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Former White House advisor on the real reason your health care costs are going up: Medicare’s doctor pay gap

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America’s doctors are rapidly disappearing into hospital systems. And government distortions, through Medicare’s payment rules, are a big reason why. Higher premiums and out-of-pocket costs for patients are the ultimate result. 

According to a new study from the Government Accountability Office, the share of the country’s doctors employed by or affiliated with a hospital system rose from 29% in 2012 to 47% in 2024.

It’s a troubling trend. Greater consolidation of physician services is a recipe for less competition, higher costs, and lower-quality care. 

The federal government is only making the problem worse. For years, Medicare has paid more for services and procedures provided in a hospital than in a physician practice. This discrepancy has enriched hospitals and strengthened their ability to acquire physician practices.

Adopting site-neutral payments — that is, paying hospitals and private physician offices the same amount for the same care — would allow independent physicians to compete on equal terms with hospital-affiliated doctors. Such competition will ensure that patients have choices in where they can seek care and cut premiums and copays in the long term.

Site-neutral payment enables healthcare services to be delivered in the lowest-cost setting that can safely and effectively provide them. Medicare’s payment disparities distort those decisions by rewarding hospitals simply for being hospitals, regardless of whether a service could be delivered just as well — or better — in a physician office or ambulatory surgery center. 

Removing those financial incentives would allow care to be organized around quality and access rather than distorting care into forms most favored by bureaucrats.

Under current law, the amount Medicare reimburses doctors in private practice is based on something called the Medicare Physician Fee Schedule. Hospital-affiliated physicians bill Medicare under the Hospital Outpatient Prospective Payment System, collecting both a professional fee based on the Physician Fee Schedule and a separate hospital-based fee.

For example, Medicare reimburses $1,375 for a colonoscopy performed in a hospital outpatient department — and $862 for one performed in an independent ambulatory surgery center. One study of 32 common procedures found that total Medicare reimbursement for the hospital outpatient department was anywhere from 124% to 861% of total reimbursement for the lower-cost physician office or ambulatory surgery center setting.

These payment disparities have yielded a host of negative consequences for the physician market.

For starters, they put independent physicians at an enormous financial disadvantage. Hospital reimbursement isn’t just higher — it’s also historically been ratcheted up on a yearly basis to account for inflation. The same cannot be said for physician reimbursement.

Between 2001 and 2025, Medicare physician reimbursement actually fell by 33% after adjusting for inflation, according to a recent analysis by the American Medical Association.

This has left a growing number of physician practices vulnerable to acquisition by larger hospital systems. In a separate study by the AMA, the need to negotiate higher payment rates was named as the top reason doctors sold their practices.

The result is a health sector that is becoming less competitive and more consolidated by the day — a trend that is raising costs for both patients and taxpayers. 

A 2021 analysis in the journal Inquiry found that a “10-percentage-point increase in vertical integration [between hospitals and physician practices] was associated with a 1.0% price increase for primary care, a 0.6% increase for orthopedics, and a 0.5% increase for cardiology.” 

When hospitals become larger and compete less with smaller physician offices they have less incentive to keep prices down. The result is of course an increase in healthcare spending and higher insurance premiums for patients.

Site-neutral payments can correct these market distortions — and deliver significant savings in the process. According to one study, adopting site-neutral payments across Medicare could save the program $202 billion over a decade — and cut beneficiaries’ premiums and cost-sharing by a combined $134 billion.

There’s no economic reason Medicare should pay different amounts for the same care based solely on where it’s delivered. The hospital lobby may be the most important reason this disparity exists. Site-neutral payments would restore some common sense to the entitlement’s structure — and bring about a more competitive healthcare market for both patients and taxpayers.

The opinions expressed in Fortune.com commentary pieces are solely the views of their authors and do not necessarily reflect the opinions and beliefs of Fortune.



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Florida man who grabbed Nancy Pelosi’s podium during Capitol riot runs for county office

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A man who grabbed then-House Speaker Nancy Pelosi’s podium and posed with it for photographs during the U.S. Capitol riot is running for county office in Florida.

Adam Johnson filed to run as a Republican for an at-large seat on the Manatee County Commission on Tuesday. That was the fifth anniversary of the Jan. 6 riot, where he was photographed smiling and waving as he carried Pelosi’s podium after the pro-Trump mob’s attack on Jan. 6, 2021.

Johnson told WWSB-TV that it was “not a coincidence” that he filed for office on Jan. 6, saying “it’s definitely good for getting the buzz out there.” His campaign logo is an outline of the viral photograph of him carrying the podium.

He’s far from the first person implicated in the Jan. 6 riot to run for office. At least three ran unsuccessfully for Congress in 2024 as Republicans. And there are signs that the Republican Party is welcoming back more people who were convicted of Jan. 6 offenses after Trump pardoned them.

Jake Lang, who was charged with assaulting an officer, civil disorder and other crimes before he was pardoned, recently announced he is running for Secretary of State Marco Rubio’s vacant U.S. Senate seat in Florida.

Johnson placed the podium in the center of the Capitol Rotunda, posed for pictures and pretended to make a speech, prosecutors said. He pleaded guilty in 2021 of entering and remaining in a restricted building or ground, a misdemeanor that he equated to “jaywalking” in the interview.

“I think I exercised my First Amendment right to speak and protest,” Johnson said.

After driving home, Johnson bragged that he “broke the internet” and was “finally famous,” prosecutors said.

Johnson served 75 days in prison followed by one year of supervised release. The judge also ordered Johnson to pay a $5,000 fine and perform 200 hours of community service.

Johnson told U.S. District Judge Reggie Walton at sentencing that posing with Pelosi’s podium was a “very stupid idea” but now says he only regrets his action because of the prison sentence.

“I walked into a building, I took a picture with a piece of furniture, and I left,” he now says.

Four other Republicans have filed to run so far in the Aug. 18 primary in what’s a deeply Republican county. The incumbent isn’t seeking reelection.

In March 2025, Johnson filed a lawsuit against Manatee County and six of its commissioners, objecting to the county’s decision not to seek attorney’s fees from someone who sued the county and dropped the lawsuit. The county has called Johnson’s claims “completely meritless and unsupported by law.”

Johnson said he objects to high property taxes and overdevelopment in the county south of Tampa, claiming current county leaders are wasteful.

“I will be more heavily scrutinized than any other candidate who is running in this race,” Johnson said. “This is a positive and a good takeaway for every single citizen, because for once in our life, we will know our local politicians who are doing things.”



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‘We don’t want to be Americans, we don’t want to be Danes, we want to be Greenlanders’: Local politicians reject Trump

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Greenland’s party leaders have rejected President Donald Trump’s repeated calls for the U.S. to take control of the island, saying that Greenland’s future must be decided by its people.

“We don’t want to be Americans, we don’t want to be Danes, we want to be Greenlanders,” Greenland Prime Minister Jens-Frederik Nielsen and four party leaders said in a statement Friday night.

Trump said again on Friday that he would like to make a deal to acquire Greenland, a semiautonomous region that’s part of NATO ally Denmark, “the easy way.” He said that if the U.S. doesn’t own it, then Russia or China will take it over, and the U.S. does not want them as neighbors.

“If we don’t do it the easy way, we’re going to do it the hard way,” Trump said, without explaining what that entailed. The White House said it is considering a range of options, including using military force, to acquire the island.

Greenland’s party leaders reiterated that “Greenland’s future must be decided by the Greenlandic people.”

“As Greenlandic party leaders, we would like to emphasize once again our wish that the United States’ contempt for our country ends,” the statement said.

Officials from Denmark, Greenland and the United States met Thursday in Washington and will meet again next week to discuss the renewed push by the White House for the control of the island.

Danish Prime Minister Mette Frederiksen has warned that an American takeover of Greenland would mark the end of NATO.

The party leaders’ statement said that “the work on Greenland’s future takes place in dialogue with the Greenlandic people and is prepared on the basis of international laws.”

“No other country can interfere in this,” they said. “We must decide the future of our country ourselves, without pressure for quick decision, delay or interference from other countries.”

The statement was signed by Nielsen, Pele Broberg, Múte B. Egede, Aleqa Hammond and Aqqalu C. Jerimiassen.

While Greenland is the largest island in the world, it has a population of around 57,000 and doesn’t have its own military. Defense is provided by Denmark, whose military is dwarfed by that of the U.S.

It’s unclear how the remaining NATO members would respond if the U.S. decided to forcibly take control of the island or if they would come to Denmark’s aid.

This story was originally featured on Fortune.com



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From Merrill Lynch to wok station: the daughter of San Francisco’s Chinese food dynasty who defied her parents—by working alongside them

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For decades, the crowds outside House of Nanking have been a fixture of San Francisco’s Chinatown, with lines frequently wrapping around the block to get a seat in the cramped, high-energy dining room, under the iconic, multicolored sign that crowns Kearny Street. But for Kathy Fang, the restaurant’s heir apparent, her presence in that kitchen represents a sharp deviation from the “American Dream” her parents envisioned for her—a deviation that initially caused them deep dismay.

Peter Fang, the restaurant’s legendary patriarch, and his wife did not build House of Nanking so their daughter could inherit it, Kathy Fang told Fortune in a recent interview. To them, cooking was a necessity born of survival, not a career choice for the educated. “For my parents being very traditional, they also didn’t want me to do it,” she explained. “In fact, we have a saying that, you know, if you don’t cut it in school, you can always go be a cook because it’s considered manual labor. You don’t need to have a proper education to go work in a kitchen.”

Her parents don’t know about “foodie” culture, she explained, and don’t even know how famous they’ve become. Speaking to Fortune as she releases the first-ever cookbook dedicated to her family’s restaurant, she said even that was a struggle.

“It took me decades,” she said about convincing her father to go along with it. “He thought that if he shared his recipes, people would just make it at home and not come to the restaurant anymore.” He didn’t understand his restaurant is a San Francisco institution, frequented by the likes of Francis Ford Coppola and Keanu Reeves, celebrities that her father wouldn’t—and didn’t—recognize anyway.

The House of Nanking on Kearny Street is a legendary eating institution that often has long lines of hungry diners hoping for a table. Renowned as much for it’s surly service as the food, it is worth the wait. Taken in San Francisco’s Chinatown.

Michael Robinson Chavez/Los Angeles Times via Getty Images

Fang, who recently turned 40, shared Reeves was her favorite actor since high school, and the first time he visited her family’s restaurant, she begged her father not to make him wait in the queue stretching around the block, as it does every night. His response was that “everybody waits in line,” until she promised to get straight A’s, and he relented. What happened next summed everything up.

“[My dad] walks up to him and says something to him. Then looks at me and goes, ‘Kathy, come over, take a picture with him. It’s Sean Connery.’ And I’m like, ‘Oh, my God. My dad doesn’t know anybody, but he’s heard of Sean Connery.” Reeves, who is famously polite and good-hearted, told the Fangs that he was “really flattered.”

“We took a picture that day and that picture sits on the wall at the restaurant,” Fang said, happily. “But the story is that nobody there knows any of the famous people who go in.” As a born and raised Californian, she would know all the celebrities, she added, but she’s always busy, running her own restaurant, Fang, in the SoMa business district, which is about a 20-minute walk away. Fang and Reeves recreated the photo 29 years later, as shown by the House of Nanking’s Instagram.

Kathy Fang is a busy businesswoman. Besides running her Fang restaurant and releasing a cookbook, she is a Food Network star as a two-time Chopped champion and a cast member of Chef Dynasty: House of Fang.” San Francisco Magazine even crowned her as a “culinary queen,” and she’s the mother of two children with her husband who, she notes, doesn’t even like Chinese food. She talked to Fortune about how she disappointed her parents by failing to become a doctor or lawyer—and finally found out how proud they were of her through her reality TV side hustle.

A calling to a crowded kitchen

Like many immigrants to the U.S. (the Fangs moved to San Francisco from the Shanghai area), the Fangs pushed Kathy toward a stable, prestigious future.

“They wanted me to be a doctor or a lawyer [or] go into the corporate world,” she said. She dutifully followed this path to the University of Southern California as a pre-med student, only to discover that, while she had no fear of cooking oil in a giant wok, she had no stomach for medicine.

“I realized I was terrified of needles, like irked by hospitals,” she said. “That would be a problem. Yeah, I still to this day cannot see a needle go into an arm.”

She subsequently landed in the corporate world, working at Fortune 100 company Johnson & Johnson and Wall Street stalwart Merrill Lynch. But the corporate environment left her feeling uninspired. When she finally called her father to announce she was quitting her job to return to the family restaurant, he was befuddled and upset. “He’s like, ‘Why, did you get fired or something?’” Kathy recalled, and she responded: “No, I just really don’t like what I’m doing and I love food, I love cooking and I like miss that kind of environment.”

The environment she missed is one of organized chaos and high-pressure efficiency. While she declined to disclose financials, and acknowledged Fang had struggled more during the pandemic (as many restaurants did), she acknowledged her family’s restaurant is a “cash cow” that has served an estimated 5 million to 6 million people over its 38 years in business, quite a feat considering the tiny footprint.

“That’s tough when you think about how big the restaurant was when they first got started,” she said, noting it could only seat 30 to 40 people for its first decade in business. “And the kitchen can only fit about two to three people.” It’s since doubled the size of its dining room, but “the kitchen hasn’t changed at all. It’s just kind of wild.”

A business career to be proud of

Kathy’s return marked a turning point for the brand. While Peter Fang had built the restaurant’s reputation through culinary ingenuity, the family was media-shy, unlike their telegenic, media-savvy daughter. She said she was approached to try food television, and she sees it as something that allowed her to share her family’s story.

“I felt like I was kind of helping build this brand that my parents already built,” she said. “Everybody knows House of Nanking, but they’d never done anything with it. They’d never done any marketing, never done any PR around it.”

Her involvement proved to her father the business could be multigenerational, easing his fears the restaurant would die when he could no longer work.

“My dad now knows that this is something that can continue down generations,” Kathy notes, adding he even looks at his 8-year-old granddaughter as a potential future successor.

Fang said strangers and customers at the restaurant have come up to her and said, “your dad’s so proud of you,” and about three years ago, she recalled, during filming for the Chef Dynasty show, her dad said during a green-room recap interview, “I’m just very proud.” But she’s never heard it directly from him. “My dad will never tell me, and that’s a very Chinese thing, they just, they’ll never compliment you to your face.”

The restaurateur shared that one of her big jobs now is managing her parents’ workload. Now in their mid-70s, they still both work the lunch and dinner shifts every single day. The thing is, Fang noted, the 18-month hiatus during the pandemic revealed that retirement might not be an option; during the lockdown, Kathy’s mother, restaurant co-founder Lily, developed health issues from no longer being on her feet all day, and her father actually went totally silent.

“My dad lost his voice because he was using it every day that the vocal cords became weak,” Kathy said. “It’s like wild… As soon as he got back to work and started using his voice again, it came back.”

She said there’s no plan for them to slow down anytime soon. “They like the routine. Staying at home is not good for them. They also, because they work every day, have never developed any hobbies or made any friends,” she said with a laugh.

There aren’t plans to further expand, either. Kathy said she respects her father’s wish to keep the business small and Chinatown-bound, waving off talk of any kind of nationwide expansion.

“I’m not going to do it if my dad doesn’t want to,” she said. “It would kind of lose that essence and soul to it.”





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