 And you have a certain primary diagnosis, you get a certain number of days of hospitalization and a fixed amount that they're going to pay you. And that's it. And it's a amount that's, you know, on the lowest possible end of what you could be paid for something of that complexity. Well, what that is, is essentially is a price control on inpatient medical care. Remember, any time you apply price controls, you get shortages. This created a shortage of inpatient hospital beds, because hospitals could not admit that many people into the hospital and incur those kind of losses. They had to back off on the number of people they were admitting, make the hospitals smaller, have fewer beds because they can't take that many losses under this payment system. This is why if you go back to your hometown and you look at a local community hospital, what you'll see is this dilapidated old, ugly building that has maybe 134 beds in it. But right next door to it, you'll see a palatial, beautiful, bigger than the hospital outpatient surgery center, or an outpatient radiology center, or a blood collection transfusion center, okay? Because they're trying to divert their activities into the outpatient setting where these price controls did not exist. The other thing that happened is it triggered cost shifting, okay? If you're going to lose that money on the inpatient side of medicine, you're going to shift costs to other areas. This is where you get your $200 aspirin in the ER. And we're trying to make up for the constraints there. You push down on a balloon on one area, it's got to expand in another. So they're trying to preserve market signaling in the presence of something that distorts it. So that's going on. The next thing that happens is what has affected my life so immensely. 1986, signed into law by one of our most conservative Republican presidents in modern history. EMTALA stands for it was part of Cobra, Congressional Omnibus Reconciliation Act of 1986. This was a sub-component of Cobra called EMTALA, Emergency Medical Treatment and Active Labor Act of 1986. And what was happening is when you go to do a residency at a public hospital or a county hospital, residencies, you're going to specialize in internal medicine, family practice, surgery, neurosurgery, orthopedics, ophthalmology, residencies are paid for with CMS funds, with funds from the Center for Medicare Services, okay. So that created an obligation for hospitals that had residencies because they were receiving funds and tax advantages to take care of indigent care. So in 1985, if you were a private hospital and you had an indigent person show up with a medical condition, you just tell the ambulance, do a your turn, you go to the public hospital, they receive funds for this sort of care, go get your care there. And that's what happened. And that's how the indigent paid for their medical care was by essentially being the patients for medical residents. But public funds were going into those hospitals. It was considered fair, but all of a sudden the public hospitals under the effects of DRGs were getting all these non-paying patients coming in and suffering even further loss than the constraints of the DRGs. You had non-paying people, okay. So they started to scream and yell and say this was dumping. You're dumping your undesirable patients onto us simply because we're the good guys. So we signed this into law. And what it does now is it requires any emergency department, any ER, to treat anyone who presents within the hospital property or 250 yards of the ER regardless of their ability to pay. What that also means is regardless of their intention to pay, how quick did you think it took people to figure out how to gain this system, okay. You want to talk about viral spread of an idea. It happened overnight. The public hospitals were all the indigent emptied out. They were like, what happened? Our waiting room used to be jam-packed and everyone was going to the more desirable hospitals because they were given a political mandate by force that they could go get that care for free. And it's an unfunded mandate with severe penalties. There's no mechanism to pay an emergency physician for seeing this. So what this did is it made emergency rooms the de facto national health plan for the uninsured, state and local governments abrogated all responsibility for charity care. And based on statistics that were done around 2000, they said the average emergency physician was providing $138,000 a year in uncompensated care. I myself, when I calculate, provide approximately $350,000 in uncompensated care based on Medicare payment rates, which as we've already discussed are price controlled. So that's the low end of the spectrum. Assuming that, applying that, I provide about $350,000 in uncompensated care, about 23 to 30% depending on the quarter that you look at of the patients that I see pay me anything. So this resulted in further cost shifting, just to survive. This is where you get your $200 aspirin in the ER. And the thing is, is the law that was intended to help the poor hurt them the worst. So there was a massive influx of nonpaying patients. And that contributed to ER overcrowding. And most people when they think of an overcrowded ER blame this scenario for the overcrowding. But I'm here to tell you, it's maybe 15% of it. Where the real overcrowding in the ER comes from is the lack of inpatient beds because of the price controls applied by DRGs. Because the people coming into the ER are sick. Okay, there's a lot of minor stuff that comes through, and you're always kind of churning that wheel. But there is no shortage of critically ill people coming through the ER. And you have to get them, you got to stabilize them, get them treated, get them ready to be admitted to the hospital. But guess what? There's nowhere for them to go. There's no bed upstairs. So they end up boarding in the ER. So the size of your ER's bed capacity starts to shrink. And then instead of having 20 beds to move a big backlog of patients in the waiting room through, you now have 10. And then a few more hours, you got five. And then you're really hosed. So the real problem with the overcrowding is not just the massive influx of people coming in the front door. You got nowhere to send them upstairs because of inpatient price controls. The other thing that happens is the on-call doctors, the people you need for backup, the orthopedist for the broken hip, the neurosurgeon for the gunshot wound of the head, they stop taking call. And they stop taking call because they know that when they get a call from the ER at three in the morning, there's a 70% chance that they're going to get up, go out of bed, take the risk of taking care of this patient for no compensation, finish up that surgery, and go to an office that's backed up. So they stop taking call. So we got no backup for a lot of different specialties. Next thing that happens, 1996, HIPAA, that stands for Health Insurance Portability and Accountability Act of 1996. And basically what this law was to do was to give government enforcement of the Hippocratic Oath, part of which was to say anything that happens between the doctor and his patient remains confidential. And the reason for this is when you collectivize medicine, the ability to keep it confidential because you're serving the collective and not the individual becomes compromised. The other thing that was happening was the government was already planning to mandate, remember, this is 1996, the internet booms going, computers are going to solve every problem on the face of the earth. So there's this huge governmental push for electronic medical records. And they worried about sensitive personal information being stolen. So they imposed huge penalties if you even inadvertently violated anyone's confidentiality. I cannot practice medicine on a day-by-day basis without violating this law every time. If someone comes from a drug house or a rave party unconscious, whoever's with them, you know, some kid with pink hair and a bone in his nose, I got to drag this kid in that's remotely their friend and say, here's the circumstance with this guy. He's dying right from lies. Do you know what he did? Okay, under this law, that's a violation. But I have to do it every day just to be able to practice. It's impossible to comply with. But if you have something called a compliance program, if you hire someone to serve basically as a government rat think within your own organization, then if you have a slip up, then you've at least demonstrated that it was an honest slip up and the penalties are less severe. So you have to occur essentially a full time equivalent of hiring a person on board to make sure that you're being HIPAA compliant. And every time you go into your doctor's office, the first thing they give you is this big long sheet of paper about your privacy rights that you have to sign. Anyone's been to a doctor's office recently knows what I'm talking about. But this was greasing the path for the electronic medical records, which I now have to deal with. This all combined signaled the death of private practice. The overhead burden from Medicare and Medicaid, private insurers, HIPAA, it eats up all your profit margins. In the past four years, 80% of the family practice dollar of family practice doctors in my community paid themselves no salary. Of the ones that did, they paid their nurses and mid-level providers more money than they were able to net out of their practice. As a consequence, these people were bought up by hospitals who had the scale to deal with the regulatory burden. And it wasn't like they were brought in as a hostile takeover. These people begged the hospital to let them be employees because they couldn't make it otherwise. That's what happened. So now, now what you have is medicine is collectivized both on the provider and the recipient side. Control is easier. You have control of both sides of the equation from a government standpoint. Even if this was an unintended consequence, you couldn't have devised a more diabolical system for getting complete control. Ultimately, this created a hospitalist movement. If you get sick in the old days, your doctor would see you in the office, say you're really sick, you need to be in the hospital. He'd do a complete history physical exam, write a mission order, send you over to the hospital, go upstairs, and he'd see you from his office. He'd either leave his office immediately if he's urgent, or see you later in the evening after office hours. But your doctor, who knew you intimately, would take care of you in the hospital. No more. All inpatient care has shifted to hospital employees, which are hospitalists. They provide the inpatient care when a patient comes in the hospital. And this happens because