The Hidden Cost Question

David 0:01

For decades, Americans have been told healthcare For decades Americans have been told healthcare is expensive because medicine is complicated. But what if the real reason is that the system was built so nobody could actually see the prices? And as the next phase of healthcare transparency rules under the Consolidated Appropriations Act come online, where has the money been hiding? We'll find out on this episode of Shift Shapers.

Prices And Quality Are Invisible

Announcer 0:36

Change either energizes or paralyzes. The choice is yours. This is the Shift Shapers Podcast, bringing the employee benefits industry interviews with individuals and companies who are shaping the industry's shifts. And now, here's your host, David Saltzman.

David 0:56

And to help us answer that question, we have invited Katie Talento. She is a nationally recognized healthcare policy expert, former White House health advisor, who has spent years analyzing the structural forces that drive healthcare costs in America. Today, she's CEO of All Better Healthcare, and she writes extensively about healthcare transparency, employer health policy, and how reforms like the CAA could reshape the economics of the entire healthcare system. Welcome, Katie.

SPEAKER_01 1:25

Hi, thanks for having me, David.

David 1:26

It's our pleasure. So, as I mentioned in the open, you've spent a lot of time writing about the structural dysfunction of the U.S. healthcare system. And despite decades of reforms, costs and complexity keep rising. So when you step back and you take a look at the system today, what do you see as the single biggest structural problem driving costs?

SPEAKER_01 1:47

Yeah, so I think the single biggest structural problem is that prices are price and quality are both completely invisible to the people who are paying for services. And whether that's the patient, you know, a lot of people complain that the real problem with healthcare is that there's a third party. That's not the real problem. The real problem is that that third, neither the third party nor the first party, nor the second party can see prices or quality. So it really isn't a market when you don't have price and quality information. And, you know, I worked in government for many years and we're always told that, you know, there was all these fights about whether we should have more free market forces or whether we just need the government to take over healthcare. And a lot of people would say, well, we need the government to take over it because, you know, the free market has failed and, you know, this can't healthcare can't work in a market. I would argue we haven't even tried a free market. You know, like we we pretend that this is a free market, but healthcare is neither free nor a market when you have no price information. And so how can anyone be a good fiduciary, which we're which they're required by law to be?

David 2:54

So is that the system behaving exactly as it was designed? Or has it just kind of simply drifted into dysfunction over time?

Why Policymakers Miss Employer Plans

SPEAKER_01 3:03

So I don't think there's any sort of master planners at the beginning of this process, you know, in the 40s when employer-sponsored healthcare began or insurance began. I I don't think there's um, you know, that sort of menacing wizard behind the curtain at that time. However, because the incentives have emerged to be what they are and to be so profitable to continue the status quo and to build upon it to make it even more opaque and more complex and to over time weaponize that complexity against the people that could force competition or that could make different uh choices. Then, yes, we definitely have the entrenched industry actors who are um not necessarily designing the system because the system's working for them, but they are paying billions of dollars in lobbying in order to keep the system exactly the way it is and to preserve their profit. And, you know, the just the pharmaceutical industry alone, and that does not include the PBMs um or hospitals or in, you know, other industries in healthcare. The pharmaceutical industry alone has four to five lobbyists for every member of Congress. That's 535 members of Congress. They have four to five of them. And they are the absolute um, and you know, there are records that have to be filed and made uh public. They are the biggest spenders in in all of interests, in all of the industries that pay for federal lobbying or state lobbying too, that pay for lobbying, they are the biggest spenders and and by like bigger spenders than the second, third, and fourth spenders combined.

David 4:45

So do you think most policymakers fully understand how opaque the system actually is?

SPEAKER_01 4:52

Not any more than any other patient, because they're everyone's a patient. So all of us sort of understand it from that perspective. But no, I mean, when I was in government, I didn't understand this at all until I had been in government like 15 years. And even then, by no means did I have the whole system clear in my mind the way it is now. And still, I mean, nobody in our business is an expert in this entire industry. It's a fifth of the economy. Nobody could be an expert in all of it. But I'm certainly much more expert now than I ever was while I was, say, working on Capitol Hill. When I got to the executive branch, I learned a little more about the employer-sponsored market. But there are these structural flaws in our policymaking apparatus that work against people, you know, people who are in charge of health policy being experts in the employer-sponsored market, which is, you know, covering 150, 160 million Americans. We spend all the oxygen in the room complaining and fighting about the ACA, which is, you know, 20-some million people. Meanwhile, like, who cares? We could buy them all insurance for free, which we basically already are doing, and instead focus our efforts on ERISA and the employer-sponsored market, the small group, the large group market. But the policymakers, they don't understand those markets. And the reason for that, David, is structurally, when little health policy stars are growing up, they want to go work for the committees on in Congress that oversee health, at least that they think oversee health. And those committees are in the House, the Ways and Means Committee and the Energy and Commerce Committee. In the Senate, it's the Finance Committee and the Health Education, Labor and Pension Committee, the health subcommittee of that committee. But those committees don't have jurisdiction over ERISA. It's the Edin Workforce Committee in the House and the Labor Subcommittee of the Health Education, Labor, and Pension Committee in the Senate. And the people there are like wage, labor, union experts. They're not healthcare experts. So then that's a problem in the legislative branch, huge problem. Then you get to the executive branch. And in the executive branch, well, where do we get all our political appointees from to like be the leadership of our agencies? We get them from Capitol Hill committees. So there's no one at those labor committees that we can like snatch up, grab, and turn into political appointees over at the Department of Labor. So even at DOL, we don't have any health policy experts that are political appointees. Of course, the career civil service over there is there and outlasts every administration, but they're not the decision makers. They're not the policymakers. The policymakers are the political appointees, and we don't have hardly ever any real experts. And that's why Washington is not coming to save us.

David 7:40

So who benefits the most from the lack of transparency?

SPEAKER_01 7:44

Well, of course, the sellers of healthcare. Obviously. So that would include the hospitals, the provider groups, uh, although the provider groups are a special case because they actually would like to get out of the network model. Um, the the hospitals, the pharmaceutical benefit managers, the insurers, but I repeat myself, and of course the pharmaceutical uh manufacturers.

David 8:08

So that brings us to the transparency provisions in the Consolidated Appropriations Act this year's. What many people are starting to refer to as CAA 2026. For listeners who've heard about CAA transparency and the rules, but but may not understand them, what exactly is changing over the next couple of years?

SPEAKER_01 8:27

Yeah, so um the DOL sort of issued a thermonuclear bomb about a month or two ago. Um, and we're still in the comment period. Um, probably by the time this airs, we won't be. But hopefully everyone will have gone and commented on the proposed rule. But Department of Labor proposed a rule that would essentially serve as kind of like the fiduciary rule that they put out on the pension side of the house in the middle of the giant financial collapse in 2009. Um, you know, ERISA, which is the federal law that governs, you know, the self-funded health plans. ERISA has a pension side of the house and it has a health and welfare side of the house. And the pension side of the house kind of went belly up or for a lot of plans, um, you know, during 2009 banking collapse. And um, and and so the Obama administration at the time did this fiduciary rule where they basically said, hey, you can't be a planned fiduciary if you're, you know, uh engaging in all this self-dealing and all these conflicts of interest. And they ended up basically breaking up the big investment banks and they had to do things very differently. And at the time there was thought, like, should they they actually considered, should we apply this to the health and welfare benefits side of the house? And that that was ruled against too complex. Um, but that's basically what they're doing now. They're starting with PBMs, but actually there's this little nugget at the end of the um proposal that's like, hey, should we do this with TPAs? Um, to which I will be replying in my comment, uh, hell yes, you should. But um, essentially what it's saying is already current law already says that in order for a um fiduciary to carry out its obligations, his or her obligations effectively. And Arissa has the highest, strictest standards for fiduciaries of any law. Um, you can be held personally liable, severally liable, like the benefits committee is not gonna save you, your corporate capacity is not gonna save you, you'll be personally liable for um basically not managing plan assets solely in the in the interest of plan beneficiaries. That is current law, okay? The question is, how do we interpret that current law? What counts as doing that? And thus far, basically, like doing the status quo that's like destroying the economy and killing every business has counted as fine because everyone's doing it. Now, CAA has come out, the new Consolidated Appropriations Act from Congress really doubles down on what the Department of Labor just proposed as well. Together they're working together. And the new rules are basically like if you're doing any of these shenanigans with your PBM, you, the plan sponsor, if you're the plan sponsor, you are not a good fiduciary. But more importantly, it's basically labeling all the actors in the pharmaceutical chain that have any decision making whatsoever, including your PBM, including your PBM's GPO, including your PBM's owned pharmacies, including any consultant who's a pharmacy consultant or a benefits consultant advising you on pharmaceutical benefits, any of those people who are exercising any discretion at all are a fiduciary. And I cannot think of a single PBM out there that's would not meet the definition that they're laying out as a fiduciary, which means they're now all bad fiduciaries because they're all self-dealing, they're all conflicted. And what these rules will require is for them to disclose that, which is a trap because, first of all, they're saying you have to disclose all these games that we know you're doing, and it lists them out, all the games. And then if you disclose these games, you're a bad fiduciary. And therefore, you could go to prison or be fined, or um, you could be considered deemed as engaging in prohibited transactions under ERISA. Further, the plan sponsor that is contracting with a PBM that is contracting with any of these entities that is acting in any of these ways, that plan sponsor is also now a bad fiduciary. And because it's accepting, you're accepting all these prohibited transactions on your plan that are acting in the benefit of PBM, GPOs, pharmacies, et cetera, instead of the plan beneficiaries.

David 12:47

Why do you think that Congress finally pushed these requirements through after so many failed attempts at transparency legislation?

Expect Bad Data And Resistance

SPEAKER_01 12:54

So the main champion for this legislation has been the ERISA Industry Committee, which is a trade group of the Jumbo Employers Health Plans as plan sponsors. And unlike all the other business coalitions in Washington, they do not let the um big health companies have a vote in their coalition. So when you've got like the Chamber of Commerce or you've got the National Business Group on Health, like these big, you know, or the business roundtable, all these big business groups that you would think would be advocating for rationalized, you know, law and policy when it comes to healthcare that would not screw over businesses. But the problem is these same groups, they have the health business, they have the health industry actors in their coalitions. So all the insurers, all the giant hospitals, uh and the for-profit hospital systems, all the um PBMs, they're all in there. And so they basically these groups will just turn over all policy setting for the group to their healthcare industry actors, even though those industry actors are screwing over every other um member of the coalition. And so Eric, which is the ERISA industry committee, Eric for short, they are different. They don't let the health industry membership in their organization have a vote. They are solely basically the trade group for jumbo plan sponsors, as plan sponsors, not as, you know, businesses generally. And they are run by a guy I used to work with. We used to work for Senator Tom Coburn, who is who he was awesome. And his staff are basically like the diaspora. We're everywhere, and we're kind of all kind of subversives. And he is amazing and brilliant uh at really not only the technical aspects of what we do of policymaking, but the political and like the coalition building and the pushing and the leverage pulling. Um, and he finally got it done. That's the real answer to your question, is Eric got it done.

David 14:54

So, where do you think the biggest surprises are going to start showing up when the data becomes visible? It and do you expect resistance from the parts of the system that have historically operated in the shadows? I mean, a lot of us have known about the PBM industry for a long, long time. But there's other players floating around back there too, aren't there?

SPEAKER_01 15:12

Yeah, there are. And uh what I love about the DOL rule is that it spells out that, you know, it doesn't matter, like it's it's not just the PBM. It's everyone the PBM's contracted with. And so, like whatever little subsidiary they have, or pharmacies they own, or GPOs they own, distributors they own, anything, anything they're affiliated with or own, um, that counts. And they have to make all these same disclosures. Now, what I think we'll see, like the shenanigans I think we'll see when it comes to quote, compliance, will be kind of what we've seen with the um first CAA from 21 when it comes to like broker comp and service provider comp, is um we'll see like just blanket assertions that were compliant. Or it reminds me of like when you have to do the gag clause attestations and you'll get like optum. I have a client who has this pharmacy consultant who has put optimum on the plan. And optimum like sends this assertion every year, like, oh, we have no gag clauses in our contracts. It took me a year and a half to get data out of optimum for a client that we both are on. Me and the pharmacy consultant both serve the same client, and that client was demanding their data, and we still don't have it all from Optum. I'm like, are you lying to the government? But it's not, they don't view it as them lying because they're just giving some piece of paper to the plan sponsor, and the plan sponsor is now filing and lying. And so I think that um that's how it'll start, and it'll take some enforcement actions. Like you're gonna get these like BS disclosures. We're doing the disclosures as required under the CIA of 26, and they're gonna be complete garbage and lies. And the uh the clients, the plan sponsors, are gonna have to say, I'm not filing that for you. You file it yourself because you're a fiduciary too, and you are required to do these disclosures, and I want you to file it, and I'm not gonna file it for you. And by the way, like I don't think it's adequate. And so we're either gonna have to change our contracts um to eliminate these games, or we're gonna have to um, you know, like fire you, right? And so what we've seen in terms of the gag clauses is that now when I'm negotiating a contract on behalf of a plan sponsor with, say, a PBM or a carrier network or whatever, and they're trying to limit audit rights, or they're trying to, you know, say, especially it'll come in the BAA. It'll come in like the BAA and the data access agreement. And and I'll and they'll say, like, oh yeah, we'll give you your data. I mean, provided that we mutually agree on the format, right? And the and I'll have to write, like, no, that you can't do that. The law doesn't allow that. Sorry, it gives me that leverage to force them to accept my changes and the red lines, right? So these sound like really wonky, like technical leverage points, but the law has really given us those leverage points. Now, most plan sponsors are not using these leverage points effectively. Um, and even when I try, I don't always win and I can't always do it. And it's a question of like, are you gonna just take it or leave it from Cigna? Like, you have to, you've got all these carriers, you only have a limited amount. They're all doing these same games. So I think that it's going to be really interesting because PBMs, there are competitors. You don't have to stick with Optim or the big three. You can move on. And there are plenty of these indie PBMs that you can choose instead that will write a contract with you. Like the PBM that I use on most of my plans, they were, they were putting themselves, calling themselves a fiduciary and contractually guaranteeing that they would pass through, contractually guaranteeing that they would pass through all revenue before long before these requirements were in place. So these new regs and laws really give those types of like mission-minded organizations a competitive advantage.

Turning Transparency Into Employer Action

David 19:03

Well, and the screwy thing about the gag clause was that all the carriers and all the PBMs and all the King's horses and all the King's men knew that the government had put the onus on employers to report about provisions in a contract that they weren't privy to. They weren't a signer to those contracts. And it was, I was working with a company that did compliance at the time, and we spent more time trying to explain that. It was like trying to undo the Gordian knot. It was just, it was crazy. But you know, that's the government. They do crazy things, but we move on. Let's talk about the solution. Transparency is useful, but only if it leads to better decisions. So, like once employers have access to this whole new level of healthcare cost data, what that should what should they actually do with it?

SPEAKER_01 19:45

Yeah, that is the question, right? And we're dealing with this right now with the price transparency regs from the hospitals and the insurance uh machine readable files that, you know, I I worked on those regs. I totally believe in price transparency. But I remember at the time I got all these arguments, and they still ring true today. Well, you know, patients aren't really going to shop. Patients won't really use price information. And I would argue, of course they won't. Like the this information, they're not the audience for this information. The audience for this information is employers. And still, I still argue that. Well, now we've got an audience, and not the majority, but the more enlightened employers, led by more enlightened benefits advisors, are looking to try to use this data. And what they're finding is that it's not very usable. And so I think one of the great things about some of the proposed rules, and especially the update of proposed um transparency and coverage rule that, again, the comment period uh just closed, um, but is is really that like they're they're continuing to beef up the requirements so that it becomes more standardized. Because let me give you an example. So I have a client in the Midwest that um mid-market, a few thousand um employees. And, you know, they were on Blue Cross when um we took over the plan. And Blue Cross will not do any of the innovative plan design things that we do, like waiving cost share and, you know, direct primary care referrals, whatever. They wouldn't do any of these things. They wouldn't let us directly contract, whatever. So we couldn't stick with Blue Cross. We gave them the chance, like, hey, please, they refuse to quote, okay? So we had to switch networks and we didn't quite know which one to switch to. Usually we'll rent a certain one, but um, you know, let's call that network A. But but we were open to other networks, regional networks, reference based pricing type networks, and we would looked at them. And we had two different analysts set, you know, do an analysis with the machine readable files to figure out well, if we use network X, like what would happen? Well, one analysis said, well, prices will go up, cost will go up$7 million. And another Analysis said costs will go down about$2 million. Well, neither of those things happened. And so it was costs went up, but not that much, but they went up. And obviously, that's not what we're trying to do. We're trying to lower costs. So really, those files were unusable for at least the analysis teams that we used. Um, now I do think that there are certain vendors out there that are doing analysis in a more sophisticated way than others. But boy, you really have to pay for that analysis. It's very difficult. Nonetheless, this is the future. This is the foundation. It is necessary, but it is not sufficient. So, yes, we must have standardized data out there. And, you know, that's what I told the government is like, you have to standardize it, standardize, standardize, standardize because, and then you have to enforce with like excruciating enforcement penalties. But right now, like it's it's not being used by a lot of actors, but more and more we're starting to see it used, especially when it's combined with claims data. So, like what the Pacific Business Group on Health, or I think they're calling it the uh purchasing business group on health now, um, they are starting to combine claims data from their members with the MRFs, the machine readable files, and they're and they're doing network analysis on behalf of members. Great. That is the same thing we're doing with my clients. And it's the same thing that a vendor like Talon, for instance, is doing. Um, there are others out there, more and more of them are gonna do this. And and then employers will use it to first make network decisions. That's obviously the first and foremost. But second, to figure out how to pay cash so that they can go around their network or go not have a network. So either pay cash or directly contract with providers and know that they're not screwing over those providers because they're providing a fair market rate. And the only way you can really do that is if you have market information.

David 23:54

Well, and given how much it costs and the all the providers to to chase payments, you would think that a deal could easily be made for paying cash on the barrel. And in point of fact, they can just have to you just have to know what the right price is.

The Contract Clauses Blocking Cash Pay

SPEAKER_01 24:09

Accept that, and this is another like huge policy gap, which I'm working on right now. Um the network contracts with both the provider and the plan sponsor prohibit those arrangements. Prohibit if you if your patient walks in with a carrier logo, that doctor has to charge the carrier. You can't pay cash on behalf of your member that day. You can't have a system back at your independent TPA that's paying cash, turning it into a claim, feeding that into your claims database. You can't then have a direct contract with that provider because supposedly there already is a direct contract with the network you're both contracted with. So these anti-competitive, I would argue, illegal contract provisions must be prohibited explicitly because I would argue they're already illegal under the Sherman Antitrust Act because they're anti-competitive. But clearly, like FTC, DOJ, they're not coming after these organizations for they're not coming after these network contracts um yet, anyway. And so um we really need clarification, either by regulation or by law, that these contract provisions are illegal.

David 25:15

Well, you know, just like human beings have done since time immemorium, they never see the light until they feel the heat. And up until now, there hasn't been any heat. And, you know, once there is, and and you're right, they are definitely anti-competitive. And and I don't know how they've gotten around this all these years, except that people have had other targets to shoot at. But, you know, be that as it may, looking beyond transparency, what other reforms, like policy-driven or market-driven, could realistically in the near term bend the healthcare cost curve.

HSAs, ICHRAs, And Market Reform

SPEAKER_01 25:46

So I do think that if you have these contract changes, because they are absolutely essential, or or we will not do anything else. So, like in Washington, my tribe, I always worked for Republicans, team GOP, they're always about the HSAs. Expand the HSAs, expand them bigger, um, take the caps off, allow them to buy more, um, have more people have them. And I would argue, like, big deal. You have an HSA. So great, you can buy like one overpriced MRI, um uh MRI at your like health plans negotiated rate. Like, it doesn't change anything. It doesn't lead to a cash economy, like they always say, because unless you can go some unless because you're still gonna be insured. Most people are still gonna be insured, meaning their HSA is going to be applied to a carrier negotiated rate, unless that doctor can see this patient with the blue cross ID card and still take cash from that patient, right? And still have a separate. And that cash price can then be applied to that patient's deductible, right? So, unless we have many, many more people using HSAs, the contract provisions are prohibited, the anti-competitive ones. And we can get, I mean, I think where we really want to see the um policy go and where the president has really like come out loudly, although I don't know that anyone at the White House is actually executing on his policy, but he has come out saying we need to take the money away from the insurers and give them to the people. So that's kind of what an ICRA is doing in a very limited place. What if we had like ICRAs on steroids where employers could simply just throw that 10 grand or 20 grand they're spending per employee into an HSA and get out of the business altogether? Um, and when they do that, because right now, given how many people have HSAs, which is uh, you know, not enough to make a difference, um there's not gonna be any price competition driven by HSAs out there in the world. Now, if you had the individual market boom, both on exchange and off exchange, because everyone now has an HSA, and that's how employers are paying their people health benefits, then now like KV bar the door, right? Because then people will go be shopping for all kinds of coverage, but also people will be choosing not to have coverage or really catastrophic coverage, and then there will be a bigger cash economy. So that's kind of like the future. I I don't think it's that distant in the future because we're we're all sort of starting to really talk about all these pieces working together like that now.

David 28:27

You know, back more years than I care to count, I was the regional director of consumerism for one of the large carriers. And it took about six months until it became clear that the average rate of savings in the United States is under 4%. And it doesn't matter whether it's a savings account with a little passbook or however it's done these days, or whether it's an HSA. And also, as somebody said on this program a couple of years ago, what we've done is we've created people who are functionally uninsured. So they have a card in their wallet and they've got a$5,000 deductible because they've got an HSA, but they're making$38,000 a year and working on the loading dock. They've got, you know, a family and an apartment and a car, uh, probably one of those rolls can hardly roll down one hill, can hardly make it up the next. And they can't put money into an HSA account. They don't even think about savings. It's not even in their lexicon. And so what have we done? We've taken little Johnny, who has a cold, and they don't go to the doctor for a while. They say, well, he'll get over it. And fast forward, as you've seen and I've seen, and all the practitioners in our business have seen, fast forward six weeks or seven weeks, and little Johnny's running up a$230,000 bill in the PICU or in the, you know, whatever. It's just insane. And it's it hasn't worked right for a number of reasons. I think it was well-intentioned, but it just hasn't, it just hasn't worked right. I think it I think the wish was the father of the thought, you know, with that stuff. And, you know, it it maybe if we give people a bunch of money and we can help educate them, but I think that's going to be a long road, don't you?

SPEAKER_01 29:57

Yeah. I mean, I I I think that essentially, you know, Republicans in 2003, when this was all created, you know, they they thought that people would be consumers. And that has always been this like fundamental flaw in our thinking. People are not going to be consumers as as much, certainly not right now. Not when there's no price information. There's not a competitive market where there even is a single price that can be known in advance and that is universally accepted. Um, however, I do think that you'll get more of that if we were to allow employers to, like you said, we we HSA is not it's useless for saving. Like most people are paycheck to paycheck. Like this is stupid conversation, just like you were saying. But if all the money from an employer flowed into that HSA and that HSA could be used to pay premiums, right? And it's it could like there's no contribution limits and it could be used to pay premiums, which is not now. Um, and everybody was in an individual market, the individual market would like flourish. There would be all kinds of interesting plan offerings that would be catastrophic, less catastrophic, whatever. You get like really competition, not just for the prices of healthcare, but for the prices of coverage, right? And so um now it would no longer be dictated by employers. It would be just this massively huge individual market. That would lead to people being insured, but with things like sidecar health or um some of these like more interesting, innovative approaches where they do create a cash um sensitive consumer because they'll only pay up to a certain amount and then it's on you. And so you're gonna shop. But all these pieces have to be in place for that kind of market to work. So we're building those pieces. And each time we add one, there's a million people out there that are like, well, this won't change anything because blah, blah, blah. That's true. It won't change anything immediately. It's all of them working together for this future that we envision.

Turning Point Depends On Enforcement

David 31:54

Well, and then folks who've spent a few years with getting money and being able to keep it in their HSAs would have the option of buying a catastrophic plan for a lot less money and still have completely adequate door-to-door coverage. So finishing up here, is as if we fast forward five years, do you think CAA transparency provisions are going to be remembered as a turning point in healthcare or just another incremental reform?

SPEAKER_01 32:18

I do think it's a turning point. Uh, it will be dependent on if enforcement occurs, right? Um, but I do think it's a turning point the same way I think that the first CAA was a turning point and the initial trice price transparency regulations were a turning point. At each point, they're seen, you know, they're poo-pooed as like they're not really going to change anything. They're not, but they give us more leverage and then we start demanding more. If we didn't have those original prices that were required under the price transparency regs, we wouldn't have even known what we need to know to demand what the CAA of 26 was is now giving us because we realized we're getting screwed, we're not, we're being lied to, like, like they're hiding fees in claims. You know, like these are all the um the things that we didn't even know until we started getting some data. And then even the researchers, even the small minority of users of like power users of that data start to expose things and educate the rest of us who aren't using the data.

David 33:17

It's like Rumsfeld said, those are those were unknown unknowns.

SPEAKER_01 33:20

Exactly.

David 33:21

Things we didn't know we didn't know. So um final question. If you had the authority to redesign just one piece of the American healthcare system tomorrow, what would you change first and why?

SPEAKER_01 33:33

I think what I would do is I would get rid of the, I would ban those contract provisions outright. Ban provisions that don't allow you um to negotiate a better deal, either a cash pay or a direct contract between the buyers and the sellers without the network involved. Um even and you can still have a network, but you're allowed to you work outside the network. That's what's not allowed right now, because then your network becomes supplementary to the, or supplemental rather, to uh the arrangements that you have. Doctors would love it. They would love it, right? The hospitals, they claim they're crying out for this. We would call their bluff, right? We'll see. Like, do you really want to contract with me directly? But for your mean old network contracts, let's see. And so um I think that that would change a lot. And um, these network contracts are really prohibiting employers from doing that today.

David 34:28

Let's talk a little bit for a moment as we close out here about your writing, because anybody who writes a column titled PBMs and Employers Could Go to Federal Prison is my kind of writer. You're pretty prolific as a writer. I know you write on Substack and some other places. Is Substack the best place to find you, or where else might people find some of the stuff you've written?

SPEAKER_01 34:47

Yeah, you can find me at katytolento.com, which is my Substack site, katytolento.com, and I put out something every week. I kind of have two hats that I wear. One is sort of like technical wonky policy benefits advisor. And then the other hat I wear is kind of like naturopath and um, you know, holistic-minded uh mother. So I, you know, it sort of alternates between both of those. And um, so I don't know if I have two different audiences or one very um eclectic audience. Um, but anyway, that's where I am. Thank you.

David 35:20

But there's something for everybody. Katie Talenta, CEO of All Better Healthcare. Katie, thanks so much for a fascinating conversation.

SPEAKER_01 35:28

My pleasure. Thanks, David.

Announcer 35:31

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