Here is an obscure story of environmental whack-a-mole that maybe only Noah could fully appreciate.

Way down south, as in somewhere between Australia and Antarctica south, is the remote Macquarie Island.  You might not have seen it in your eco-travel brochures – to the extent there is overlap between readers of this blog and eco-travelers – because one early visitor to the island described it as ‘the most wretched place that can be conceived.’

Cruise ships arrive every Wednesday!

No one even discovered the place until the early 1800s and then all they found were some rare birds hopping around the huge population of fur seals sprawled out all over the desolate outcropping.

Well, at that time, seals meant oil, and oil meant money, and money meant hunters.

So, the ships started to arrive (maybe it was Carnival Cruise Lines? maybe they docked on Wednesdays?), but they brought more than hunters.

Rats stowed away on the ships. Lots.

No one liked the rats, so someone got the brilliant idea to bring some cats to eat the rats.

Plus, there were now a lot of hunters and, in a strange plot twist, shipwrecked sailors.  Instead of just rescuing the sailors (seems like that would have been a good option), rabbits were imported as a food supply.

The feral cats, in particular, were ruthlessly efficient and had eliminated virtually all the birds.  Conservationists were sad about that and worked to eradicate the cats.

But with the cats gone, the rabbits did what rabbits do – breed and eat and poop – and in the process ate almost half the vegetation on the island.

Now, there is an ongoing multi-million-dollar campaign to get rid of the rabbits.

You almost have to laugh at one unintended consequence after another, but then you remember this is an ecological meltdown.

I tell you that story, only in part because of my well-documented disdain for the rabbits destroying my yard (I am getting help with my issue), but more to make this point…

At the start of 2021, nearly 70% of physicians worked for a large institution (health system, big corporation, private equity-backed company). There are a lot of motivations for physicians to make this move, but in large part many throw in the towel on owning their own practice simply because the finances don’t work anymore.

Last week we discussed the Medicare cut coming to physician reimbursement in 2023, a move ostensibly intended to reign in healthcare costs.  But it will drive more physicians to give up the fight and take the employment deal from some big entity.

Besides my rabbit issue, another thing we’ve discussed here frequently is the undeniable fact that the cost for physician services goes up, not down, when they leave independent practice, particularly if they do so by becoming health system employees.

This will lower healthcare costs how?

There are too many rats…ship in some cats!

There are too many cats…ship in some wolves!

There are too many wolves…ship in some hunters!

The hunters are hungry…ship in some rabbits!

Well, here we go again.

No, no, not talking about Biden v Trump, 2024 edition – and aren’t we all glad for that?

Nor the latest crypto meltdown – though I can’t tell if that is some fascinating dumpster fire we can enjoy from afar or a sign of the apocalypse.  (Wait, I could have made that statement about either of the two things we are NOT talking about, couldn’t I?)

Instead, it is time for the annual silly dance around the Medicare fee cuts to physician reimbursement, though this time it seems a lot more real for a couple of reasons.

For the non-healthcare people who might have accidentally stumbled onto this blog, here is the quick tutorial…

Like, forever ago, Congress passed a law that requires ‘budget neutrality’ for Medicare, which put a bunch of math into law and the process of subsequent Medicare spending on autopilot…which, unlike their own salaries year after year, really means ‘flat.’

There really is a lot of math, wild hand waving and gesticulations, smoke and incense, and a magic potion made from the sweat of a rare Brazilian toad.  The outcome of all of this is a single number called the ‘conversion factor.’

The conversion factor is what Medicare pays a physician for a ‘relative value unit.’  RVUs – more complicated math, more hocus pocus, more reptilian body fluids – are a proxy for how much work and smarts and expenses it takes for a physician to care for a patient.  A quick and easy thing gets a few RVUs; a long and complicated thing gets more RVUs.

Take your RVUs and multiply them by the conversion factor (more math, but easy, no witchcraft required) and wa-la, Doc, there is your check from Medicare.

This whole charade started in 1998 and the conversion factor was $36.69.  One RVU was worth just less than two $20 bills.

CMS just announced the 2023 conversion factor and it is $33.06, down $1.55 from 2022. The line graph for 25 years looks like a dead snake…very flat.

Yes, there are additional cuts on top of this do to other Congressional gamesmanship around the sequester…remember that?  So it could be even worse.

Breaking news that you may not yet have heard…inflation is high. Like, really high.

That is a big cut to the top line at the same time operating costs for physician practices are going up faster than ever.  This really could break things.

So, now we forecast doom and the breakdown of the entire system; physicians and Congress types both swear deep fealty to Granny and protecting senior healthcare; handwringing ensues…and at the last-minute Congress will pass a stop gap measure the blunt the cuts.

We’ll kick the broken can down the road again.  Heck, we’ve got a lot of experience doing this, so we’re pretty good at it.

In the meantime, our political situation means that the chance of Washington coming up with a real fix is less likely than my landing an endorsement deal for a shampoo company.