In this episode of Healthcare Americana, Christopher Habig engages in a thought-provoking conversation with Dr. Anthony DiGiorgio, an Assistant Professor of Neurological Surgery at the University of California, San Francisco, and a Senior Affiliated Scholar with the Mercatus Center.

Together, they delve into the intricate world of Electronic Health Records (EHRs) and their impact on healthcare. Dr. DiGiorgio acknowledges the benefits EHRs have brought, such as improved access to lab results and imaging, but also sheds light on their challenges, including the time-consuming nature of order entry and documentation. The regulatory burden on physicians for EHR usage and the potential role of AI in streamlining these processes are explored.

Additionally, the pair discuss the influence of regulations on healthcare, the concept of free-market principles in medicine, and the need for physician ownership of hospitals. The episode concludes with a powerful message emphasizing that a free-market approach can restore the patient-physician relationship and empower patients to control their healthcare financing, ultimately improving the quality of care.

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[0:00:38] Christopher Habig: Welcome to Healthcare Americana coming to you from the FreedomDoc Studios, I am your host, Christopher Habig, CEO, co-founder of Freedom Healthworks. This is a podcast for the 99% of people who get care in America. We talk to innovative clinicians, policymakers, patients, caregivers, executives, and advocates who are fed up with the status quo and have a desire to change it. We take you behind the scenes with people across America that are putting patients first and restoring trust in American healthcare.


Today’s episode, we are going to dive back into really the definition of what it means to provide quality health care. We’re talking EMRs, we’re talking quality metrics, we’re talking, do these things actually help in care settings? Or are these burdens to patient care and the doctor-patient relationship? How we navigate them, and pretty much touching anything and everything under that umbrella. Please welcome to our show, Dr. Anthony DiGiorgio, Assistant Professor of neurological surgery at University of California, San Francisco, and a senior affiliated scholar with Mercatus Center. Dr. DiGiorgio, thanks for coming on to Healthcare Americana. Thanks for joining us.


[0:01:49] Dr. Anthony DiGiorgio: Thank you very much for having me, and thanks for all the hard work you’re doing on your podcast. This is great work.


[0:01:54] Christopher Habig: It’s a labor of love. It is absolutely. I get to meet fun people and say like, “You know what? This is an interesting topic.” So longtime listeners of the show will know that the quality word – actually, the word quality, let me say that or the cue word is one of my triggers, right? I kind of joke like, I need that like DJ. Whatever time everybody hits that and I buzzers go off. What in the world does the word quality mean in health care? And everybody has a completely different definition of it. So you’ve recently been published in JAMA, you’ve been talking about all these different things on how quality metrics. Well, I’m not going to put words in your mouth. So Dr. DiGiorgio, what is your view of the word quality in healthcare, and how quality metrics affect the care setting?


[0:02:44] Dr. Anthony DiGiorgio: That’s a great topic to talk about. Clearly, I’m very passionate about it. So the key word, as you mentioned, as triggering for a lot of doctors, right? We hear quality, and we immediately think about quality metrics. We think about the V word, or the V acronym, value-based payment, which is a natural offshoot of the quality movement. So quality metrics are nebulous, as you mentioned. They can mean a bunch of different things, depending on who’s defining quality, right? Even amongst different patients, quality can differ.


Some patients may look at extending their life as quality, some patients may just want different functional capacity in their life, and that’s their definition of quality. Some patients may want a handful of medications, and to be shown the door, and that’s their definition of quality. So it really differs depending on who you ask. Measuring quality is not a bad thing, right? I think any industry in America measures quality, right? Any firm in any industry in America is going to have their own quality metrics that arise naturally within that firm. Every industry, every firm has internal metrics they track. It would be insane for any firm to not track quality metrics. Our division at UCSF, of course, we track quality metrics. These are metrics that come up within the division that we decide are valuable to us as neurosurgeons, that we want to look at going forward.


The problem with the quality movement is when it was associated with the value-based payment movement, where Medicare decided it’s going to define what quality is from a top-down approach. And then withhold or give bonuses on payments based on physicians and hospitals meeting these somewhat arbitrary quality metrics. And so I think that’s really where the quality movement has started to frustrate physicians, is that these metrics don’t always necessarily aligned with what physicians think are important quality Indicators. There’s numerous examples. I’m happy to get into, and we go over some of them in our piece in JAMA, that I had the honor of publishing with AMA president, Jesse Ehrenfeld, and one of the affiliate scholars at AEI, Dr. Brian Miller.


[0:04:50] Christopher Habig: The article is titled, Improving Health Care Quality Measurement to Combat Clinician Burnouts released September 1st, 2023. So everything within their, I’m like, there’s a couple different subjects within that title itself. Obviously, burnout is a huge one. How much do you find that a burdensome quality measurement tied to reimbursement affects physician burnout or dissatisfaction with their career?


[0:05:16] Dr. Anthony DiGiorgio: Huge, huge effect, and it really depends, the quality metrics affect different physicians differently. I know some obstetricians who have 80 metrics in their department for obstetrics, 80 different metrics for one physician that they have to meet. I mean, it’s not possible to keep track of all those, as you’re performing your daily job as a physician, and also keep the patient’s best interests in mind.


[0:05:40] Christopher Habig: Let me ask you, just to jump in there from an ad quality metrics from an OB standpoint, do you find when people look behind the screen kind of Wizard of Oz style and say, “You know what, these metrics are just for revenue maximization, not necessarily getting this person healthy and keeping them healthy”?


[0:05:59] Dr. Anthony DiGiorgio: Correct. Yeah, it is, again, it’s top-down metrics that have been devised by CMS. It’s CMS using the power of Medicare and Medicaid, to then influence payment, and these payment bonuses and penalties can be in the millions of dollars. So yeah, it’s about revenue. Again, there’s very little data that these metrics actually increase quality. At the end, that of course is a triggering, nebulous word. But even the Government Accountability Office in 2019 issued a report saying, these metrics don’t align with the overall goal of improving what we would define as healthcare quality.


[0:06:37] Christopher Habig: When a topic of value-based payments come up, and I get asked this a lot just sitting in my seat. They’re like, “Well, what do you think about value-based care?” I’m like, “Well, this sounds great. It’s Orwellian in practice. It’s doublespeak completely.” They’re like, “What do you mean?” I go, “Well, in my view, a hospital cannot afford a readmission, because that’s what you’re talking about. That’s when penalties come in. So if anybody ever goes to the hospital, they don’t want you to come back. So they either want you to get better, or they want you to die. That is it.” And they laugh, and I’m like, “Well, that’s an extreme example, but that’s where the incentives are driving people.”


[0:07:11] Dr. Anthony DiGiorgio: I mean, you may laugh, but that’s actually been studied. The hospital readmissions reduction program was one of the first quality metrics to be implemented by CMS. And they’ve studied it and showed that, sure enough, if you disincentivize readmissions, readmissions go down, the quality metric worked, it got readmissions to go down. Unfortunately, they also showed that it came with an increase in mortality, because hospitals were doing exactly that. That was in another JAMA paper showing that hospitals reduced readmissions, and they increase mortality when they did that. And that makes sense. There’s anecdotal evidence that physicians were told to not readmit patients that come back to the ER, because they didn’t want to affect their hospital’s quality metrics.


[0:07:54] Christopher Habig: I am not laughing because it’s funny, doc. But I’m like, this is not –


[0:07:57] Dr. Anthony DiGiorgio: It’s tragic.


[0:07:58] Christopher Habig: It is a classic example, and we see this all the time, misaligned incentives in health care. I might be romantic, I might be a purist in this, but I’m like the goal of our healthcare workers, everybody who’s in there. These are people who chooses to help other fellow human beings. They want them to be better, and they want them to live a healthier, better lifestyle, right? Like going back to quality, quality of life, like that actually means something that’s relatively ubiquitous to people, but yet still very much variable. But the payment structures are just so screwed up. And when people say, “Oh, healthcare is broken in America.” I’m like, “Now, it still makes a lot of money, it just – everything else – the way we pay for it is broken.”


Now, you’re a big proponent of saying, look, we can actually drive positive change through maybe not CMS, but to state Medicaid programs. Give us a little glimpse on your thinking when it comes to that topic.


[0:08:53] Dr. Anthony DiGiorgio: I’m a big proponent of the free market, obviously, while I’m here. And I’ve probably read a little bit too much Hayek, and Friedman and Thomas Sowell. But I believe in things coming from the ground up. Medicaid is actually a pretty good area where that can be done, because there’s so much leeway between states and how they design their Medicaid programs. So I’m going to the issue of quality if states want to have quality metrics, come from the ground up and emerge naturally. I think that that’s great, and I think that that would really allow different metrics to arise and show you what works what actually can improve the overall delivery and function of healthcare. And not just have these heavy-handed top-down things coming from a detached CMS, which operates at a federal level.


So Medicaid, I’ve been a physician at safety net hospitals basically my entire career. So I have a lot of interest in how Medicaid functions. Medicaid is really great because like I said, it has that sort of experimental nature where different states can try different things, since each state is in charge of its own Medicaid program with some leeway. And then using the free market within Medicaid, and things like Medicaid managed care organizations really allows these interventions to sort of percolate up from the bottom to arise naturally, and not be just these heavy-handed CMS mandates that come from federal government.


[0:10:12] Christopher Habig: That’s what I love about America, is like 50 different experiments, right? I feel too often that the free market advocates just refuse to even acknowledge or think about the Medicaid population, where that Medicaid population is growing. In Indiana, one in four Hoosiers are on Medicaid right now, in our Healthy Indiana Plan. The expense just went from $2 billion to $4 billion in health care expense to serve that population. It’s the number one insurer in the state. Yet, our leaders are not looking at this, our elected officials are not looking at this as a way to say, “You know what, maybe we can use Medicaid to come in and make our landscape more competitive. Maybe we can come in and challenge insurers think that they have almost this monopoly in this hospital pricing, all this kind of stuff. Can leaders, if they have the stomach for it, use Medicaid program to come in and implement more free-market minded initiatives?


[0:11:13] Dr. Anthony DiGiorgio: I think they can. They require some leeway. Unfortunately, the federal government does have some handcuffs that it puts on Medicaid programs. You couldn’t just make say a voucher program and give your Medicaid beneficiaries a voucher to go purchase private insurance. However, yeah, I think that there is a lot, some leeway that can be obtained via waivers with the federal government, where you could really design your Medicaid program to utilize a lot of these free market forces.


I think the overall goal should be fewer people on Medicaid. I think a safety net program is essential. I do believe that that we can strive for universal coverage, given free market principles using Medicaid as a broad safety net. But the key is to make sure that the people on Medicaid are the ones who actually need Medicaid, and not people who might actually be better served on a private insurance plan. Either they’re healthy enough, they could get a lower premium. You know, efficiencies can be certainly improved in the ACA marketplaces, where these people could probably get pretty affordable care on a private insurance plan. Therefore, just leaving Medicaid for the people who really do need this social safety net that can’t otherwise get a reliable health insurance coverage via the free market.


[0:12:24] Christopher Habig: I’m curious, because we talked to a lot of different people on the show who say, “We need Medicare for all”, then other people say, “Abolish all the safety net,” point fingers, all this kind of fun stuff. I’m curious to see, in your mind, how we can square having a safety net that actually works, actually gives people the ability to go access a physician to become healthier? How do we do that using free market principles without backsliding, and in some circles, they’ll say, “Look, we don’t want to strengthen the ACA, because that’s a political football, back and forth”? So how do you single thread that, because I feel like that is the ultimate question. Like we can answer two or three of those questions, but we can’t answer, “Well, we need better personal insurance when there are no options out there.” So there’s a lot of moving pieces. Dr. DiGiorgio, how do we get to that end point?


[0:13:16] Dr. Anthony DiGiorgio: Yeah, I think the principles of free market competition, driving improvement both in – there’s an obvious word, again, quality and in cost. And because quality is so individual specific, that allowing people to have options to choose different insurance plans, different coverage via health savings accounts, the capitated plans, giving people the option to choose what’s best for them. And then making sure that there is this backstop of a social safety net, where nobody’s going to be left holding a six-figure bill, because they were in some trauma or had cancer diagnosis show up out of nowhere. Really, again, reserving that social safety net for those that have no other options of private insurance, and then making sure that that Medicaid is just reserved for those.


So, again, if you’re a young, healthy individual, you can probably get fairly reasonable private insurance with not a whole lot of government subsidy behind that. That could actually free up Medicaid for those who truly do need it.


[0:14:15] Christopher Habig: Where do you see the role of insurance alternatives playing in this?


[0:14:19] Dr. Anthony DiGiorgio: I think there’s a huge role. I think that – and it’s a matter of, you know, again, another kind of buzzword, but equity is, why do we restrict alternatives like health savings accounts to people who are in private plans? Why don’t Medicaid beneficiaries deserve that as an option? Can they not save away some money, maybe with a government subsidy to have more control over their own healthcare options? I think that right now, we say Medicaid patients, your only option is Medicaid, you must go into this program that has very few options. If you give them more control, that would, again, here the buzzword, quality would improve because they would be able to get the health care services that they find most important for their individualized health.


[0:15:00] Christopher Habig: Staying on a subject of Medicaid patients, we hear all too often, it’s a very broad brush, and it doesn’t seem like a lot of states have the data and information to say, “This is true and this is not true.” But most of the stories we hear coming into clinical settings is, my Medicaid patients don’t show up. My Medicaid patients are most likely to be abusive. They don’t follow physician instructions. How do you react to that? Has any state done a good job of saying, “Well, we’ve actually surveyed all this. This is true, or these are completely false. These are just stereotypes”?


[0:15:33] Dr. Anthony DiGiorgio: You’re right. It’s a broad brush. Medicaid, as you mentioned earlier, Medicaid is growing, and it actually is the largest insurer in the country right now, insurers a plurality of Americans, and about 80% of my patient population is Medicaid. They are a very heterogeneous, very differentiated population. You’re right, there are – I have a significant part of my patient population who are homeless and have significant substance abuse problems. I also have a significant part of my population that bounce between different jobs, and don’t – a hard working individuals who don’t otherwise have access to regular employer sponsored health care. So it is a broad brush.


And yeah, there are challenges that come with treating Medicaid patients. And that’s why we need the social safety net to be there for the homeless person with substance abuse problems, who can’t get employer-based health care, and who can’t even really manage a health savings account. That safety net needs to be there for that individual because they’re going to get care regardless. But at the same time, we can provide better options for that hard working individual who is kind of bouncing between jobs and can’t get reliable access to employer based health insurance.


[0:16:36] Christopher Habig: We’re going to take a quick break. We’re going to hear from our fantastic sponsor, FreedomDoc, and then we’ll be back with Dr. Anthony DiGiorgio exploring EMRs, and all the fun that they bring to a physician practice. So first, quick message from our sponsor, FreedomDoc.


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Once again, we are talking with Dr. Anthony DiGiorgio, Assistant Professor of neurological surgery at University of California, San Francisco, and senior affiliated scholar with Mercatus Center. So obviously, big proponent of the free market, you’ve done all kinds of studies, you’ve helped consult on legislative initial efforts at the state level, at the federal level. I’m curious when you’re working with the state out in California, and then working with federal, we covered a lot in the first part of this episode of, well, these things need to fall into place in order to do this type of stuff. What is the lowest hanging fruit out of any of the projects you’ve worked on that you’re like, “This wouldn’t be that big of an effort to accomplish”?


[0:18:09] Dr. Anthony DiGiorgio: I think quality metric reform, as we touched on earlier, I think is pretty low hanging fruit. I think CMS would have a lot of leeway in reforming how they do quality metrics, and they are starting with that. There is meaningful metric reform that was started in 2017 has been carried over in the Biden administration. So I do want to applaud the efforts there. I think other low hanging fruit is preforming, and I think you’re setting me up for this, but reforming the electronic health records and reforming the meaningful use mandates that came with the electronic health records. I have a lot of my research going into that. I think the way AI is moving with GPTs and large language models, I think that that whole field is ripe for disruption, as long as the government can just get out of the way and allow that to happen naturally.


[0:18:55] Christopher Habig: What gives you any faith that that’s actually going to have.


[0:18:59] Dr. Anthony DiGiorgio: I have to have faith or be too depressing.


[0:19:02] Christopher Habig: Well, there’s an old saying that, first, do no harm, right? And I just wish that the government, every elected official would also take that oath that we make our physicians take anytime they get into office, right? Unintended consequences. So all right, let’s go there, I appreciate you giving me credit there for being a far more forward-thinking host than I think I really am. But let’s talk about EMRs, right? What are you seeing as far as the biggest pain point from an EMR usage when it comes to a clinical setting?


[0:19:32] Dr. Anthony DiGiorgio: I don’t want to just bash EMRs across the board. I think they have really improved some aspects of clinical care. If you talk to older docs, say, back in my day, we had to go to the basement radiology, and hunt down all the MRIs, and hang them up for our attending physicians, and having help us if we missed one CT scan. Then it’d be the end of the day. Or we had to go gather all the lab results from the lab and have those written out. That no longer is the case, right? We have one click. We can get most of our labs and imaging. So there are improvements.


However, the tradeoff has been very onerous in terms of order entry, of documentation, and the expectation that physicians are always available to be on their EMR. It’s almost because the EMR is too accessible. We’re expected to always be able to access it. So we ran a study here at UCSF in the neurosurgery department, where we looked at our on call residents, and we pulled their audit logs. We could see from the EHR, how long how long they were actually logged into the EHR, on an overnight 24-hour shift. In a 24-hour shift, they spent 20 hours logged into the EHR. It’s clearly a tradeoff inefficiency, because they weren’t spending 20 hours gathering, imaging and lab results prior to the implementation of EHR. So where is this that these massive inefficiencies have come with what really should be a time saving technology, right?


If you, again, went back 20 years and said, “Hey, we’re going to digitize charts.” Every physician would say, “Great, this is going to save so much time.” So why is that not panned out? And there’s a lot of pain points that we’re able to identify in some of our studies that are really kind of tethering our physicians to the EHR.


[0:21:20] Christopher Habig: So go ahead, go there, like, please do. Why did that not come true? What is standing in the way?


[0:21:28] Dr. Anthony DiGiorgio: I think part of it is the meaningful regulations that say that physicians have to be the ones putting in a large portion of the orders. An order entry in EHRs is really, really inefficient. So for example, I timed it once, ordering a simple MRI is about 57 clicks or keystrokes, takes about 90 seconds. Whereas in paper charts, writing MRI on a sheet of paper and handing it to a nurse is a much quicker task. Every little thing requires an electronic order, and it all has to be put in by a physician. So if the medication was ordered by mouth, but the patient has a feeding tube, the nurse can’t just switch that to feeding tube. A physician has to go into the chart and switch that order to, by feeding tube.


So all these little things just add up, and it’s really death by 10,000 clicks. And then there’s regulations on top of that. So if Congress has another, or CMS has another regulation called appropriate use criteria, anytime you order imaging, you have to justify to the EHR why you’re ordering that imaging, and of course, it questions you. So I will see a patient clinic, I’ll write my notes, I’ll say, “Patient has brain tumor, we need to monitor every six months with new MRI.” I will then put in the 57 clicks and keystrokes toward the MRI, and then a pop up shows up and says, “Are you sure you need this MRI? Are you sure that’s the right imaging modality?” And then I have to click through and say, “Well, yes, this patient has a brain tumor? Yes, I need this imaging.” It says, “Well, did you try a CT scan first?” And of course, I had tried a CT scan first, it’s in the chart, but I still had to put that through in –


All these things added up, and when we pulled our audit logs from the residence, yes, it’s two minutes here with this one thing, and it’s another two minutes here, and it’s another three minutes here. All these different little regulations that all add up and all of a sudden, you’re spending 20 hours on a 24-hour shift logged into the EHR.


[0:23:17] Christopher Habig: How many hours are actually spent face to face with the patient in contrast?


[0:23:21] Dr. Anthony DiGiorgio: Yes. I mean, if they’re on the computer, they’re probably not giving their full attention to the patient. So yeah, exactly.


[0:23:27] Christopher Habig: Less than four. In 24-hour shift, 20 is on a computer, you got four hours to actually talk to a living human being, walked the halls, use the – get some food, whatever it is. So it’s like, “Holy cow.” I know we’ve seen different stats. For every 10 minutes visit, you got to spend another 20 outside the exam room, or give or take on that. Nobody sends me any hate mail on my math on that one. I’m kind of seeing this trend, I think where insurance company, insurance billing codes, excuse me, Medicare, there’s this thirst for data, and it’s almost gone too far, where maybe we could get by with 100 codes rather than 300,000 codes. But it’s just like thirst for data and being detailed. I think it comes from a good place, but the execution of it has been so sloppy, and everybody’s just been lost in the shuffle from it, and is actually – I don’t care in my mind has taken a step back because of these tools that were supposed to come up here and really save healthcare and make it better.


[0:24:34] Dr. Anthony DiGiorgio: Yeah, I totally agree. This is where I do think that there’s some potential in AI. Again, I am a little bit pessimistic, because I think that there’s this thought that AI is going to save us, and like I mentioned, if you had gone back 20 years and said, “Electronic health records will save us,” most people would agree. So I am a little bit pessimistic that AI won’t be rolled out in a way that can actually deburden or detether the physician from the EHR. But I’m hopeful, I’m hopeful that instead of having to justify every little order I do that the AI will be able to look through the chart and say, “Yes, this is indicated.”


But then, again, I’m fearful that it will just be another pop up that will say, questioning my clinical intuition. So I think there’s a lot of different ways this can go with it from a regulatory standpoint, to make sure it goes down one of those two paths.


[0:25:25] Christopher Habig: That’s exactly what I was going to say is, I don’t see how AI gets around that problem that you just talked about of. Say it’s analyzing like a rash on someone’s leg, I don’t know how you bring in the art side of medicine, to say, “Okay, I see this before. I’ve recognized this.” All these different things are adding up and going down this way. Maybe, right? I don’t see how you can get that into computer program, because you just talked about how computer programs are actually standing in the way trying to make sure, again, probably well intention that, “Hey, just making sure you did this, and didn’t just hit another button over here.” But at the same time, you’re second guessing the person that we’re depending on, the profession that we’re depending on with a piece of code.”


[0:26:08] Dr. Anthony DiGiorgio: Right. I think there’s a long way from technology and regulatory standpoint where AI can actually provide diagnoses or treatment recommendations, right? Like you mentioned, AI looking at a rash under a leg. Now, the other big use case scenario is AI reading a CT scan or an MRI. I think that’s a long way off, mostly from regulatory standpoint, right? We don’t have – the FDA doesn’t have the regulatory processes in place by which it can approve software that is continuously updating and learning on the job, which AI does.


However, I think the regulatory processes are in place for AI to deeper than the physician. So if I am the one that’s ultimately making the decision, AI can make my path to that decision easier. Again, you’re going back to the example of the brain tumor patient. If I write my note, this patient has a brain tumor, AI should know what I normally do for this patient. AI should be able to read my note and be able to read that patient’s past history, and it should go ahead and place that order for me. It should code my note and provide the billing for that note as well. And then it should be able to summarize their clinical brain tumor history for their primary care provider, for their oncologist. So that that person then doesn’t have to go through and click through 300 prior notes looking for that little piece of information.


So that’s where AI really could be revolutionary. And I think the regulatory framework is actually in place for that to happen now, because it’s not actually providing any diagnoses or treatment recommendations. It’s simply summarizing, and processing information to make it more efficient.


[0:27:38] Christopher Habig: Dr. DiGiorgio, I’m curious, given your work at the Mercatus Center, given familiarity with the Free Market Medical Association, and all the great companies and people that make that up. How have you seen this Free Market Medical movement with direct primary care, even concierge medicine, cash pay surgery centers? How have you seen those – I guess that wave, that momentum influence our previous discussion from a federal, and from a state level, and from a patient choice concern?


[0:28:07] Dr. Anthony DiGiorgio: Again, I appreciate everything you guys are doing because I’m a trauma doctor, a neurosurgeon, and specializes in trauma. I’m never going to be part of a concierge cash pay system.


[0:28:18] Christopher Habig: Don’t say never. Never say never.


[0:28:20] Dr. Anthony DiGiorgio: I can’t do what I do, and really function at a trauma hospital serving Medicaid patients yet.


[0:28:29] Christopher Habig: Yet. Yet. I’m going to keep harping on it yet. Okay.


[0:28:34] Dr. Anthony DiGiorgio: I think there are ways we can get there to have better free market influences in like, say example, my situation. One is reversing this ban on physician or hospitals, why can’t I run a trauma center? I think I’d be okay at it. I think there’s certainly some issues with the way a lot of trauma centers are run. So why can’t physicians have buy-in and partial ownership of hospitals? I think that that’s kind of ridiculous that there’s this this prohibition on physician on hospitals that came with passage of the ACA.


[0:29:04] Christopher Habig: Lobbyists.


[0:29:05] Dr. Anthony DiGiorgio: Yes, of course.


[0:29:07] Christopher Habig: There was a recent article about American, I think American Hospital Association or something like that came out and said, “Physician-owned hospitals are still a very bad idea.” And I’m like, “Wow, this is right. This is.” Again, it goes back to Orwellian doublespeak all the way through.


[0:29:21] Dr. Anthony DiGiorgio: Yeah. Some of the arguments for that were well meaning arguments against yourself or for all, right? So they’re worried that if I own the hospital, I’m going to refer the patient to the MRI scanner that I own in the hospital I own, and I’m going to refer them to the oncologist group that’s in the hospital I own, et cetera. But that’s something that major health systems already do. So I don’t know why I’m any more prone to that behavior than say, mega health system x. You know, take your choice.


[0:29:51] Christopher Habig: It’s great point. That’s an absolute great point. So yeah, I jumped in there when he got me. So please, finish your thought on how the free market institutions, companies, startups, individuals are continuing to influence medicine from a state and federal level.


[0:30:07] Dr. Anthony DiGiorgio: Your organization is a great point, and I think just showing that these cash pay surgery centers that these direct primary care that they do provide excellent patient quality at a low cost, and that the free market – that healthcare is not this unique commodity that is somehow immune to free market forces. Just because we need a robust safety net, and healthcare doesn’t mean the free market can’t work to help drive down costs and improve quality. There’s plenty of social services, social needs that we consider essential education, housing, food that have robust free markets. There’s no reason that because we think healthcare is the social good, that is somehow outside the realm of free market and these free-market forces don’t matter. I think that is a pretty flawed argument.


[0:30:55] Christopher Habig: I think it’s a good distinction to make, because a lot of people default to the fact that, “Oh, healthcare doesn’t work for the little guy, and it’s a free market, free market has failed it.” And it’s an important distinction you just made that healthcare is one of those ones higher education is the other one, and there’s a lot of similarities there. It has the most government involvement. It’s really a monopoly or an oligarchy for most standpoints that we have, and it’s a very controlled, very regulated industry. That’s why we’re here, not because of any type of free market forces.


Dr. DiGiorgio, you already kind of explained a little bit on what your perfect healthcare system looks like, so I’m not going to end with that question. I’m going to give you the famous billboard question. So you are made billboard czar of the United States, you got it controlled. What any message you want to, it’s got to be the same one, and it’s got to be legible from 80 miles an hour on the highway, you got every billboard in the country to help educate people about this topic and other things you’re passionate about in healthcare. What do you put on there?


[0:31:53] Dr. Anthony DiGiorgio: I would say something to the effect of, free market is the only way to restore that patient physician relationship, that if the patient has control over their healthcare financing, then you don’t have to worry about government saying you can’t do X, Y, Z. You don’t have to worry about government judging these arbitrary quality metrics, or government imposing this inefficient EHR. If the patient has the ultimate control, then it’s really just about what happens between that patient and a physician, and dictating your medical care.


[0:32:26] Christopher Habig: We’re going to have to drive by really slowly, to read all the print on the Billboard, but I believe message was well received. We’ll work on getting that on t-shirts, so that we can proliferate that one. Dr. Anthony DiGiorgio, Assistant Professor of neurological surgery, University of California, San Francisco, and senior affiliated scholar with Mercatus Center. Dr. DiGiorgio, thanks for joining us here on Healthcare Americana.


[0:32:53] Dr. Anthony DiGiorgio: Thank you very much for having me.


[0:32:54] Christopher Habig: That’s going to do it for this episode of healthcare Americana. If you haven’t yet, be sure to subscribe the show on your favorite podcast platform. Check us out online at to catch previous episodes, subscribe to our mailing list, and visit our online store. Once again, I am your host, Christopher Habig. Thanks for listening.




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[0:34:12] Christopher Habig: Hi, again, everyone. This is Chris. In Healthcare Americana, we’re always on the lookout for great stories to tell in the healthcare industry. We’d like to hear yours. Check out, and send us your ideas for episodes or if you’d like to be a guest. Thanks again for listening. Hope you enjoy it.