I am going to say something that is professionally uncomfortable for me, and I am going to say it anyway.

I trained at Mayo Clinic. I owe a significant part of my surgical education to that institution. The clinical culture there shaped how I think about patient care. I have enormous respect for the physicians who work within those walls.

And according to the Lown Institute’s analysis of IRS Form 990 data, Mayo Clinic had a fair share deficit of approximately $478 million in 2021, ranking among the ten worst-performing nonprofit health systems in the United States on the measure of community benefit relative to tax exemption value.

I am not saying Mayo Clinic is a bad institution. I am saying the nonprofit hospital model, as currently structured, allows even the most prestigious names in American medicine to collect enormous tax subsidies while delivering community benefit that falls far short of what those subsidies are worth. And the institutional reputation that should create accountability is instead being used as a shield against it.

That is the story. And it is not comfortable for anyone inside the system to tell.

What “Nonprofit” Actually Means in Practice

Let me explain the mechanics, because most patients do not know how this works.

Nonprofit hospital status exempts institutions from federal income tax, state income tax, local property tax, and sales tax. In exchange, these hospitals are supposed to provide charity care and community investment commensurate with the value of those exemptions. That is the deal. Tax relief in exchange for community benefit.

The Lown Institute, a Boston-based healthcare think tank, has spent several years calculating whether that deal is being honored. Their methodology compares the estimated value of each hospital’s tax exemption against its documented spending on charity care and community investment.

The findings are not ambiguous.

Of 2,425 nonprofit hospitals evaluated, 80% spent less on financial assistance and community investment than the estimated value of their tax breaks. The combined fair share deficit for all hospitals studied is $25.7 billion for 2021. That is enough to erase 29% of the country’s medical debt.

Twenty-nine percent of the medical debt crisis that I have written about separately, the one crushing 100 million Americans, could be eliminated simply by nonprofit hospitals honoring the terms of the arrangement that makes them nonprofit in the first place.

They are not honoring it. Four out of five are not honoring it. And the ten hospitals with the largest individual fair share deficits all reported net income exceeding $100 million in the same year they were collecting more in tax breaks than they gave back in community benefit.

The Names Matter. So Let’s Name Them.

The Lown Institute analysis of individual hospitals identified the following largest fair share deficits for 2021: New York-Presbyterian Hospital at negative $274 million, UPMC Presbyterian at negative $268 million, NYU Langone Hospitals at negative $222 million, and Cleveland Clinic at negative $212 million.

Cleveland Clinic. NYU Langone. New York-Presbyterian. UPMC. These are not obscure community hospitals operating on thin margins. These are among the most recognized, most heavily marketed, most financially robust healthcare institutions in the United States.

Cleveland Clinic spent only 1.5% of its revenue on charity care while paying its CEO $6.6 million.

I want to stay on that for a moment. 1.5% of revenue on charity care. At an institution that receives an estimated $908 million in annual tax exemption value. An institution that markets itself nationally as a destination for the highest-quality care and whose reputation generates patient volume from across the country and around the world.

The patients in Cleveland who cannot afford to use that institution are subsidizing, through foregone tax revenue, a system that is not returning that subsidy in care.

That is the transaction. It is happening in plain sight.

Institutional Reputation as a Shield

Here is the mechanism that makes this possible and keeps it from changing.

Prestige functions as accountability insulation in American healthcare. The more recognizable the institution’s name, the more difficult it is for journalists, regulators, or policymakers to sustain scrutiny. When the Lown Institute published its findings on Mayo Clinic, Mayo called the methodology “deeply flawed.” The Minnesota Hospital Association called the conclusions “false, sensational, and based on cherry-picked categories.”

The hospitals’ counterargument centers on what counts as community benefit. The IRS allows research spending and medical education to be counted. Hospitals with large research programs and residency training budgets argue that these activities constitute community investment. The Lown Institute’s methodology focuses on financial assistance to patients and direct community health investment, excluding research and education from the calculation.

Both positions reflect real values. Medical research creates long-term community benefit. Resident training produces the physician workforce the country needs. These are not nothing.

But the argument that research and education justify a $274 million gap between tax exemption value and direct community benefit requires a patient who cannot afford their bill to accept that the institution treating them as a revenue source is actually serving the community by publishing papers and training physicians.

That patient is standing in an emergency department with a bill they cannot pay, at an institution that received tens of millions in tax relief, and is being told the research wing justifies the arrangement. I do not find that convincing.

The CEO Compensation Test

There is a simple test I apply when evaluating whether an institution’s nonprofit status reflects genuine mission alignment.

Compare the CEO’s compensation to the charity care percentage.

The Mayo Clinic emerged as the highest-compensating nonprofit health system over a recent five-year period, with median annual total executive compensation of approximately $148 million. Cleveland Clinic followed, with median annual total executive compensation of approximately $115 million.

These are not single-executive figures. These are aggregate compensation for all listed executives in IRS filings. But the scale matters.

When a nonprofit institution pays its executive team $115 million to $148 million annually while maintaining a nine-figure gap between its tax exemption value and its community benefit spending, the “nonprofit” designation is performing a function. It is reducing the institution’s tax burden. It is not describing the institution’s relationship to the community it serves.

I am not making a blanket argument against physician or executive compensation. I run an organization. I understand that competitive compensation is necessary to attract and retain talent in a competitive market. That is a separate conversation.

What I am arguing is that an institution cannot simultaneously claim nonprofit status, market itself as a charitable institution serving its community, and maintain a $200+ million gap between the value of its tax subsidies and its community investment. At some point, the accounting requires intellectual honesty.

What Reform Actually Requires

The IRS has not updated the substantive requirements for nonprofit hospital status in a meaningful way in decades. The Affordable Care Act added some community health needs assessment requirements. The reporting has improved. The accountability has not.

What genuine reform requires is straightforward. Community benefit spending should be benchmarked against tax exemption value with a minimum threshold. Institutions falling below that threshold should face either tax liability or mandatory remediation plans with enforcement. Research and education should be credited, but not as a substitute for direct financial assistance to patients who cannot afford care.

Senator Bernie Sanders has called repeatedly for congressional action on this issue. The Senate Health, Education, Labor, and Pensions committee has held hearings. Legislation has been proposed. It has not passed. The lobbying resources of major health systems are substantial, and the reputational currency of institutions like Mayo, Cleveland Clinic, and NYU Langone translates into political influence that insulates them from accountability.

This is a pattern I have seen replicated at the organizational level in orthopedic surgery. Institutions with strong reputations operate with more latitude than the evidence of their practices would otherwise allow. Reputation substitutes for accountability. The more prestigious the brand, the more the brand protects the behavior.

At Indiana Orthopedic Institute, we publish our outcomes. We measure what we do against what we claim. That is not virtuous positioning. It is the minimum standard that any organization, nonprofit or otherwise, should be held to.

The hospital down the street is not required to do the same. And if it has the right name on the building, it probably never will be.

What I Want Patients to Know

When you receive care at a nonprofit hospital, you are receiving care at an institution that does not pay income tax, property tax, or sales tax on its operations. Those exemptions are funded by the public. They are funded by you.

You are entitled to know whether the institution serving you is honoring the community benefit obligation that those exemptions require. That information is public. The IRS Form 990 is available for every nonprofit hospital. The Lown Institute has done the work of compiling and calculating it.

The gap between what these institutions receive and what they return is documented. It is not a rumor. It is a public record.

The prestigious name on the building does not change the arithmetic. It just makes the arithmetic easier to ignore.

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I think about those patients when I read the Medicare Trustees’ 2025 report, released last month, which moved the Medicare Hospital Insurance trust fund insolvency date from 2036 to 2033. Three years earlier than last year’s projection. Eight years from now.

When that trust fund runs out, payments to hospitals and physicians like me get cut by 11% automatically, unless Congress acts. The patients in my waiting room, who paid into this system for 40 years, will either lose access to providers who can no longer afford to see them at 11% below already compressed reimbursement rates, or watch the program they funded become something unrecognizable.

And as of today, there is no credible plan to prevent that.

The Clock Is Running. The Math Is Getting Worse.

The Medicare Trustees estimate the Medicare Hospital Insurance trust fund will be insolvent by 2033, at which point Medicare Part A benefit spending will be slashed by 11%. This is not a distant projection. The youngest baby boomers are currently 61 years old. They will be 69 when the trust fund runs dry. The wave that was always coming is fully here.

The program covered approximately 67.6 million people at the end of 2024. Total enrollment is projected to increase substantially by 2030, driven by the continued aging of the baby boomer generation. This demographic shift is changing the ratio of workers paying into the system compared to beneficiaries drawing benefits.

The structure of the problem is straightforward. Medicare Part A is funded by a 2.9% payroll tax. The working-age population paying that tax is shrinking relative to the retired population drawing benefits. The cost per beneficiary is rising as that population ages into higher-need care years. The reserve is being drawn down. By 2033, the math closes.

Part B premiums are projected to nearly double between 2024 and 2034, from $2,100 per year to more than $4,000 per year. Seven million Medicare beneficiaries already spend more than 10% of their annual income on Part B premiums alone. That burden doubles in a decade under current trajectory, before accounting for any trust fund crisis intervention.

The people most exposed to this are not abstractions. They are my patients. Working-class Americans who did everything the system asked of them, paid their payroll taxes for decades, and are about to discover that the contract they believed in is financially unsustainable.

Then Congress Made It Worse

Into this fiscal environment, Congress passed and the President signed the One Big Beautiful Bill Act on July 4, 2025.

The nonpartisan Congressional Budget Office estimated that the OBBBA will reduce federal Medicaid spending by more than $900 billion over a decade. Specifically, CBO estimates the health coverage provisions would reduce federal outlays by $907.5 billion over ten years, with 4.8 million people losing health insurance coverage by FY2034.

I want to be precise about what this means in practice, because the political debate around this legislation has generated significant confusion.

The OBBBA does not technically reduce spending below current levels in nominal dollar terms. Healthcare costs grow every year. What the cuts do is reduce that growth significantly below what it would otherwise be. The patients who lose Medicaid coverage as work requirements take effect, eligibility redeterminations accelerate, and provider tax restrictions constrain state funding, do not disappear. They become uninsured. And when they need care, many of them will arrive in emergency departments, or delay care until conditions become acute, or lean harder on a Medicare system that is already fiscally strained.

More than 300 rural hospitals are currently at immediate risk of closure, especially now that the OBBBA is projected to cut Medicaid spending by over $1 trillion. The average operating margin for rural hospitals was 3.1% in 2023. Forty-four percent were already operating with negative margins. A $900 billion reduction in federal Medicaid support does not land evenly. It lands on the institutions with the least cushion.

When rural hospitals close, the patients they served do not stop getting sick. They drive farther, wait longer, and arrive in worse condition when they finally reach care. The savings Congress booked on a spreadsheet will be partially recouped, with interest, in emergency care costs, worse surgical outcomes, and longer recovery trajectories for patients who should have been treated earlier.

I operate on the downstream consequences of delayed and foregone care every week. The math the OBBBA uses is not the math that shows up in my OR.

The Conversation Nobody Is Having

Here is what is missing from the public debate about Medicare solvency, and I want to say it directly because I have standing to say it.

The Medicare program as currently structured cannot deliver on its promise indefinitely without either more revenue, lower costs, or reduced benefits. Those are the only options. Everything else is accounting.

More revenue means higher payroll taxes, broader tax bases, or both. Lower costs means reforming what Medicare pays for and how much, including painful conversations about end-of-life care, technology adoption, and the administrative infrastructure that consumes roughly $680 per beneficiary more in the U.S. than in comparable countries, per KFF analysis. Reduced benefits means patients get less than they were promised.

No politician running for office wants to say any of those things plainly. The result is a policy environment where the Trustees issue annual warnings, the insolvency date moves closer, and Congress oscillates between cutting the program’s funding (OBBBA) and expanding its obligations (proposed GLP-1 coverage for Medicare patients, projected at $27 billion annually within a decade).

Both moves, the cuts and the expansions, are happening simultaneously. The program is being asked to do more while the financial foundation supporting it is being actively reduced.

The GLP-1 coverage expansion deserves specific attention here. I have written about the clinical complexity of these drugs, including the muscle loss data that the press releases omit. What I have not said publicly is this: adding a $27 billion annual obligation to a program eight years from insolvency, without a corresponding revenue mechanism, is not healthcare policy. It is political positioning.

The patients who would benefit from GLP-1 coverage under Medicare are real. The cardiovascular outcomes data is real. I am not dismissing either. What I am saying is that a financially honest conversation about GLP-1 Medicare coverage requires simultaneously answering the question of how a program eight years from insolvency funds a new $27 billion per year commitment.

Nobody is answering that question. Not in the coverage expansion proposals. Not in the reconciliation bill. Not in the campaign materials of anyone currently in office.

What the Surgeon in the Room Understands

I perform joint replacements on Medicare patients every week. I know what the reimbursement looks like. I know what an 11% cut does to the economic model of a surgical practice. I know how many orthopedic surgeons, across the country, are already making access decisions based on Medicare payment rates.

An 11% automatic cut at trust fund insolvency does not arrive with a warning bell and a transition period. It arrives on the day the reserve hits zero, applied immediately to every Medicare claim submitted. The practices and hospitals operating on thin margins around Medicare reimbursement do not absorb that cut gracefully. They reduce Medicare patient volume. They close. Or they exit certain service lines and certain geographies.

The patients most exposed are not wealthy. More than one-third of Medicare beneficiaries reported delaying or going without care in 2023 because of cost. Those are people already at the margin of access. An 11% provider payment cut does not affect them at the margin. It eliminates their access.

At Indiana Orthopedic Institute, the ASC model and the operational structure we have built provide more insulation against Medicare payment volatility than a hospital-employed practice or a purely Medicare-dependent facility. That is a design advantage I built deliberately, because I have watched the trajectory of this program for my entire career and I do not believe the political class will act before the crisis rather than after it.

I hope I am wrong. The data says I am not.

What Honest Leadership Would Require

An honest conversation about Medicare would acknowledge three things simultaneously.

First, the program’s value is real and the commitment to beneficiaries is legitimate. Medicare is the primary healthcare coverage for 67 million Americans who paid for it. Honoring that commitment is a genuine obligation, not a political talking point.

Second, the fiscal trajectory is unsustainable without structural change. The 2025 Trustees report moved the insolvency date three years earlier in a single year. That is not a rounding error. That is a program accelerating toward a cliff.

Third, the cuts already enacted through OBBBA do not solve the solvency problem. They reduce Medicaid, which has a separate funding mechanism. The Medicare Hospital Insurance trust fund is funded by payroll taxes. Cutting Medicaid by $900 billion does not extend Medicare solvency by a single day.

The politicians celebrating the OBBBA as fiscal responsibility and the politicians proposing GLP-1 Medicare expansion as healthcare progress are, in different ways, performing for different audiences. Neither is having the conversation that the 2025 Trustees report demands.

The clock is at eight years. The math is getting worse. And the people who will feel it first are the ones who can least afford to.

I sat in a hospital boardroom early in my career. The conversation was about productivity. Specifically, about RVU targets for the surgical department. Relative Value Units, the metric hospitals use to measure how much billable work a physician generates in a given period.

The administrator running the meeting had never operated. Had never stood at a table for eight hours managing a complication. Had never had a patient look at them before anesthesia and say, “I trust you.”

He had a spreadsheet. And the spreadsheet said I was not producing enough.

I left that meeting with a clarity I have carried ever since. The system was not designed to make patients healthier. It was designed to generate units. And I was the unit generator.

That was the moment I started building something different.

The Numbers Behind the Takeover

The transformation of American medicine from a physician-led profession to a corporate employment structure has been the most consequential change in healthcare delivery over the past two decades. Most patients do not know it happened. Most physicians feel it every day but rarely say so publicly.

The American Medical Association has tracked physician practice ownership since 2012. The trend line is unambiguous.

In 2012, 60.1% of physicians worked in private practice. By 2024, that share had dropped to 42.2%. In the same period, the share of physicians working in hospital-owned practices rose from 23.4% to 34.5%, and physicians employed directly by or contracted with hospitals doubled, from 5.6% to 12.2%.

Only 35.4% of physicians had an ownership stake in their practice in 2024, down from 53.2% in 2012, and less than half the roughly 76% share estimated in the early 1980s.

In one generation, American medicine went from a profession where three quarters of physicians owned their practice to one where fewer than four in ten do. The physician went from the business owner to the employee. And with that shift, the entire incentive architecture of care changed.

What an RVU Actually Is

Most patients have never heard of a Relative Value Unit. Most physicians wish they could say the same.

The RVU system was developed in the 1980s as a mechanism for standardizing Medicare payments. Each clinical procedure and encounter is assigned a unit value based on estimated physician work, practice expense, and malpractice cost. Hospitals and health systems then set productivity targets based on RVU generation. Meet your target, you are in good standing. Miss it, the conversation with your supervisor begins.

The logic seems rational on paper. Measure what physicians do. Compensate accordingly.

The reality is something else entirely.

Current RVU-based systems strip physicians of autonomy, creativity, and deeper professional satisfaction. The pursuit of RVUs becomes a primary driver in medical decision-making.

When the metric that determines your compensation and employment security is the number of billable units you generate, the clinical question “what does this patient need?” becomes entangled with the financial question “what generates the most RVUs?” Those two questions do not always have the same answer. And in a production-driven environment, the financial question tends to win.

The patient who needs a longer appointment. The complex case that requires thinking, not doing. The conversation about prognosis that generates zero units and takes forty-five minutes. These are the things the RVU system punishes. Not because anyone designed it to punish good medicine. But because the metric does not measure good medicine. It measures throughput.

What Happens to the Physician Inside the Machine

I want to be honest about what the corporate employment model does to a physician over time, because it is something most doctors will not say publicly while they are still inside it.

It starts subtly. The EMR dashboard appears. Your productivity ranking relative to peers is visible in real time. Your RVU count is reviewed quarterly. A nurse manager begins attending your scheduling meetings. Clinical decisions that were once yours alone, what imaging to order, which patients to prioritize, how long an appointment needs to be, start requiring approval from administrators whose clinical credentials do not qualify them to make those decisions.

The language changes too. Patients become “encounters.” Appointments become “throughput.” The OR schedule becomes a “production calendar.” I watched this language arrive in hospitals where I trained and worked, and I watched what it did to the physicians around me.

The RVU model plays a significant role in the burnout crisis by incentivizing volume over quality, forcing physicians to churn through patients to meet productivity quotas. Over 50% of physicians report feeling burned out.

Burnout is the word we use because it sounds like a systems problem rather than a moral one. What I observed in those physicians was not burnout in the clinical sense. It was the progressive erosion of professional identity. The feeling, accumulated over years, that the judgment they spent a decade developing was no longer the primary variable in the room.

When physician authority erodes, patients notice, even if they cannot name what they are sensing. The appointment feels rushed. The doctor seems distracted. The plan feels formulaic. That is not a perception problem. It is an accurate reading of a clinical environment where the physician is constrained, monitored, and measured against metrics that have nothing to do with whether the patient in front of them gets better.

The Administrator Layer That Doesn’t Treat Patients

Here is what has grown as physician autonomy contracted.

Between 1975 and 2010, the number of physicians in the United States grew by 150%. In the same period, the number of healthcare administrators grew by 3,000%. That ratio has continued to shift. The people setting clinical policy, designing productivity dashboards, determining which procedures require administrative approval and which don’t, are increasingly people who have never practiced medicine.

I am not making a blanket argument against healthcare administration. Complex organizations require administrative infrastructure. Financial management, regulatory compliance, facilities coordination, these are real functions that require skilled professionals.

What I am arguing against is the inversion of authority that occurs when administrative metrics become the primary governance structure for clinical decisions. When an administrator with a spreadsheet has meaningful control over a surgeon’s clinical choices, the authority structure is wrong. Not inefficient. Wrong.

The consequences are not abstract. When patient care time is driven by administrative mandates rather than clinical judgment, negative consequences include poor quality of care and outcomes, errors, and low patient satisfaction ratings. For clinicians, the consequences include low morale, moral distress, burnout, and higher rates of staff turnover. American Speech-Language-Hearing Association

Every one of those outcomes costs money. Every one of them costs something more important than money too.

What I Built Instead

When I founded Indiana Orthopedic Institute, I made a decision that was either courageous or naive depending on who you asked at the time: physicians would lead the organization, and administrative infrastructure would serve the clinical mission, not govern it.

That meant the surgeon in the room has final authority on clinical decisions. It meant building our compensation model around outcomes and value, not RVU count. It meant creating an environment where a physician could take the time a patient needed without being penalized on a productivity dashboard for doing so.

We built it as an ASC-anchored model deliberately. The ambulatory surgery center structure, when physician-owned and physician-led, removes the hospital system’s leverage from the equation. The OR schedule is not a production calendar managed by a hospital administrator. It is a clinical tool managed by the surgeons using it.

The results are not theoretical. We grew from two people to over 100 employees and 16 surgeons in roughly three years. Physician retention is not a problem we manage. It is a strength we built. The surgeons at Indiana Orthopedic Institute are not looking for exits. They came here because they were looking for an alternative to the model I left.

That is not a recruitment pitch. It is evidence that the physician-led model is operationally viable, financially sustainable, and clinically superior to the production-target model that now dominates the industry.

What I Tell the Physicians Reading This

You became a physician because you wanted to make clinical decisions on behalf of patients. That instinct was correct. It is also the instinct the corporate employment model is systematically trained out of you.

The discomfort you feel when the dashboard contradicts your judgment is not a sign of poor organizational fit. It is a sign that your professional identity is intact. Honor it.

The path I took, building the alternative rather than complaining from inside the existing structure, is not available to every physician in every market. I understand that. The financial barriers to independent practice are real and have been deliberately constructed. Medical school debt, credentialing complexity, payer contracting leverage, hospital employment contracts with restrictive covenants, all of these are features, not bugs, of a system designed to make physician independence as difficult as possible.

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But the path exists. The ASC model exists. Physician-owned group practice exists. The regulatory environment is shifting in ways that, for the first time in decades, modestly favor independent practice over hospital employment.

The hospital system will tell you employment is security. It is. The same way a cage is security.

The patients you trained to serve need you making decisions based on what they need, not on what the spreadsheet values.

That is the incision point.

The scale is moving. The before-and-after photos are striking. The cardiology data looks promising.

Nobody is talking about what’s disappearing along with the fat.

I operate on muscle. I have for over 20 years. When I open a joint, I see the tissue quality, the structural integrity, the mechanical reality of how a body has been treated over decades. And I am telling you: the conversation around GLP-1 drugs is missing the most important clinical variable in the entire equation.

You are not just losing weight on Ozempic. You are losing muscle. And depending on how you’re taking it, you may be losing a lot of it.

The Number Nobody Puts in the Press Release

Multiple studies on semaglutide and tirzepatide have now documented the same finding: somewhere between 25% and 40% of total weight lost on GLP-1 agonists comes from lean mass, not fat.

Read that again.

This is not speculation. The STEP 1 and SUSTAIN 8 trials, the flagship semaglutide studies published in the New England Journal of Medicine, found that 39-40% of total weight lost on the drug was lean mass. These are Novo Nordisk’s own studies. The ones used to secure FDA approval. The ones cited in every press release announcing this drug as a breakthrough.

The lean mass finding was in the data the whole time. It just wasn’t in the headline.

If you lose 50 pounds on Ozempic, somewhere between 12 and 20 of those pounds may be muscle. Not fat. Muscle.

In the orthopedic world, we have a clinical term for the condition of low muscle mass relative to body weight. We call it sarcopenia. And sarcopenia is one of the most reliable predictors of poor surgical outcomes, increased fall risk, fracture, joint degeneration, and loss of functional independence I have ever seen in practice.

We are potentially manufacturing sarcopenia at scale, celebrating it as weight loss, and calling it a healthcare breakthrough.

I have a problem with that.

What I See in the OR That Nobody Sees on a Podcast

When I perform a total knee or hip replacement on a patient with significant muscle loss, the procedure changes. The mechanical environment around the joint is different. Soft tissue tension is different. Rehabilitation trajectory is different. Outcomes are measurably worse.

I have watched patients come into my OR having lost substantial weight before surgery, believing they had optimized themselves for the procedure. Sometimes they had. But increasingly I am seeing patients who lost weight rapidly, on drugs or otherwise, and whose muscle quality tells a completely different story than their BMI does.

The scale moved. The tissue didn’t improve. In some cases it got worse.

This is not an abstraction. This is what I see with my hands.

The emerging data on bone density compounds the problem. GLP-1 receptors are expressed in bone tissue. Early research suggests semaglutide may reduce bone mineral density, particularly with rapid weight loss. The STEP trials were not designed or powered to detect fracture risk, so that signal exists in the background of the most-cited efficacy data, largely unmeasured.

We don’t know what we don’t know yet. And that should concern every clinician prescribing these drugs without a musculoskeletal assessment in the protocol.

Rapid Weight Loss Has Always Been a Red Flag. Why Did We Forget That?

This is the part that genuinely puzzles me as a physician.

For decades, the clinical consensus on weight loss was clear: slow and deliberate produces better outcomes than rapid. One to two pounds per week. Sustained behavioral change. Preservation of lean mass as a primary goal alongside fat reduction.

We built that consensus on outcomes data. We built it because rapid weight loss, whether from crash dieting, surgical procedures, or illness, consistently showed the same downstream consequences. Muscle loss. Bone density reduction. Metabolic rate suppression. Rebound weight gain that included disproportionate fat restoration.

Now a drug produces 15% total body weight loss in 68 weeks, and the clinical conversation has almost entirely abandoned the lean mass question. The headline metric became total weight. The nuance disappeared.

I understand why. The cardiovascular outcome data is genuinely compelling. A 20% reduction in major cardiovascular events in the SELECT trial is not a number to dismiss. But cardiovascular endpoints and musculoskeletal endpoints are not the same endpoints. A drug can reduce heart attack risk and increase fracture risk simultaneously. Both things can be true.

The question nobody seems to be asking in a clinical setting is: what is this patient’s muscle mass before we start, and what is the protocol to protect it?

The Protocol That Should Exist But Usually Doesn’t

I am not categorically against GLP-1 therapy. In specific patients, with specific risk profiles, managed carefully, the case for short-term use is legitimate.

But “managed carefully” means something specific to me. It means a baseline DEXA scan before initiation. Not a scale weight. A DEXA scan, which gives you body composition: fat mass, lean mass, bone mineral density. The actual numbers that matter.

It means resistance training as a non-negotiable co-intervention, not an optional lifestyle recommendation. The evidence on preserving lean mass during caloric restriction is unambiguous. Progressive resistance exercise is the primary tool. If a patient is on a GLP-1 and not actively building or maintaining muscle, they are losing it. Full stop.

It means protein intake calibrated to lean body mass, not general dietary guidelines. The RDA for protein (0.8g per kg of body weight) was not designed for patients losing weight rapidly on a drug that suppresses appetite and may impair muscle protein synthesis signaling.

And it means an honest conversation about the goal. If the goal is fat loss with muscle preservation, the current standard dosing protocol, designed to maximize total weight loss, may not be the right protocol for every patient.

This is where the microdosing conversation becomes clinically relevant. There is no large-scale RCT on lower-dose, slower-titration GLP-1 protocols designed specifically for lean mass preservation. That data doesn’t exist yet. But the physiological rationale is sound: slower weight loss, matched with structured resistance training and adequate protein, should produce a better body composition outcome than the maximal-dose, rapid-loss approach the STEP trials optimized for.

I want that study done. Until it is, I am paying close attention to what I see in my patients and in the emerging literature.

What I Tell Surgeons and What I Tell Patients

To surgeons: if you have patients on GLP-1 drugs heading toward a joint replacement or any major musculoskeletal procedure, add a body composition assessment to your pre-operative workup. Not weight. Composition. You need to know what you’re operating on before you’re operating on it.

The prehabilitation protocols we’ve developed at Indiana Orthopedic Institute exist precisely because we understand that the tissue quality a patient brings into the OR determines a meaningful portion of their outcome. A 50-pound weight loss that came 40% from muscle is not the same surgical preparation as a 50-pound fat loss with muscle preservation. The BMI may be identical. The mechanical reality is not.

To patients: the number on the scale is not the outcome. Body composition is the outcome. Before you start any significant weight loss protocol, including GLP-1 therapy, know your baseline lean mass. Track it. Protect it with resistance training. Eat enough protein, because your appetite suppression will work against you here.

The drug will make you lighter. That is not the same as making you stronger, more functional, or better prepared for the second half of your life.

I have seen what sarcopenic bodies look like at 65 and 75. I have seen the fractures, the falls, the failed rehabilitations, the joint replacements that don’t recover the way they should because there wasn’t enough muscle to rebuild around. That trajectory begins decades earlier, in choices and interventions that seemed beneficial at the time.

GLP-1s may be a genuine tool. The cardiovascular data says they can be. But a tool used without understanding its full mechanical consequence is just a risk you haven’t measured yet.

Measure the muscle. Then decide.

I have a question I cannot stop asking.

The United States spent $14,885 per person on healthcare in 2024. Switzerland, the second highest spender in the world, spent $9,963. The average among wealthy peer nations was $7,371.

We spent double what our peers spend. And according to KFF and the Peterson Center’s most recent analysis, the average life expectancy in those comparable countries is 82.7 years. In the United States, it is 79.0.

We are spending twice as much to die three and a half years sooner.

I am an orthopedic surgeon. I am also an engineer. And I can tell you with certainty: when a system consumes double the inputs and produces inferior outputs, the problem is not under-funding. The problem is the system itself.

The Numbers That Should End the Debate

Let me stack the data because it needs to be seen together, not scattered across separate news cycles.

The U.S. ranks 33rd out of 38 OECD countries in average life expectancy. The obesity rate in the U.S. is 43%, compared to an OECD average of 26%. The U.S. opioid mortality rate is 223 per 1 million people, against an OECD average of 30 per 1 million. U.S. healthcare spending as a percentage of GDP is 16.6%, against an OECD average of 9.2%.

Read those numbers in sequence. We are spending 80% more of our economic output on healthcare than the average wealthy nation. We have the highest obesity rate in the developed world. We have the highest opioid death rate. And we rank 33rd out of 38 in how long our citizens actually live.

This is not a healthcare financing story. This is not an insurance access story. Those are real problems, and I write about them directly. But they do not explain this gap. Countries with universal coverage and lower administrative overhead still do not have a 43% obesity rate. The gap between American health outcomes and peer nation outcomes is too large and too consistent to be explained by billing complexity or prior authorization.

The sickness is upstream of the healthcare system. It is being manufactured before patients ever see a physician.

55% of American Calories Come From Ultra-Processed Food

I want to be precise about what I mean by upstream, because this is where the argument gets dismissed as wellness content rather than clinical reality.

The CDC released results from the National Health and Nutrition Examination Survey covering 2021 through 2023. The finding: among Americans aged one and older, an average of 55% of total calories came from ultra-processed foods. Among children aged 18 and younger, the figure was 61.9%.

More than half of the caloric intake of the average American, including the children, comes from products specifically engineered to override satiety signaling, maximize palatability, and drive repeat consumption. The NIH randomized controlled trial published in Cell Metabolism demonstrated this mechanism directly: subjects eating ultra-processed food consumed 500 more calories per day than those eating whole food, without reporting higher hunger at baseline.

The downstream consequence of that caloric architecture, sustained over decades, is exactly the disease burden we are now spending $5.3 trillion annually trying to manage.

A 2024 umbrella review published in The BMJ, covering 45 meta-analyses and nearly 10 million people, found that greater exposure to ultra-processed foods was directly associated with a 21% higher risk of all-cause mortality, a 66% higher risk of heart disease mortality, and a 40% higher risk of type 2 diabetes.

Those are not small associations. Those are the chronic disease profile of the United States, summarized in a single study.

What I See at the Operating Table

After 10,000+ joint replacements, I can tell you something specific about the American disease burden that does not show up cleanly in life expectancy statistics.

I see it in tissue quality. I see it in the inflammatory state of joints in patients who are 55 years old but whose biological tissue architecture presents like someone 20 years older. I see it in the comorbidity list that now accompanies the average joint replacement candidate: type 2 diabetes, hypertension, obesity, metabolic syndrome. Conditions that were once exceptions are now the baseline.

The patients I operated on 15 years ago, as a group, were less metabolically compromised than the patients I operate on today. Same procedures. Meaningfully different physiological starting points.

The surgical implications are real and measurable. Higher infection rates in patients with uncontrolled diabetes. More complex soft tissue management in severely obese patients. Longer recovery trajectories in patients with significant sarcopenia. More post-operative complications across the board.

I am not describing a moral failure of individual patients. I am describing the clinical consequence of a food environment that has been systematically engineered to produce metabolic disease, combined with a healthcare system that treats the disease while leaving the engineering untouched.

The Plan Nobody in Power Will Actually Name

I want to be direct about what a real plan would require, because the political conversation keeps generating frameworks that deliberately avoid the hard parts.

A real plan would acknowledge that 55% of American calories coming from ultra-processed food is a policy failure, not a personal choice failure. The GRAS loophole allows food manufacturers to self-certify the safety of additives without independent FDA review. SNAP, the federal nutrition assistance program serving 42 million Americans, allows billions in federal spending to flow to products with no meaningful nutritional value. School nutrition standards, rolled back repeatedly under food industry lobbying pressure, govern what 30 million children eat during their developmental years.

These are not natural market outcomes. They are policy decisions. And they can be changed by policy decisions.

The MAHA commission’s report named ultra-processed food as a primary driver of the chronic disease crisis. That is the correct diagnosis. The question is whether the named diagnosis produces structural intervention or remains a talking point while the food industry’s lobbying apparatus ensures the underlying policy architecture stays intact.

I am watching. So far, the diagnosis has not produced the treatment.

A real plan would also require the healthcare system to stop being financially dependent on chronic disease management. The current system profits from treating obesity, diabetes, hypertension, and their downstream consequences. It does not profit from preventing them. That misalignment is not an accident, and it will not be corrected by adding more chronic disease management programs to a system whose incentives run in the opposite direction.

What the Engineering Lens Tells You

I trained as an engineer before I trained as a surgeon. The engineering perspective on this problem is unambiguous.

A system that spends double the input cost to produce inferior output has one of two problems: a process failure or a design failure. Process failures are fixable with optimization. Design failures require redesign.

The American healthcare system is not failing because of a process failure. Physicians are working harder than ever. Hospitals are adding capacity. Insurance companies are processing claims. The machine is running.

The design is wrong.

The design treats disease management as the primary product and prevention as an optional service. The design funds research into pharmaceutical interventions while dramatically underfunding food environment research and policy. The design allows the entities most responsible for the chronic disease burden, the food industry and the pharmaceutical industry, to be among the most influential voices in the policy rooms where solutions are theoretically being developed.

At Indiana Orthopedic Institute, I built the organization around a different design premise: patient-centered care, clinical research, and innovation working in alignment, with the physician’s judgment at the center. It is a small-scale proof of concept. The macro problem requires macro redesign.

But the redesign starts with a decision to stop calling this a healthcare problem and start calling it what it actually is: a food system problem with healthcare consequences we are billing at $14,885 per person per year.

What Has to Change

To the patients reading this: the system is not going to fix this for you. Understanding that 55% of American calories are ultra-processed is not a wellness insight. It is a survival fact. The data on what that food architecture does to your metabolic health, your inflammatory state, your long-term mortality risk, is not ambiguous anymore.

To the physicians and healthcare leaders: stop accepting the premise that chronic disease is the natural condition of an aging American population. It is not natural. It is manufactured. And our clinical protocols need to reflect that the patient’s food environment is as relevant to their surgical or medical outcome as their imaging or their labs.

To the policymakers: the OECD data is public. The mechanism is documented. The policy levers are identified. Every year this redesign is delayed is another year of 33rd place life expectancy, $14,885 per capita, and a 43% obesity rate in the wealthiest country in human history.

That is not a healthcare crisis. That is a choice. And it is being made, repeatedly, by people with financial interests in keeping the design exactly as it is.

I want to tell you about a specific Thursday.

I had a patient scheduled for a total knee replacement. The surgery had been planned for six weeks. The pre-operative workup was complete. The implants were ordered. My OR team was ready. The patient had taken time off work, arranged for someone to drive them home, and mentally prepared for what they knew would be a difficult but necessary procedure.

The prior authorization was denied at 4:47 PM the day before.

No clinical review. No conversation with me. A determination made by someone who had never examined this patient, never reviewed imaging with a surgeon present, never stood at an operating table in their life, that the surgery was not medically necessary.

We appealed. We won. It took eleven weeks.

In those eleven weeks, that patient’s muscle atrophy progressed measurably. Their pain increased. They took more medication. They lost more function. The surgery they eventually received was more technically complex than the one I had planned, because the joint had continued to deteriorate while we waited for an insurance company to reverse a decision that should never have been made.

That is not a bureaucratic inconvenience. That is a patient harm. And it happened because a system was designed to produce exactly that outcome.

The Numbers the Insurance Industry Hopes You Won’t Connect

The American Medical Association surveys physicians annually on prior authorization. The 2024 results are not ambiguous.

Nearly one in four physicians reported that prior authorization has led to a serious adverse event for a patient in their care, including hospitalization, permanent impairment, or death.

Read that sentence carefully. One in four physicians. Serious adverse event. Including death.

This is not a fringe finding from a small sample. This is 1,000 practicing physicians across specialties, surveyed by the largest physician organization in the United States, reporting that the prior authorization process has directly contributed to patients being hospitalized, permanently harmed, or killed.

And then consider this number from KFF’s analysis of Medicare Advantage data: 80.7% of prior authorization appeals were overturned in 2024. Across all years examined, more than eight in ten appeals overturned the initial denial.

Those two numbers, held together, tell you everything you need to know about this system.

One in four physicians has had a patient seriously harmed by a prior authorization delay or denial. And more than 80% of the denials that get appealed turn out to be wrong.

The denials are not clinical determinations. They are a bet. The insurance industry is betting, correctly, that most physicians won’t have time to fight, that most patients won’t know they can appeal, and that most of the harm caused by the delay will never be formally attributed to the denial that caused it.

Why Physicians Stop Fighting

Here is the part of this story that should make every patient in America angry.

Only 18% of physicians report that they always appeal a prior authorization denial. Among those who don’t: 62% said they don’t believe the appeal will succeed based on past experience. 48% said patient care cannot wait for the health plan to approve the authorization. 48% said they have insufficient staff time or resources.

The system has convinced physicians that appeals are futile. It has done this by making the process slow, opaque, and exhausting enough that even when physicians know a denial is wrong, the calculus often favors finding an alternative path for the patient rather than fighting an 11-week battle with a fax machine.

Meanwhile, the appeal overturn rate sits above 80%. The denials that get challenged almost always get reversed. But fewer than 12% of denied requests are ever appealed.

That gap, between the 80% overturn rate and the 12% appeal rate, is the insurance industry’s business model. The math is straightforward: deny broadly, make the appeal process painful enough that most physicians and patients don’t complete it, and collect the savings on everything that goes unchallenged.

I have been in enough boardrooms to recognize a strategy when I see one. This is a strategy.

What This Looks Like From the Operating Room

The prior authorization problem is discussed largely in policy terms: administrative burden, appeal rates, reform legislation. What gets lost in that framing is the clinical texture of what actually happens to patients.

When an orthopedic surgery is denied and then delayed by weeks or months, specific things occur. Muscle atrophy advances. In a patient already experiencing significant deconditioning, this is not a minor variable. The tissue quality I encounter in the OR is directly affected by how long a patient has been waiting. A surgery performed at the right clinical moment and the same surgery performed three months later after a denied appeal are not the same surgical experience. The outcomes data bears this out.

I reviewed outcomes at Indiana Orthopedic Institute specifically because I wanted to understand whether prior authorization delays were showing up in our clinical numbers. They are. Patients who experienced significant delays between surgical recommendation and procedure date showed measurably worse pre-operative functional scores, longer recovery trajectories, and higher rates of complications requiring additional intervention.

We are not measuring the cost of prior authorization in administrative hours. We are measuring it in outcomes. And the outcomes are worse.

Beyond orthopedics, the harm calculus is even more acute. Cancer patients waiting for authorization on chemotherapy regimens. Cardiac patients waiting for approval on procedures with time-sensitive intervention windows. Psychiatric patients waiting for medication approvals while their condition deteriorates. More than nine in ten physicians report that prior authorization delays access to necessary care, and more than three-quarters report that patients abandon treatment entirely due to authorization struggles.

Treatment abandonment. Not inconvenience. Not delay. Patients stopping care because the authorization process outlasted their capacity to fight it.

The Insurer Pledge That Means Nothing

In June 2025, roughly 60 health insurers pledged to streamline prior authorization requirements following pressure from the Trump administration. Reform by the end of 2025 through 2027. Transparency improvements. Faster turnaround times.

The AMA surveyed physicians three weeks ago to assess whether those pledges are landing.

Only one in three physicians believes the latest insurer pledge will make a meaningful difference.

That skepticism is not cynicism. It is pattern recognition. The insurance industry has made voluntary reform commitments on prior authorization for over a decade. The volume of prior authorization requests has grown 42% since 2019. The denial rates have remained elevated. The harm has continued.

Voluntary pledges from an industry whose financial model depends on the behavior those pledges are supposed to change are not reform. They are delay.

What Structural Reform Actually Requires

The Improving Seniors’ Timely Access to Care Act would codify specific prior authorization reforms for Medicare Advantage. Real-time decisions for routinely approved services. Prohibition on denials by algorithms without clinical review. Continuity of care protections when patients switch plans. These are reasonable, targeted requirements.

They have not passed.

The CMS finalized a rule in 2024 requiring Medicare Advantage insurers to respond to prior authorization requests within 72 hours for urgent cases and 7 days for standard requests. That is a floor, not a ceiling. And it covers Medicare Advantage only, leaving commercial insurance largely untouched.

What genuine reform requires is simple to state and politically difficult to execute: prior authorization decisions must be made by clinicians, not algorithms. Denials of procedures deemed medically necessary by a treating physician must be reviewable by a physician in the same specialty. Turnaround times must be clinically meaningful, not bureaucratically convenient. And the denial-and-delay strategy must face financial consequences when it results in demonstrable patient harm.

At Indiana Orthopedic Institute, we have built internal infrastructure specifically to fight prior authorization denials aggressively and consistently. We appeal everything that is clinically defensible, because the data says we will win most of those appeals, and the patient in front of us deserves someone who will not accept a wrong answer from an algorithm.

It costs us resources. It costs us time. We do it anyway, because the alternative is accepting a system designed to outlast us.

Most practices cannot afford to do what we do. That is also by design.

What I Am Asking You to Understand

Prior authorization, as currently practiced, is not a clinical tool. It is a financial instrument that operates by interposing administrative friction between a physician’s judgment and a patient’s care.

One in four physicians has had a patient seriously harmed by it. More than 80% of challenged denials are reversed. Fewer than 12% of denials are challenged.

Those numbers describe a system that is working exactly as intended. Not for patients. Not for physicians. For the organizations collecting premiums and denying claims.

The AMA president called it correctly: physicians are fighting for patients with fax machines as their only weapon. That is not a healthcare system. That is a gauntlet.

And until the financial consequences of patient harm caused by prior authorization denial fall on the entities causing the harm, the math will not change.

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I see the same patient over and over. The names change. The joints are different. But the story is identical.

They had pain three years ago. Manageable pain. The kind where a partial procedure, a targeted intervention, a course of physical therapy might have arrested the damage and bought them a decade. They didn’t come in. Not because they weren’t in pain. Because they still owed $4,200 from the last time they interacted with the healthcare system. And they couldn’t face another bill.

So they waited. They took ibuprofen until their kidneys started to protest. They wrapped the joint. They stopped walking as far, then stopped walking much at all.

By the time they sat in my exam room, the joint was gone. Not damaged. Gone. Bone on bone. Mal-aligned. Muscles atrophied around a structure that had been mechanically failing for years. The simple procedure was no longer available. What was left was a complex total joint replacement, a longer recovery, a higher complication risk, and a bill that dwarfed the one they’d been afraid of in the first place.

The system didn’t save money by making them wait. It guaranteed they would cost more. And it guaranteed they would suffer more getting there.

100 Million People. $220 Billion. One System.

Let me give you the scale of this.

More than 100 million people in America, roughly 41% of adults, are carrying medical debt they cannot pay. That is not a fringe problem. That is nearly half the adult population of the wealthiest country in the history of human civilization.

Americans owe at least $220 billion in medical debt. Approximately 14 million people owe over $1,000, and about 3 million owe more than $10,000, according to KFF analysis of government data. And that number almost certainly understates the real burden, because it doesn’t fully capture medical charges shifted onto credit cards, loans from family members, or payment plans that patients are quietly defaulting on every month.

Medical debt is now the most common form of debt on consumer credit records. As of recent data, 58% of all debts recorded in collections were for a medical bill, according to the Consumer Financial Protection Bureau.

Not student loans. Not car payments. Not credit cards. Medical bills. The leading category of debt in collections in America is the bill you got for being sick.

And here is the clinical consequence that nobody in the finance conversation is discussing: about 1 in 7 people with health care debt say they have been denied access to a hospital, doctor, or other provider because of unpaid bills.

They are being locked out of the system by the debt the system gave them. That is not a side effect. That is the mechanism.

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What Delayed Care Actually Costs

I want to be precise about what happens clinically when a patient delays musculoskeletal care because of cost.

A published analysis in The Lancet Rheumatology found that surgical delay of more than six months is associated with 50% greater odds of worse outcomes for joint replacement patients. Six months. That is the clinical window. Beyond it, the trajectory changes.

The joint continues to degrade. The surrounding musculature weakens. Compensatory movement patterns develop as the body tries to offload the damaged structure, creating secondary problems in adjacent joints, the spine, the opposite limb. A patient who needed a straightforward procedure at year one often needs a significantly more complex one at year three or four. The surgical risk profile is worse. The recovery is harder. The functional ceiling is lower.

And the cost is substantially higher, at every level: to the patient, to the insurer, to the system.

This is the economic argument that the system refuses to make honestly. Delayed care does not reduce healthcare spending. It defers it, concentrates it, and multiplies it. The patient who couldn’t afford the early intervention will eventually arrive in an emergency department, or in my OR, or in an intensive care unit. The bill will be larger. The outcome will be worse. And somewhere in the accounting, someone will record this as the cost of care rather than the cost of a system that made care inaccessible.

I have performed over 10,000 joint replacements. I can tell you with certainty: the most technically demanding cases I operate on are not the ones with the most severe underlying disease. They are the ones where severe disease was allowed to progress, unaddressed, for years. Those cases are harder. They take longer. They carry more risk. And they almost always come with a history of a patient who tried to manage the problem themselves because they could not afford to come in sooner.

The Insured Patient Who Still Couldn’t Come

I want to push back on one assumption that shapes this conversation: that medical debt is primarily a problem of the uninsured.

It is not. In the past five years, more than half of U.S. adults report they’ve gone into debt because of medical or dental bills, according to the KFF survey. That includes tens of millions of people who had insurance when the bills arrived.

High-deductible health plans have shifted enormous cost exposure onto patients. A family with a $6,000 or $8,000 deductible is, for practical purposes, uninsured for the first portion of the year. They have a card in their wallet that says they are covered. They are not covered. They are one diagnosis away from a debt they cannot service.

I have seen this repeatedly at Indiana Orthopedic Institute. A patient comes in with a plan. The deductible hits. The math changes. The follow-up doesn’t happen. The physical therapy gets cut short. The outcome suffers. The insurance company has technically fulfilled its contractual obligation. The patient is functionally on their own until the calendar resets.

This is by design. High-deductible plans reduce insurer exposure by transferring it to patients. They suppress utilization, which is the point. The suppressed utilization includes necessary care, which is the problem nobody in the insurance industry will say out loud.

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The ASC as a Partial Answer

When I built Indiana Orthopedic Institute, cost transparency was not a marketing decision. It was a clinical one.

I had watched patients make medical decisions based on fear of a bill they hadn’t received yet. I had watched people delay care, ration medications, and skip follow-up appointments because the financial unpredictability of the hospital system made every interaction feel like a potential financial catastrophe.

Ambulatory surgery centers, when structured correctly, offer a fundamentally different financial model. Procedure costs are lower, often substantially. The absence of hospital overhead, administrative bloat, and facility fees compresses the price in ways that matter clinically, because price affects access, and access affects outcomes.

A patient who can afford to come in at the right time gets a better result. That is not a controversial claim. It is a clinical fact.

The broader fix requires policy that high-deductible plans don’t currently support. Price transparency requirements with real enforcement. Surprise billing protections with teeth. Medical debt reform that stops the collections machinery from blocking future care access. These are structural changes. They require political will that has, so far, been reliably outweighed by industry lobbying.

But the individual surgeon, the individual practice, the individual health system can make choices right now that reduce the financial barrier to early intervention. Transparent pricing. ASC-first pathways for appropriate cases. Financial counseling as a standard part of care coordination, not an afterthought.

What I Want You to Understand

The patient who waited too long is not a cautionary tale about personal responsibility. They are an indictment of a system that made timely care unaffordable and then charged them more for the damage the delay caused.

They did exactly what a rational person does when the financial stakes are unpredictable and the consequences of being wrong are catastrophic. They waited. They hoped. They managed.

And by the time they arrived, what could have been a repair had become a reconstruction.

The system spent $5.9 trillion on healthcare in America last year. One hundred million people still can’t afford to use it when they need it most.

That is not a resource problem. That is an allocation problem. And it is killing people slowly, one deferred appointment at a time.

I had a conversation recently with a third-year surgical resident who told me she was seriously considering leaving medicine. Not because she didn’t love operating. Because she had spent the previous Friday doing 11 prior authorization requests instead of seeing patients.

She is 29 years old. She has $310,000 in medical school debt. She trained for seven years to use her hands and her judgment to help people. And the system handed her a fax machine and a denial queue.

We are burning our own pipeline. And the people in charge have every financial reason to keep doing it.

The Numbers Are Not Projections Anymore. They’re Arrivals.

According to the Association of American Medical Colleges, the United States is on track for a shortage of up to 86,000 physicians by 2036. The surgical specialty shortfall alone could reach nearly 20,000. These are not speculative estimates from advocacy organizations with an agenda. This is the AAMC, the body that accredits medical schools and tracks physician supply nationwide, issuing a structural warning that has gone largely unaddressed for over a decade.

The shortage isn’t coming. It’s here. In rural counties, it arrived years ago. In specialty care, the wait times are already the evidence.

And while the supply side of the equation gets the headlines, almost nobody is talking honestly about what is destroying the supply we already have.

39 Prior Authorizations a Week. Every Week.

The American Medical Association surveys physicians every year on the prior authorization burden. The 2024 results: physicians complete an average of 39 prior authorization requests per week. That consumes roughly 13 hours of physician and staff time, every single week. More than 40% of physician practices now employ staff whose entire job is processing prior authorization paperwork.

Let me translate that into clinical time.

13 hours a week is nearly a full working day and a half. For a surgeon, that is two to three cases. For a primary care physician, that is 20 to 25 patient appointments. Vanished. Not into care. Into a bureaucratic process designed, explicitly, to slow down and deny access to treatments physicians have already determined are medically necessary.

Here is the number that should end the debate: more than 27% of physicians report that prior authorization requests are often or always denied. More than one in four requests, rejected outright. And when physicians appeal those denials, the overturn rate is extraordinarily high, which tells you exactly how valid the original denials were.

This is not a quality control mechanism. It is an attrition strategy. And it is working.

Who Benefits from a Doctor Shortage

I want to name something that rarely gets named directly: the physician shortage is not an accident, and it is not uniformly a problem for every player in the healthcare system.

Hospital systems benefit from it. When physicians are scarce and burned out, hospital employment becomes the default. The negotiating leverage shifts entirely. A physician with $300,000 in debt, no independent practice infrastructure, and a specialty that requires expensive equipment and facility access does not have many options. The hospital knows that. The employment contracts reflect that.

95% of physicians report that prior authorization somewhat or significantly increases physician burnout, according to the AMA. Burnout drives early retirement. Burnout drives physicians out of clinical practice and into administrative roles. Burnout drives that third-year resident to start reconsidering her career before she has even fully started it.

Every physician who exits the clinical workforce early is a physician who did not need to be recruited, trained, or competed for. The shortage creates leverage. The leverage is the point.

The insurance industry benefits from it too. A system with fewer physicians, longer wait times, and more administrative friction processes fewer claims. Prior authorization exists to delay and deny care. A burned-out physician who stops fighting denials, who stops appealing, who just moves to the next patient because there are 40 more in the queue, is an insurance company’s ideal outcome.

I am not describing a conspiracy. I am describing aligned financial incentives. In my experience, those are more dangerous than conspiracies because nobody has to coordinate them. The system just selects for behaviors that serve the system.

The Residency Bottleneck Nobody in Congress Will Fix

Here is the structural problem that sits underneath all of it.

The number of federally funded residency positions has been effectively capped since 1997, when the Balanced Budget Act froze Medicare Graduate Medical Education funding. Medical schools have expanded. Applications have grown. The physician pipeline has more people trying to enter it. But the bottleneck, at the residency level, has barely moved in nearly 30 years.

We are producing more medical school graduates than we can train. Match Day, the annual ritual where medical students learn whether they secured a residency position, has thousands of unmatched applicants every year. These are people who completed four years of medical school, passed licensing examinations, and cannot enter the workforce because there are not enough funded training slots.

The fix is not complicated. It requires Congress to lift the residency funding cap. The AAMC has recommended it. The AMA has recommended it. It has bipartisan support at the conceptual level. It has gone nowhere for a generation because the financial interests that benefit from physician scarcity are better organized than the patients who need more physicians.

That is the honest answer.

What We Did Instead

When I was building Indiana Orthopedic Institute, I made a specific decision early: we were going to create an environment where surgeons wanted to practice, not one where they felt trapped.

That meant eliminating the administrative noise that drives physicians out of medicine. It meant building ASC infrastructure that returns decision-making authority to the surgeon. It meant aligning financial incentives so that the people generating clinical value participate in the value they generate. And it meant treating physicians as the primary asset of the organization, not as a cost center to be managed.

We grew from two people to over 100 employees and 16 surgeons in roughly three years. I am not telling you that to impress you. I am telling you because the retention argument is operational, not theoretical. Physicians stay when the environment respects them. They leave when it doesn’t.

The national conversation about the physician shortage keeps returning to supply-side solutions: expand medical schools, extend scope of practice to non-physician providers, use AI to increase efficiency. Some of those have merit at the margins. But none of them address the fundamental mechanism driving physicians out of the profession they trained for.

You cannot solve a retention crisis by recruiting harder. You have to fix what is causing the exits.

What Has to Happen

The residency funding cap needs to be lifted. Full stop. The Physician Shortage Reduction Act has been introduced in multiple congressional sessions. It has not passed. Patients in underserved areas continue to wait.

Prior authorization needs structural reform, not voluntary pledges from insurance companies. The AMA has been advocating for the Improving Seniors’ Timely Access to Care Act for years. It addresses only Medicare Advantage. The broader problem remains untouched.

And hospital systems need to understand that the employment model they depend on is consuming the workforce they need. You cannot squeeze physicians indefinitely and expect the pipeline to keep filling.

To the residents and young physicians reading this: the system will tell you this is just how it works. That the prior authorizations, the administrative burden, the eroding compensation, the loss of clinical autonomy are the price of practicing medicine. That is not medicine. That is what happened to medicine. And it is not inevitable.

Build your own path if you can. Demand structural change if you can’t. And do not mistake the system’s financial interests for clinical reality.

The patients need you in the OR, not on the phone with a denial department.

Your surgery is scheduled. You’ve done the prep. You’ve arranged time off work. You’ve had the pre-op conversation with your surgeon.

What nobody told you is that the person who keeps you alive during that procedure, the anesthesiologist, may not be there.

This is not a hypothetical. This is the operational reality of American healthcare right now, and it is accelerating. The anesthesia crisis is a slow bleed that patients don’t see, administrators are scrambling to manage, and surgeons are watching reshape their entire operating model in real time.

I’m going to tell you exactly what’s happening. And why it matters for every single person who might ever need a surgery, which is to say: everyone.

Why the Pipeline Is Running Dry

Start with the numbers. Nearly 30% of anesthesiologists are projected to leave the workforce by 2033, leaving an anticipated shortfall of 12,500 providers. A separate projection puts the gap at 6,300 anesthesiologists by 2036. Choose whichever number you find more comforting. Neither one is acceptable.

The core driver is an aging workforce compounding against frozen training capacity. Fifty-nine percent of practicing anesthesiologists are 55 or older, with 17% nearing retirement age. The average age of an anesthesiologist in 2020 was 52.6. You don’t need a medical degree to see where that trajectory leads.

Then there’s the pipeline. In the 2025 Match, 1,805 PGY-1 anesthesiology residency positions were offered to more than 3,000 applicants, leaving over 1,200 unmatched. More than 1,200 people who wanted to become anesthesiologists were turned away. Not because they weren’t qualified. Because the federal government, through the Centers for Medicare and Medicaid Services, has effectively capped residency positions since 1997. CMS has maintained Medicare-funded GME position caps with minimal growth in anesthesiology residency positions despite major demographic shifts.

That is a policy failure masquerading as a market problem.

Burnout is pouring fuel on an already-burning house. Anesthesiology leads all physician specialties in burnout, with 40.6% of anesthesiologists planning to leave their current roles within the next two years. The specialty’s 2024 burnout rate was 50%, driven by long hours, limited autonomy, and administrative burdens such as prior authorizations.

And COVID accelerated everything. The older population of anesthesia clinicians who may have been on the cusp of retiring said “I’m done with this” when COVID arrived. And they left. They did not come back.

How Hospitals Are Winning the Bidding War, and Who Loses

Here’s what patients don’t see from the waiting room.

Hospital systems and ambulatory surgery centers, the physician-owned outpatient facilities I built Indiana Orthopedic Institute around, are now in direct competition for the same shrinking pool of anesthesia providers. And hospitals are not competing fairly.

Large hospital systems have leverage that independent ASCs structurally cannot match. They offer guaranteed patient volume, institutional benefits, and most critically, stipends. Direct financial subsidies paid to anesthesia groups to lock in their coverage. The supply-demand curve has shifted dramatically, especially given the dire shortage of clinicians and the no-holds-barred attitude hospitals have taken toward supportive stipends to keep and retain clinicians.

The result: anesthesia groups that once served ASCs are being pulled toward hospital contracts. The guaranteed volume and the financial backstop are simply more attractive than the fee-for-service model ASCs traditionally offered.

ASCs are now paying for that imbalance directly. The share of ASCs expecting to pay anesthesia stipends jumped from 28% in 2024 to 44% in 2025, according to a VMG Health report. Those stipends, which were effectively nonexistent five years ago, are now approaching $200,000 at the median. In 2018, ASCs with stipends were estimated at $25,000. Today the median number is nearly 8X that, closing in on $200,000.

That cost doesn’t disappear. It gets absorbed into operating margins, compressed into the same financial models that ASCs built their value proposition around, which was: lower cost, better outcomes, more efficient care. The relatively lower reimbursement rates for ASCs, combined with these increasing costs, have made the business model much more challenging.

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At the same time that ASC costs are rising, anesthesia reimbursement from payers is going the wrong direction. Average professional anesthesia reimbursement fell 5.5% from 2019 to 2023. CMS finalized a further 2.83% cut to the anesthesia conversion factor for 2025. Less reimbursement, higher labor cost, fewer providers. That is not a cycle that self-corrects.

When anesthesia coverage falls short, ASCs have reported room closures or canceled cases, creating financial strain and disrupting patient care. Room closures are not an abstraction. They are a patient who waited six months for a hip replacement, arrived at their surgery date, and was sent home.

This is already happening. Routinely.

Why This Is a Systems Problem, Not a Scheduling Problem

I want to be precise about what I am describing, because the temptation is to frame this as a staffing inconvenience that administrators can solve with better planning and a few locum tenens contracts.

That framing is wrong.

By 2023, 78% of facilities reported an anesthesia staffing shortage, compared with 35% before COVID-19. That is not a blip. That is a structural fracture. The model that assumed anesthesia coverage was a commodity, available on demand, has broken down.

The training pipeline cannot self-repair quickly. The Resident Physician Shortage Reduction Act of 2021 aims to increase residency slots by 2,000 each year across all specialties between 2023 and 2029, far less than the projected shortfall. It will take a much larger federal investment to address the projected increase in demand over the next decade. That legislation, even if it works as designed, is not remotely scaled to the problem.

Meanwhile, the aging population is driving surgical demand in the exact opposite direction from workforce supply. Older patients need more procedures. More procedures require more anesthesia coverage. More anesthesia coverage requires providers who are not there.

The demand curve and the supply curve are moving away from each other. Nobody in Congress is treating this like the emergency it is.

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What Actually Has to Happen

I am not interested in just naming the problem. I have spent my career building structures that solve it. Here is what needs to happen, in order of how quickly it can be executed.

1. Expand CRNA scope of practice nationally. CRNAs’ scope of practice varies by state; however, 32 states and Washington D.C. allow CRNAs to practice independently. The remaining states are restricting access to care based on turf protection, not patient safety evidence. A nationally standardized, full-scope CRNA practice model does not solve the shortage alone. But it immediately deploys existing capacity that is currently sitting idle behind regulatory walls.

2. Unlock the GME bottleneck. Congress froze Medicare-funded residency positions in 1997. The population has grown by 70 million people since then. Expansion often follows institutional resources rather than community need, with some high-growth, low-income regions lacking adequate training pipelines. Federal investment needs to be redirected toward high-need geographic areas, not prestige academic centers that have adequate coverage already.

3. ASCs must restructure the anesthesia relationship. The old model is finished. Historically, anesthesia groups operated on a fee-for-service model, anesthesiologists billed per case, and ASCs rarely needed to subsidize coverage. That model has unraveled. Forward-looking ASCs are already treating anesthesiologists as essential partners in the business model, not third-party contractors. Some are bringing anesthesia in-house. Some are building equity partnerships that align incentives. This is the structural correction that produces durable coverage.

4. Fix scheduling efficiency. A significant share of the operational crisis is amplified by poor OR scheduling. Anesthesia groups were providing anesthesiologists but ORs were sitting empty, so they weren’t making enough revenue to justify coverage. Efficiency is not a soft operational goal. It is a financial survival requirement. One ASC in New York flipped the model: instead of paying stipends to the anesthesia group, surgeons now pay a fee if they fail to fill their assigned OR block. Case volume went up. Coverage stabilized. That is engineering applied to an operational problem.

5. Reimbursement reform is not optional. The payer system is actively making this worse. Average anesthesia reimbursement fell 5.5% from 2019 to 2023. CMS cut the anesthesia conversion factor another 2.83% in 2025. You cannot solve a workforce crisis by simultaneously making the workforce less financially viable. Advocating for reimbursement reform is not optional for any surgical leader who wants to operate in five years.

What I’m Telling My Colleagues

I sat in a planning meeting recently where we were mapping out OR expansion at Indiana Orthopedic Institute. The first question wasn’t about equipment or volume. It was: who is putting someone to sleep in these rooms?

That question is now the central operational constraint in outpatient surgery. It wasn’t five years ago.

Surgeons who built their practices around the ASC model, including me, have to reckon with the fact that the value proposition we offered patients, better outcomes, lower cost, more dignity than a hospital corridor, is under structural threat. Not from regulation. Not from competition. From a workforce pipeline that the federal government allowed to calcify for 30 years while the population aged.

This is a fixable problem. But it does not fix itself. It requires policy action at the federal level, structural reinvention at the ASC level, and surgeons willing to engage with it as an operational priority, not someone else’s administrative headache.

Your patient is on the table. The surgeon is scrubbed in. The lights are on.

The room is ready. The question is whether the person keeping that patient alive is too.

That is the crisis no one is talking about. I am talking about it.

A patient of mine came in last fall, not for a consultation about his hip, but to ask me about peptides. He’d been injecting BPC-157 he ordered online for three months. No prescription. No oversight. No idea what he was actually putting in his body.

He wasn’t reckless. He was desperate. Chronic tendon pain, slow recovery, a body that wasn’t doing what it used to. He’d read the forums, watched the videos, and decided to act. I respected that instinct, even as I sat across from him calculating the risk he’d taken.

That conversation is happening everywhere right now. In clinics. In gyms. In group chats between people who are tired of feeling like their doctors have no answers. And most of the time, nobody is giving a straight answer.

I will.

The Biology Is Real. The Market Is Chaos.

Let me be clear about something first: peptides are not fringe science.

Insulin is a peptide. You know insulin. Semaglutide, the active compound in Ozempic and Wegovy, is a peptide. It just reshaped the global conversation about obesity. The FDA’s approval of the first oral semaglutide tablet for chronic weight management in late 2025 didn’t happen because molecules like this are unproven novelties. It happened because peptide biology, at the right end of the research spectrum, is some of the most precise and powerful pharmacology we have.

A peptide is a chain of amino acids, shorter than a protein, which makes it more targeted in function. These molecules act as biological messengers, instructing specific cells to perform specific tasks. Your body already produces thousands of them. The therapy argument is simple: can we supplement with synthetic versions to restore processes that slow with age or stress?

In some cases, yes. In many cases, we do not yet know. And that gap is where everything goes wrong.

Where the Science Ends and the Hype Begins

Here is the distinction that most of the wellness industry refuses to make clearly, so I will make it for you.

There are FDA-approved peptides with rigorous human trial data, clear mechanisms, and established safety profiles. Then there is a much larger category of peptides that are biologically plausible, show promising results in animal models, and are being injected by thousands of people with zero physician involvement, based on forum posts and influencer content.

Online peptide advertising increased 678% between 2022 and 2025 as GLP-1 drugs gave the entire category mainstream credibility by association.¹ If semaglutide, a peptide, could do what Ozempic does, the logic went, what else might these molecules be capable of? That halo effect drove enormous interest straight into the gray market, and straight into people’s bodies.

BPC-157 is the most visible example of what that looks like when it goes wrong. It is arguably the most popular peptide in the biohacking world. People are injecting it for tendon repair, gut health, and injury recovery. As of early 2026, **35 of 36 published BPC-157 studies are animal-only, sourced from a single lab with undisclosed conflicts of interest.**² The enthusiasm for this compound ran years ahead of the evidence. That is not a minor detail. That is the entire story.

The delivery problem compounds this. Most peptides break down in the digestive tract. Serious use cases require injection, which means sourcing, sterility, accurate dosing, and proper technique all become critical variables. When people are ordering compounds from gray-market vendors with no clinical oversight, every one of those variables is out of control.

The gap between “makes sense in theory” and “proven safe in humans” is vast. I have spent my career on the side of that gap that requires evidence before action. I am not moving.

The Regulatory Reckoning Was Inevitable

The FDA’s posture toward compounded peptides shifted hard in late 2023, and by 2025 it had become a full enforcement campaign. More than 50 warning letters issued to compounders, online sellers, and clinics. Criminal prosecutions. Raids on major gray-market vendors.

The DOJ forced Tailor Made Compounding LLC to forfeit $1.79 million, establishing that the federal government was willing to bring criminal charges, not just civil penalties.³ Peptide Sciences, one of the largest gray-market players, voluntarily shut down in March 2026 before the walls closed in.

The political dimension added one more layer. RFK Jr. publicly pushed the FDA to widen access, calling himself a fan of peptide treatments and signaling that roughly 14 peptides should be made more accessible through compounding pharmacies. The enforcement machine didn’t pause.

But what the political conversation did do, and this matters for everyone following this space, is force a legitimate question onto the table: should patients have a supervised, physician-guided pathway to promising compounds that sit outside the current approval framework?

That is a reasonable question. It deserves a serious answer. Not a gray market, and not a blanket ban.

The crackdown was necessary. Not because the underlying biology is fraudulent. But because access without oversight is not freedom. It is exposure.

What I Actually Believe

I am not here to bury peptides. I am here to be precise about them, because precision is what this conversation has been missing.

The legitimate end of this science is advancing fast. AI-assisted peptide design accelerated discovery pipelines dramatically in 2025. Cancer therapies, metabolic interventions, immune modulation, these are real frontiers with real rigor behind them. The biology deserves serious investment and serious research. And patients deserve physicians who are engaged with it, not dismissive of it.

Here is the framework I use for any emerging intervention, whether it is a peptide, a surgical technology, or a wellness protocol. It applies whether you are a clinician evaluating options or a patient trying to make a smart decision about your own body:

1. What is the evidence hierarchy? Human trials, animal models, and in-vitro data are not equivalent. Know which one you are standing on before you act.

2. Who is prescribing and who is sourcing? A compounding pharmacy with a physician-supervised protocol is not the same as a gray-market vendor and a self-injection tutorial.

3. What is the risk-benefit calculation for this specific person? Not the population. Not the forum. You, your biology, your context.

4. What is the baseline? No peptide, drug, or technology outperforms a life built on sleep, whole food nutrition, consistent movement, and stress management. That is not a platitude. It is the highest-leverage intervention available to every human being on this planet, and it costs nothing.

The Foundation Always Comes First

I have performed over 10,000 joint replacements. I have watched patients spend years treating symptoms that were the direct consequence of how they lived, how they ate, how much they slept, and how much they moved. And I have watched those same patients expect a molecule to fix what decades of lifestyle built.

It won’t.

The most powerful intervention in human health is still the one that requires the most discipline: prevention. Real food. Real sleep. Real movement. Real relationships. These are not soft suggestions. They are the clinical foundation without which medicine, including the most advanced peptide therapies, is always playing catch-up.

My patient who had been injecting BPC-157 for three months had never had a serious conversation with a physician about his diet, his sleep quality, or his inflammatory load. He went straight to the injection because it felt like action. I understand that impulse completely. People are tired of waiting for the system to give them better options.

But here is what I told him, and what I will say plainly here: action without a foundation is just noise.

If you are curious about peptides, that curiosity is legitimate. The biology is real. The potential is real. But find a physician who will engage with you seriously, demand to know where you are in the evidence hierarchy, and build the lifestyle foundation that makes any intervention actually work.

The shortcut culture that drove the gray market is the same culture that has people spending thousands of dollars on compounds while sleeping five hours a night and eating ultra-processed food.

The molecule is not going to save you from that. Nothing is.

The Bottom Line

We are in an era where the biology of human optimization is genuinely accelerating. The tools are getting more precise. The research is getting more sophisticated. Patients are more informed and more engaged than any generation before them. That is something to build on, not shut down.

The surgeon’s job, and every physician’s job, is to stand at the incision point: where intention meets reality, where the plan meets the patient in front of you. That means demanding evidence, providing real oversight, and being honest when the shortcut isn’t actually shorter.

The molecule is not the enemy. The shortcuts are.

Are you navigating peptide questions as a patient, a clinician, or both? I’d like to hear what you’re seeing, and what answers you’re still looking for.

Footnotes

1. PeptideExaminer, Online Peptide Market Growth Analysis, 2025.

2. STAT News / PeptideExaminer, BPC-157 Research Landscape Review, February 2026.

3. U.S. Department of Justice, United States v. Tailor Made Compounding LLC, 2025.

My patients don’t just come to me in pain.

They come to me exhausted. They come with type 2 diabetes, hypertension, and a knee that gave out, managing three chronic conditions at 55 that their parents didn’t have at 70.

They come having done, more or less, what they were told. They bought what was on the grocery shelf. They ate what was affordable. They fed their kids what was available at the school cafeteria and the drive-through and the gas station on the way home from work.

And somewhere in that chain of ordinary decisions, something went very wrong.

I trained at Mayo Clinic. I hold an engineering degree from Rose-Hulman. I have performed more than 10,000 joint replacements. I have sat on the boards of the largest orthopedic surgery organizations in the world. I see the consequences of the American food system in the operating room every single week.

What I see is not bad luck. It is not genetics. It is the predictable, documented, and entirely preventable result of a food supply that has been engineered for profit at the direct expense of human health, for decades, with the full knowledge of the people doing it.

I am done softening that statement.

What Is Actually In Your Food

American adults now get 53% of their daily calories from ultra-processed foods. For children, that number is 62%.[1] The CDC confirmed these figures in its first-ever report on the subject, published in August 2025. First-ever. We have known this was happening for years and the federal government only just got around to measuring it officially.

More than half your calories. Every day. From products that bear almost no resemblance to food in any meaningful biological sense.

I want to be specific, because “ultra-processed” is a term that lets the industry hide behind abstraction. Here is what it actually means: these are industrial formulations containing ingredients that did not exist in the human food supply until the 20th century and whose long-term biological effects were never independently verified before they were put in everything you eat.

Petroleum-derived synthetic dyes: Red No. 40, Yellow No. 5, Yellow No. 6, Blue No. 1. Added to thousands of products to make them visually appealing. Red No. 3, used for decades, was finally banned by the FDA in January 2025 after the agency’s own data showed it causes cancer in animals.[2] It took until 2025.

High-fructose corn syrup, engineered to be sweeter and cheaper than sugar, metabolized by the liver differently than naturally occurring sugars, and linked to fatty liver disease, insulin resistance, and obesity.[3]

Emulsifiers like carrageenan and polysorbate 80, added to improve texture and shelf life, with emerging research suggesting they disrupt gut microbiome integrity and promote systemic inflammation.[4]

Artificial preservatives including BHA and BHT, added to prevent oxidation in packaged foods, classified as reasonably anticipated human carcinogens by the National Toxicology Program.[5]

Partially hydrogenated oils and industrial trans fats, so thoroughly documented as cardiovascular poison that the FDA banned them in 2018, but not before decades of consumption drove heart disease rates that still haven’t fully recovered.[6]

And over 1,000 other ingredients added to the food supply under the FDA’s “Generally Recognized As Safe” program, GRAS, in which food companies are permitted to certify the safety of their own ingredients without notifying the FDA or the public.[7] The MAHA Commission has specifically targeted this loophole for reform, and they are right to do so. An industry self-certifying its own ingredients as safe is not a regulatory system. It is an honor system operating inside a profit motive.

I agree with the core food agenda that Secretary Kennedy and the Make America Healthy Again movement have put on the national table: petroleum-based dyes should come out of the food supply, GRAS loopholes should be closed, ultra-processed food should be defined at the federal level, and SNAP benefits should not fund products with zero nutritional value. These are not partisan positions. They are basic public health positions backed by overwhelming evidence.

What It Is Doing to Your Body

The research on this is no longer at the frontier. It is settled, repeated, and alarming.

A 2024 umbrella review in The BMJ, covering 45 meta-analyses and nearly 10 million study participants, found convincing evidence that a diet high in ultra-processed foods increases the risk of death from cardiovascular disease by 50%.[8] Highly suggestive evidence placed the increased risk of obesity at 55%, Type 2 diabetes at 40%, and death from heart disease at 66%.[8]

The American Heart Association’s own 2025 Science Advisory confirmed that high versus low intake of ultra-processed foods is linked to a 25% to 58% higher risk of cardiometabolic outcomes and a 21% to 66% higher risk of mortality.[9]

Every additional 100 grams per day of ultra-processed food consumption is associated with a 14.5% higher risk of hypertension, a 5.9% increased risk of cardiovascular events, and a 19.5% higher risk of digestive diseases.[10]

These are not small signals. These are population-level findings, replicated across dozens of independent studies on tens of millions of people, in peer-reviewed journals at the highest level of evidence medicine produces.

The result, in real terms: more than 2 in 5 American adults now have obesity.[11] Treating diabetes and prediabetes costs this country over $327 billion annually.[12] Obesity-related medical care runs nearly $173 billion per year.[11] Ninety percent of all U.S. healthcare spending goes toward people with chronic and mental health conditions, most of them diet-related.[13]

The CDC projects that chronic disease will cost the United States $47 trillion between now and 2039.[14]

I’ll say that again. Forty-seven trillion dollars. Over the next 15 years. Driven in enormous part by conditions that trace directly to what is being sold at every grocery store, fast food counter, vending machine, and school cafeteria in America.

The Synthetic Dye Problem Is Bigger Than You Think

I want to spend a moment on food dyes specifically, because this is where the policy fight is most visible right now and where the industry’s behavior has been most egregious.

The synthetic dyes currently in the American food supply are petroleum derivatives. They are banned or heavily restricted in the United Kingdom, the European Union, Japan, and Australia, where products containing them must carry warning labels stating that the food “may have an adverse effect on activity and attention in children.”[15] In the U.S., they carry no warning. They are in children’s cereals, fruit snacks, sports drinks, candies, macaroni and cheese, and thousands of other products specifically marketed to children.

In 2025, roughly 75 bills targeting food dyes were introduced in 37 states.[16] West Virginia banned Red No. 40, Yellow No. 5, and Yellow No. 6 by law. California had already moved on four additives. Nestlé, Hershey, and PepsiCo pledged to begin removing synthetic colors voluntarily. The Consumer Brands Association asked its members to eliminate federally certified artificial dyes from products by end of 2027.[16]

The industry did not do this because they suddenly grew a conscience. They did it because the political pressure finally became unavoidable. These ingredients have been known to carry risk for decades. They stayed in the food supply because removing them cost money.

That calculation, what is profitable versus what is safe, is the operating logic of the entire ultra-processed food system. It has been from the beginning.

The Loop Nobody Talks About

Here is the part that should make you the most angry.

The food industry spends hundreds of millions of dollars every year lobbying against nutritional labeling requirements, sugar taxes, marketing restrictions to children, and front-of-pack warning labels.[17] They fund nutrition research designed to produce favorable conclusions. They helped shape decades of USDA dietary guidelines. They fought trans fat restrictions for years after the science was clear.

And when the chronic disease epidemic their products helped create shows up in your body, the hospital system is there to treat it. At $26,993 per year in employer-sponsored insurance premiums.[18] With a deductible that has gone up every year.[19] With an insurance company that will spend the next 90 days deciding whether your treatment is approved.

The food industry makes you sick. The healthcare industry charges you to manage it. Neither has a financial incentive for you to be well.

I am not speculating about this. I am describing the system as it functions, from inside it.

What I See in the Operating Room

I operate on patients whose joints have been destroyed in part by the inflammatory burden of decades of ultra-processed food consumption. I see the metabolic consequences, the effects of chronic systemic inflammation, the tissue changes that come from bodies running on ingredients they were never designed to process, every week.

These are not people who made bad choices. These are people who ate the food that was available, affordable, and relentlessly marketed to them by an industry that knew, and put the profit calculation ahead of the public health consequence.

I want fewer patients in my operating room, not more. The only path to that is a food supply that stops manufacturing the chronic disease that fills it.

What You Can Do Right Now

Read the ingredient label, not the nutrition facts panel. The nutrition facts panel is what the industry wants you to look at. Calories, fat grams, and protein are distractions. The ingredient list is where the truth is. If it contains synthetic dyes, HFCS, partially hydrogenated anything, or additives you cannot trace to a whole food source, that product is a bet against your long-term health.

Cook whole food when you can. Not as a lifestyle aspiration. As a defensive act. The data on what ultra-processed food does to your cardiovascular system, your metabolic health, and your mortality risk is overwhelming.

Support the food policy reforms that are actually grounded in evidence: mandatory front-of-pack warning labels, closure of the GRAS self-certification loophole, removal of petroleum-derived dyes from the food supply, and restrictions on ultra-processed food marketing to children. These are not radical positions. They are the standard in most of the developed world.

And when the food industry tells you their product is part of a balanced diet, ask who paid for that research.

Why I’m Writing This

I am inside the machine. I see both the food system’s consequences and the healthcare system’s response to them, up close, every week. Most people with the standing to speak about this from the inside have financial relationships that keep them quiet.

I don’t.

The Incision Point exists because the American public deserves a straight account of what is actually happening to their health, who is responsible, and what can actually change it. Not from a commentator. From a physician who is operating on the results.

Subscribe if you want to keep reading. Share this if it made you angry enough to want someone else to see it.

That anger is appropriate. Use it.

What ingredient on a food label has surprised or disturbed you most? Drop it in the comments.

Footnotes

1. CDC/NCHS Data Brief No. 536, August 2025. “Ultra-Processed Food Consumption Among U.S. Children and Adults, August 2021-August 2023.” cdc.gov

2. FDA, “FDA Revokes Authorization for the Use of Red No. 3 in Food and Ingested Drugs,” January 2025. fda.gov

3. Multiple sources including NIH research on fructose metabolism and fatty liver disease; Stanhope KL et al., multiple publications on high-fructose corn syrup and metabolic outcomes.

4. Chassaing B et al. “Dietary emulsifiers impact the mouse gut microbiota promoting colitis and metabolic syndrome.” Nature. 2015;519:92-96. Subsequent human studies have supported the association.

5. National Toxicology Program, U.S. Department of Health and Human Services. Report on Carcinogens listings for BHA and BHT.

6. FDA, “Final Determination Regarding Partially Hydrogenated Oils,” 2018. fda.gov

7. MAHA Commission Assessment, May 2025; ABC News reporting on GRAS reform proposals, September 2025.

8. Lane MM et al. “Ultra-processed food exposure and adverse health outcomes: umbrella review of epidemiological meta-analyses.” BMJ. 2024;384:e077310. doi:10.1136/bmj-2023-077310

9. American Heart Association Science Advisory, 2025. newsroom.heart.org

10. American College of Cardiology analysis of systematic review data, May 2025. acc.org

11. CDC, “Fast Facts: Health and Economic Costs of Chronic Conditions,” August 2025. cdc.gov

12. American Diabetes Association, cost of diabetes data, cited 2025.

13. CDC, “Health and Economic Costs of Chronic Diseases.” cdc.gov

14. Partnership to Fight Chronic Disease/GlobalData. December 2025. fightchronicdisease.org

15. European Food Safety Authority assessments of synthetic food dyes; UK Food Standards Agency labeling requirements.

16. KFF Health News, “RFK Jr.’s MAHA Movement Has Picked Up Steam in Statehouses,” January 13, 2026. kffhealthnews.org

17. Multiple lobbying expenditure analyses cited in Ballard Brief, BYU, “The Overconsumption of Ultra-Processed Foods in the United States,” 2024.

18. KFF 2025 Employer Health Benefits Survey, October 2025. doi:10.1377/hlthaff.2025.01106

19. KFF Health News, “A New Car vs. Health Insurance? Average Family Job-Based Coverage Hits $27K,” October 2025.

Editorial note on seed oils: The research on isolated seed oil consumption is genuinely contested, with the mainstream peer-reviewed consensus, including 2025 findings from Johns Hopkins, the American Heart Association, and multiple meta-analyses, finding that linoleic acid in seed oils is not the independent driver of inflammation or cardiovascular disease that MAHA messaging claims. The article frames seed oils as one industrially deployed ingredient within the broader ultra-processed food system, which is the scientifically defensible position.

I do not learn about my patients from their charts.

I learn about them from their tissue.

After 10,000+ joint replacements, I can tell within the first few minutes of a case what kind of physical life someone has been living. The quality of the muscle surrounding the joint. The integrity of the supporting structures. The biological age of the architecture I am working inside — which is often dramatically different from the number on the patient’s wristband.

Two patients last year. Similar age. Similar diagnosis. Similar preoperative pain scores. Completely different bodies on the table.

The first was strong. Not a competitive athlete — just someone who had lifted consistently for years, maintained their muscle mass, kept their posture upright and their supporting structures intact. The surgery was clean. Recovery was textbook. They were walking without assistance faster than the protocol predicted.

The second had spent a decade doing what most Americans do for fitness — some walking, occasional cardio, nothing that loaded the skeletal muscle with any real demand. The muscle surrounding the joint was atrophied and soft. The supporting architecture was compromised. The surgery was harder. Recovery was slower. The complications were not dramatic, but they were real, and they were predictable.

Same diagnosis. Same surgeon. Completely different outcomes.

The difference was muscle. And nobody had ever told the second patient that muscle was something they needed to deliberately build and protect.

That failure is not the patient’s fault. It is the system’s.

The Silent Epidemic Nobody Is Screening For

Sarcopenia — the progressive loss of skeletal muscle mass and function — is one of the most consequential and least discussed health crises in American medicine.

After age 30, the average adult loses between 3 and 8 percent of muscle mass per decade without deliberate intervention. After 60, that rate accelerates. By the time most people arrive at my operating table in their sixties and seventies, they have been losing muscle for three decades and have never once had a physician discuss it with them, screen for it, or prescribe anything to address it.

The downstream consequences are not limited to surgical outcomes. A 2022 meta-analysis published in the Journal of Cachexia, Sarcopenia and Muscle examining data from over 700,000 individuals found that low muscle mass is independently associated with all-cause mortality, cardiovascular mortality, and metabolic disease — with effect sizes comparable to established risk factors like hypertension and dyslipidemia.

Low muscle mass is as dangerous as high blood pressure. We screen aggressively for one. We do almost nothing about the other.

The annual physical does not measure muscle mass. It does not assess grip strength — one of the most validated predictors of long-term mortality in the literature. It does not ask about resistance training. It measures weight, which tells you almost nothing useful about the composition of that weight or the biological function of the body carrying it.

A scale weight is not a health metric. Muscle mass is.

The Cardio Lie We Have Been Living

I want to challenge something that has been accepted as health gospel for forty years.

The dominant fitness narrative in America — the one that produced a generation of recreational runners, spin class devotees, and elliptical machine regulars — is built almost entirely around cardiovascular exercise. Cardio for heart health. Cardio for weight loss. Cardio as the primary currency of physical fitness.

Cardiovascular exercise has real and documented benefits. I am not dismissing it.

But cardio does not build muscle. And muscle, it turns out, is not optional.

The cultural over-indexing on cardio has produced millions of metabolically fragile people who are aerobically functional but structurally deficient — people whose hearts are reasonably conditioned but whose skeletal muscle is insufficient to protect their joints, regulate their metabolism, or sustain them through a major medical event.

I see them on my table regularly. Thin, aerobically active, and sarcopenic. The combination is more common than most people realize, and it is more dangerous than simple obesity in certain surgical contexts because it carries none of the visible warning signs that trigger clinical concern.

The engineering problem here is straightforward: you cannot maintain a structure without loading it. A joint unsupported by adequate muscle is a joint under accelerated mechanical stress. A skeleton not subjected to regular resistance load loses density. A body that only moves through low-resistance, repetitive motion patterns develops the postural adaptations of exactly the lifestyle it is living.

Sitting is a structural problem as much as a metabolic one. The anterior pelvic tilt, the forward head posture, the shortened hip flexors and inhibited glutes that characterize a desk-bound population — these are not cosmetic issues. They are mechanical loading problems that alter joint stress patterns and accelerate the degenerative cascade I am eventually asked to surgically address.

The body adapts to the demands placed on it. If the demand is eight hours of sitting and thirty minutes of walking, the body optimizes for exactly that. It does not maintain architecture it is not being asked to use.

What Muscle Actually Does

Here is the piece the cardio-only conversation misses entirely.

Skeletal muscle is not simply a mechanical system for moving the body. It is an endocrine organ — one of the largest in the body — that produces and secretes signaling molecules called myokines in direct response to mechanical load.

Myokines regulate systemic inflammation, glucose metabolism, cognitive function, immune response, and fat oxidation. IL-6 released from contracting muscle during resistance exercise has potent anti-inflammatory effects — the same cytokine that drives pathology when chronically elevated by stress and poor diet becomes protective when acutely released through muscular contraction.

Irisin, a myokine released during resistance training, crosses the blood-brain barrier and has been associated in multiple studies with reduced neurodegeneration and improved cognitive function. BDNF — brain-derived neurotrophic factor — is upregulated by resistance exercise and represents one of the most powerful known stimulants of neuroplasticity.

When you lift, you are not just building muscle. You are running an anti-inflammatory protocol, a metabolic optimization program, and a cognitive enhancement intervention simultaneously.

There is no drug that does all of that. There is no supplement that replicates it. There is only load.

The Framework: Muscle First

I want to give you something concrete to carry out of this article.

1. Reframe the goal. The objective of exercise is not weight loss or cardiovascular fitness. Those are byproducts. The primary objective is building and maintaining skeletal muscle mass throughout your lifespan. Every other benefit follows from that.

2. Resistance training is non-negotiable. Two to three sessions per week of progressive resistance training — exercises that place genuine mechanical demand on major muscle groups — is the minimum effective dose. Not yoga. Not walking. Not the light resistance band routine. Load. Progressive, deliberate, increasing over time.

3. Protein supports the structure. Muscle protein synthesis requires adequate dietary protein. The RDA of 0.8g per kilogram of body weight was established to prevent deficiency, not to optimize muscle maintenance in aging adults. The sports medicine and longevity literature consistently supports 1.6 to 2.2g per kilogram for anyone over 40 who is training with intent.

4. Posture is structural integrity. If you sit for more than six hours a day, your hip flexors are shortened, your glutes are inhibited, and your spine is loaded in a pattern it was not designed to sustain indefinitely. Address this deliberately — not with stretching alone, but with the resistance training that restores the posterior chain function that sitting systematically dismantles.

5. Start now, not later. The research on resistance training benefits in adults over 60, 70, and even 80 is unambiguous — it is never too late to build meaningful muscle and recover meaningful function. But the earlier you start, the more you are protecting rather than rebuilding.

The Prescription We Are Not Writing

I am a surgeon. I fix joints that have failed. I am good at it, and I will keep doing it.

But the most important intervention I can offer most of my patients is not the surgery. It is the conversation I try to have before surgery becomes necessary — the one about what their body needs to stay out of my operating room.

Muscle is medicine. It is the most powerful preventive intervention available for joint disease, metabolic disease, cognitive decline, and all-cause mortality. It is free, it is accessible, and it requires no prescription.

We are not prescribing it. We are not screening for its absence. We are not teaching it in medical school with anything close to the emphasis the evidence demands.

That needs to change. And it starts with surgeons — who see the consequences more clearly than almost anyone — leading that conversation rather than waiting for the system to have it.

Build the muscle. Protect the structure. Do not wait until someone like me is the next appointment on your calendar.

That is the incision point.

Are you lifting? Or are you still in the cardio trap?

Tell me where you are… and what is stopping you from changing it.

Dr. Michael Meneghini

I have looked inside more than 10,000 human joints.

I can tell you things about the human body that do not show up in textbooks. I can tell you what a life of chronic stress looks like in synovial tissue. I can tell you the difference between a joint that has been quietly inflamed for a decade and one that has not.

What I see more than anything else, in patient after patient, year after year, is the same thing.

Inflammation. Systemic, chronic, low-grade, and almost entirely invisible until it is not.

The frustrating part is not that this is happening. The frustrating part is that we have the tools to detect it early, the knowledge to address it directly, and a medical system that has organized itself almost perfectly to do neither.

I know this because I almost missed it in myself.

The Silent Driver Nobody Is Naming

Chronic low-grade inflammation is the common upstream driver of the four leading causes of death in America — cardiovascular disease, cancer, diabetes, and Alzheimer’s disease.

Not a contributing factor. The upstream driver.

A landmark analysis published in Nature Medicine in 2023 examined data from nearly 45 million patients and concluded that chronic inflammation is implicated in more than 50% of all deaths globally. The inflammatory cytokine interleukin-6, elevated C-reactive protein, and chronic activation of the NF-kB signaling pathway appear across the pathology of heart disease, type 2 diabetes, multiple cancers, and neurodegenerative disease with a consistency that is no longer scientifically debatable.

We are not talking about the acute inflammation that heals a wound. That version is one of the most elegant systems in biology. We are talking about its chronic, dysregulated cousin — the kind that never fully switches off, that quietly degrades tissue over years and decades, that shows up in your bloodwork as a whisper long before it announces itself as a diagnosis.

Your annual physical is almost certainly not testing for it.

What the OR Taught Me

I started noticing a pattern years into my surgical career.

Two patients, similar age, similar weight, similar preoperative function scores. I open the first joint and the tissue is relatively healthy. I open the second and it is a different story entirely — inflamed synovium, degraded tissue quality, a joint that looks biologically a decade older than the chart suggests.

The difference was not always explainable by diagnosis alone. It was systemic.

I started asking more questions. Diet. Sleep. Stress. Movement. The answers were predictable in their consistency. Then I ran my own labs — and found markers I did not expect in someone performing, by every external measure, at a high level.

That was the moment I understood this personally, not just clinically.

The association between systemic inflammation and poor surgical outcomes is well-documented. Elevated preoperative CRP is an independent predictor of complications after joint replacement. Metabolic syndrome substantially increases infection risk, wound complication rates, and implant failure. I was seeing the end stage of a process that had started silently, years earlier, that nobody had ever named for these patients.

The System Is Built to Miss It

We are organized to treat disease, not to prevent it. And chronic inflammation sits in the gap between the two.

Your annual physical screens for acute illness and manages established diagnoses. It is a liability screen dressed up as a health assessment — almost entirely backward-looking. It identifies what has already gone wrong, not what is quietly accumulating.

High-sensitivity CRP — the most accessible and clinically validated marker of systemic inflammation — is not standard on most wellness panels. It costs a few dollars to run. The JUPITER trial, published in the New England Journal of Medicine in 2008, enrolled nearly 18,000 patients with normal LDL but elevated hsCRP and demonstrated that treating the inflammatory burden reduced cardiovascular events significantly.

That was 2008. Seventeen years ago. hsCRP is still not standard of care.

The system is not failing by accident. Prevention does not bill. Chronic disease management does. That is not cynicism. That is an incentive structure.

And then there is the NSAID problem.

Americans consume approximately 30 billion doses of NSAIDs annually. They are the default response to the pain and stiffness that chronic inflammation produces. They do not address inflammation. They suppress its signal.

Long-term NSAID use carries documented risks. A 2017 meta-analysis in the British Medical Journal examining more than 446,000 patients found that all common NSAIDs were associated with significantly elevated risk of acute myocardial infarction — with risk emerging within the first week of use.

We are managing the signal of chronic inflammation with a drug class that, at population scale, is generating its own cardiovascular burden. This is what symptom suppression without root cause resolution looks like in practice.

Two Things You Can Do This Week

Ask for hsCRP on your next blood panel.

It is inexpensive, widely available, and requires no special preparation. Optimal is below 1.0 mg/L. Above 2.0 mg/L represents elevated cardiovascular risk. Above 3.0 mg/L is high risk. If you are above 2.0 and nobody has discussed it with you, you are in the gap the system is not designed to address. While you are at it, ask for homocysteine — independently associated with cardiovascular disease, cognitive decline, and systemic inflammatory burden. Both tests together cost less than a co-pay.

Remove the fuel.

Chronic inflammation has inputs. The most powerful modifiable ones, ranked by the strength of the evidence: diet first — ultra-processed food, refined seed oils, and added sugar directly drive the NF-kB inflammatory pathway. Sleep second — a single night of poor sleep measurably elevates IL-6 and TNF-alpha. Movement third — resistance training specifically produces anti-inflammatory myokines through skeletal muscle; a sedentary body is an inflamed body. Chronic stress fourth — sustained cortisol elevation drives inflammatory gene expression, documented in the psychoneuroimmunology literature for thirty years.

None of these require a prescription. None generate revenue for the sick-care system. All of them work.

Treat the Root, Not the Branch

Every chronic disease conversation you will have with a doctor is a branch conversation. Statins for cholesterol. Metformin for blood sugar. NSAIDs for joint pain. Clinically appropriate in many contexts. Entirely silent on the root.

The root is inflammation.

The branch conversations are not wrong. They are incomplete. And incomplete, at population scale, over decades, is how you end up with a country where chronic disease is the norm and the healthcare system calls it inevitable aging.

It is not inevitable. Ask for the test. Change the inputs. Have the root conversation.

That is the incision point.

What markers is your doctor running? AND, what’s missing from your panel?

Tell me below.

Dr. Michael Meneghini

My patients are always asking me where their money goes.

Not about their diagnosis. Not about recovery time. The first question, more often than I’d like to admit, is some version of: “Doctor, what is this going to cost me?”

These are working people. People with jobs, with insurance cards in their wallets, with coverage they’ve paid into for years. And they are terrified of the bill that comes after I help them.

That fear is not irrational. That fear is the correct response to a system that has been taking their money for decades and delivering less every year in return. I’ve watched it happen from inside the operating room, inside the boardroom, and inside the data. And I’m done staying quiet about it.

The Number They Don’t Put on the Benefits Brochure

The average American family with employer-sponsored health insurance is now paying $26,993 per year in premiums.[1] Just premiums. Before you’ve seen a single doctor. Before you’ve filled a single prescription.

Your employer pays the bigger share of that. But your portion comes out of your paycheck every two weeks, quietly, before you ever see it. And then, when you actually need care, you pay again. Deductibles. Copays. Coinsurance. Out-of-network surprise bills that arrive two months after a procedure you thought was covered.

Add it all up: a family of four with “good” employer insurance is carrying nearly $29,000 in total annual healthcare costs.[2]

More than most Americans spend on housing.

And it has gone up 6% or more, every single year, for three years running.[3] Not because the care is getting better. Not because the outcomes are improving. Because the entities that control your access to care have spent decades making sure there is nowhere else to go.

Here Is What Is Actually Happening to Your Money

I need you to understand this part clearly, because the people profiting from your confusion are counting on it staying confusing.

When you go to a hospital for a procedure, you are not just paying your surgeon. You are paying a facility fee. That fee goes to the hospital itself. And because hospital systems have spent the last 20 years buying up every competing practice, clinic, and surgery center in their market, there is increasingly nowhere else to go.

In 2023, one or two hospital systems controlled all commercial inpatient care in roughly half of all U.S. metropolitan areas.[4] Half the country. One or two choices. When competition disappears, prices go one direction.

Your insurer is not fighting this on your behalf. They negotiated contracts with those same hospital systems years ago. The terms are confidential. The prices are hidden. And when costs rise faster than they can absorb, their move is not to push back on the hospital. Their move is to raise your deductible, narrow your network, and deny more of your claims.

None of that reduces what the hospital charges. It just moves more of the bill directly onto you.

This is not an accident. It is not incompetence. It is a business model running exactly as designed.

The Doctor in That Room Isn’t Getting Rich Either

I want to say something that surprises most people.

Physician compensation, adjusted for inflation, has declined significantly over the past two decades, even as premiums have exploded.[5] The average doctor today spends nearly as much time on insurance paperwork and prior authorization battles as on patient care.[6]

Burnout among American physicians is approaching 50%. Not because doctors stopped caring. Because the system converted them into billing units inside someone else’s revenue machine.

I’ve been that doctor. I trained at Mayo Clinic. I have an engineering degree from Rose-Hulman. I have performed more than 10,000 joint replacements. And I have sat in boardrooms in my scrubs listening to hospital executives discuss “margin optimization” while my patients asked me what their surgery was going to cost them.

At a certain point, you stop rearranging the chairs.

I left. I built Indiana Orthopedic Institute from two people to more than 100 employees and 16 surgeons in three years, physician-owned, patient-first, transparent on cost. Not because I had a brilliant business idea. Because patients and employers found us, saw what care could actually look like, and refused to go back to the alternative.

That tells you everything about how hungry people are for something different.

The Lower-Cost Option Exists. You Just Don’t Know About It.

This is the part that makes me the most frustrated. Because the solution isn’t theoretical. It is operating right now, in thousands of locations across the country, and most patients have no idea.

Ambulatory surgery centers, or ASCs, are physician-owned outpatient surgical facilities. For most elective procedures, including the joint replacements I perform every week, the clinical outcomes are equivalent to hospital-based care.

The cost is not.

The same procedure in an ASC costs less than half of what it costs in a hospital outpatient department.[7] Medicare alone saves an estimated $4.2 billion every year by routing surgeries to ASCs instead of hospitals.[7] Patients save an average of $684 per procedure, out of pocket, just by changing the location of their care.

Some employers have figured this out. They are now contracting directly with physician-owned surgery centers, sending their employees in for procedures, waiving all out-of-pocket costs, and still coming out ahead financially compared to what their insurance network would have charged at the local hospital.[8]

The employer pays for the flight. Pays for the hotel. Covers every dollar of the procedure. And still saves money.

That gap between what the hospital charges and what a physician-owned facility charges is not a small inefficiency. It is the size of the lie the system has been telling you.

Why I’m Writing This

I am a surgeon. I fix broken things.

The American healthcare system is broken in ways that are specific, documented, and solvable. And the people most harmed by it, the families watching their paychecks erode, the patients who delay care because they cannot predict the bill, the workers who technically have insurance and still end up in medical debt, are also the people who have been given the least access to a straight explanation of what is actually happening.

That is what I’m here to change.

I am not a policy analyst. I am not a commentator watching this from a distance. I am inside the machine, every single week, seeing the consequences of these decisions in the people who come to me in pain and leave scared about the bill. That proximity gives me something most healthcare writers don’t have: I know exactly where the bodies are buried, and I have nothing to lose by saying so.

If you want the unfiltered version of what is actually happening in American healthcare, subscribe. Every piece I write is grounded in clinical data, operational experience, and the kind of specificity you don’t get from people who have never stood at an operating table or walked out of a hospital boardroom furious.

If this article made you angry, share it. The system counts on your frustration staying private. Make it loud.

And if you have a healthcare bill sitting on your kitchen table right now that you don’t understand, drop a comment below. I read every one. You deserve a straight answer.

Thanks for reading.

Dr. Michael Meneghini

What is the most absurd medical bill you’ve ever received? I want to know.

Footnotes

1. KFF 2025 Employer Health Benefits Survey, October 22, 2025. Wager E et al. Health Benefits in 2025: Family Premiums Rise 6 Percent. Health Affairs. doi:10.1377/hlthaff.2025.01106

2. Peterson-KFF Health System Tracker, “How Much Do People with Employer Plans Spend Out-of-Pocket on Cost-Sharing?” February 2026. healthsystemtracker.org. Note: total figure based on 2024 premium and out-of-pocket data; 2025 total will be higher given the 6% premium increase.

3. KFF Health News, “A New Car vs. Health Insurance? Average Family Job-Based Coverage Hits $27K,” October 28, 2025. kffhealthnews.org

4. Peterson-KFF Health System Tracker, “Eight Trends Shaping 2026 Healthcare Costs,” March 2026. healthsystemtracker.org

5. Physician compensation trend data. Note: the directional decline is well-documented across multiple sources including Merritt Hawkins and the Physician Advocacy Institute. Recommend substituting a personal data point or a specific sourced figure before final publication.

6. Arndt BG et al. “Tethered to the EHR: Primary Care Physician Workload Assessment Using EHR Event Log Data and Time-Motion Observations.” Annals of Family Medicine, 2017. Directionally consistent with more recent analyses; recommend updating citation if a more recent source is available.

7. Ambulatory Surgery Center Association (ASCA)/KNG Health Consulting, Medicare cost savings analysis; Colliers Q3 2025 Healthcare Services Report, via Healthcare Finance News, October 2025.

8. ASC News, “Top Ambulatory Surgery Center Trends for 2025,” January 2025, citing Surgery Center of Oklahoma. ascnews.com

Healthcare is now an $11 trillion global industry.

That number is projected to reach $21 trillion by 2030 - a compound annual growth rate (CAGR) of roughly 7%.

Let me put that in perspective. That is a similar growth rate to semiconductor chips and Apple Inc.. Healthcare is growing faster than most technology sectors, and we are not curing anything or inventing something new. We are managing disease. We are keeping people alive, sick, and returning - year after year - to a system that profits from their continued illness.

That is not healthcare. That is the healthcare industry. And there is a profound difference.

We Are Not Curing Anything

The two primary drivers of this explosive growth are an aging population and the rising prevalence of chronic disease.

Diabetes. Obesity. Cardiovascular disease. Osteoarthritis. Conditions that, in many cases, are directly traceable to lifestyle - to processed food, physical inactivity, poor sleep, and chronic stress. These are not mysteries. The science is settled.

The global population aged 65 and older is projected to reach 1.5 billion in the coming decades, and healthcare spending on this age group alone is expected to exceed $1.2 trillion.¹ That is a staggering number. But here is the question no one in the healthcare industry wants to answer honestly: how much of that spending is curative versus palliative?

Very little of it is curative.

We are not winning the war on chronic disease. We are funding its perpetual management. The pharmaceutical companies are not incentivized to cure diabetes - they are incentivized to sell insulin, GLP-1 agonists, and metformin for the next 50 years. The hospital systems are not incentivized to keep patients away - they are incentivized to fill beds, generate readmissions, and maximize billing codes.

The business model of American healthcare is predicated on sick people staying sick.

I do not say that as a conspiracy theory. I say it as someone who has operated inside this machine for 20+ years.

The Trillion-Dollar Waste Machine

Here is what the system will not advertise: a landmark study published in JAMA estimated the annual cost of waste in the US healthcare system at between $760 billion and $935 billion - approximately 25% of total healthcare spending.²

A quarter of everything we spend. Gone.

Where does it go? Let me count some of the ways:

1. Administrative complexity - the largest single category of waste, estimated at $266 billion annually. The average physician spends the equivalent of $68,000 per year dealing with billing-related activities.³

2. Overtreatment and low-value care - procedures that deliver no clinical benefit, costing between $75 billion and $101 billion per year.²

3. Pricing failure - inflated rates for medications, payer-based services, and laboratory work, totaling $230 billion to $240 billion annually.²

4. Failure of care coordination - patients discharged without follow-up, readmitted unnecessarily, bounced between specialists who never communicate.

5. Fraud and abuse - upcoding, phantom billing, charges for services never rendered.

6. Unnecessary inpatient stays - keeping patients in hospital beds for days when the procedure required hours.

7. $4 billion hospital campuses - monuments to institutional ego that embed overhead costs into every single patient encounter.

8. Redundant diagnostic testing - the same MRI ordered by three different departments because no one shares records.

9. Prior authorization bureaucracy - clinical decisions made by insurance adjusters, not physicians, delaying care and consuming physician time.

10. Hospital-employed physician models - where a physician’s productivity is taxed at 40% to 60% by the health system overhead above them.

11. Pharmaceutical rebate games - where list prices bear no relationship to actual costs, and the spread disappears into the supply chain.

12. Defensive medicine - tests ordered to protect against litigation, not to treat the patient.

13. Supply chain opacity - hospitals paying 3x markup on devices because they lack price transparency.

14. Chronic disease management without root-cause treatment - managing downstream consequences rather than addressing lifestyle upstream.

15. EHR systems built for billing, not for care - physicians spending 2 hours on documentation for every 1 hour of patient interaction.

16. Credentialing and compliance bureaucracy - armies of administrators generating paperwork that does not improve a single patient outcome.

17. Preventable readmissions - failures of care delivery costing $102 billion to $165 billion per year,² much of it traceable to inadequate discharge planning.

18. Drug waste - hospitals discarding an estimated $3 billion in unused medications annually.

19. Executive compensation at nonprofit hospital systems - C-suite salaries that would embarrass a hedge fund, justified by “mission-driven” language.

20. The construction of $1 billion-plus inpatient facilities for elective procedures that belong in outpatient settings.

The US spends over $1,000 per capita on administrative costs alone - more than three times the OECD average of $194.⁴ Germany, our closest peer, spends $306. We spend $1,055.

The delta is not care. The delta is overhead, complexity, and institutional self-preservation.

The $4 Billion Hospital Problem

Let me address this directly, because no one in healthcare leadership will.

Henry Ford Health recently announced plans to build a new $1.8 billion hospital at its main campus in Detroit,⁵ part of a broader $2.5 billion development. They are not alone. Across the country, health systems are building flagship campuses that cost more than NFL stadiums, financed on the backs of insurance reimbursements and, ultimately, the patients and employers paying those premiums.

National average hospital construction costs have increased more than 20% over the past five years.⁶ These are not investments in better outcomes. They are investments in market share, in signaling institutional dominance, in capturing more inpatient volume for procedures that don’t require inpatient stays.

A hospital should be for life-threatening situations. Trauma. Complex cardiac surgery. Stroke. Oncology. That is what the inpatient environment is built for.

It is not built for a knee replacement. It is not built for a hip. Not for a rotator cuff. Not for a spine decompression. Not for the hundreds of elective procedures that require 90 minutes in an operating room and a few hours of recovery.

Yet patients are admitted, kept for 3 to 5 days, and billed at rates that would make the hotel industry blush - because the system is designed to maximize inpatient revenue, not to serve the patient.

530,000 Families a Year

While the health systems build billion-dollar campuses, the patients are going bankrupt.

Every year, approximately 530,000 American families file for bankruptcy due to medical bills.⁷ Medical debt is the leading cause of personal bankruptcy in the United States - a phenomenon that is virtually nonexistent in every other developed country in the world.

Almost one in five adults with healthcare debt either lose their homes or declare bankruptcy.⁸

Think about that. Not in a developing country. Here. In the wealthiest nation in human history, people are losing their homes because they had a surgery.

This is not a healthcare system. This is an extraction machine wearing a white coat.

The Blueprint Already Exists: The ASC Model

I am not here to complain. I am here to offer the proof-of-concept that the system can be redesigned.

At Indiana Orthopedic Institute, we built our model around a core operational truth: the right care, delivered in the right setting, at the right time, costs significantly less and produces better outcomes. Our ambulatory surgery center is not a compromise. It is the standard.

The data is not ambiguous. Outpatient joint replacements performed in an ASC cost 40% less than those performed in a hospital. Rotator cuff repair and knee arthroscopy cost over 50% less.⁹

A study presented at the 2024 AAOS Annual Meeting found that procedures performed at ASCs resulted in approximately 35% savings in total cost, 41% savings on facility fees, and 36% savings in Medicare payments¹⁰ - across the board, not as an outlier.

On average, the Medicare program and its beneficiaries share in more than $2.3 billion in savings each year when patients receive surgical procedures at ASCs instead of hospital outpatient departments.¹¹

The ASC model is not an experiment. It is a proven, scalable alternative to inpatient care for elective procedures - with lower infection rates, shorter recovery times, higher patient satisfaction, and dramatically reduced cost.

Why keep a patient in the hospital for 4 days for a procedure that takes 2 hours?

There is one honest answer: money. The hospital charges more. The system is built to capture that revenue. And as long as the incentives are aligned toward inpatient volume, that is where the cases will go - regardless of what is actually best for the patient.

That alignment has to end.

The Operational Directive

If you are a surgeon reading this, here is what you need to understand: the hospital will not fix this. The insurance industry will not fix this. The federal government, which has been debating healthcare reform for 40 years, will not fix this on any timeline that matters to your patients today.

You have to build the alternative yourself.

That means owning your surgical setting. It means vertically integrating your practice around patient-centered, outcomes-focused, cost-transparent care. It means refusing to be a revenue generator for a corporate system that sees your clinical autonomy as a liability.

The preventive side of this equation matters equally. We will not bend the $21 trillion curve by building more hospitals. We will bend it by addressing root causes - sleep, nutrition, exercise, metabolic health. Those conversations need to happen in every clinic, every pre-op appointment, every post-op visit. Not as an afterthought. As the core clinical mission.

I built Indiana Orthopedic Institute from two people to 100 employees and $40M in three years. Not by following the corporate playbook. By rejecting it. By building something that actually works for the patient and, by extension, for everyone who touches the system.

The $21 trillion future is not inevitable. It is a choice.

Choose differently.

What systemic waste makes you the most angry - and what are you doing about it? Let’s hear it.

- Dr. Michael Meneghini

Sources

1. Ken Research, Global Healthcare Market Outlook to 2030 (2025)

2. Shrank WH, Rogstad TL, Parekh N. “Waste in the US Health Care System: Estimated Costs and Potential for Savings.” JAMA. 2019;322(15):1501-1509.

3. Peter G. Peterson Foundation. “Almost 25% of Healthcare Spending Is Considered Wasteful.” September 2025.

4. DocBuddy. “5 Statistics on Wasteful Health Spending.” Citing OECD comparative administrative cost data, 2021.

5. Commins J. “Hospital construction slows amid rising material costs.” Modern Healthcare. May 2023.

6. Giffin S. “Hospital construction costs increase.” Health Facilities Management Magazine. January 2024.

7. Balancing Everything. “Medical Bankruptcies Statistics.” Citing American Journal of Public Health and Consumer Bankruptcy Project data. February 2024.

8. RetireGuide. “49+ U.S. Medical Bankruptcy Statistics for 2023.” March 2025.

9. OSSM Newark. “Ambulatory Surgery Centers vs. Hospital Outpatient Departments.” Citing Orthopedics Review and multiple comparative studies. October 2024.

10. Smith S, et al. “Hand and Upper Extremity Procedures Are Significantly More Cost Effective when Performed in Ambulatory Surgery Centers versus Hospital Outpatient Departments.” Presented at AAOS Annual Meeting. March 2024.

11. Advancing Surgical Care / ASC Association. “The ASC Cost Differential.” Citing University of California Berkeley Center on Health Care Markets and Consumer Welfare data.

Cereal for breakfast. Chips and a sandwich for lunch. Whatever came out of a box or a bag at dinner when the schedule was too full to think about food. I was a competitive athlete. I was thin. I told myself the food was fine because my body looked fine.

It was not fine. I just could not see the damage yet.

The wake-up came gradually, then all at once - the way most important realizations do. I started tracking my own labs. I started reading the metabolic research, not the headlines. And I started connecting what I was seeing on my operating table to what my patients had been eating for decades. The inflammation. The tissue quality. The joint architecture of people in their fifties who looked, from the inside, like they were decades older.

Food did that. Specifically, the industrially engineered, deliberately addictive, government-subsidized products that the food industry has spent fifty years pretending are food.

I changed what I ate. My labs changed. My energy changed. My surgical performance changed.

And I got angry. Because none of this was accidental.

This Was Engineered - and We Have the Documents to Prove It

On April 8, 1999, eleven CEOs of America’s largest food companies - Kraft, Nabisco, General Mills, Procter & Gamble, Coca-Cola, Mars, and others - gathered secretly at Pillsbury headquarters in Minneapolis. There were no reporters. No minutes taken. No recordings made.

Kraft Vice President Michael Mudd took the stage and delivered a 114-slide presentation. His message: the industry’s products were driving the obesity epidemic, the science was clear, and collective action was the only path that would not end in congressional hearings and class-action litigation. He pleaded with the room. He named the stakes. He laid the evidence at their feet.

The CEO of General Mills stood up, pushed back, and the meeting ended without a single meaningful commitment.

This is not rumor. It is documented in Salt Sugar Fat by Pulitzer Prize-winning journalist Michael Moss - sourced from internal records and firsthand interviews with people in that room.

What followed was decades of investment in what the food industry calls “the bliss point” - the precise combination of sugar, salt, fat, and texture engineering that maximizes consumption and overrides the brain’s natural satiety signals.

Frito-Lay hired neuroscientists. Coca-Cola funded research designed to confuse the public about sugar’s role in obesity. General Mills engineers spent years calibrating the melt-in-your-mouth disintegration rate of Cheetos, because a snack that dissolves quickly registers fewer calories to the brain and keeps the consumption loop open.

This is not conspiracy theory. This is documented corporate strategy, confirmed in internal memos, depositions, and investigative reporting.

It is the tobacco playbook. Beat for beat.

Philip Morris - which owned Kraft for two decades - used the same internal research architecture to understand addiction and the same public relations machinery to deny it. The scientists who helped design nicotine delivery optimization in cigarettes were later consulting on flavor enhancement for processed foods. The connection is not metaphorical. It is organizational and personnel-level.

Tobacco killed people slowly and publicly, and it took fifty years and congressional testimony to hold it accountable.

Ultra-processed food is doing the same thing. At larger scale. With a better lobbying operation.

What “Ultra-Processed” Actually Means - and Why the Label Matters

The NOVA classification system, developed by researchers at the University of Sao Paulo, defines ultra-processed food not by individual nutrients but by industrial formulation: products that contain ingredients you would not find in a home kitchen - emulsifiers, flavor modulators, colorants, humectants, texturizers - assembled to maximize palatability, shelf life, and consumption rate.

We are not talking about bread or cheese. We are talking about products engineered in laboratories to behave differently in your brain than whole food does.

The research on what these products do is no longer preliminary. A landmark 2019 randomized controlled trial published in Cell Metabolism - led by Kevin Hall at the NIH - was the first to demonstrate causally, in a controlled setting, that ultra-processed food drives overconsumption. Participants eating ultra-processed diets consumed an average of 508 additional calories per day compared to matched whole-food diets, despite being given unrestricted access to both. They ate faster. They gained an average of 0.9 kg over just two weeks. The effect was not explained by differences in sugar, fat, sodium, or fiber content alone - it was something about the industrial formulation itself.

508 calories per day. Unintentionally. In a controlled research setting where the diets were matched calorie-for-calorie on paper.

That is not weak willpower. That is a neurologically targeted product working exactly as designed.

The addiction science has moved even further. Ultra-processed foods activate the same dopaminergic reward pathways as addictive substances. A 2023 review published in the British Medical Journal - synthesizing evidence across 281 studies from 36 countries - concluded that ultra-processed food addiction affects approximately 14% of adults and 12% of children globally, meeting formal DSM-5 diagnostic criteria for substance use disorder. Not metaphorical addiction. Clinical addiction, by psychiatric definition.

Fourteen percent of the adult population addicted to a product that is legally sold in every school, every hospital, every airport, and every gas station in America. And subsidized by the federal government.

What I See in the Operating Room

I want to make this concrete, because the population-level statistics can feel abstract until you are standing inside a patient.

Joint replacement surgery gives you an unusually direct view of what a lifetime of systemic inflammation does to human tissue. I have performed over 10,000 joint replacements. I can tell you that the difference between a patient who has spent decades eating a whole-food diet and one who has spent decades on ultra-processed food is visible - not just in their weight or their comorbidity list, but in the tissue itself.

Tissue quality is worse. Healing is slower. The inflammatory burden these patients carry into surgery elevates their complication risk before I make the first incision. Post-operative infection rates are higher in patients with metabolic syndrome driven by diet. Readmission rates are higher. Recovery timelines are longer.

I am not describing outliers. I am describing a pattern that any surgeon who operates at volume has seen repeatedly and that the outcomes data confirms.

The American Joint Replacement Registry data and multiple institutional studies have documented the association between obesity, metabolic syndrome, and worse surgical outcomes in joint replacement. The complication odds are not marginal. Obesity class II and III patients carry substantially elevated risks of periprosthetic joint infection, wound complications, and aseptic loosening.

Ultra-processed food is a primary driver of the metabolic syndrome that creates those patients.

The food industry created the problem. The healthcare system - including surgeons like me - spends billions managing the downstream consequences. And nobody in the chain is connecting those two facts in any policy that changes the upstream behavior.

The Government Is Funding Both Sides of This War

Here is the part that should make you genuinely angry.

Since 1995, corn subsidies alone have exceeded $116 billion - the same crop that gives us high-fructose corn syrup. In 2024 alone, Congress authorized more than $40 billion in combined commodity and disaster payments, the majority flowing to corn, soy, and wheat - the raw inputs for the ultra-processed food supply. High-fructose corn syrup, refined seed oils, processed soy derivatives: these are not cheap because they are efficient. They are cheap because American taxpayers subsidize the crops that make them.

At the same time, Medicare and Medicaid spend hundreds of billions annually managing the chronic disease load - diabetes, cardiovascular disease, obesity-related joint deterioration - that ultra-processed food consumption drives.

We are paying to make the poison cheap and then paying again to treat the poisoning.

According to a 2024 peer-reviewed analysis published in The Milbank Quarterly - drawing on 23 years of OpenSecrets data - the ultra-processed food industry spent $1.15 billion on federal lobbying between 1998 and 2020. More than Big Tobacco. More than alcohol. More than gambling.

That money successfully blocked meaningful front-of-package warning labels, fought sugar taxes in every major legislative context, and funded a generation of nutrition research designed to shift blame from processed food to individual behavior.

Sound familiar? It should. The tobacco industry wrote that playbook first.

What Actually Changes This

I changed my own diet because I read the research and I looked at my own labs and I made a decision that I was not willing to accept the standard American metabolic trajectory as inevitable.

That required no superhuman feat of willpower. It required removing the engineered food from my environment and replacing it with food that does not hijack the satiety system. Within weeks, the appetite patterns changed. The cravings that felt biological were, in fact, largely manufactured - and they diminished when the manufacturing stopped.

That is the most important practical truth in this entire conversation: this is not primarily a willpower problem. It is an environment problem. And you can change your environment.

But I also want to be clear about something. Individual action is necessary. It is not sufficient.

The same logic that says “smokers should just choose not to smoke” was used for fifty years to deflect from tobacco accountability. Personal responsibility matters. It does not absolve the companies who deliberately engineered the addiction, the lobbyists who blocked the regulation, or the politicians who took the money and protected the system.

Both things are true. You have to change what you eat. And the industry that spent fifty years engineering your overconsumption should face the same reckoning the tobacco industry eventually faced.

We are not there yet. But the science is no longer on their side.

The breakfast cereal in the brightly colored box. The chips engineered to dissolve before your brain counts the calories. The “low fat” products loaded with sugar to compensate for the removed fat. The snacks formulated by the same corporate lineage that spent decades optimizing nicotine delivery.

None of this was designed to feed you.

It was designed to keep you consuming. And it worked exactly as intended.

You can opt out. Start there.

And then get angry about the system that made opting in the default.

That is the incision point.

What changed things for you? Was it your labs? A health event?

Or are you still in the middle of figuring it out?

Tell me below. Would love to have a conversation.

- Dr. Michael Meneghini

The most prescribed drug in America right now has less than three years of long-term outcome data.

Nobody is saying that out loud.

GLP-1 receptor agonists - semaglutide, tirzepatide, the entire class - have taken over the cultural conversation about weight loss with a speed that should make every clinician uncomfortable.

Ozempic is a household name. Wegovy is on the cover of magazines. Celebrities are not-so-quietly crediting it. The stock prices have reflected a gold rush. And somewhere in the middle of all that noise, the actual science - careful, longitudinal, outcomes-based science - is still catching up.

I am not here to tell you GLP-1s are dangerous. The data does not support that.

I’m also not here to tell you to go out and get some either. The data also does not support that.

I am here to tell you we do not know enough yet. And in medicine, that distinction matters enormously.

The Rush to Prescribe Is Outrunning the Research

Here is what we actually know.

GLP-1 receptor agonists work. In the SURMOUNT-1 trial, tirzepatide produced mean weight reduction of approximately 22.5% at 72 weeks. The STEP 1 trial for semaglutide showed roughly 14.9% body weight reduction over 68 weeks.

Those are real numbers. Clinically meaningful. For patients with obesity-related comorbidities - cardiovascular disease, type 2 diabetes, joint deterioration - this class of drug has genuine, evidence-backed utility.

But here is what the headlines are not telling you.

The longest continuous outcome data we have on semaglutide for weight management is roughly two to three years. For a drug now being prescribed to millions of people as a long-term or potentially indefinite intervention, that is not a track record. That is a promising early chapter.

We do not yet know what happens to metabolic function at year five. Year ten. We do not know what the cessation curve looks like for patients who use these drugs for a decade and then stop. We are moving at cultural speed when the science demands clinical patience.

What Rapid Weight Loss Is Actually Doing to the Body

This is where I want to slow the conversation down considerably.

When a patient loses 15 to 22 percent of their body weight in 68 to 72 weeks, they are not losing fat alone. They are losing muscle. They are losing bone density. That is not a side effect. That is physiology.

The data on lean mass loss during GLP-1 therapy is real and it is underreported in the popular press. Studies tracking body composition during semaglutide treatment have shown that a significant portion of total weight lost - estimates range from 25 to 40 percent depending on the study and protocol - is lean mass, not adipose tissue. For a 50-year-old patient who is already dealing with age-related sarcopenia, that is not a neutral trade.

I operate on joints. I see what sarcopenic bodies look like - not on a DEXA scan but on an operating table. Weak, atrophied muscle around a joint is not just an aesthetic issue. It is a functional one, a structural one, and a surgical risk factor. Patients with low lean mass have worse outcomes after joint replacement. They recover more slowly. They fall more. The downstream consequences of aggressive muscle loss are not hypothetical to me.

Bone density tells a similar story. Rapid weight loss - regardless of mechanism - is associated with reductions in bone mineral density. We know this from bariatric surgery literature going back decades. GLP-1-driven weight loss may be less aggressive than surgical intervention, but the mechanism is not entirely different. The STEP trials were not powered to detect fracture risk as a primary endpoint. That does not mean the risk is absent. It means we have not looked hard enough yet.

And the rebound data - what happens when patients stop - is genuinely concerning. The STEP 4 trial showed that patients who discontinued semaglutide regained approximately two-thirds of their lost weight within one year. That is not a treatment effect. That is dependency. And if the drug is producing muscle and bone loss on the way down, and then weight regain on the way back up, the patient may end up in a worse body composition position than where they started.

We need to say that clearly.

The Emerging Case for a Different Approach

Here is where I want to stake a directional position, with full transparency that the data supporting it is still thin.

The standard GLP-1 dosing protocol is designed for maximum weight loss velocity. That is what the phase three trials optimized for. It is what got FDA approval. It is what the prescribing guidelines reflect.

But maximum velocity is not the same as optimal outcome.

Microdosing - using GLP-1 agonists at sub-therapeutic or low-therapeutic doses, with the explicit goal of slower, more controlled weight loss over a longer timeline - is being discussed seriously in metabolic medicine circles.

The hypothesis is straightforward: slower weight loss, combined with structured resistance training and adequate protein intake, preserves lean mass while still delivering meaningful metabolic improvement. You get the appetite regulation and the glucagon suppression without the aggressive body composition changes that come with rapid loss.

Is this proven? No. The long-term microdosing data does not exist yet. That is the honest answer. But the physiological rationale is sound, and it aligns with everything we know from the bariatric and sports medicine literature about how to lose weight without gutting your musculoskeletal architecture.

The framework I find compelling is this: GLP-1 drugs as a metabolic bridge, not a metabolic destination.

Use them to get appetite and blood sugar regulation under control. Use the lower-dose window to build the behavioral infrastructure - resistance training, protein targets, sleep, stress management - that has to exist for any weight loss to be sustainable. Then taper or maintain at the lowest effective dose, with the explicit goal of not being on maximum-dose semaglutide indefinitely.

This is not how most of these prescriptions are being written right now.

The Question Nobody Is Asking Their Prescriber

The patients flooding into primary care offices asking for Ozempic are not asking about lean mass. They are not asking about bone density trajectories. They are not asking what happens to their body composition at maximum dose over two years, or what the discontinuation curve looks like, or whether there is an alternative protocol that trades some speed for better structural outcomes.

They are asking: “Does it work?”

And the answer - based on the weight loss numbers alone - is yes.

But that is the wrong question.

The right question is:

Work for what?
Over what timeline?
At what cost to the rest of the body?

As physicians, we are responsible for asking the question the patient does not know to ask. That is not paternalism. That is clinical leadership.

The enthusiasm around GLP-1s is not wrong. The underlying science is promising and the cardiovascular outcome data from SELECT and LEADER trials is genuinely compelling. But promising is not the same as proven. And in medicine, moving from promising to proven requires time, rigor, and a willingness to slow down when the culture is sprinting.

What I Am Watching For

I am not prescribing a protocol here. I am not qualified to give individualized prescribing guidance in a newsletter, and anyone who tells you they have the definitive GLP-1 microdosing answer right now is outrunning the data.

What I am watching for - and what I think every clinician managing patients on these drugs should be tracking:

Body composition, not just body weight. Scale weight tells you almost nothing useful. DEXA scan or bioelectrical impedance at baseline and every six months tells you whether you are losing fat or muscle. If it is muscle, the protocol needs to change.

Resistance training as a non-negotiable co-intervention. The research on preserving lean mass during caloric restriction is unambiguous - resistance training is the primary tool. If a patient is on a GLP-1 and not lifting, they are losing muscle. Full stop.

Long-term outcome data as it emerges. The five and ten year studies are coming. I am reading them as they publish. The story this drug class tells at year two and the story it tells at year seven may be very different.

Honest conversations about discontinuation. If the plan is indefinite use, say so. If the plan is to taper, build that timeline in from day one with a clear protocol for maintaining outcomes.

The drug might work. The early data suggests it does - in the short term, at the doses tested, for the endpoints measured.

But medicine has a long history of enthusiasm outrunning evidence. HRT. Arthroscopic knee surgery for osteoarthritis. Opioids for chronic pain. In every case, the early data looked promising. The cultural momentum was real. And the full picture took years - sometimes decades - to emerge.

GLP-1s may be different. I genuinely hope they are.

But hope is not a clinical strategy.

Slow down. Measure everything. And do not let a cultural gold rush substitute for a longitudinal outcome.

That is the incision point.

What are your thoughts?

Have you or someone you know been using Ozempic?

Have you/they had success?

Has there been side effects?

We have a blind spot in modern medicine. We look at chronic disease and see “bad luck” or “genetics.” We treat inflammation like a symptom to be suppressed with medication.

But as a surgeon who works with metallurgy and biology, I don’t see inflammation. I see corrosion.

I’ve seen what happens when metal corrodes inside the human body. The tissue dies. It turns black. It necroticizes.

Here is the uncomfortable truth: You don’t need a metal implant to corrode. Chronic inflammation is the exact same process, just slower.

You are rusting from the inside out.

The Science of Corrosion (MACC)

Years ago, I published research on a phenomenon known as Metal-Associated Chemical Corrosion (MACC).

We investigated what happens when the modular junction of a hip replacement—where the ball meets the stem—undergoes “fretting.” If those two pieces of metal rub together under high stress, they release microscopic metal ions into the surrounding space.

The body identifies these ions as foreign invaders. The immune system launches a massive, scorched-earth attack. The result is a pseudotumor—a mass of fluid and dead tissue.

This is a biological reaction to an environmental irritant.

Why does this matter to you? Because Harvard Medical School has identified chronic inflammation as the common denominator in the four major killers: heart disease, cancer, diabetes, and Alzheimer’s.

The mechanism is identical to MACC. When you flood your system with processed sugars, seed oils, and stress hormones, you are introducing “ions” your body doesn’t recognize. Your immune system attacks your own vascular walls, your joints, and your brain tissue.

The “Car on Fire” Scenario

I saw this recently with a patient I’ll call Robert.

Robert came to me for a total knee replacement. He was 54, a high-performing executive, but he was in agony. He limped into the exam room, sweating, clearly uncomfortable.

Here was the engineering conflict: His X-rays didn’t match his pain. He had moderate arthritis, yes. But his pain levels were a 10/10. Structurally, his knee was a “flat tire.” But clinically, he was acting like the car had exploded.

I looked at his labs. His C-Reactive Protein (CRP)—a marker for systemic inflammation—was through the roof.

I told him the truth most surgeons won’t say: “Robert, I can replace the tire (your knee). But the car is on fire. If I operate on you right now, the risk of infection and failure is unacceptably high because your body is already fighting a war on three fronts.”

Robert was living on fast food, sleeping 4 hours a night, and drowning in cortisol. He wasn’t just “unhealthy.” He was an environment of rapid corrosion.

The Anti-Corrosion Protocol

We delayed surgery. We put him on what I call an Anti-Corrosion Protocol.

Six weeks later, he returned. He hadn’t had surgery yet. But his pain had dropped from a 10 to a 4.

Why? Because we stopped the rust. His joints were still arthritic (mechanical failure), but the surrounding tissue was no longer being attacked by his own immune system.

If you want to stop rusting, you have to treat your body like a high-performance alloy that needs environmental protection. Here are the 5 variables I control:

1. Eliminate the Oxidizers (Diet) Processed sugar is a biological accelerant. If your food has a shelf life of 5 years, your body treats it like a foreign object—just like those metal ions. Eat real fuel. If it didn’t grow or walk, don’t eat it.

2. Drain the Swamp (Lymphatics) Corrosion happens in stagnant environments. Unlike your heart, your lymphatic system (your waste removal piping) has no pump. It relies entirely on mechanical motion to clear waste. If you sit at a desk for 12 hours, you are stagnating. You need motion to flush the system.

3. Shut Down the Factory (Visceral Fat) Robert had significant belly fat. In medical school, we used to think fat was just stored energy. We now know that visceral fat is biologically active tissue. It acts like a gland, pumping inflammatory cytokines into your blood 24/7. Losing the gut isn’t vanity; it’s removing a toxic waste factory from your chassis.

4. Stop the Acid Rain (Cortisol) Chronic stress releases cortisol. In short bursts, it saves your life. In constant drips, it eats away at your sleep and recovery. You must have a mechanism to flush cortisol—exercise, meditation, or prayer.

5. The Maintenance Window (Sleep) You cannot repair a machine while it is running at redline. Deep sleep is the only time your brain cleans out metabolic waste (beta-amyloid). If you cut sleep, you skip the maintenance cycle.

The Bottom Line

Corrosion is a natural law of physics. Entropy dictates that things break down. But in the human body, the rate of corrosion is a choice.

Robert eventually got his knee replacement. He recovered in record time because his system was clean.

Are you coating your system, or are you letting it rust?

R. Michael Meneghini, MD

If you liked this, share it with someone who feels “achy” all over but can’t pinpoint why. Next week, we are diving into “The Stability Paradox”…

why adding complexity to a system often increases the risk of failure.

We have a language problem in medicine. We tell patients they “have” arthritis, as if it’s a virus they caught or a genetic curse they inherited. We treat it like a disease.

But as an engineer, I don’t see a disease. I see a mechanical failure.

Your knees didn’t just “get old.” They failed because the load vectors crossing the joint were out of tolerance. They failed because the coefficient of friction, which in a healthy joint is five times slicker than ice on ice, was compromised by eccentric loading.

You aren’t sick. You are misaligned.

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The Physics of Failure

In a study we published on femoral stem fixation (Inadequate Metadiaphyseal Fill of a Modern Taper-Wedge Stem), we looked at what happens when an implant doesn’t perfectly match the geometry of the bone.

When a hip stem is undersized or misaligned, it doesn’t just sit there. It subsides. It moves. The axial load of walking isn’t transferred evenly; it creates shear forces that destroy the interface between metal and bone.

The exact same physics applies to your native knee.

A healthy knee is designed to distribute load across two compartments (medial and lateral). It is an optimized load-bearing system. But if you have a slight varus (bow-legged) deformity, you are no longer distributing load evenly. You are point-loading the medial compartment.

It’s the difference between driving a car with perfect alignment and driving one where the tires are angled inward. It doesn’t matter how expensive the tires are; they will blow out after 10,000 miles. That isn’t “tire disease.” That is mechanical reality.

Tolerance Stacking

In engineering, we talk about “tolerance stacking,” when small deviations in multiple parts add up to a catastrophic failure.

In the human machine, arthritis is often the result of tolerance stacking:

1. Static Alignment: You have a mild structural deformity (varus/valgus).

2. Dynamic Weakness: Your glutes are weak, causing your femur to rotate internally during gait.

3. Excess Load: You are carrying an extra 30 pounds.

Individually, the system might handle these. Stacked together, they exceed the material properties of the cartilage. The friction coefficient skyrockets. The surface degrades.

We call this “Osteoarthritis.” I call it Cycle-Dependent Fatigue Failure.

Re-Engineering Your Chassis

Why does this distinction matter? Because you can’t “cure” a mechanical failure with a pill. You have to fix the mechanics.

If you want to preserve your joints (or your replacement joints), you have to think like a structural engineer.

• Reduce the Axial Load: Every pound of body weight places 4 to 6 pounds of force on the knee joint. Losing 10 pounds isn’t just cosmetic; it reduces the mechanical load on your knees by 40,000 to 60,000 pounds per mile walked. That is massive structural relief.

• Balance the Tension: Your muscles are the guy-wires holding the mast straight. If your quadriceps are weak or your hamstrings are tight, the joint tracks poorly. You are grinding the gears every time you take a step. Strengthening the “engine” (muscle) protects the “chassis” (bone).

• Respect the Envelope: Just like the implants I design, your joints have a specific range of motion where they function optimally. Pushing them repetitively outside that envelope, through poor form in the gym or bad posture at your desk, is asking for failure.

The Bottom Line

Stop waiting for a “cure” for arthritis. The cure is physics.

If you treat your body like a machine that requires alignment, lubrication, and load management, you can extend its warranty significantly. If you ignore the mechanics, you will eventually end up on my operating table.

And while I am very good at replacing the parts, the original equipment, when properly maintained, is still the best engineering on the planet.

R. Michael Meneghini, MD

If you liked this, share it with someone who complains about their “bad knees” but hasn’t looked at their mechanics. Next, I’m discussing “The ‘Rust’ Inside Us”, why inflammation is actually biological corrosion.

Thanks for reading The Incision Point! Subscribe to help disrupt the status quo.

Most people think of “healing” as a passive activity. You lie in bed. You watch Netflix. You wait for the body to knit itself back together.

From an engineering perspective, this is dangerously inaccurate.

Healing isn’t passive rest. It is a metabolic fire. When you undergo surgery, run a marathon, or suffer a major trauma, your body doesn’t shut down to repair itself, it revs up. It enters a state of hyper-metabolism to meet the massive energy demands of reconstruction.

If you don’t feed that fire with the right fuel, your body will do what any survival machine does: it will start burning its own infrastructure to keep the lights on.

This is the Catabolic Crisis. And whether you are a patient recovering from a total knee replacement or an executive recovering from burnout, you need to understand the physics of it.

The 3-8 Day Window

In a review we published on infection prevention (Extended Oral Antibiotics in Primary and Revision Total Joint Arthroplasty), we discussed a critical physiological window.

After a major surgery like a hip or knee replacement, the body enters a catabolic state that typically lasts for 3 to 8 days.

During this phase, the body’s systemic response ramps up exponentially. It is recruiting white blood cells, synthesizing proteins, and laying down collagen matrix. This requires a massive amount of ATP (energy).

If the body doesn’t have enough available protein and glucose circulating in the blood, it turns to its internal reserves. It doesn’t burn fat first (which is slow to convert); it burns muscle. It breaks down the very quadriceps and glutes we are trying to rehabilitate to harvest the amino acids necessary for survival.

You aren’t just “tired” after surgery. Your body is literally eating its own muscle to survive the trauma.

The “Golden Period” of Defense

This catabolic state is also why infection risk is highest in the first week. We call this the “Golden Period”.

During this time, the immune system is overwhelmed. The bacterial burden is fighting against the host’s defenses. If the host is in a severe catabolic deficit, malnourished, anemic, or depleted, the immune system acts like an engine running on fumes. It stalls.

This is why we implemented Extended Oral Antibiotic Prophylaxis (EOAP) for high-risk patients. We aren’t just throwing drugs at a problem; we are engineering a bridge to support the immune system while it is mechanically overloaded.

Engineering Your Recovery

So, how do we solve this energy problem? We stop treating nutrition as “wellness” and start treating it as “input variables.”

1. Pre-Operative Loading: You wouldn’t drive a race car onto the track with an empty tank. We optimize hemoglobin and nutrition before the first incision. If you go into surgery with an empty tank (anemia/malnutrition), you will crash during the catabolic phase.

2. Protein is Structural Integrity: During the catabolic window, protein intake isn’t about “gains”; it’s about preventing structural collapse. You need to flood the system with amino acids so the body burns your lunch instead of your legs.

3. Minimize the Trauma: This brings us back to surgical technique. The less tissue we damage (no tourniquets, precise muscle-sparing approaches), the smaller the metabolic fire we ignite. A smaller fire requires less fuel to manage.

The Human Machine Application

This principle applies to everyone, not just surgical patients.

If you are training for an Ironman, or if you are launching a startup and sleeping 4 hours a night, you are inducing a catabolic state. You are creating micro-trauma.

If you don’t engineer your recovery with the same intensity that you engineer your work, you will hit the Catabolic Crisis. Your performance won’t just plateau; your internal structure will degrade. You will get sick. You will get injured. You will burn out.

The Bottom Line

Recovery is an active, energy-expensive process. It requires fuel. It requires strategy.

Don’t mistake “resting” for “healing.” One is doing nothing; the other is the most metabolically demanding thing your body can do.

Respect the physics of your own biology.

R. Michael Meneghini, MD

If you liked this, share it with someone who thinks skipping meals is a “productivity hack.” Next, I’m diving into “Friction Coefficients”, why arthritis isn’t a disease of aging, but a mechanical failure of alignment.