Cerame Mario MD General Surgery

04/30/2026

I have expressed my distain for the politicians that have routinely voted themselves an annual increases in their operational expenses. In fact,

“Unlike their personal salaries (which have been frozen since 2009), Congress has approved multiple increases to the Members’ Representational Allowance (MRA) — the operating budget for House offices that covers:

* staff salaries
* district office rent
* travel
* constituent mail
* office equipment / operations

The Congressional Research Service’s historical tables show MRA increases and decreases almost year by year. Looking just at the last 20 years (roughly FY2006–FY2025/26), the overall House MRA pool increased in approximately 12–14 separate years, depending on whether you count small formula adjustments versus larger across-the-board increases. (From ChatGPT.)

And yet physician reimbursement has remained static over the past 35 years. Almost all private insurance companies have followed Medicare’s policy, which has kept physician reimbursements static. Legislation in the past few years has forced physicians to have an operational electronic medical record, forced physicians to provide translators for individual who do not have English as their first language, have had to pay increases in liability insurance, and have had the same pressure to salaries for their staff, and keep up with the pressure to provide state-of-the-art, and now somewhat routine, scanning devices, x-ray, machines, skilled technicians to handle the luminous increases in technology.

Fake news you say? You can find this on virtually any AI source, but my “go to AI“ has been ChatGPT
“Medical liability premiums from 2019–2026 have been rising , with the last several years showing the strongest increases since the mid-2000s The conversion factor (the dollar multiplier applied to RVUs) was roughly:

* 1992: about $31
* 2001 peak: about $38
* 2025: about $32.35
* 2026: about $33.40–$33.57 depending on APM participation

So after 35 years:

* Nominal increase: only around 7–8%
* Inflation over same period: roughly 130–150%

That means the inflation-adjusted purchasing power of Medicare procedural reimbursement is dramatically lower.

A physician getting paid the equivalent of $100 for a procedure in 1992 would need roughly $230–250 today to have the same purchasing power.

Instead, many comparable reimbursements are closer to $105–$120 nominally (sometimes less depending on code revisions).

That’s a substantial real decline.

What happened to individual CPT procedure codes?

It varies because CPT codes get:

* revalued
* split
* bundled
* reassigned RVUs
* shifted between facility/non-facility payment structures

But across many procedural specialties:

Lower-complexity office procedures:
Often flat to modest nominal increases

Many surgical/interventional codes:
Frequently flat or reduced

Evaluation & Management (office visit) codes:
Generally did better after recent CMS reweighting

That last point is important: Medicare has deliberately shifted reimbursement emphasis somewhat away from procedures and toward cognitive / longitudinal care management, which many procedural specialists see as a redistribution of payment.

The 2026 CMS rule even includes a 2.5% efficiency adjustment reduction for many non-time-based procedural services, reinforcing that trend.

A practical way to think about it

If you’re asking:

“Has procedural reimbursement kept pace with practice costs over 35 years?”

No.

Practice expenses have risen sharply:

* staff wages
* malpractice premiums
* compliance/admin burden
* technology costs
* facility overhead

while core procedural reimbursement has generally been:

* flat,
* slightly up nominally,
* significantly down in real purchasing power.

A lot of specialty societies estimate the inflation-adjusted decline in Medicare physician payment since 2001 alone at roughly 25–35%, depending on methodology.

Over the full 1992–2026 span, many procedure-heavy practices would argue the real erosion is even greater.

So the shortest honest answer:

Procedure-related CPT reimbursement has probably increased only about 5–15% nominally over 35 years for many common services — but after inflation, that often represents a real decrease of 40–60% in purchasing power.

That’s a big reason physician groups have been so vocal about reimbursement pressure despite healthcare spending overall continuing to rise.”

So if you are forced to wait for an appointment for three or four weeks, blame the politicians. If you think the quality of medical care has decreased, blame the politicians, if you don’t like the direction that medicine has been trending in, BLAME THE POLITICIANS.

09/26/2025

Congress‘s actions to reduce Medicare payments to physicians, limit their ability to form a union (or strike), fix the flailing Medicare budget and not provide physicians with the same protections that they themselves have created laws for, (ie, to guarantee that salary payments keep up with inflation,) has led to a severe drop in medical school applications.

I, for one, do not think that exempting foreign positions from the exorbitant visa work fees is the answer. It’s like lipstick on a pig.

AMA president Bobby Mukkamala, MD, writes in US News & World Report (9/25) that the administration’s H-1B visa fee decision “may be intended to boost the hiring of Americans, but it will bring unintended consequences for patients and our entire health care system.” He argues that the U.S. “relies heavily on foreign-born doctors because of a crippling shortage of physicians across the country; in just over a decade, we’re expected to face a shortfall of 86,000 doctors as our population ages and people live longer. Charging a six-figure visa fee to get qualified foreign-born doctors to fill that gap will only make the situation worse.” Dr. Mukkamala writes, “The AMA stands ready to work with the administration and our partners in medicine to support our patients and communities. Investments we make today will ensure our nation has the physician workforce it needs to confront the health challenges of tomorrow.”

09/23/2025

I’m going to just post this without a commentary. We will all have our own opinions on the value of this new regulation.

ACIP votes to limit access to COVID-19 vaccines
The New York Times (9/19, Mandavilli) reported the Advisory Committee on Immunization Practices “voted unanimously on Friday to further limit access to COVID vaccines,” recommending “that adults 65 and older receive the shots only after discussing the potential benefits and risks with a health care provider.” The panel also said that everyone between 6 months and 64 years old could get the vaccine after consulting with a provider. The two decisions “raise questions about whether Americans can continue to walk into their neighborhood pharmacies for routine vaccinations or whether in some states they will first need a doctor’s permission.” While the approved recommendations “were less restrictive than many had expected,” they will still “make it more difficult for pharmacists in some states to administer the shots to older adults.”
The AP (9/19, Stobbe, Neergaard) reported that in addition to “declining to recommend” COVID-19 vaccines to anyone, the panel “also urged the CDC to adopt stronger language around claims of vaccine risks, despite pushback from outside medical groups who said the shots had a proven safety record from the billions of doses administered worldwide.”

09/12/2025

It has long men known that exercise improved survival in breast cancer patient. And this is probably not earthshaking news that it is related to a mediator.

“Single exercise session can increase levels of molecules that slow breast cancer cell growth, study shows
The Washington Post (9/11, Reynolds) reports, “Exercising muscles pumps out substances that can suppress the growth of breast cancer cells, according to an important new study of exercise and cancer.” The study “involved 32 women who’d survived breast cancer. After a single session of interval training or weightlifting, their blood contained higher levels of certain molecules, and those factors helped put the brakes on laboratory-grown breast cancer cells.” Furthermore, the study “offers clues about the specific types of exercise that may be most effective against malignancies and underscores just how potent a single session of exercise can be for health.” They found that “the cancer-fighting impacts were greatest with the blood drawn after interval training,” likely because “this blood contained the highest concentrations of certain, beneficial myokines, especially IL-6.” The study was published in Breast Cancer Research and Treatment.”

08/28/2025

I used to love when I did for 35 years to put food on the table, put them through medical school. However, people do not realize how the pace of medicine has changed. For instance, did you realize that:

The average reimbursement for a laparoscopic cholecystectomy (LC) has, when adjusting for inflation, decreased by 21-28% since 2013 nationwide.
National med mal premiums have gone up to widely variable extents depending on the state
In a state like Florida, remuneration for your first 140 LC cases every year gets sent to your med mal insurer just to cover the premiums
Other studies demonstrate that inflation adjusted reimbursements for the 20 most common general surgery procedures have decreased by 24.4% since 2000. His data appeared in the July issue of the journal of the American College Surgery. 

With regards to the laparoscopic cholecystectomy, in my busiest year I did about 50. I truly feel sorry for all those individuals who have spent eight or more years getting through college and medical school, and then another 4 to 8 years in postgraduate training to be able to have the privilege of taking care of patients. It is no wonder to me that cadre of  physicians that are taking care of the infirmed these days it’s not what it used to be. IMHO.

08/16/2025

Does it bother you that Congress is discussing legislation to allow pharmacists to evaluate, diagnose and treat patients in cases that require physician oversight.

I truly believe that Congress is trying to fix the physician shortage debacle by allowing inappropriate management of patient illnesses by substandard physician oversight. We see this already in hospitals where physician extenders are seeing patients with little or no oversight, ordering tests that are often inappropriate adding to the cost of medical care. I fear that what what will happen is that the CEO's that are presently in charge of hospital systems will try to burden the physician which now has ever-increasing responsibilities with more and more physician oversight tasks without regard to his/her present burdens.

When was the last time you were in the ER and had your abdomen examined. I have gone down to the ER to see a patient with "dark stools" not even have an order for occult blood put in, or a patient with abdominal pain tell me that no one examined the abdomen even though they complained fo abdominal pain, and were sent down for a CT abdomen with contrast. I could go on and on about the inappropriate and deficient care that patients are getting not only in the ER, but in walk in centers, as well.

The legislation would allow pharmacists to diagnose and treat patients without having received the necessary education or training to do so.

08/04/2025

I am mortified!

The AP (8/1, Stobbe) reported a federal health official confirmed last week that experts from “more than a half-dozen of the nation’s top medical organizations” were “disinvited from the workgroups that have been the backbone of the Advisory Committee on Immunization Practices. The organizations include the American Medical Association, the American Academy of Pediatrics and the Infectious Diseases Society of America.” In a joint statement Friday, the AMA and several organizations said: “To remove our deep medical expertise from this vital and once transparent process is irresponsible, dangerous to our nation’s health, and will further undermine public and clinician trust in vaccines.”

Here is the full link:

U.S. health officials have told more than a half-dozen of the nation’s top medical organizations that they will no longer help establish vaccination recommendations.

07/25/2025

From the JAMA:

Emerging colorectal cancer trend sparks concern
Colon cancer is becoming more common in people under 50, with rates up 2% yearly in younger patients, experts say. Why earlier screening is a must.

Take a deeper dive:

FIT test or colonoscopy? Catching colon cancer earlier
What patients should know about cancer screening and prevention
AI is changing colon cancer screening and easing doctor burden

07/22/2025

How is this for ambiguity?

The New York Times (7/21, Barry) reports, “Over nearly four decades since Prozac [fluoxetine] was approved for the treatment of depression, waves of concern about the effects of antidepressants during pregnancy have resulted in a practical consensus: Though use of the drugs may be associated with a slight rise in the odds of birth defects, the risk of leaving a mother’s depression untreated is often greater.” Now, among a “select group of experts convened by the Food and Drug Administration on Monday to discuss the safety of antidepressants during pregnancy, around half said that women should receive a more clear and forceful warning about potential risks to the fetus.” HHS spokesperson Andrew Nixon “said the agency would not comment on whether there were plans to require a so-called black box warning about the use of selective serotonin reuptake inhibitors, or SSRIs, in pregnancy.”

07/12/2025

From AMA News:
More evidence highlights health hazards of va**ng
The New York Times (7/9, Blum) reports a recent study published in ACS Central Science found that the mist from popular vapes contains “such high levels of heavy metals that one researcher thought their machine had malfunctioned.” This follows other studies suggesting “va**ng can affect the heart, lungs and brain.” Experts told The Times that “the liquids in e-cigarettes can release known carcinogens, like formaldehyde and acetaldehyde, when heated. These and other chemicals can damage blood vessels, drive inflammation and contribute to cardiovascular disease risk.” Va**ng can also lead to chronic inflammation in the airways and lungs, as well as exacerbating asthma and COPD symptoms. Research has also shown that “e-cigarettes are addictive. Dependence can be especially problematic for adolescents, whose brains are developing.”

06/18/2025

Inhaling a burning leaf cannot be healthy. I have often told those who claimed that smoking w**d has never been proven hazardous, that it is a matter of time before that will play out. There are better forms of delivery.

Clear lines can still be drawn between cannabis use and MACE
MedPage Today (6/17, Lou) reports, “With newer data, clear lines could still be drawn between cannabis use and major adverse cardiovascular events (MACE), a meta-analysis confirmed.

MedPage Today adds, “Based on two dozen pharmacoepidemiological studies published from 2016 to 2023, excess cardiovascular risks were apparent in self-reported ever-users and those detected from drug screens in the real world: Acute coronary syndrome: RR 1.29, 95% CI 1.05-1.59; Stroke: RR 1.20, 95% CI 1.13-1.26; Cardiovascular death: RR 2.10, 95% CI 1.29-3.42.” The findings were published in Heart.

06/03/2025

Here is an interesting study In JAMA .

Exercise improves survival rates in patients with colon cancer, study finds
The AP (6/1, Johnson) reports a “first-of-its-kind international experiment showed” that a “three-year exercise program improved survival in colon cancer patients and kept disease at bay.” Researchers “followed 889 patients with treatable colon cancer who had completed chemotherapy.” Half of study participants received information promoting fitness and nutrition, while half “worked with a coach, meeting every two weeks for a year, then monthly for the next two years,” to discuss ways to increase their physical activity. Researchers observed that “after eight years, the people in the structured exercise program not only became more active than those in the control group but also had 28% fewer cancers and 37% fewer deaths from any cause. There were more muscle strains and other similar problems in the exercise group.” The study was featured Sunday at the American Society of Clinical Oncology’s annual meeting and published In The New England Journal of Medicine.