The Hidden Game Behind Your Medical Bill (And Why You’re Losing)

I used to believe the system just needed small fixes.

Then I saw what was really happening behind the scenes.

Most people think healthcare is just “complicated.” That’s not true. It’s designed in a way that keeps you in the dark… and paying more than you should.

In this episode, I walk through what I’ve learned from inside the system—and why so many smart people still miss what’s right in front of them.

This isn’t about politics. It’s about control, incentives, and why the rules don’t work the way you think they do.

If you’ve ever felt confused, frustrated, or like something just doesn’t add up… you’re not wrong.

You’re just seeing the cracks.

In this episode, you’ll learn:

• Why “free market healthcare” might not exist at all
• The quiet shift that changed how much you pay—and why you didn’t notice
• What insiders understand about pricing that most people never hear

This one may change how you see every bill you’ve ever paid.

If something in this episode made you stop and think… you’re going to want to follow this guest closely.

Katy Talento is a Harvard-trained epidemiologist and naturopathic doctor who spent years inside the highest levels of healthcare policy. She served as a White House health advisor and worked directly on some of the biggest decisions shaping the system today.

But here’s what makes her different…

She walked away from all of it.

Now, she focuses on helping everyday people and employers understand what’s really going on—and how to navigate it without getting taken advantage of.

If you want to see what she’s seeing before everyone else does, start here:

Website: KatyTalento.com Instagram / X / LinkedIn: @katytalento Facebook: katytalento.nd

Trust me… the more you learn from her, the harder it is to look at healthcare the same way again.

Other resources mentioned in episode:

• https://dollarfor.org/

Transcript

SPEAKER_00 0:00

Not once, but twice. George Washington did something unprecedented. He relinquished his authority. The first time happened after the end of the Revolutionary War. He was the commander-in-chief, the continental army. Everybody thought he was just going to be a king with an army. And he said that said, I'm done, resigned his commission, went back home to his farm. He loved it. But he was called back to duty and he served as president for two terms. At the end of the second term, he said, You know what? I'm done. I'm going back to the farm. That's what I really want to do. People were shocked because that never happens. King George III said, I can't believe he did this. Everybody was amazed. In fact, they started a society, the Society of Cincinnati, after the famous Roman general who did the same thing. He was called up from his farm. He went won a war and went back to his farm. He had dictorial powers, and he said, I don't want him, I'm done. Great. Now I bring this up because we have a very unusual and exciting guest today. And her name is Katie Talento. And Katie was on the inside of DC. She was an advisor to five U.S. Senators. She was running all over Capitol Hill. She was Capitol Hill. And then she became a special White House assistant to President Trump in his first term. Now almost everybody takes that kind of insider action and traction and gets a top lobbying job, or they work for an agency, they get a no-show job at a big healthcare conglomerate. But she had she had the golden tick in her hand, she goes, I don't want that. I'm not going to do that. And instead, she said, I'm going to become a benefit consultant. And I'm going to actually help people navigate this system. I'm going to start writing and speaking and spreading the word about what's bad and change it from the outside because I did it on the inside. So I am so excited to have Katie Talento here today. And I'm just going to really quick this is a podcast for informational purposes only. It's not medical advice. Please see your physician if you have a problem. Katie, welcome. I'm so excited to have you here.

SPEAKER_01 2:04

Thanks so much for having me. It's a pleasure to be with you.

SPEAKER_00 2:06

You are the modern-day Cincinnatist. So I know most people don't think about Cincinnati anymore, but I love that you did that to step away. And what was the biggest lesson that you took from being the special assistant to the president?

SPEAKER_01 2:23

I think probably what I came away with is that nobody is really qualified for these jobs. They're too powerful for any one human. And especially when you're talking about um, and it wasn't just anyone human. Like we have a team, politics is a team sport. Um, but I think also when you're talking about health care, especially, um, you know, there are energy staffers and education staffers and labor staffers in Washington, but health staffers have a unique sort of um ineptitude because healthcare is so vast. It's a fifth of the economy, it's a multi-trillion dollar industry. Even industry experts aren't experts in the whole thing. And so the idea that we can somehow like understand this all after a few years, you know, working for some backbench or senator or whatever, like it's, you know, none of us are qualified to do what we're doing. And so you you really have to spend a lot of time on your knees.

SPEAKER_00 3:17

You know, I'm glad you said that. That was one of the things that I retired in 23 and I started going on X, and I was like, I want to learn about healthcare policy. And people are posting on there, and I'm like, oh my gosh, I had no idea about how bad things were. And like you said, the depth and breadth. And there's a lot of things I think I'm very knowledgeable about, and a lot of things I have no clue about as well. You know, the nuances of healthcare financing, hospital charge masters, those sorts. I have no idea, but I love reading about it. And could you talk to us about your work on the transparency executive order?

SPEAKER_01 3:50

One of our biggest sort of fumbles, I think, was in the first year when President Trump wanted to do repeal or replace, up, you know, up at that first when he was first elected. Um, you know, none of us really recommended that we do that first, but he wanted to. So um, yeah, so that went down in flames. And uh and so we we uh the lesson I took from that was we're Republicans here, like we don't do vast government-wide, giant take over the whole thing, regulate the whole thing programs. And and if we do, we always end up like doing it a little bit less than the Democrats, which makes us just look like you know, the Grinch that stole Christmas. So there's no, there's no future in that. So I was thinking, well, what is something marginal, like kind of on the edge, but that isn't like a vast, you know, scheme for all of healthcare that will really make a difference in all of healthcare and that's completely inarguable and nonpartisan. And price transparency was, in my mind, the thing, you know. Um I had been wanting to do that idea for a while. And um so, but I got pushed into it by this crazy woman named Cynthia Fisher, who now runs this um group called Patient Rights Advocate. But she was smart. She brought in a former boss of mine because I would never take meetings. Who has time, right? For like interesting new ideas. We just want to meet with you about this interesting new idea. I'm like, I don't have time for like new ideas. We don't think here, that's not what we do here. So um, so I wouldn't even take the meeting with this woman I'd never met it, but she was smart and brought in my old boss, uh, a retired senator Tom Coburn, also a physician. Oh yeah. And so the two of them came in. She knew I like couldn't turn him down and I love him like a father. And so um, you know, I was halfway through the meeting with them. And during most meetings, including this one, you're basically thinking about like lunch, how do I say no to them? How do I get out of this without hurting anyone's feelings? Like, you know, I don't have time to add more work to my plate. So I just need to say no in like a polite way. And then about halfway through the meeting, I was like, why are you saying that? Is this all going on inside my head? Like, why? You know that they're right. You know you want to do this anyway. Like you've been wanting to do it. Why not just say yes and like start working together on all the manifold problems that arrive when you decide you want to do this? So um, so I did. And uh, they had brought a draft executive order, and you know, so I took their draft and said, all right, we gotta, we gotta start working on this. And um, and so, you know, over the next, I don't know, six to eight months, we did sort of write up a new executive order, how would it look, and um sent it over to HHS. They were completely horrified and um, you know, kind of wrote memos about why this was the stupidest idea ever. Um, and we all kind of laugh about it now because eventually everyone got on board. Um, and everyone who, like even those who sort of initially opposed it, colleagues of mine, friends of mine, um, over at the department, they, you know, we kind of laugh about it because they were opposed at first, but now we're all really proud of it, including them. And um, and a lot of them work on these issues related to transparency still. But ultimately, everybody in sort of like Bushian Republican politics, um, and that's kind of the swamp I grew up in as a staffer, was like traditional conservative Republicans. We were for, you know, free market. And so basically, private industry was better than government. We don't regulate, we don't have absolutely have to. And, you know, regulation is basically like usually worse than not regulating because government's so stupid. So that's not always wrong. That's very often correct. But um, in healthcare, it, you know, our knee-jerk defense of private industry had continued so long, like kind of non-cognizant of the fact that private industry had increasingly become indefensible. And yet we still had this like knee-jerk defense instinct. And um, and and President Trump was like the first populist who didn't have those preconceived notions. And so he was really kind of coming at it from like, these industries are really gross and self-serving and they're actually hurting people. And maybe they do need to be smacked down a little bit andor a lot. And so I because I had worked on the campaign, I had kind of um been more read in. I've been converted more, it's a this way of thinking, than my colleagues who came into the Trump administration a little later and were sort of still holding their conservative traditional Republican views. And so that's why they oppose this. Like regulation is usually stupid and creates like perverse incentives and you know unintended consequences, and they're not wrong. But um, but in this case, it really was desperately needed because healthcare is neither free nor a market. And it, you know, a lot of people, a lot of Democrats especially say, look, the free market's failed and we need, therefore, to have the government take it over. But actually, I would argue back like the free market hasn't even been tried. We don't have price information, we don't have quality information. Like what other industry gets away with this? And so this isn't a free market. Let's try a little free market. And so, um, and that was kind of the angle I use with my more libertarian-leaning colleagues. There were quite a few um who really oppose us, kind of like econ PhD types who um definitely were afraid of regulation as you know, creating problems. So we started a little journal club because they didn't really want to do this. So they didn't really believe that if we did price transparency that it would lead to lower prices and price competition, which I thought was insane. I felt like, am I arguing with a bunch of physicists about whether gravity is real? Like, I don't get it. This is like, you know, you need price information to have price competition. Why am I have why do I have to convince econ PhDs in this? I agree. But I did. And uh, so we had a little turtle club, whatever, for a while. And eventually, um, honestly, one of the things that really helped was um a buddy of mine from graduate school, um, this little guy named Marty McCary, when we were back in our early 20s, um, we were in school together and we had stayed friends, and he had sent me his book, his pre-publication of the price we paid. And I literally like sent the PDF around, or actually maybe it was a pre-print copy. I don't remember. I sent the book around to literally everyone who works on healthcare in the government, um, in the the political appointees who were sort of opposed to this. And it was after that, honestly, that I stopped getting as much pushback. And I think it's because, like I said, most Republicans who grow up in Washington as health policy people, they don't grow up, there's sort of a structural flaw. They don't grow up wanting to work on the congressional committees that oversee the Department of Labor. They don't, that's not with which is of course where all of health care is taking place is under the federal law called ERISA, which is regulated by the Department of Labor. Instead, we all grow up wanting to work for the Senate Finance Committee, the Senate Health Committee, the House Ways and Means, the House Energy and Commerce Committee, those are the committees that regulate CMS, Medicare, Medicaid, FDA, CDC, NIH. Um, and so all of us like gravitate toward those committees. But what it means is that like the types of plans and the industry that controls the health coverage for half the country, which is self-funded health plans regulated by the Department of Labor, there's no one in Washington who understands how they work. And so, and and like the perverse incentives and what all the vendors and industries and sub-industries out there are doing that are just screwing the American people through those types of plans. And as a result, nobody really understood PBMs, nobody really understood carrier contracts, um uh what third-party administrators really do versus what the carrier versions of those really do. Um, and so you have a bunch of people who just didn't understand much of healthcare. And honestly, Marty's book put it into very plain English and had a chapter on kind of like each aspect of the most 101 aspect. And I was kind of shocked. And and he really walks through like what the corruption is in in each sector of the healthcare economy. And it really, I think it educated a lot of us. And after that, we start I started getting a little less pushback because I don't think the Republican, you know, Illuminati really thought that this industry was as corrupt as it is, and that really, I mean, it was around then, like 2017, 2018, that kind of all started seeing that um in a way that I don't think kind of the elite policymakers had prior to prior to then.

SPEAKER_00 12:40

Well, they're really good at messaging, and I think the thing is, unfortunately, everybody always is blaming the physicians. And you'll go back to the 60s, they said, okay, we need Medicare, Medicaid, and that's when the government really started getting involved. They came up with the term provider, is under that legislation. And then I remember when they came up with the HMO Act of 1973, and they said, we're spending health, our our healthcare spending is out of control. We have to rein in the physicians, they're going crazy. Now it's kind of laughable when you look at what we're spending in the 60s, or we're looking at spending in the 70s. It's really almost nothing. We're about 8% of GDP back then, and we were really pretty close to other countries. We aren't that far off. There's that one graph that kind of shows us, and it really it spreads in the 1980s, is where it really breaks. And you know, they came up with this whole HMO idea, and I think that's in my mind where a lot of things went wrong because then you had this proposition from the insurance companies. They said, we'll pay us one premium and we'll cover everything. But from that point on, we never knew what the price was for anything. And we never knew if we were getting a good deal or a bad deal, and we turned over all of our health care, the most private part of our lives, to a corporation. It made no sense when you think about it. But no, everybody's like, well, I'm getting this great deal. And and I agree with you, you know, the price transparency should be bipartisan. Everybody should say, yeah, you should be able to see it. And I really don't understand why everybody thinks that the market in healthcare is different than any other market. And there was that study by the American Enterprise Institute that looked at the long-term uh cost of cosmetic procedures, and that went up at half the GPU, it went up 38% over 21 years versus 66% for CPI and hospitals were at 240 and 132 for medical services. You're like, wait a minute. People are really good at shopping. You know, they they can do this. And there's the proof, but I know all the elites are like, oh, they can't shop. It's too and I don't know what's complex about a CT scan or a CBC that makes it harder than buying a Ford SUV with a lot of features. I don't know why that one's harder, but now do you think that transparency are you happy with the way that has evolved? Do you think the executive order should have been changed a little bit, or where do you think we need to go from here?

SPEAKER_01 15:03

I think the only thing wrong with the executive order, well, the executive order isn't really the issue. It's more the regs that unfolded from the order, right? Because the order is just like a love letter to the secretary to do some regs on this. And so um I think the only thing I would have changed, honestly, about the regs is much tougher enforcement. Um, and I think that we we thought that compliance would happen because it's the law. And we're so naive. Um and so, no, compliance does not happen. And so um, yeah, I think and the, you know, when I left or when President Trump left um office in that sort of interregnum period, um I was terrified that the Biden administration would succumb to the industry pressure that of course we had all been subject to but had resisted. Um, and I just, you know, maybe I didn't respect them as much. And I'm like, you're gonna cave. And they didn't, you know, they well, they did it to the PBMs, but they did it to everybody else. And they um they doubled down on the enforcement. They like increased enforcement penalties by like 10 times. And so that's fantastic. Um, I'm not sure they actually, you know, did a lot of enforcement, but I appreciated the lip service. They didn't undo the regs. I mean, they did, they undid a lot of our regs. And so they could have just pulled them, reversed them, and they didn't. And so I was so grateful for that. But it speaks to just how bipartisan and overwhelmingly supported price transparency is and was, and why it was like such a political win as well as a policy win. Um, even the industries who were vehemently opposed, I mean, they were suing us in court to try to get out of this reg, um, they got laughed out of court twice, which was awesome. But even though they were vehemently opposed, they couldn't really say so in public. And they just had to like engage in sort of back office count subterfuge, you know, to try to uh counter it. So I appreciated that that you know, it wasn't pulled back exactly. The PBMs um sued and they sued the Biden administration, and the Biden administration kind of got them to back off by agreeing to, you know, not defer enforcement of their peace. Um, and so we still don't have really uh net drug prices being being reported. However, I that is absolutely gonna change based on um new law that passed passed by Congress, which I couldn't believe. Like they never do anything good. And look, they just passed this amazing law um uh just a like a month ago or so about PBMs and drug prices and uh fiduciary responsibilities and full disclosures of indirect and you know, indirect like shenanigans that PBMs and GPOs and um pharmacies and everything that they're like doing to pharmacists, everything they're doing to uh drug manufacturers, everything is getting exposed by this new law that was passed as part of the large omnibus funding bill. Um and then three days before that bill passed, the Department of Labor put out a very similar reg, uh proposed reg. And so um I think the comments are still open on that. I need to get on task of writing the comment to that. But um, so the comment period is still open. So we will see, but uh you know, it's a little the law gives it a little bit of time to comply, whereas the reg gives it less time, but they haven't finalized that reg yet. So I really think that this is now inarguable. And anyone who's sort of pushing back, like the the momentum is only going in one direction for all these industries, and they better like examine their business models because honestly, this law burns down the PBM, and I would argue TPA business models, um, and PBMs are the carriers, and PBMs are the profit centers for the carriers. Carriers are limited in some ways, depending on what kind of plan to how much profit they can make and how they can eke out that profit. But they what they do is they just profiteer on their PBM side and the side that's like eating up, gobbling up all the physicians and the facilities and hospitals and all the delivery, all the healthcare delivery side.

SPEAKER_00 18:58

I do agree. Yeah, you're right. It's one in the same because we really have to stop thinking as PBMs. It's right that one big conglomerate.

SPEAKER_01 19:05

The Borg. It's the Borg.

SPEAKER_00 19:07

It is. It's not just that one piece of it. But I do agree because the thing was when I was practicing, I really didn't have time to look at all this stuff. And I would read these things, and you know, the pharmaceutical companies would say the PBMs are bad, and they would say it's the pharmaceutical companies. I was like, I'm not really sure. And once you discover, and the worst thing for PBMs is once people really realize what they do, there's no justification for it at all.

SPEAKER_01 19:31

And well, I mean, listen, it used to be a reasonable value prop that, like, oh, look, employer, you have 300 employees. You can't go to Pfizer and get a volume discount on 3,000 employees or 300 employees, that I, as your middleman, can go and get a volume discount on like 300,000 or 3 million employees. That seems reasonable. Pay me a little bit, uh a little bit of that discount I get for you, and I'll give you the rest. Like, totally reasonable. We have middlemen like that, wholesalers, distributors, and every other industry. What happened is um Congress, they lobbied Congress to exempt them from a law that prevents kickbacks in healthcare. And so then now they can receive all those so-called kickbacks, which are they call rebates, um, but they can receive all that in indirect compensation. And they just started pocketing all the discounts or part of the discounts or redefining the discounts as the kind that they don't have to give back to you. And so it's it became this corrupt system. But I don't think the original idea was so horrific. It's just that it's been so perverted since then.

SPEAKER_00 20:40

Well, the first thing you said is the key when you said the discount, because there's no reason for a rebate. A rebate's a terrible idea. If I'm a business, I've said, listen, give me a discount today, and you and then it's over with. But with the rebate, you have to follow it. It comes six months later, then you have to follow it, and you have to keep your contract for a year. No one knows where it goes, then it's going offshore. And it's a joke. Just give us a discount, and then all of a sudden your business model is over. And I agree with you. Pay like a small administrative fee that is not tied to the amount, the net price or list price, whatever price they want to call, and get rid of the net and list price and just have one price, you know, with the discount that's at the so that shows up when the patients dare at the counter and they get that price. I mean, it's so basic.

SPEAKER_01 21:27

I mean, if you think about it, uh if the PBMs were sitting here, I hate like being unfair to anyone, but if the PBMs were sitting here, they would say, Walmart and Amazon do the same thing. Like, nice product you got there. Be a shame if no one could find it to buy it. So give me, give my customers a discount, and I'll put you on my website or I'll put you on my store show. That's essentially what PBM's value prop was. The problem is that Amazon really does pass on discounts to you, like their products are in fact affordable. Right. So that's just completely different. Different with um with drugs, but also um, you know, it it it these guys like someone is paying the list price, right? They're taking this discount, but they're not passing it on to the consumer. And um, and so PBMs really have perverted this so that like your employer is paying that full price um and they're taking the kickback, and there's no one, no other place to go. But really, there is another place to go now. There are independent, there are sort of truly fiduciary and pass-through PBMs that you can use instead. So you can't, there's no way that an employer or benefits consultant like me can go and like look at an OptimRX contract, find all the scams. And even if I can find all the scams, I usually can, but even if I can't find all the scams, it doesn't matter because even if I could, they're not gonna change them for me. Like I'm not gonna send my red lines on their contract back to them and they're gonna be like, okay. So they just, it's just a take it or leave it proposition. And so there's really no way out. You have to fire them.

SPEAKER_00 23:02

No, and I agree. And I was happy that Eli Lilly in Genitech fired. Now, Eli Lilly fired, I think they had CBS Cure mark was their PBM. They fired them, which is great because also they're a customer of them, they have to deal with them. But that tells me I have to believe for Eli Lilly to make that big break with them that they're getting tired of them and they're gonna phase them out. That's my it's my opinion. I I don't have any inside information on that. I publicly encourage David Riggs to fire the big three PBMs. I'm sure he's listening to us. So it, you know, so I do encourage that. The other thing that I love that you wrote, and I've shared this with a million people, is outsmart the medical bill trap. And could you walk us through some of the highlights? This is gold. I love this. I want everybody who's listening, please go to kittytolento.com. There's great information there. Follow her on LinkedIn, Substack. She is the real deal. Well, please tell us about what you wrote there. It's gold.

SPEAKER_01 24:03

Thanks so much. So, you know, I think this was born of just being a particularly obnoxious and also informed patient and consumer and lover of patients, because we all are in our families and friends. Um, and so I just kind of learned these tricks over over time, um, either through benefits consulting or just through understanding the law behind these issues. So the first thing you want to do to sort of not get raped and pillaged by your healthcare borg, whether it's your carrier or your, you know, fake, you know, nonprofit, nonprofit tax exempt charity hospital, is um you want to get the billing codes of whatever's gonna happen to you. So you call them up, you say, what are the billing codes of this, you know, colonoscopy you're gonna give me, or this surgery um, or this, you know, vaginal delivery. And you get the billing codes. These are like usually five digit codes, and um, they might have a letter in front of them if it's like a chemo. Um, and so then you go, you put those billing codes into Chat GPT and you say, What is the Medicare rate for these codes in my zip code? So you gotta get a little geographic modifier in there. And and Chat GPT will give you like, you know, a range of what's what Medicare usually pays. And the reason we ask that is because we want to get a sense of like, what does this thing cost the, you know, the seller of care, whether it's the doctor or the hospital facility. And Medicare is close to cost. It was designed to be cost plus a little profit. I would argue it still is. Most uh facilities, hospitals, and doctors like argue that they're losing money on Medicare. And I say I would say the data suggests otherwise. But anyway, so um, it's basically about what the thing costs. Great. Now that I know what the thing costs, then I'm going to look for the cheapest site of care. Because what happens is, you know, everybody has to make a profit. So they're going to charge you what it costs, but then they're also going to add a little bit of profit. If it's a hospital-owned facility, they're going to add a massive amount of profit in the form of a facility fee. So if you go to a, yes, if you go to a particular type of facility that is not owned by a hospital, if you go to an independent physician practice, you go to an independent imaging center, if an independent ambulatory surgery center, um, you can you can save a crap ton of money. And so ask your doctor who's like ordering this thing for you or is gonna do the thing, is there a place that you can do this thing that isn't owned by a hospital? And the best way to make sure that his answer is yes is to go to a doctor who isn't owned by a hospital. So if you if you know I I always to this day, still in my own hometown market, I will go, you know, to ChatGPT and ask, show me all the non-hospital-owned neurology practices in my town. Um, because they're out there and you just may not realize it. And so start there for sure. Like don't go to a place that has a hospital logo on it. Um, and you could tell on their website they'll have the hospital logo. So then when you ask your doctor that, they're gonna say, Oh, well, I do surgeries at this, you know, independent surgery place on this day and I do the hospital on that day, just say, hey, let's do it at the independent surgery place or let's do it at the imaging center that's not the radiology department of the hospital. So um, so then when you've chosen your site of care that's a lower cost site of care, then you call them up and ask them for a good faith estimate. You'll need to have scheduled. So once you've scheduled, call them up, ask them for what's called a good faith estimate. This is required under our regulations that they have to provide you exactly how how much it's gonna cost, including all the various ancillary doctors and procedures and whatever's gonna happen, plus a facility fee if there is one. And you know, they're not, it's not totally legally binding, but it is pretty obnoxious if they charge you something else and it gives you the opportunity to fight back later. So ask for that. Now, after you see that, and you then you can compare that to the Medicare price, and you can say, oh, also there might be other billing codes on there that they hadn't told you about first. And so great, now you know all the billing codes. And so go back, compare it to Medicare in your Chat GPT question. How much profit are they charging you? Is it reasonable? And what percent of Medicare is it? So it's a hundred, a hundred percent of Medicare is the Medicare cost. Are they charging you 180% of Medicare? Are they charging you 240% of Medicare? Like if you can't do that math, just ask Chat BT that question. And so um essentially this 100 to 100 to 150% of Medicare, meaning zero to 50% above the Medicare price is a good price. Um hundred and fifty to 200 is fair, it's okay. And then anything above 200 and especially above 250 is raping and pillaging. So um now raping and pillaging is the norm. So your average doctor, like average price, commercial insurance price is 250% of Medicare. In a hospital, it's 300% of Medicare. So that's three times the Medicare rate. That's not good. Don't pay that if you can at all avoid it. So once you figure out, like, if the price is good, reasonable, whatever, then you want to think about when do I do this? Okay. But no, before you get to the when am I gonna do this, you also want to ask, now that you know what their like rate is under your insurance plan, now ask them, what would the price be if I were a self-paid patient? If I just paid cash up front on the data service or before the data service. They probably will come back at you with um, either we can't do that because we know you're insured now. And then you can say, you still have to give me the cash price, you have to report it to the government anyway. So just tell me what it is. Um, but usually they won't play that game. Usually they will tell you what the self-pay rate is. So if that cash price is better and you're still under your deductible, like you, you're gonna have to pay a big chunk of this, it's worth paying the cash price. However, go to your HR department, ask them, hey, I'm about to pay the cash price, meaning I'm gonna save you a bundle. And it because it's this much different than the commercial rate that you negotiated with your insurance company that's supposed to be getting you discounts, but actually uninsured prices are cheaper than what you're getting with your stupid insurer. And so why don't you make sure that this cash amount that I'm about to pay is applied to my deductible? Because otherwise, I'm just gonna not do the cash price, I'm gonna do the insured price, and you're gonna have to pay for part of this, right?

SPEAKER_00 30:31

Or even or even just pay the whole thing for me, you know, if it's a really big savings.

SPEAKER_01 30:35

Well, now we're talking. This is what we do on our health plans. We waive the deductible if you do, if you go to a great site of care. Right.

SPEAKER_00 30:41

Um really incentivize them to do that. You know, I think that's that's that the one thing I would say for physicians for Medicare, it really depends on the specialty.

SPEAKER_01 30:50

Yes.

SPEAKER_00 30:51

So for like OBGYN, we don't really do a lot of Medicare procedures. So Medicare fee schedule for us doesn't really make a lot of sense. For other specialties, it does. So I think that's a little nuanced. But the other thing is usually the physician part isn't a very big part of the bill anyway.

SPEAKER_01 31:08

So it's like you know, when I talk about your doctor is gonna be like 25 to 5,000, 2,500 to 5,000. The facility where you deliver is gonna be like 7,000 to 10,000. That's all very normative. If it's above 10,000, start shopping elsewhere.

SPEAKER_00 31:24

Right. So some of that's a little bit different. I love all this, I love the reference-based pricing that you have because otherwise people have nowhere to go to get an idea. The other thing I will say for physicians, and I was guilty of this, most physicians, especially if they're employed by a hospital, have no idea what anything costs. They have no idea what the CT down the hall costs, what the lab down the hall costs, or what it is across. They don't have an idea. So we're not trying to harm you, they just have don't know. So don't assume they know and be your own advocate, which you always talk about. But anyway, I interrupted you. Please, so please continue on this great journey.

SPEAKER_01 31:59

Yeah, you're so right. Doctors don't realize um that they might be violating their Hippocratic oath by sending a patient to something they can't afford and not exploring other lower cost options with them, because what we find is even small costs that you know a doctor might think aren't that big of a barrier are a huge barrier for working class people. We see in the pharmacy, um, in the pharmacy setting, what we call the walk-away price. So basically, if the point of service cost to that patient is $50 or more, a quarter of all patients just walk away and don't fill the prescription.

SPEAKER_00 32:36

And we never see that.

SPEAKER_01 32:37

$50.

SPEAKER_00 32:38

We don't see that.

SPEAKER_01 32:39

Imagine you're sending someone to like the radiology department down the hall and you think it's just an X-ray or a CT scan or whatever. And that's like more than they can afford. So um, that's one of the beauties of something like direct primary care where you know the x-ray machine's in the office, you know. Um, so okay. So now you've asked your HR department to apply that cash amount to your deductible. They may or may not say yes. It's worth asking, right? Um, and lots of times they don't know how. And or their like stupid blue cross plan won't let them or won't make it easy and whatever. So it's probably not their fault. Um, they're not very sophisticated if they're not able to do this. And you should tell them like there are other options out there to call Katie. But anyway, so um then you want to think about like what time of year is it? Okay. If it's the end of the calendar year, you might have already satisfied your deductible, which is great, and then you won't owe as much and you won't have to worry about this as much, although your employer certainly will and might raise your rates next year. But if you if you go at the beginning of the calendar year, um, you're probably gonna be under your deductible, but especially think about if you've got like a multi-date, you know, process. If you're like getting chemo or you're getting um one knee and then the other knee or whatever. Like if you're doing something expensive in December and then you're doing another expensive thing in January, you might be paying your deductible twice. So just think about that. Um, so be cognizant of the calendar. And then obviously, if you're lower income, um, every hospital is required by law under the Affordable Care Act to have a financial assistance program. And you can you can qualify for that assistance program even if you're insured and you have like big out-of-pocket costs that you can't afford. So let's say you've got a $3,000 deductible, you don't have $3,000 sitting in your bank account. Um, you can go ahead and schedule that procedure. And when the bill comes for your portion, you send that bill to their financial assistance program, you apply for their financial assistance program. Read the qualifications for the program before you, you know, do plan on all this because you want to make sure that you'll qualify. And so you can read the criteria. There's a charity out there that helps you with this, and it's called $4. So $4.org. And they will like get you this charity assistance. They'll help you talk through it in the beginning. They will often negotiate away your bills under charity assistance programs with hospitals. They're brilliant, they're wonderful. Um, okay, so that's all before the date of service. Now it's a lot of homework, but it's worth it. Um, now you go in on the date of service. Okay, so you walk in and now they've like they're lobbing a bunch of clipboards at you or an iPad to do a bunch of paperwork. And so the important thing here is that in that paperwork is a form that says, we are going to charge you whatever we want. And if your insurance doesn't pay us everything that we want, we're going to charge you and you're going to be responsible for it, signed you. And so um, you don't want to sign that form, at least not in that form. They're hiding it in a bunch of they're hiding it in a bunch of other forms, like I consent to be treated today and I consent to have my medical information shared with other doctors if necessary, like reasonable stuff, you know? Um, and so it all looks reasonable and you're just like, Katie, Katie, Katie, Katie, right? You're just signing, sign, sign. Don't do that, okay? Pay attention. If it's paper, um, you can edit the paper, edit the paper. But usually what I do instead of doing that, because these days it's largely on the iPad, um, typically what I'll do is I'll just get to the signature line and I'll write, I did not agree to this, or I did not read this instead of signing my name. So I do not sign my name, I just write plainly, I did not agree to this. Nobody is looking at this, okay? They're just like, check that she signed this thing, it comes back from the iPad elves saying she signed it. Um now, if it's actual paper, you can edit, like where it says we agree to charge, you agree that we can charge you whatever, and I'll just strike out the whatever and say, you know, reasonable amounts not to exceed 200% of Medicare, right? And then I'll sign it. Um, but if you're not, if you don't feel comfortable doing all that, just just sign, sign. I did not agree that agree to this. Okay. Um, then if they like screw you later, they try to overcharge you, or they charge you more than your good faith estimate, or more than you expected, or more than they're posting in their price transparency files, which you can look up later, then you can come back at them and say, you know what, I didn't agree to this and you didn't post it anywhere publicly. Um, and in fact, when you do get that bill, do not freak out at first. Do not freak out. Okay. It often is not gonna be what you're actually gonna have to pay. And um, and never ever, ever pay that first bill. Instead, when you get the first bill, call them and call the number that's on that bill and say, I want an itemized bill. So they send you the itemized bill. Does it match the good faith estimate they gave you in advance? Does it match the price transparency rates that they post online, which you can get from patientrightsadvocate.org? They have a spreadsheet, it'll have your hospital. You can find, like, okay, here's my plan, here's what these CPT codes are charged to my plan. Do they match? Because if they don't match those and they don't match the good faith estimate, you're gonna write back, hey hospital, um, thanks for everything, but I'm not I never agreed to pay this price. You can check the consent form. I didn't agree to it. Also, you didn't tell me it in advance because the good faith estimate was wrong, and you didn't even tell the government the correct one. So now we're gonna use my price. My price is 150% of Medicare. I've already paid that in my portal. You can see that that's what I've paid. Please zero out the rest of my balance. And this may not work right away. They may send keep sending you bills. If if they do, just respond back either by phone or in writing. Again, say the same thing. And um, and eventually they will zero out your balance. Now, if you get scared and you're like nervous waiting, because they're gonna, these letters are gonna get increasingly threatening, like we're gonna send you to collections. Um, first of all, the if a collection, if a collector calls you can say, This bill is actively under dispute, I can send you the records of how I've disputed it. They're not allowed to report you to any credit bureau if it's under dispute. So fear not, do not freak out when they start throwing the collections card around. Okay. And so, but if you get scared and if you want to sort of like end this, go find a lawyer, pay the lawyer 300 bucks to put your letter on his letterhead and send it via servicing process, like to their registered agent, the general counsel's office of the hospital, and it will get zeroed out. Your balance will get zeroed out. They're not gonna write you a letter saying we zeroed it out, they're just gonna zero it out.

SPEAKER_00 39:07

The one thing that's interesting I found is that when the hospitals sell medical debt, they sell it for 1%. It's incredible. So if you start thinking about that, you're like, okay, what do they really think this is worth? They know it's not worth a lot. And but they scare everybody, like you said. And it doesn't mean, you know, and there's people that they send the collections and they, you know, they're paying five times what that cost actually was in interest or because they didn't know. So the main thing, think of that 1% number and say, you know, there's a lot of room to negotiate negotiate here. And the other thing is I know for a lot of the hospitals, the cash price is this phony charge master, very elevated price that they use to discount the PPO contracts. So a lot of times if they ask, if you ask for a cash price and it's crazy, you just have to say, okay, I'm not interested in that fake price. I want a real price. Like you said, you know, use the reference base with Medicare and does that.

SPEAKER_01 40:03

Yeah, sometimes you're right. When you ask for a cash price, they're gonna give you their sticker price. Rarely, though. That more often happens in like a bougie specialist office, right? Where they're like, well, here's our out-of-network price, and it's like a million dollars, and there's no way you can get around it. It's for the rich people or the Saudi Sheik. Sure. So um, you know, and that's fine. Like if you're in a bougie specialist office, like you chose the bougie specialist, and there's no way around it, really. But if you're talking about a hospital, you're exactly right. Their choice is between the 150 you already paid them or you getting sent to collections and they basically getting nothing out of that. So usually they'll accept the 150 and go away.

SPEAKER_00 40:40

Yeah, no, I I think that makes sense. The other thing I'm excited about and concerned at the same time is this program, which I hate the name, hospital at home. It should be acute care at home, where you know you're able to treat people with COPD, congestive heart failure, people that are not going to need ICU or surgery. And now, with the event of all these great monitors that you know you can monitor 24-7, you can have them at home. And the thing, I mean, I love the idea is because we need to get people out of the hospitals. We need to get them in a better environment, what better environment than our homes. Well, my concern is that they're A, letting the hospitals direct it. And if you're saying you don't need to be in a hospital, why do we need the hospitals directly? That's a terrible idea. And B, we're paying the hospitals at the same rate they would get as if they were in the hospital, which again, why not get cost savings? And I think this should be something directed by your physician, and then you should use the home health individuals, put that together. So I think we need a waiver for a physician to direct it. And to me, this is very much like how we used to have inpatient surgery for everything. You'd have your gallbladder out, you'd be in the hospital for seven days, you have a huge scar, and then in 1991, it changed. 50% of the surgeons said, Oh, we can do this laparoscopically. Now it's done, you go home. And if it's done at Amulatory Surgery Center, you save huge amounts of money. But it only worked when they got it out of the hospital. So I love your thoughts on that. I mean, that's my thoughts. And let me know if you agree with that. You think I'm crazy, or where do you land on that?

SPEAKER_01 42:17

Yeah. So I you're responding to an article I wrote. Um, I think it was called like hospitals or Soviet-style hellscapes that aren't fit for humans or something. Yes. So, like, yeah, hospitals are bad. Let's stay out of them. Um, and one of the I, you know, it was such an apocalyptic article that I wanted to have some like bright light at the end. And so um, one bright light is that there are kind of efforts to create solutions that are, you know, sufficiently equivalent acute care options that aren't in a hospital. And so I would I would push back a little bit on what you're saying first in a couple ways. First, not all vendors that are doing this are in fact hospitals. So there are some vendors that are like just we've hired some acute care physicians, they're back at like NASA headquarters where we've got like all the screens up, and it's not a hospital-based operation. Um, and so their charge for this is different, or you know, but the second thing I would say is even if the charge is the same, and even if it's being run by your local hospital, which you know, we hate or whatever, there are there is no risk-free place, okay? Getting out of the hospital and the totalitarian things and the harms, the absolute measurable harms that happen in a hospital, even if I'm paying the same, you know, I'm paying the same to the same evil people, like I don't care. I want my loved one out of that hellscape because nothing good's happening there. And they're not healing there because they have fluorescent lights and they don't see the air and they are treated like children and they're like strapped down to their beds with fire alarms going off if they move. And like the food is god awful and like not fit for human consumption. And and like people are act like little totalitarian bureaucrats. And they're patted on the head and treated like children. I cannot stand the even a second thinking about how hospitals are. So no matter what it costs for my loved one or for me, anywhere else is better, even if it costs more. So um so I think that is an innovation.

SPEAKER_00 44:15

I do think that like it's a great innovation. I I love the whole idea.

SPEAKER_01 44:20

I think it'll improve, I think it'll start to move away from like hospital control. There will be other vendors. And I would love to see, like, even for, I mean, this primarily right now, it's for like the most acute people who really do need like serious acute monitoring. But I look forward to seeing like, you know, even the like the people who who let's say, like, for instance, my daughter was like trying, they tried to hold her hostage when she gave birth to a baby. And so um, you know, they they wouldn't let her leave without calling CPS on her. And this, she'd already been there 24 hours. They wanted their 48 hours. And so um, like I would argue as these innovations grow, these like hospitals away from the hospital, we'll be able to offer those types of services to more and more types of patients. So, like, okay, hospital, like you're super obsessed with monitoring my newborn grandson or whatever, fine. Um, like let's do it this other way. Let's do it with this wearable or whatever. Like, I just like the movement in that direction. And the more we start to be willing to, especially employers are willing to pay for this or Medicare willing to pay for this, the more innovation will happen that will disempower and dethrone the acute care hospitals in our communities.

SPEAKER_00 45:35

Well, here's the other thing interesting with the monitoring. And I was really thinking about this because anytime there's a new system, being a physician, I'm like, okay, what's the downside? What's the upside? I really like get my arms around it. But I was thinking, you're wearing the wearables, you're in your home and it's 24-7 monitoring. You're in the hospital, you're not monitored 24-7. You might have vitals taken once or twice a shift. And we all know what happens. Yes. So what happens is you get, and I've been in hospitals, I've been as an OB, you're in there in the middle of the night all the time. So what happens is at night, you know, it's pretty thinly staffed. If there's a patient that deteriorates in the middle of the night, that's it. Nobody else is really getting any attention or vitals or anything because everybody's running to this room. You know, somebody else and they kind of catch that late. Because I, you know, now they're on the bad EHR and then you know they're tied up with that. They're looking at this instead of the old days. The nurses were in the room with the patients, and they would call us and say, you know what, Mrs. Joan just seems a little agitated. I can't put my finger on it. Could you come in? Sure. So everything's caught a little bit later now, but now all these people aren't getting monitored. And you're paying this huge, you're paying this rate that you could have stayed at a suite at the four seasons. And like you said, the food's terrible. Nothing else is included. You get this bed for $3,500 at a nonprofit hospital. And why do they charge more than a for-profit hospital? But different conversation. But the thing is, you're actually, it is delusion. You actually are being monitored more intensively at home. And I think that, and you have your loved one right there with you, and they're gonna notice a change. And one of the things I always like to do as an OB and as a dad, you know, my wife is phenomenal with the children. I was always working. So I said, you know what? I want you to pick out the pediatrician and you're empowered. If you say, you know what, I think something's wrong with the children, they seem off, bring them in. A great pediatrician always asks the mom, what do you think is going on? If they say something's wrong, and same thing for me, if I have patients come in and go, I don't feel good, I'm like, please come in now. Let's see you. Something's going on then. But you know, I love that at home because you get back to that. And you're right, the food in hospitals, I've eaten so much hospital food, I'm glad I'm still alive. It's the worst. I don't know who designs it. It's so bizarre. And but you're right, all those things. So I think that's very helpful. And above all that, even the humanistic and the treatment, all that, we can't afford the rate of rise of hospital inflation. And the hospitals get a pass, I think politically, and I'd love your thought on this, but there's usually in every congressional district, there's probably a nonprofit hospital. They're one of the largest employers. They always have this giving wall. They get all this, you know, they get this persona that it's Mother Teresa running, and they're given charity care. So everybody loves them. And I think the congressmen are afraid to go against them because of that. That yeah.

SPEAKER_01 48:33

Their association is handing out checks, right, to politicians. Big time. And they are the largest employer in the in the congressional district. And if you're a senator, they're like, then you're dealing with the academic medical centers, which are like the university of your state, right? That's true. Um, that has like millions of ancillary facilities, tens of thousands of employees, um, the sports team that you can't take down, you know. So like it is hard to buck up against hospitals. And I do think people, you know, I got lobbied by every swampian interest in town. And people will ask me, like, who are the worst bond villains um in the whole healthcare industry? You know, is it the, is it the, you know, drug makers and who is it? And I'm like, it's the for-profit charity hospitals and the PBMs. And like they're they're neck and neck. But um, I detest these, like, um, I'm not for-profit, it's the nonprofit charity hospitals. They're supposedly charities. They have this like white hat, you know, like you said, we're the we're the beacon of light in your community when really they are the sucker of value out of their communities. They're sending it back to some conglomerated board that's running multi-state hospitals and that their executives make like $20 million salaries. It's it's completely disgusting. And, you know, one of the things that we try to do is just create community-owned health plans that are networks of doctors and hospitals and facilities that really try to keep the boorgs out of. So if there's an independent, small, single hospital, we really want to build that hospital up and and try to bring direct primary care, try to bring um, you know, support the birth centers or the independent OB practices or the um the nurse midwives. And and like we really, really try to keep people out of hospitals because nothing good happens there. Nothing. And I think you're gonna be, you might be a little offended, I'm not sure, but probably. Um, my next article is gonna be about hospital birth.

SPEAKER_00 50:30

I won't be offended. You know, I always get challenged. And you know, here's what I love. You know, you and I agree on probably 90%. Then there's gonna be 10% we disagree with, and that's fine. And what I try to do when someone writes something that's provocative and is outside of what I've done, I try to say, okay, is there something I can learn here? Is there something I can pick up? And one of the things that really to me is humbling as a physician is no matter how smart you think you are, no matter how good you think you are, you still need to be a little bit better. And you can't listen to patients enough. I have so much respect for patients. And I think what we need to get, if I didn't say anything, uh, is we really have to get healthcare back to the patients and the physicians in the room, get rid of all the other extra vendors, players, and there's so much money in it. There doesn't need to be this amount of money. We're actually, I would say uh number one, we're insuring too many things. We need to simplify health insurance just for catastrophic things, and we're spending too much money. We don't need to spend all this much money on it and make it simple and uh do the tough choices on things. So no, I love that you're provocative, Katie. I I really respect because I know in my heart that you want to do what's best for everybody, and that's what drives you. So we have that same driving force. And you're do you're coming at it from a different perspective. And I, you know what? I think the more perspectives, the better. Let the market determine which one wins.

SPEAKER_01 52:02

Yeah, well, what you said what I think is the absolute most important thing, and I actually do reference, I will be referencing this in my piece is the the idea of listening to patients, right? Like nobody has been inside their body for the past 30 years or 40 years or however old they are. Right. Like they have, right? They know the slightest change. And when a woman is giving birth, you know, there are there are only a few like true emergencies in birth. And when they happen, the woman often knows, almost always, like something just changed, uterine rupture, right? Like that's a very different feeling than contractions, right? Or transverse line, like that nothing's happening here, right? There's an arm hanging out of me. So like there are things that we know. And if we have a physician in the room paying attention between the physician's expertise and the woman's expertise in her body, that's the safest place to be, you know? And so it's just but that's almost never what's happening in that room. It's almost never that dynamic of those two people.

SPEAKER_00 53:01

I will say this too. The labor and delivery nurses are crucial. And, you know, in each labor and delivery unit is different. They're they're all very, very unique. And I've seen some that are just so phenomenal with patients and so empathetic and caring. And that makes such a big difference for a first-time mom. And it's it's great when you see that. I mean, it's just magical when they're there, especially if they have their own children. And, you know, that's the part that you AI is never going to understand. That's the part you can't put on a spreadsheet. You know, you have to have the right people in the right jobs. And when you do, it's it's magical. And when you don't, it's, you know, then it's doesn't work as well. So I would add that they're very important as well.

SPEAKER_01 53:48

They they can be very important for good or for evil, honestly. Like I think you're right that when you have a rock solid L and D nurse, like that is amazing, increasingly they're being suppressed by the Borg and the protocols, and they start acting like totalitarian enforcers of protocol. And I think that um that's not why they went into nursing school. It's not their personalities, like the system is turning them into its enforcers. And um, I think that's really dangerous. And if you talk to nurses, like I think increasingly, which of course you do, I think increasingly they feel this. And the best of them are often looking for ways out. Like, okay, can I go get my midwife certification? Like, can I practice somewhere else? Can I do some other approach? Because um increasingly, like these are just like in acute care and other issues, other, you know, types of conditions, which again, pregnancy, is it really an emergency medical emergency? I don't know. Is it really a medical event at all? I don't know. But um It's a life event, we'll call it. Um it's a what?

SPEAKER_00 54:49

It's a life event and but I will say, I mean, it's interesting because there's so many physiologic changes with it. But I'm gonna look forward to this piece and I'm gonna read it and I'm gonna push back all you want. No, it's fine. I I'm gonna read it with an open mind. You know, I always do. What would you do? What would be your number one thing if President Trump called you on the phone and said, Katie, I miss you. Give me some advice on how to reform healthcare.

SPEAKER_01 55:15

Um, okay. Well, it's funny you asked, but I I would uh just send him the article I wrote about this, which is like, here's what you should do. And your instincts were already right. Like you've already intuited what you should do. Because um, in the fall, in around November, he tweeted or he social media posted out um what he wanted, which was take away the money from the big insurers and give it to the people. And so I have what I call um his, I basically I call his idea school choice for healthcare, where we give money to people and they instead of like into an HSA or some type of account, um, and not just like a few dollars for their HSA to purchase ancillary things around their deductible, up to their deductible. That's not what I mean. I mean you give them all of it. So if you're an ACA um subsidized enrollee, you get your entire ACA subsidy into an account. If you're an employee, your employer puts the entire amount they're paying or can put the entire amount they're paying for you today, which is about like for a family of four, over $25,000 into your account. And then you don't have to have the employer buying your group health plan for you. You can go out and buy whatever insurance works for you or no insurance. You can get a healthcare sharing ministry, you can get some catastrophic plan, you can get nothing, you can have direct primary care, you can just pay cash, whatever you want. That's and then we would because part of the problem is you know, we talk about cash pay and the cash economy and how important that is. And it is, but it's not enough at this point to change the system, to reward having a single cash price and having um healthcare sellers, whatever, doctors, hospitals, facilities, sellers of care competing on the basis of that sole cash price. That is not where we are today. And the reason for it is the cash payers out there are too small a segment of the market. They're either people who are shopping for the cheap stuff on their with their HSA because your HSA takes care of basically your cheap stuff. Um, or they're like moguls who aren't uninsured, who are uninsured and they're just paying cash for everything. That's not a big enough group. And so, and also it's not the cheap stuff we need to worry about. It's the really expensive stuff we need price competition for the most. And so, what I would argue is we really need to have cash pay at scale. And the only way we can have cash pay at scale is if employers are paying cash. And so we're starting to do this in the plans I design is trying to figure out ways that employers can pay cash. You can't do this if like Blue Cross is running your plan or Cigna is running your plan. And so you have to be working towards this post-network world while you still have a network on your plan for a while. Maybe you're renting it from Aetna or wherever, but they're not running your plan. So you need an independent third-party administrator who can help you actually pay cash on behalf of your employees, or we can just get out of the employer-sponsored insurance altogether, or both, right? We get out of it altogether by putting that money from the employers into people's own accounts and they go out and they pay cash or they buy their own insurance. That's how we bring innovation at scale because half the country is insured by their employer, more than half the country. And so we've got to whatever thing, whatever we want to happen has to happen there with that money and those people.

SPEAKER_00 58:31

No, I do agree with that. Could you do something where you could set aside, I mean, this would be my idea. And you can tell me I'm crazy because I know you you you are a vocal woman. I love that. Could you do is you know, take a sliver of that money and buy a truly catastrophic policy and say, okay, this is your your cat policy here. And then here's all the things you're gonna shop for, and we're gonna have a navigator, because I'm stealing this idea from CrowdHealth, which is a great program. We're gonna have a navigator in our HR department. So when you call and say, hey, you know what, I have this knee surgery coming up, you know, you say, Oh, we've got somebody who really does great quality care but takes good cash price, you know, those sorts of things. And mirror that together. Because I think people do need assistance to try to sort this out and find because it's difficult to find the best deals right now, the best intersection of quality and price, which I would call value. So it's it's difficult for individuals right now because of the lack of transparency. But I think if you had a good healthcare navigator in a company, and this shouldn't be HR, this should be somebody who's really knowledgeable, and then you pair that together, then I think you'd have something really powerful. And I do agree we can't wait on Congress to think this big because there are a bunch of small people. Sorry, Congress. We have to have the employers do that. But I think that might be a nice way just to have that little piece of that CAD policy. Is that reasonable?

SPEAKER_01 59:57

It's not only reasonable, it's literally what we do when we build our nurse navigators that we put on the plan. Okay. And you call your nurse navigator if you need care, and she'll give you, we invest in a bunch of quality databases. So we have Johns Hopkins, we have Medicare data, we have commercial claims quality metrics, and and we research the highest quality doctors at the lowest cost sites of care. And then we'll come, the nurse will come back and give you two or three options that are in network. And you don't have to choose them. You can go out and like be raped and pillaged if you want. But if you choose one of those options, then we'll waive your deductible and co-insurance. So it's so it's free for you.

SPEAKER_00 1:00:35

I love that. So it's great. That's that's where we need to go. I'm shocked that I feel like there's so many self-insured companies that say, okay, here's our big decision. Are we gonna go a blue cross this year or Aetna? Oh, wait a minute, maybe Cigna. No, maybe United. And they just get caught in that world and they get, of course, their associated PBMs, because that's part of the whole thing. And, you know, they sit there and then they say, Oh, I got it, 10%. And their broker comes up and goes, you know, you're my favorite. So I'm gonna give you all 8%. I work for you, you know. And they just keep doing it year after year. And then the employees don't realize that they're actually the ones paying for it.

SPEAKER_01 1:01:13

Yeah. Well, what you're describing is, you know, an employer thinks they're hiring an agent to go purchase for them health plan. And um, and they're like the buyer's agent. That's that's what they think they're buying. And then it turns out that the buyer's agent is actually being paid far more by the seller. So, you know, a lot of brokerage firms are, oh, we're an Aetna house or we're a Blue Cross or a United House. And like your recommendations from that agent are gonna be blue cross because that's what they get paid the most for for a bunch of bonuses that you aren't paying them. And kickbacks from the stop loss insurer and the PBM that they're referring you to, and you get they're getting a bunch of revenue from other places. And one of the really great things that happened in 2021 in the Consolidated Appropriations Act then that President Trump signed was uh required brokers to disclose not only the direct compensation that you think you're paying them, which you might be paying more than you think, um, in some secret way. So they have to show what are you paying them, you, the employer, but also what are they getting paid because of your account from everyone else too? And not all of the big brokerage firms are doing this particularly honestly, but they are required to by law. And really, you what you've hit upon right here is the key driver as to why so much of the employer-sponsored market has not changed. It's because you know, it's no HR person can be in like a sophisticated purchaser of healthcare. It is a fifth of the economy. Like they cannot possibly know all the ways they're getting screwed and how to evaluate the different options and how to build these like crazy unbundled health plans, like I was describing with the nurse navigator. Like, they can't, they need someone who can do this for them. And when they're being told that, oh, I'm your trusted advisor and I'm acting on your behalf when really I'm just the sales force for the carriers. Um, that is truly, truly the problem. And so at the root is um getting a trusted benefits advisor who is not conflicted and who will show you their compensation up front, who agree by contract not to take compensation from anywhere else. There are advisors out there who will put that in their contract and they are worth their weight in gold.

SPEAKER_00 1:03:25

That's perfect. No, I love that. And I'm glad that we came together on that. See, that's like I said, I think we're 90% affiliated. That's why I love that. And it no, I think those great ideas. How would companies find those good advisors? What's the best way?

SPEAKER_01 1:03:41

So um, it's gonna sound a little self-serving, but there is an organization called Health Rosetta. Um, you can go to healthrosetta.org. And what they are is they start off as a nonprofit organization to really credential advisors like that, to like certify, ooh, honest advisor here, you know? And so, and they have these requirements to get certified. You have to agree that you're not gonna take revenue from anywhere else. And if you are, you disclose it totally upfront and um and you disclose all your conflicts of interest and you act solely in the fiduciary interest of your um employer clients. And so they have a directory of certified health resident advisors. I'm one of them, there, but there are hundreds of others, and we all kind of do this type of plan. With some of us have different approaches, some use nurse navigators, some use non-nurse navigators, like whatever. And some prefer this independent fiduciary PBM and others prefer that one. But really, we're all kind of doing the similar types of unbundling these plans from the carrier board and making an experience more affordable and higher quality for the enrollees and the patients and lower cost for the employer.

SPEAKER_00 1:04:42

And I will add, more humane is, you know, as I'm kind of going through these things. I I did an interview with uh Andy Schoonover from Crowd Health, and it was kind of funny, is everything he designed on there was based on empathy and the golden rule. It was just amazing. I was like, wow. You know, they when people call in, they have the same navigator. So you always have the same person and they know you, and you know, they they want to help you when you have a claim. And I've never felt that with a major insurance company. They they you they act like you're a criminal. It's like, well, you liked me yesterday when I said the premium in today you don't like me. And it uh it's it's kind of crazy, but I really love that. I love that you went to be a benefit consultant with Health Rosetta instead of becoming a company shill when you left the White House. So that is awesome. I I can't thank you enough for that. And how was it? Did you have a lot of act? You must have had a lot of access if you're in the White House to the president. How was that interacting with him on a personal level?

SPEAKER_01 1:05:43

Yeah, well, it's funny because he is both exactly as you see him publicly when in private. He's it's it's it's it's this paradox. He is both exactly like you see when he's alone in private, but also he's so Kind and responsive and interested in other people. And that's often not how he's perceived publicly. And so, like, it's both and um he's he's very, very astute of body language. And he's like his EQ is so high that he it's actually like when you're in the room with maybe five people who are all disagreeing or whatever, and they're higher in the totem pole than me, maybe. One like trick that you have to get the president's attention to get called on is to just kind of roll your eyes or like just make the slightest little like body language disapproval of what's being said, and he'll be like, you, what do you think? That's funny. He's just like really interested in in people. He really wants to hear from people. So um he won't read a memo, which makes it kind of hard to staff him, but um, but he listens and he especially responds well when you tell him a story. He'll never forget that story. So whenever I was trying to like teach him an issue, I would try to think of an illustrative story because I know he'll never forget it. And that's how he learns.

SPEAKER_00 1:07:01

No, I you I love that. And I love he's got great instincts. I think that's phenomenal. And I also love that you're a Harvard-trained epidemiologist. And I will say, as a physician, it's very difficult. We are not trained in studies. We're we're, you know, we're not researchers. And we really depend on our medical societies to kind of interpret these things and give us some guidance. And they come up with this guidance, and then there's good and bad with that. So that theory is good, but I think most of them are the same way. They're clinicians as well. But you're kind of stuck with the guidance because then it's kind of out there and you can't go against that. And that's the hard part. And I know that hormone replacement therapy, that women's health initiative study now, you know, they've removed the black box, which is great, the black box warning on hormone replacement therapy. But that's a great example. And I really think before, and I did write about this and you saw it. Before we had these big uh studies that change everything, we should replicate it. We should double-check it because it comes, it changes everything for 20 years, and then invariably they come back and go, oh, that actually wasn't true. And everything you've been doing is wrong. And one of the things that I saw in my practice was that, and this started with the opioid epidemic, they said pain is the fifth idle sign. And the government said, if people are in pain, they cannot get addicted to opioids, and there was this big pitch. They said, physicians, you are under prescribing pain medications, you need up your game. They had the zero to ten pain scale. We're getting all these calls, and then they harass the poor nurses, you know, they're gonna get in trouble. And I was like, I'm not doing that. That's a bad idea. So I would just I'd get these calls, a patient has a pain scale of 10, and I'd go there and they'd be reading the paper. This is how long ago it was. And then I would just sit down with the patient and just explain to them what that means, or like, oh yeah, it's not that bad. You know. But all that came by and there was all this pressure. And the government conveniently doesn't say that anymore, but they had a hand in that opioid crisis. And now then they send a letter to Surgeon General some years later, sent a letter to every physician saying you need to not prescribe as much uh opioids. So I wrote back to him. I said, you know what, I'm actually fine. I didn't listen to the first bad advice, so now I don't need to change. But thanks. You know, but I really think physicians out there, I would say always be very critical and think for yourself. So when something comes through and you're like, this is the the way you have to do it, say, okay, does that make sense? And look for other data sources and always be a little skeptical, is what I'm saying. I think that's important to do.

SPEAKER_01 1:09:42

Yeah, and those professional societies are um largely have revenue models that are not fully apparent to their physician members. Um, and so there may be lots of pharmaceutical money that's funding all their conferences or um, you know, the junkets that they're taking people on. And, you know, there have been studies done on even you don't have to like receive a bunch of kickbacks, even just that one pharma rep coming and buying you and your team lunch once a week or once a month or once a quarter has an impact. And otherwise they wouldn't be doing it. And so, like, it's really so easy to um it's not so much that you get corrupted. I I think about this when I was lobbied, you know, long before they passed laws preventing lobbyists from buying us stuff. Um, you know, I I had a steak lunch every day. Like some lobbyists would take me to lunch every day. I did not think that I was corrupt. And I would not say that I was. How the corruption happens is those people become the ones you call when you have a question about the issue. They or they have an issue they want to talk to you about, and you take their calls because now your friends and they get to frame the issue for you before the patient group or before the provider group comes in. Like, so then it's just um it's that slow corruption. And I think you see that in the professional societies as well. Um, you know, I worked on the open the president's opioid initiative. This was a huge campaign promise of his, and we tried to hit it from all angles, you know, the prescribing practices, the disposal practices of unused opioids. Um, but you know, how this really got put in. And I remember being a pill staffer when, like, we have to have this pain bill because patients aren't getting enough pain medicine. And I was like, that was in 2001 or two. And what was going on like how it really changed is because Jaco, the accrediting bodies of these hospitals, like started scoring hospitals on those stupid little like smiley face posters. And, you know, like, how bad is your pain? Is it this or is it, you know, like it's so stupid. Anyway, and then, you know, I remember again, Marty McCary, I basically learned everything about how medicine's going from Marty. Marty's like, man, I used to hand those out like candy. I feel like such an idiot. I can't imagine how many people I got addicted because he was a surgeon. And so it's just horrible. And you're absolutely right about the replicability replication crisis. But one thing about that HRT study, it's not that it needed to be replicated, it needed to be read. So, what actually happened is the first study, the study itself, had non-statistically significant results. It didn't actually say what the lead author said in his press release that it said. And so if anyone read the study, they would realize. And in fact, when he was putting out those press releases and, you know, like lying about his results, his findings, several of the authors on the studies, it was a bunch, it was like a multi-site study with a bunch of investigators. Several of those investigators peeled off and they were like, We're not, we're not gonna be part of this. But it didn't matter. It was too late. Like it spread like wildfire that uh, you know, estrogen and progesterone they cause um breast cancer or stroke or dementia or whatever, all the things that we're told. And so a generation of women, their health has been totally compromised by this lie. And the second thing I would say is so that's a situation where like it didn't need replication, it just needed reading. But in the replication question, like, no one ever got a Nobel Prize for replicating a study. And nobody hardly ever gets an NIH grant for replicating a study. And so our entire research enterprise in biomedicine is, you know, designed against doing good science rather than just like interesting science. And so um, I think that's that's a huge problem we see in the Alzheimer's debate, like massive fraud in Alzheimer's research has diverted good scientists down potentially promising paths because they were chasing fraudulent paths based on outright fraud, like fake pictures and charts and Western blots and graphics in their in their journals. Like, so we've got I I appreciate that now we have an NIH director um named Jane Badacharya who built his career on like kind of exposing shenanigans like this. And so I'm hopeful, and he's talking about these problems, but it's extremely difficult to change these institutions.

SPEAKER_00 1:13:59

No, 100%. And I appreciate everything you've said today. I'm gonna wrap that up and I'm gonna look forward to your next piece because I look forward to all your pieces, and they're always provocative and they're always well thought out. And I really want everybody listening, please go to katytolento.com and check out everything. And so I'll give you a little warning right now. Some things are gonna throw you off a little bit. You might say, oh my gosh, this is different than usual, but that's the point of it. But she's always pushing in the right direction. I have great respect for you, Katie. Thank you so much for being here. I really appreciate it.

SPEAKER_01 1:14:33

My pleasure. And thank you for never having anything to prove so that you can just be open-minded and humble and modest about medicine and science. And so thank you. Thank you for having me.

SPEAKER_00 1:14:43

Absolutely. And thanks, all my listeners. I really appreciate it. And please like and follow both Katie and I on our socials, and we'll we'll put her socials on the show notes so you don't have to take any notes. So don't worry about that. And we'll see you next time. Thank you so much.