Back from hiatus, Anish and Dr. DiGiorgio swap travel notes on Japan and San Diego before diving into Anish's recent Substack piece mapping emergency cardiac care access across the United States — where 98% of Americans live within 90 minutes of a PCI-capable hospital, a level of coverage no peer country (including Canada) comes close to matching. They extend the analysis to thrombectomy-capable stroke centers, trauma coverage, and what it really means when the Commonwealth Fund ranks the US last. The conversation turns to whether the "rural healthcare crisis" narrative justifies continued subsidies (critical access designation, 340B, DISH payments, the new OBBA rural fund) or simply props up a monopoly structure that blocks physician-owned hospitals and ASCs. They unpack Mark Cuban's HSA-plus-catastrophic-coverage proposal, its blind spots on chronic illness and supply-side cost, the two-midnight rule lawsuit between Jefferson and Aetna, cost-plus reimbursement grandfathering, and how CMS's new "efficiency adjustment" has made it financially rational for neurosurgeons to hand off post-op critical care — inadvertently telling the origin story of neurocritical care as a specialty. They close with the new CDC director announcement and a look ahead to next week's guest, Dr. Elad Levy.

00:00 Back from hiatus — Japan, San Diego, and American public transit

03:45 Happy tax day and the Bay Area commute problem

04:45 Anish's Substack piece: mapping PCI access across America

07:50 Why PCI capability is the right proxy for emergency care infrastructure

10:00 Building the map — counties, census tracts, and the 90-minute door-to-balloon window

14:30 98% coverage: the US vs Canada, Russia, China

18:24 Thrombectomy-capable stroke centers and the 60-minute brain window

22:07 What do you actually want from a healthcare system?

27:12 The original sin of Medicare and the employer tax exemption

30:13 Rural hospital subsidies: critical access, 340B, DISH, and the OBBA rural fund

37:02 Physician-owned hospitals, Stark Law, and ASCs as an alternative model

40:30 Mark Cuban's HSA plan: stop-loss, direct primary care, and the $2,100 family premium

44:13 Extending the idea to Medicaid — wealth accrual and the 100% benefit cliff

46:31 The chronic illness problem and federal reinsurance as a backstop

47:57 The missing piece: supply-side deregulation and lowering cost of care

50:19 Jefferson sues Aetna: the two-midnight rule and who the real villain is

53:04 UCR, cost-plus reimbursement, and the hospitals still grandfathered in

55:37 The CMS efficiency adjustment and the neurosurgeon's 8-day break-even

58:45 The origin story of neurocritical care as a specialty

01:02:16 New CDC director Erica Schwartz and next week's guest Dr. Elad Levy

@anish_koka and @drdigiorgio

@drsloungepod

Resources:

Quantifying the Rural Access Problem: Emergency Cardiac Care as a Window into American Healthcare — https://anishkokamd.substack.com/p/quantifying-the-rural-access-problem

America Has Solved the Hardest Healthcare Access Problem Better Than Anyone Else — Here's the Data — https://anishkokamd.substack.com/p/the-us-healthcare-system-has-basically

Interactive PCI Access Maps (US & Canada) — https://anishkoka.github.io/pci-access-maps/

YouTube: https://www.youtube.com/@TheDoctorsLounge