that there's any room for coming together because it's like the two part, I mean, like you cannot be for Medicaid expansion. And you're not even talking about Medicaid expansion, you're talking about like reducing the amount of Medicaid expansion over the next 10 years, right? I mean, if the Republican proposal is to reduce it by 800 billion over 10 years, 80 billion per year in a program that's almost a trillion a year, right? And that causes these... crazy cavalcades about ⁓ my god you know the world is ending it just seems Anthony DiGiorgio: Histrionics, yes. How many people did Schumer say was gonna die because of this? It was a lot. Anish Koka: Yeah, right. was a lot. mean, has that already happened or people dying everywhere now or what's going on? Is that, is that what that's already happening right now? Right? Yeah. He said how many, well, the study said 55,000 people or something. Right. Um, but you know, it seems like, yeah, it seems like it is impossible. So I wish, I wish there were someone on that side that would, I mean, the only person that seems to be somewhat reasonable, but I don't know what his views are on, on healthcare is, is Federman. Um, but Anthony DiGiorgio: You haven't seen the bodies outside your house? Yeah. Yeah. Anish Koka: He seems to every now and then say something that Republicans say, anyway, I don't know. It seems a very, very difficult forward if one is looking for some of, know, it's everything that is going to have to be passed on a pure Republican only vote. ⁓ You know, you don't expect to. ⁓ Anthony DiGiorgio: I mean, I would love to see the days of old-fashioned satiation. Like maybe you try to reach a deal where you extend the AC subsidies and do site-neutral reform and do 340B reform. I mean, I would love to see some across the aisle, handshaking. Again, I'm sympathetic to the idea they don't want to give the Republicans a win heading into the midterms and then possibly blow their chance at taking the midterms. So I get the politics of it. It's just, it's unfortunate. That's the system. But hey, Anish Koka: Right. Right. Right, right, the politics of it. Yeah, the politics of it. Correct, yeah, yeah, correct, correct. Yeah, I guess so. It's remarkable that we've made it so far with given how the sausage is made. So, but yeah, the politics that you're right. You're absolutely right. The politics dictates that ⁓ you don't want to deal. You want chaos and you know, yeah, so maybe, yeah, you want chaos and you want things to look as bad as possible so that you can win, you can win the next election. So, well, we'll see, we'll see how it goes. So, all right, sir. Anthony DiGiorgio: That's what the founders wanted, right? That we will. Anish Koka: Thanks so much. Great job. Thanks for all the hard work. It's impressive that you're able to pull stuff together so quickly and do such a great job in such a short fashion. So kudos, kudos to you, All right. All right. See you next week, Anthony DiGiorgio: My pleasure, happy to help wherever I can. Thank you.