Dutch Rojas - Healthcare

10/27/2025

If only we designed healthcare the way we designed IKEA instructions, clear, pictorial, and universally understandable.

Instead, we hand people 80-page PDFs in 8-point font with words like “actuarial equivalent tier variance.”

Meanwhile:

- 50% of U.S. adults read below an 8th-grade level.
- 28% may struggle to read an introductory email.

Now imagine them trying to figure out if their kid’s inhaler is covered under a high-deductible plan with an HSA.

The US healthcare system was not designed for humans, it was built it for lawyers, actuaries, and consultants, then wondered why people didn’t engage (maybe that was the point).

If you want behavioral change, you need behavioral design, not more PDFs or portals.

As Rory Sutherland has said before:

“Logic makes people think. Emotion makes people act. Confusion? Confusion makes people quit.”

10/27/2025

America’s biggest hospitals are all nonprofits. Nonprofits!

Yeah, the CEO makes $12 million,
but it’s a humble $12 million.

For the mission, right?

Last week in Houston, I was in a nonprofit health system with valet parking, a sushi bar, and more marble than the Vatican.

You know you’re in trouble when the receptionist offers you an old fashioned before you meet the billing department…

10/27/2025

If government involvement in healthcare were the solution, one would expect the programs it directly operates to be models of efficiency, quality, and cost-effectiveness.

The evidence suggests otherwise. Medicare, Medicaid, the Veterans Health Administration (VA), and Tricare all suffer from significant problems that undermine the case for expanded government control.

The VA, in particular, has been plagued by scandal.

In 2014, it was revealed that VA medical centers across the country had been systematically manipulating wait time data to hide the fact that veterans were waiting months for appointments, with some dying while on secret waiting lists.

Despite multiple legislative overhauls and billions in additional funding, problems persist.

A 2022 report found that the VA was still reporting misleading wait times, with deceptive practices continuing years after the scandal.

The VA’s failures are not merely administrative; they represent a fundamental breakdown in accountability that is characteristic of government-run systems insulated from competitive pressure.

Jones, A. L., et al. (2021). National Media Coverage of the Veterans Affairs Waitlist Scandal and Women Veterans’ Distrust of the VA Health Care System. National Center for Biotechnology Information.

Supplemental Digital Content is available in the text. Key Words: distrust, race and ethnicity, s*x, veterans

10/26/2025

Who Pays. Who Gets Paid.

Independent doctors pay taxes,
sign personal guarantees, put up collateral, and are told they’re “for-profit”, said like an accusation.

Nonprofit health systems pay no taxes,
collect subsidies, issue tax-exempt bonds,
and then use that money to buy the doctors who funded them.

Result = wealth transfer disguised as morality.

The Story Problem

We’ve been sold the wrong narrative.
“Nonprofit” has become a marketing advantage disconnected from actual behavior.

The label was meant to signal community service.

But when it’s used primarily as a financial tool to consolidate power and eliminate competition, the story has rotted from the inside.

Meanwhile, the independent physician, who stakes personal capital, accepts personal risk, and signs their name to their work, gets painted as the greedy one.

This is signal confusion.
And it’s destroying trust.

What We’re Really Rewarding

Tax-exempt status was designed to reward community benefit.

But if the real optimization is happening around market dominance, bond ratings, and acquisition targets, while community benefit becomes performative, we’ve created perverse incentives.

We’re punishing entrepreneurship and accountability while rewarding scale and tax advantage.

Then we act surprised when we get consolidation and wealth transfer.

The Path Forward
Tell a better story.
Loudly.

Independent practice can mean something to patients: transparency, accountability, skin in the game.

Turn the “accusation” of being for-profit into a badge of honor:

“Yes, I profit when you get better.
My incentives are aligned with yours.”

And demand nonprofits prove their story is true.

If they’re truly nonprofit, show the community benefit.

Show the charity care.
Show the reinvestment.

Make them earn the moral high ground instead of just inheriting it through tax code.

You can wait for policy to fix the incentive structure.
Or you can change the narrative and make patients see what you see.

The choice is yours.

10/26/2025

An 18,617% markup on a common heart medication.

If a street vendor did this, we’d call it a scam. When a ‘prestigious’ academic hospital does it, we call it… healthcare?

The logic is impeccable, if you’re the one selling.

10/25/2025

Why are Washington D.C. health insurance premiums expensive?

Start here.

Certificate of Need (CON) laws artificially limit supply by D.C. bureaucrats.

When you artificially restrict who can build healthcare facilities, you get:

- Incumbent health systems with zero pressure to reduce costs
- Higher utilization rates at existing facilities (driving up per-unit costs)
- Market power to raise prices without competitive consequence

The cost of asking permission:

- Pay 3% of project cost just to apply (minimum $5K, max $300K)
- Publish your intent, then wait 60 days before you can even submit
- Then wait 6+ months for review while competitors formally oppose you
- These barriers don’t improve safety. They improve incumbent market power.

The math:

- CON blocks low-cost ASC capacity
- Incumbents capture all surgical volume
- They bill what they want because patients have nowhere else to go
- Insurance companies pass those costs to employers and individuals

Premiums are 20% higher because the CON policies artificially restrict competition.

Who decides this?

In Washington, D.C., the SHCC defines “public need” and decides whether low-cost competition is allowed.

The committee consists of:
Jacqueline Bowens (Chairperson),
Barbara Bazron, Judy Brinckerhoff,
Ruth Fisher Pollard, Sheila Holt,
and Denise St. Jean,
all longtime healthcare “professionals.”

D.C. claims to care about affordability.

However, the CON policy, enforced by regulators and paid for by incumbents, is the mechanism that keeps premiums high.

10/25/2025

Why do nonprofit health systems get to:

Write off losses as “charity care,”
Collect DSH,
UPL,
340B,
and GME bonus money,

Pay zero federal taxes,
zero state taxes,
zero property taxes,

Issue tax-free bonds and call it “community mission”,

while independent physicians treating Medicaid patients at a loss get nothing, not even a deduction?

If you can explain that without hiding behind platitudes, I’m all ears.

If not, just admit it clearly:

You’re not “protecting the poor.”
You’re protecting the St. Cartel.

10/24/2025

Want to save on drugs and pharmacy benefits?
Too bad.

Non profit health systems get discounts through the 340B program, then bill full price and keep the difference.

Patients save nothing.
Independent clinics get nothing.

Another hidden tax on the sick.

10/24/2025

Nonprofit health systems pay zero taxes.

They avoid federal, state, and local tax.

Then they sue low-income patients over medical bills.

“Nonprofit” is just branding.

Your taxes fund their monopoly and your high insurance premiums.

10/23/2025

Since 2010, doctors have been banned from opening new hospitals.

Not bad hospitals.
Not unsafe hospitals.

Just physician-owned hospitals.

Why?

Because they threatened the Governor controlled non profit health system monopolies.

And Americans are paying for that protection racket.

10/23/2025

Ever wonder who actually decides how much doctors earn for surgeries, visits, or procedures?

This episode takes you inside the mysterious but powerful Relative Value Scale Update Committee (RUC), the body that determines physician payments for Medicare and beyond.

If you care about fairness in healthcare, innovation, or why a complex surgery can pay the same as a routine one, this conversation is for you.

Podcast Episode · The Doctor's Lounge · 10/03/2025 · 26m

10/22/2025

What if you could buy a physical therapy visit straight from Google Shopping, via a post on X, or Instagram?

I can’t see why not..