Rethinking Healthcare Together: Aligning Employers and Health Systems

Speaker A: Foreign. This is the Disrupt Healthcare podcast. Employers think they're buying health care. In reality, they're just buying access to a really expensive billing system. This is the solo episode that I want to do for this Disrupt Healthcare podcast, and I've been part of several interesting conversations over the last few months, uh, with healthcare systems that are figuring out how they can get closer to the employer marketplace, with employers that are just downright frustrated, advisors that are on each side of the spectrum, some that constantly will fight to keep things the same, and some that are constantly fighting to change it. And with a lot of people that are either investing in the space or looking to get in the space, it's, it's a trillion dollar business. And when we think about it, let's just frame up the reality of it, right? The health care system, it's finally breaking. I'm, um, going to use the word breaking, but I think what's happening is the misalignment and the fact that it's built incorrectly is just now coming to be, um, you know, front and center. And in mind, when I think about this, I really think about it. And let's go the major talking points here. It's a $4 trillion business. You know, 18% or so of our GDP. Break that down. Employers, top two, top three expense, typically only behind. Payroll costs are rising faster than wages. Employers are frustrated. Whatever profit they're doing, some of it's eating away, uh, the health care expenses are eating away at it. And health care was one of the reasons people come to work. So they're losing the differentiation that they of. And when we think about what's now happening, right, I want everybody to kind of take a step back and say, if you are in a system, if you're an advisor and you're producing this system, or if you're an employer and you're in a system where a couple of things are true. Number one, the carriers are controlling the data. If you do not have access to data to be able to make good decisions and understand where your class are coming from, just logically, how do we think that we're actually going to fix things? That's number one. Number two, let's break it down into the pharmacy benefit. Um, that's been a joke for years, and now Washington's finally starting to catch up. So you're seeing a lot of things there. But the reality of it is the pharmacy pricing is so distorted, um, that the government CEO Trump rx, we have Mark Cuban in this business. I mean, we've got a whole Bunch of things for. The reality of it is we've been doing this for years and it all just boils down to transparency. The network. So you buy your carrier typically because of the doctor and, and hospital network. So I want you to think about that. If the question was who handles, who offers, who delivers your health care and you ask that question to employees, what do you think the answer is? Because I'll tell you, the answer more often than I'd like to think about is that people mention their carrier, Blue Cross, United, Cigna as who is providing their health care. That's not health care, that's health insurance. And so when you think about the networks, the networks are just more and more and more, hey, we have the biggest network. But the reality of it is what's the true cost of care? Do you know how much you're actually paying for that mri? The reality of it is in the same market that could range thousands of percentage points in the reality that you as an employer, you as an advisor have of building a solution back to the hidden data and the bad, uh, back to the hidden cost is how do you actually build something that's going to work if you don't even understand what the starting point is? And the system foundationally is not built for any level of fiduciary responsibility. That F word is such a big deal right now. And the reality of it is when you have no idea how much you're paying for cost, you have no idea a lot of times how much you're paying your different service partners, your broker, your pbm, um, your tpa. Do you know if they're making back end deals? The reality of it is it's so opaque, hey. That there's no way that you understand what it is that you're paying. So how in the world could you be a fiduciary if you don't know what you're paying? The system is just built completely wrong and it boils down to misalignment of incentives. I want you to think about this. It's this question, who is silly incentivize to keep costs down? Let's run through the, through the, through the parallel. Well, a insurance company gets paid on um, premium. The more premium, the higher their revenues. Revenues equals premium. Who wakes up in the morning wanting to lower their revenues? Nobody. So the insurance company, typically a publicly traded company whose fiduciary responsibilities to their shareholders, not to the end customer, which is employees and their family members and the employers that they work for. So when you think about that, the Health insurance company is not incentivized. Typically, a broker is getting paid a percentage of premium. So if I have more premium, I make more money. So that incentivization is, is not necessarily there. A PBM gets paid more in spread revenue more. The more transactions that do more, the hidden, opaque ways of getting money, they're not incentivized. The retail pharmacies need to pump out more pills. Hospitals need to fill beds. Doctors need to see patients. So the reality of it is nobody is incentivized to perform the outside function of what the end consumer actually wants. And how do we stop us? Like we ask ourselves every day on this Disrupt podcast. But like, let's really ask ourselves as I'm sitting here the beginning of March report this, what are most employers and advisors truly doing to change the paradigm Now? The good news is that there's a lot of things that are working in our favor right this second. Transparency, regulations. The more and more the PBMs slip on banana peels, the more and more conversations with pricing transparency, the fact that this vertically integrated system is just there to maximize revenue, the more and more regulatory and shining of the light that happens, that should be more motivation for employers. It should be more motivation for advisors. You have more employers that are doing this. I've talked to, um, several, uh, innovative vendors, um, you know, the RBP vendors, the medical management and advocacy vendors. And they're saying they had banner years of employers that are entering this non, you know, traditional world. So you have more employers that are raising their hand, say, you know what, this isn't actually working for me. But it takes that initiative. The more and more tech that's out there is exposing true prices, it's helping with data access, it's helping fund health care a different way. And when you start thinking about the paradigm, if this paradigm isn't working for employers, it's not working for employees. And hospitals will tell you the more out of pocket they're having to run around and chase, the more their accounts receivable and their collections are higher. They got to fight every year, every four years with the commercial insurance companies, who is trying to make more money. The hospital wants to make more money. And neither one of them are, you know, able to kind of function without the other. So this whole notion of direct contracting starting to be a bigger deal. So transparency, tech, employers that are leading the charge, direct contracting, there's all of these tailwinds that are occurring. Uh, and I want to leave you with a couple of things that if I look into my crystal ball and think for the next 10 years, what are we really thinking about? I think the reality of this is more employers will own more of their health care strategy. I uh, think the days of reacting based on renewals is dead. I just don't think prudently financially and the proof set that that are coming out with more and more employers that are doing things and seeing these results. So like you're going to be one degree of separation as an employer of other employers, you know, that are changing the paradigm in their health benefits approach. So owning the health care strategy, that is truly, first of all having a strategy. What's your strategy? If you're listening to this and you don't have a healthcare strategy, you don't know that you're doing these things on purpose and you're just continuously making plan design changes and edits to your program based on how bad or good the renewal is, you're absolutely missing the boat. And that needs to stop. Um, advisors, I think because the employers want to own the health care strategy, advisors have to switch from being transactional brokers to truly being health care architects and consultants. If you don't understand the paradigm of how claims actually works. If, if what comes out of your mouth is a claim is just a claim when the reality of it is we know that you can pay $600 for an MRI, you could spend $6,000 for an MI. We know that protruda can be sourced for 80,000 versus 350,000. We know that a, uh, at home infusion of that truda can be, I don't know, $1500 an hour versus $350,000 annually. We know these things as advisors, we don't know these things as brokers. And as brokers we continuously talk about the insurance company as if they're the solution as opposed to working with the employers on truly driving down health care costs. We have to hit both the supply and the demand side. But speak of demand, we need to demand something different. Advisors, if you're not in your RFPs saying as a condition to win this bid, you must give this data on um, this frequency in this format and make sure that the carriers are being responsive to the needs of the employers and doing so on the front end rather than asking for it later and then saying, uh, you know, we don't allow that level of data, we don't allow that frequency, we don't put it in that format and if we do, you're going to get charged $2,500 for my own data. What, Excuse Imagine if that happened in other aspects of your business. If uh, your telecom provider charged you to get your invoices on a call by call basis to understand, um, you know what, what kind of volume and calls you're doing. You hear that out of my mouth and it sounds asinine, like no way at&t Verizon, T Mobile would charge me to get my utilization. That happens every day in health care. We just accept it. And I think the notion of, of over this next 10 years that the traditional carrier marketplace gets bigger. Maybe I've brainwashed myself because this is the world that I play in. But again, beginning of March 2026 at 10:30am, um, I wouldn't venture to gam that the traditional space doesn't grow as fast and the world doesn't get more traditional. The world continues to demand change and typically the leaders, the people who have built and created these infrastructures to maximize the status quo, those typically are not the outfits that drive change. It just, it just doesn't happen. I don't care if it's health care or any other industry. So I'll leave you with this. If you're an employer and you're still working with the same carrier, the same broker and you look back at your 10 year report card and you're not happy, I asked you to think about the definition of insanity, right? Like what is it that I am going to do? And I think the reality of it is is just getting the data and have people explaining how your plan can actually impact health care cost. Can you buy a prescription less expensively? Can you buy an MRI less expensively? What are we doing to control the cost of what it is that we're paying for health care? If that is not able to be clearly articulated within the context of the program that you are in today, have to ask you, well, how else are you going to achieve victory if you don't know what you're paying for the mri? Nor can you control how much you pay for the mri, nor does your plan have a way to incentivize the member to go get a cheaper mri. How in fact do you think that you are going to impact your cost if you can't change the fact that in February you, you saw a Skyrizi claim on your irks and the first thing your advisor says is well, it kicks out a 30% rebate but you can't do anything to get the Skyrizi off of your plan. Buy it more inexpensively, incentivize that member to engage as a better consumer, and therefore they win. And you win again, I ask you, what are you going to do? It's February now. You're going to see one in March and April and June and July and August. And at, uh, 25, $30,000 a pop, what is it that you're going to do? So I leave you with that crystal ball thought that employers are absolutely going to and should own their health care strategy. Advisors need to switch from the transactional approach of carrier centric models and carrier centric everything to being an advisor, being a consultant, being a health care care architect and making sure that plans are designed that could actually do something to reduce the cost of health care. That's transparency, that's data. That's, uh, getting closer to health care providers, not further away. And so that crystal ball, those initiatives, those questions, I just needed to record this and say that again. The healthcare system, um, it's finally being exposed. We're seeing it in all angles. It's not broken, it's completely designed. Wrong. The real question is, what are you going to do to change it? Because that word changes is exactly what needs to been in order for something different to occur. Don't subscribe to the definition of insanity because you can continue to do the same things, continue to get the same results. And, uh, we have already read that chapter. Read a new book, pick up a new chapter, lead the charge. And I promise you, if you spend more time and attention and worry about making sure the patient is incentivized to be a better consumer of healthcare, if you focused on that piece of it, good things will happen. Thank you so much for listening to this solo episode of the Disrupt Healthcare podcast. We're going to do more of these from an editorial standpoint. Uh, and if you liked it, give us a comment. If there's a subject you want us to cover, let us know. Give us a like, give us a share. And, uh, thanks so much for helping us disrupt healthcare.