Private Practice Issue 36:

FAKE PLASTIC TREES: Creating Uncertainty Where Certainty is Needed and How to Fight It

“Sometimes the grass is greener on the other side because it’s fake.”

-Unknown

Overall, 2025 has been an interesting year as Q1 comes to a close. We have seen very drastic changes to some of the seminal institutions that fund research, check the safety of food, medications, drinking water, and make recommendations regarding global health, immunizations, and other critical health infrastructure. To wit, we are seeing the levying of tariffs the likes of which have not been seen since the Smoot-Hawley act of 1930 with an uncertain outcome to average people (I.e. our patients) and to some of our businesses.

It seems difficult to calibrate given the rapid rate of changes. My mom, who has a 401k, takes social security, has Medicare, and is on disability due to severe mobility issues from a near-death illness in 2019, has survived a 90% chance of dying. She is not completely aware of things, and views the world through the lens of conversations with my brother and myself, and of course, infomercials. She relies on income and medical care from things that a lot of us used to count on. My son, a precocious 12-year-old, has expressed concerns about affording basic things given what some are predicting will be a very rough next few years from a fiscal standpoint. Many of my friends, like me, are knocking on the half century mark, are not investing, not saving, and using their income to park in other places than the market.

Medicare, its recipients, and physicians who take Medicare are still waiting for Godot. We have not seen relief from the Medicare cuts “the Doc Fix,” that Congress was considering, because it wasn’t put into the budget. Now, we have a new head of CMS, former cardiothoracic surgeon Dr. Mehmet Oz. Many neurosurgeons have celebrated his nomination, as his brother-in-law is a neurosurgeon.

So far, Dr. Oz has been consistently championing Medicare Advantage, which most of us have seen is essentially privatized Medicare. We have seen skyrocketing denials, increased clawbacks, and several investigations that found the publicly traded companies found guilty of upcoming diagnoses and essentially grifting billions from the government in subsidies, then turning around and denying care to patients. Strange, considering the current initiative within the administration is fighting graft, overspending, and fraud that we would want to keep funding such a venture. With the recent $25 billion dollar pay bump, and no Medicare doc-fix in sight, one wonders how many “free-market” types are questioning if the current administration is intent on fixing anything regarding the healthcare system at all.

Where does this leave surgeons in private practice is key to planning viability in the near and medium term. We have found ways to keep going, by forming alliances, merging practices, finding new revenue streams, and staying diversified in what we do to stay open. We have learned that in being honest with ourselves is important to continuing to operate our businesses. In my own practice, I have learned advocacy is local. A multitude of trips to DC have been a lot of fun, and learned a lot about the echo chambers of Congress. In fact, I had a sitting senator tell me back the exact story I told him about a patient’s misadventures with Medicare Advantage. In fact, he persisted in continuing to tell me the story even after I politely told him a second time. The most recent efforts in DC have yielded a group of lawmakers who seem to think that because most physicians are still taking Medicare, that they don’t care about Medicare cuts, and further – that the rate cutting has not led to consolidation.

Many of the true believers among us will react predictably- “that’s not true, they understand – it’s the fault of _____” , “things are going to get better because they will eventually do the right thing.” I think we have learned that from double digit cuts in Medicare reimbursement, the clock of an inflationary adjustment for Medicare rates, and not even a cost-of-living adjustment (COLA) for Medicare since its inception that no one is coming to save us.

There are things we can do in our own practices if lawmakers cannot help us.

For starters, since Medicare represents many of our practices, considering becoming a non-par provider for Medicare is an option. In that sense, one can take a little less from Medicare, but patients are responsible for a greater amount. This is a tricky balance to strike and it really relies on your abilities to first, navigate the Byzantine halls of Medicare to get that status and to of course, notify your patients of the change. Many will balk at even paying a little, and obviously you will have to have that talk with them and be understanding. For some, especially with inflation and the diminishment of their retirement accounts may be especially want to spend anything extra. Therefore, you have to be ready for that hit.

Completely opting out of Medicare is an option for some, but a drastic and sometimes terrifying step. Dropping Medicare altogether might look attractive to some, while there is still that option. This requires especially difficult navigation, extra forms, contracts and very difficult conversations with patients. For many of us, that is just not a viable option. And imagine the Byzantine halls of Medicare but now with a candle instead of a flashlight. Some will also pepper in that it’s an immoral option. I would argue if it is between staying open and not staying open, all cards are on the table.

Some surgeons add in extra fees, such as cancellations, booking fees, extra charges for services like excessively large amounts of records. Again, transparency is key in keeping patient trust and to make sure collections are done properly, at the time of service, and fairly. Charges like these are not covered benefits of Medicare, but there is most certainly a need to discuss with local and state medical societies to make sure you are coloring within the lines.

As private practice surgeons, we have been through numerous administrations, and this one is not any different in terms of the ineffectiveness of fixing our healthcare system unless they decide to shore up traditional Medicare.

There are several other key issues to focus in on the next few years: site neutrality, physician-owned hospitals, and scope of practice. But being realistic in our advocacy on changing these issues is important to keep our collective sanity. We see decisions made in DC and the state level that we know makes no sense and may actually hurt us. Defunding and privatizing Medicare will not save it, any more than setting a house on fire will get rid of the termites infesting it.