Marshall Allen | Keynote Speaker | Managing Healthcare Costs in the Digital Age | 4C Digital Health

You know, there's a lot of influence and power that comes with really well told stories. And I have a very strong justice streak, a very strong sense of right and wrong. And so I started in journalism. I did kind of general reporting for five years at Smallpapers in Los Angeles. Then I went to the Las Vegas Sun. And it was at the Las Vegas Sun In 2006, my editor took me out to lunch and said, hey, Marshall, we want you to cover the healthcare beat. And the first words out of my mouth, no lie, were, I can't imagine anything more boring than writing about healthcare. It just sounded, like, dreadful. I think I'd read so many bad stories. You get press releases like crazy in healthcare. Stories about the new hospital robot or the new study that says, coffee's bad for you or coffee's good for you. I just didn't have a lot of understanding of it or respect for it. But as soon as I started writing about it, I always wrote about it from the point of view of the patient. I would.

Talk to patients, I would get their medical records, I would get their bills. I would have them waive their HIPAA privacy rights so that I could do a thorough 360 evaluation of the care they received. I could go to the hospitals, the insurance companies, the doctors. I could have them explain what was going on. As I did this, I did a lot of stories about patient safety issues and a lot of stories about the cost of care. And I saw literally that this is life and death for people, sometimes literally with patient safety and quality problems, sometimes with the cost of care, it might be bankruptcy or medical debt.

As I saw how truly absurd the health care system really is. Again, with my ministry background, I'm looking at this through a moral and ethical lens. What's been happening to working Americans and employers is immoral and it's unethical and it's wrong, and it's not always illegal. Sometimes it's also illegal, but you don't even need to prove that it's illegal. All you need to do is stand up and say, this is not right what's happening here. There's a facade that's been.

Hiding the problems. But it's. Once you pierce that facade and you investigate these cases, as I've done now hundreds of times over the last 16 years, you see that these problems are. First of all, they're fixable, they're solvable, but also they're causing a great amount of harm. And so after the Las Vegas sun, I spent five years there. Then I went to ProPublica. I spent 10 years at ProPublica and there I continued the same type of work investigating these stories, examining the system. I think the facade might be too, that there's any system at all. It's actually, there's no actual coordinated system here. It's a group of individual stakeholders, whether it's hospitals or doctors or pharmaceutical companies or PBMs or insurance companies, they're all trying to get their bigger piece of the pie. And then the employers and the working Americans who are paying for it have really no influence in terms of how things actually operate.

When you were at the Las Vegas sun, when you began reporting on health care, were there any particular examples where you realized, you know, maybe this is boring, but maybe I have, I have some skills, had the opportunity to tell the story. Were there, are there any specific examples that come to mind?

Yeah, there's a lot of them. In the beginning, I remember writing about a military war photographer named Nicholas Raven and he was over in Iraq or Afghanistan somewhere shooting photos and he got injured on the job, came back to the states and tricare, the insurance company that was covering him, was denying payment on all of his job related injuries. And he had been working, he and his wife had been working for years to try and get these bills settled. He was unable to work, going deep into debt, tens of thousands of dollars in debt. So huge amount of stress for their family. And as soon as I called, as a journalist, they fixed it. And that's what often happens, you know, as soon as there's a bit of accountability for something that is completely unjust, they step in and they fix it. So these are fixable problems, but it needs to, they need to have the motivation to fix it. They need to have the incentive to do the right thing often. And when the media calls, you know, people end up responding because they know that it's going to, going to be public. And so in that case, it got fixed. But as I did these stories, I learned a lot about what people can do for themselves to bring about accountability and to. What I like to say is give people the incentive they need to do the right thing and then also what employers can do. So that's what led to my book.

And so you found that you had the opportunity by telling these stories to get the attention of.

The insurance companies.

Yeah, or even policymakers. So sometimes I was going to ask, so policymakers.

And what about readers? What about, I mean, that is a challenge.

It's a huge challenge.

They're the ones who vote for the policymakers.

Right. Yes. And getting people's attention about healthcare is very difficult. But at the sun or at ProPublica, my stories were always among the most read, the most shared, the most widely shared. And it's because my goal is to always make people see how it's directly relevant to their lives right now. So you kind of have to acknowledge. Okay, I know this sounds boring. I know you think that you don't care about this, but let me explain to you. When I was at ProPublica in 2017, I spent the whole year doing a series of stories on wasted healthcare spending. You can look it up. It's called wasted medicine and you can Google that. And the amount of waste in our health care system is estimated to be about $800 billion a year. Maybe as high as a trillion dollars a year. That's from jama. This is all researched. I'm not exaggerating. That's higher than our Defense Department budget. That's more money. We're wasting more money in healthcare and it's wasted on things like outrageous prices. The price variation is unjustified and.

No explanation for it other than profiteering. The complex way we pay for claims is wasting hundreds of billions of dollars estimated. The over treatment problem is huge. There's a lot of treatment people get that they don't actually need. And then of course, they're still on the hook for those bills. Fraud is a massive problem as the 4C folks are uncovering. Whether it's fraudulent or just inaccurate payments, it's hard to say it's always fraud, but it's a complete mess.

You can get the attention of people when you say, this is why you are paying so much for healthcare right now. The promise I make in my book and in my health literacy videos, again to get people's attention is if you pay attention and learn some of these tips and tactics, you and your family can save hundreds or even thousands of dollars per healthcare encounter. And many Americans don't have enough money to pay these bills. About 40% of Americans don't have more than $500 in their bank account to pay an unexpected bill. So this is causing debt, it's causing harm. And when you show people what they can do about it, they do get more motivated to engage.

So talk a little bit about the Allen Health Academy. So you've covered this for a number of years and at some point you decided to use the video?

Yeah, so that came out of the book. So I wrote the book, the book published last year and an insurance broker was reading the book and the book is a guide. So it's a guide for employees before employers.

Yeah, and it's called Never Pay the First Bill, and it's right here. And it's a great read. I'll say. I love reading it so much that I found myself reading passages, reading. Reading them with my eyes. And then also I had to read them aloud because I liked hearing it so much. I wanted to. I wanted to internalize it twice, both with my eyes and my ears. But I highly recommend it. And it's going to be out.

Yeah, they have copies available as long as they last in the back. So if you want a copy, please get one. And it's a guide. It's like a handbook about that. Yeah, it's like a handbook. There's eight chapters for employees about how to understand your medical bills, how to look up billing codes and check them to see if they're accurate and fairly priced, how to win an insurance company appeal when they deny you the care that you need. And then there's three chapters for employers about fraud, about.

The complex relationship with brokers, you know, the conflict of interest that's built in to the system and. And how employers can even set the price. You know, as some employers are doing now, they're breaking away from the traditional way of operating with the big traditional insurance plans and they're really unbundling their benefits packages, going with a transparent pass through pbm, working with a TPA that's not hiding and, you know, screwing them with lots of fees, working with a broker who they pay a fee to instead of a commission that's coming from the insurance company. So breaking free from these conflicts of interest and hidden fees, working with an analytics company like a 4C that's going to look at their claims and analyze them and identify all the overpayment and all the fraud and then push back on their behalf. So all of these things. The subtitle of the book is and Other Ways to Fight the Health Care System and Win. It's the winning part that is really the most interesting thing to me about what's happening right now. There is winning to be done. Winning that's happening. And there's a lot that employers and individuals can do to fight back and win. And that's really, I think, the good news here.

And we'll get a little bit more into the prescriptions that you have in the book a little bit later. Talk a little bit about the health academy.

Yeah, so I wrote the book and I had a health insurance broker tell me your book is great. But most employees aren't going to read a book. So what he wanted was a series of health literacy videos, short videos. Each video is about five minutes long. There's 16 videos in the curriculum. So I took the book and I turned it into a video curriculum. And it's an on demand program. You can see more about that@allenhealthacademy.com and it's a curriculum that basically walks people through. Here's what's been happening to you. Here's why your costs have been going up and here's why it's unjustified and here's what you can do about it. So it breaks it down into nice bite sized pieces in a video format. So it's more engaging than a book. And the real vision here is to empower the employees on health plans so they know in advance what to do. Like sometimes I have a video on how it's better to pay cash than it is to use your insurance plan. Especially with the hospital price transparency. Now, you see a lot of times the cash prices are lower than the discounted insurance company rates. And so sometimes it's good to ask if you can pay cash. How to get an itemized bill. You know, you have to get an itemized bill to check it and make sure that the codes are accurate and fair. Well, I show people how to use hipaa. The HIPAA privacy law says every patient has a right to their medical information and their billing information. And so when you and I have a template in the book and in my videos, here's how. Take this letter that I'm writing for you. Put your name in here, put your insurance company in your hospital, send them a letter that says I need an itemized bill with billing codes. And if you don't give it to me, I'm under hipaa. You owe me this information. And if you don't give it to me, I'll file a complaint that you're violating my HIPAA rights. And believe me, they respond when you know the right terminology, you know the law and you can explain that. And so people use that to get an itemized bill. So there's a lot of these tactics that are in the videos.

That's awesome. So let's talk a little bit about, I'd like to start talk about it from the employer standpoint first and then we can talk about the employee's standpoint. But the title of this panel is Our Health care system is not Broken. It was made this way. And then as he, as he describes the first portion of the book relates to employees and their rights and how they can fight back and win. And then the second is giving employers advice about how they can also protect themselves with products like what we have on display here. And at 4C, talk a little bit about the structural, overall, structural problem. And when you say the system is not broken, it was built this way.

Talk about, well, you have to come, I want to reframe. I'm trying to reframe the way we look at this. And we've put too much trust in the healthcare system. We've believed the marketing material, we've believed the facade that's been built of this. First of all, scientific expertise and everything's always evidence based. Or you go into a big gleaming hospital with its marble interior and you think, wow, these people must really know what they're doing. You look at their advertisements and they say, we're here because we're healers, we care about the patients. And on the clinical side, I think that's generally true. I think on the clinical side, my book really doesn't hammer the doctors and nurses and everyone else. I think obviously there are some poor actors in that space, but generally the clinicians are as much of a victim of this problem as the patients and the employers are. But when you look at the rest of the system, the billing side, the price setting side, the negotiating side, you have a lot of profiteering that takes place. And I honestly think a fair word for it is swindling. The definition of swindling is taking someone's money using deception. And whether it's illegal or legal, there is so much deception in this business. Just things that an employer or a patient would never expect because it's so frankly dishonest. You know, it's dishonest to have spread pricing in pharmacy. So this is just built into pharmacy where the, the pharmacy benefit.

Manager tells the employer it cost $100 to fill a prescription and actually they paid the pharmacy $10 and that $90 is the spread. That's what they keep in the middle. That's spread pricing. That's built into all the major PBMs for all the different drugs. That's just the way business has been done and it just hasn't been challenged in the past. The employers either haven't known about it or once they know about it, it becomes a very difficult conversation. There's relationships here, there's politics involved with these things. The employer might feel liable to their employees because they've maybe not been aware of it, they've been ignorant, or they've maybe even mismanaged it. Maybe they have a relationship with a broker that they really like, but that broker is being paid by the insurance company. And so they're seeing now that maybe the broker is operating more on behalf of the insurance company than they are the employer. Well, that's a, that's a difficult conversation. And so it takes courage to, it takes real leadership to turn this around for employers. But employers really are starting to do this now.

And what are some of the, what is the gamut of the costs that you talk about in your book as it relates to the employers? And talk about that a little bit. What are the real costs?

Well, the costs are going up and up and up. I think now a family health plan is average cost is about 23,000 or 22 or 23,000, according to the Kaiser Family Foundation. That's before the price hikes that we're seeing coming up this coming year, where I'm hearing as much as 20, 30% price increases for a lot of health plans. And most of the cost has also been passed down to the employee. So if you just look at the cost of inflation, it's gone up by about 19% over the last 10 years. Premiums have gone up about 55% over the last 10 years, and deductibles have gone up about 111%. This is according to the Kaiser Family foundation, between 2010 and 2020. So the costs get passed on to the workers. And this is all money coming out of the compensation of the employees. 100%. This is employee compensation. And so this is where it creates a liability for the employers, which is there's a lot of really interesting things happening right now that are changing things like I've heard people say, well, what's going to change now? I mean, this has been going on for decades. In fact, it has been going on for decades. There are so many things happening now that are turning things that the disruption is already happening. And I think it's going to accelerate a lot because now employers can see their data. As Ron talked about earlier, if they work with the right vendor, they can get their data, they can analyze their data, and they can see, wow, if I go to one hospital for a knee replacement, it's 20,000. If I go to another one, it's 80,000. Well, there's no difference in the knee replacement. This is more standardized than people think. It's not. It doesn't take a different type of expertise at this hospital to this hospital to justify a 4x price increase. So now employers are becoming more aware of that or the really absurd things are seeing. You know, the billed charge is $1,000. You would think you get a discount on that, but instead they pay them more than $1,000. Now with price transparency, you're seeing that even on hospital websites they're required to post their negotiated rates. I've been looking these up all over the country and it's fascinating because you see unjustified price variation everywhere. And the structural problem is Medicare and Medicaid government plans have been allowed to pay one amount and then the employers have been expected to pay 2 times the Medicare rate, 3 times, 5 times, 10 times the Medicare rate or more. And I look at this just to reframe it, and I say this is price discrimination against working Americans. Why are we expecting working Americans to pay two to 10 times more than a Medicare patient would pay for the exact same service at the exact same hospital? It's not right. And I make the comparison sometimes to like if my mom and I went to McDonald's and got a burger, she's over age 65, so she's on Medicare. So McDonald's would charge her $3 for the burger. They charge me, you know, $10, $20, $30. We don't accept that at McDonald's. We don't accept that in any other part of our life. It's not justifiable. And when you push back against it, you do have the power to change it and individual employees do and employers do.

Talk about the price transparency. So obviously that is driven by the corporations language that was included a couple of years ago. Talk a little bit about that. What is the status of that and are, are those prices being posted? Are they being updated regularly? Talk about that.

So the hospital price transparency final rule went into effect at the beginning of 2021, and it's a massive breakthrough where hospitals are now required to post their cash prices, their Medicare prices, and all their discounted prices with insurance companies on their websites, they're required to post a shoppable.

You know, spreadsheet or display of 300 shoppable services. And then they're also required to post a machine readable file of all their prices. And the compliance has been really spotty. But I think that's going to improve. Medicare just issued a couple penalties against a couple hospitals for not complying. So I think as more penalties come online.

That'S going to make a big difference. So it's spotty right now. I would say maybe 20% of hospitals seem to be fully complying and there's different estimates of that. But even where it's happening, you're seeing this absurd, unjustified price variation. And that gives the employer, the people a lot of leverage to push back on it.

That's what I was going to ask. So in places where they are being properly shared and there is transparency, is that information being used in a way that, that, that, that helps the problem?

Well, we're just at the early stages of that and what I'm showing people how to do is how to look it up themselves. So if you get a bill for an emergency room visit or for a, you know, whatever, whatever service you received and you can go and see, well, I'm on an Aetna plan or something and for some reason my price is twice as much as the, as the Medicare rate or the United Healthcare rate. I'm showing people how to contest that, how to negotiate that and how to successfully even take it to small claims court. I have a chapter in my book and I have a video on how to sue in small claims court. And it's a very effective tool for individuals to use. I think what really needs to happen now is the health plans need to change their design where maybe they write into their plan that I want to be the lowest payer.

Why would I say that it's okay to pay me more? And it's really showing that these insurance companies, which we assumed were the fierce protectors of their members, using their market power, using their, you know, their numbers to get better rates, they're not often getting better than the cash rate. A lot of times they're finding it's better to go in and be uninsured or be self pay than it is to be on an insurance plan. And so once the employers see this, once their advisors help them see this, once they work with the right vendors to, you know, develop say direct contracting relationships with facilities, all those things are now building, that momentum is building and it's bringing about a great amount of change.

Can you share with us any specific examples from your book dealing with employers, brokers that relationship?

Yeah, I think the first thing employers need to do is find an advisor or a broker who will introduce some of these solutions to you. Too often the traditional payment arrangement for the brokers is to be paid through commissions and bonuses by the insurance companies. And now with the Consolidated Appropriations act from the end of 2021, I believe that's required to be public information now. So starting, I think in 2022, the brokers and advisors need to disclose all of their direct and indirect compensation that they're making on every health plan. And it's now the employer's responsibility to get this information and now use their fiduciary responsibility to protect that health plan's assets and make sure that they are operating truly in the, in the benefit of the members. Again, this is employee compensation that's being used for this. So if it's being mismanaged, that can create liability for the employers.

Talk about ERISA and why that has not been a more useful tool in bringing change than it has up to this point. And what do you think, what do you see in the future in terms of using that law to demand better?

So I don't have a great answer about why it hasn't been happening already, other than it's complicated. People have been trusting the healthcare system and now they're beginning to see that their trust has been betrayed. More data is becoming available, there's more transparency now. And so more people are jumping on board and making this information accessible. So I think that's why it's becoming more accessible. And so we're really discovering and seeing come to light what's been happening for decades. And now attorneys are getting involved. And so I think this is a really promising thing that now you have attorneys who might be filing some cases or already filing cases against employers for violating their fiduciary duty. That's going to change things a lot. So this all happened in the retirement system years ago. And the same principles apply in the health care benefits system where if you're mismanaging the benefits, which are again, it's employee compensation 100% that's being used to pay these bills. So if you're mismanaging the employee compensation this way, it creates liability. But for some examples. So if you look at a group like Health Rosetta, that's a group of brokers and advisors or even like next gen benefits, these are some of the groups, they tend to work with smaller employers. They are putting in innovative practices where they're bringing down the cost of benefits by 30, 40, even 50%. Like Ron said, it is possible while delivering better benefits and lowering the cost for their employees. So you do see that happening around the country. But again, it's in the very early stages here. This is just the early adopters. This is the most courageous employers. I think the employers who are leading the charge on this tend to be like a family owned company where the owner is the also the decision maker. They don't have to run everything through a bunch of committees. They can, you know, they see what's happening and they say, I'm going to change this, and then they can put those changes into place. You also see, of course, some of the jumbo employers putting in some of these different types of plans. So you're seeing it on that end as well. But it's still very early. So I think, you know, we're going to see a lot more of it.

One of the things that you talked about up front was is this is not about just playing defense, but it really is about going on offense and winning. Talk a little bit about that as it relates to the self funded employer.

Well, so again, like to take direct contracting, I mean, if you're able to look at your data and identify that you're overpaying for a certain service, let's say it's childbirth and you know that you have a certain number of employees, they're going to have a certain number of babies, you can anticipate that this is a cost that's going to come. If you have employees of a certain age, you can create a direct contracting relationship with a hospital in town to make sure that you're managing that cost in advance. So you have that relationship set. The price will be much lower because you're directly paying the provider and you're sending your employees to them. And the plans that I've talked to who are doing this are they're still allowing the employee, if they want their choice and they want to go to a different doctor, a different hospital, they can do that. But then they'll have the cost sharing in place that the plan traditionally has. But if they go to the direct contracted hospital or doctor, they'll waive all cost sharing. So it's much lower cost for the employees. You're seeing employees now send their employers send their employees to a surgery center for an operation when they could have gone to, they would have traditionally just picked a hospital and gone to a doctor and who knows what price it would have been hit with. So they can negotiate some of these things that are scheduled in a way that really makes sense for the employer, for the employee, and for the healthcare clinicians, the providers. And they're also incentivized to have more of these relationships. You're hearing more and more of the hospitals and the doctors, the surgery centers desiring to have these relationships. They get paid quickly, they get paid up front. They can have a lot of the administrative cost taken out of the equation for them.

Let's talk about the employees from the patient standpoint. Talk a little bit about, and I'D love to hear any individual stories that you'd like to share that are in your book that might highlight the points that you're making. But talk a little bit about the true costs to them as the beneficiaries of these plans.

Well, now, the Kaiser Family foundation just did a survey of thousands of Americans and their estimate now is that 100 million Americans are in medical debt and about 1 in 5Americans has medical debt in collections. And so we are talking about a massive amount of harm being done to the employees. And what I like to show people is how empowering it can be to be equipped. So this is something I'm now helping people do every day. I get a lot of messages to me on LinkedIn or on my website and I love helping people. But also a lot of people just use the book and the videos. But I'll give you some examples.

A guy named Jeff was referred to me because he wanted help finding a doctor for back surgery. He had a lot of neck pain. I helped him find some doctors, but I also told him, just to warn you, Jeff, a lot of back surgery is unnecessary. A lot of times it doesn't work. It's extremely expensive. Make sure you.

Are skeptical and consider other options. He went to two surgeons. The first surgeon told him, Jeff, he examined him. He said, we need to book this surgery right now. If you even go play golf on Saturday, I'm worried you're going to be paralyzed. So he really put a lot of fear into Jeff. But Jeff went for a second opinion to another doctor. That doctor also recommended surgery. Jeff decided to go to physical therapy. He had six physical therapy appointments. He learned some basic stretches and exercises he could do. He changed his diet. And then Also Jeff's about 50 years old. He is a third degree black belt in taekwondo and he's been training like he's a 20 year old. And he decided to start reducing the impact of his training and training like he's a 50 year old. And lo and behold, his neck pain completely went away within weeks. He was just fine. And he had no need for that surgery that they had recommended. And so now Jeff just shakes his head. He's become a friend of mine since then and he shakes his head just thinking about an unnecessary operation he would have undergone with great risk of complication, long term effect for his health. And then of course for his health plan that would have been tens of thousands of dollars that it would have cost. So sometimes we think it's hard and complicated. It's actually not that hard. Sometimes you Just need to have some skepticism. Another example that I love is a woman named Leslie Donovan, who's a mom of five in Northern California. And if you know the term Sutter Health, Sutter Health is notorious in the healthcare industry as a hospital system that's been in trouble a lot of times for over billing. So Leslie got over billed, overcharged for some ultrasounds at a Sutter Health facility. Again, she just used my book. She got an itemized bill, she looked up the billing codes, she could see that she was being overcharged. She contested it. I have a warning letter, a 30 day warning letter in my book that people can use a template to send the hospital to notify them that you're going to sue them in small claims court and if they don't give you the fair deal that you deserve, you'll sue them. She sent them the letter, they ignored it and she sued them in small claims court in Northern California. And of course I've helped a lot of patients do this. Now as soon as the hospital gets that notice that they're being sued, well, that's a pain for that hospital. I mean, how many hundreds of dollars an hour is an attorney for the hospital having to pay be charged to deal with some nuisance? 1300 dollar bill from a patient. So the hospital attorney calls her, let's settle this. They settle the case. In that case, they waived all the bills. She said, I'm willing to pay you a fair price. They just waived the whole thing and took care of it. Speaking of upcoding, a mom in California, Jenny Sisson, I love this story because her daughter went to a hospital for appendicitis. It was a rural facility, so they had to transfer the child to another facility. Jenny got that hospital bill from the first hospital and saw it was billed at a level five emergency visit, which is the highest, most complicated case. Well, a case of appendicitis is not a life threatening case. The appendix hadn't ruptured. Jenny could immediately see this isn't like a drug overdose where you had to rescue someone or a car accident where you had to, you know, deal with a trauma case. It's just a kid with some appendicitis. So she just called the billing department and said, hey, this doesn't seem like a level five to me. And they again, she didn't even have to ask much. They went and consulted and they waived her $465 charge for that cost sharing portion of her bill. Now again, her health plan still overpaid, but in that case she didn't have to pay the out of pocket. Then she doubled down on it. She went to the other hospital where the child had her appendix removed. And.

I have information in my book and I have a video on hospital financial assistance policies. Financial assistance policies are required by the IRS for nonprofit hospitals to provide charity care to patients who qualify. And in this case, Jenny had a sizable family and so they had some other medical bills. And she qualified for charity care and saved $4,280 on that medical bill. She ended up having to pay about $800 for that surgery. So in this case, she saved about $4,800 just by contesting upcoding. And the patient is in the best position to challenge upcoding because they know what actually happened. And then also using hospital financial assistance.

One of the things that I love about the book is it also takes head on the idea that most people feel like they don't have, they can't take on the insurance company, but you advise.

To recognize that you can take them on. You give them the tools to do that. One of the things that one of the tools that I thought was very useful was do a little research, get the email for the CEO of the company and then make sure to copy him on it as well or her on it. Because there are benefits to that, right?

Yeah. So it's as much like psychological tactics as practical tactics because you have to know when you're talking to that lower level person in the billing department, they're just giving you the script. You know, they probably don't even know how the billing works. They're just telling people, do you want to be put on a payment plan or do you want me to send you to collections? Those are basically the two things they have to say to patients. And so you don't always get real far with that, but when you take that, you know, case and you escalate it. So again, there's a woman in Portland I'm thinking of with the Providence Health System where she was hit with an out of network bill and it was for care that she received after in January of this year. Well, the Surprise Bill act went into effect at the beginning of this year. The Surprise Bill act, again, is a really interesting law. So there's these piecemeal laws are actually doing some good, I think. And now you can call a hotline for the Surprise Bill act and there's a person at HHS who will answer the phone. I called and talked to him myself when I was helping her and they will now you can file complaints for surprise bills. So I told this woman, okay, So I wrote her a template. I love these templates. And if you go to my newsletter website, it's marshallallen.substack.com I have all these templates on my site and I have them linked in my videos too. But I love the templates because I like to kind of write it in a way that, you know, it's kind of going to get people's attention. And so I wrote one for her and she adapted it to her case and sent it to the general counsel, the CEO of the Providence Health System, saying, your bill is a surprise bill that's in violation of the no surprises Act. I called the hotline, which she did call the hotline, and they said that this would be the type of case that they would investigate. And so I'm urging you to, under the surprise bill act, come to an agreement with my insurance company. That leaves me out of it. This is you. You can't bill me this way. She got a call the next day from the head of the billing department saying, I don't know who you talked to, but I got something from the CEO's office that said, we need to take care of this. And so they immediately took care of it with apology. You just have to know how to push the right levers of power to get the things done. And unfortunately, this is completely unfair that we're in this situation. I mean, it's ludicrous and absurd that I had to write a book to help people navigate the healthcare system, But I just don't have any trust that the politicians are going to figure it out. Again, we talk about the health care system is not broken. It was made this way. Well, look, if the politicians would have wanted to fix it, they could have fixed this by now. But the real fixes that we need are so disruptive to the status quo that it is not a politically tenable thing for them to do. And so the politicians on both sides of the aisle have not fixed this. And then the health care system, all the promises about value based care and everything else. Well, look, there need to be winners and losers here. We're spending about 4 trillion a year right now in health care. More than that, let's say 25% of it is waste. So we need to take about a trillion out of the system. Well, that's the healthcare system's revenue. That's their profits, that's their bonuses. The healthcare system is also not incentivized to take care of this. The real people with the Incentive are the employers and the employees. And they hold the power because they have the money. And so we need to stop just handing our money off to people without checking where it's going.

So as you, as you look at this problem going forward, you think the future is bright. What are, what, what are some of the things that you see from the private sector that are, are going to be instrumental in trying to harness these costs?

Well, I love coming to something like Foresee and seeing their presentation they did yesterday. And every conference I speak at, there are always the vendors who are at the tables outside here who have real solutions that they are providing to employers and they are making a difference. They're delivering better care at a lower price. It is possible, it is happening right now, but we need the employers to get educated, get informed, and get engaged and then have the courage to take it on. And so I think it's a partnership that needs to be between the employees and the employers because the employees are also a big piece of this. They have to understand why they need to engage with these solutions. They have to understand why their employer is urging them to go to a different hospital for their knee replacement, say, than they just want to choose their doctor or something like that. The employees need to be educated and the employers need to be educated. And so that's really the campaign that I'm on, is to get the word out about the solutions and spur people on and encourage them to, to embrace these solutions and put them into practice.

Right. Well, we're delighted to have you with us today at this point. I was hoping that we could come up with some questions from the audience for Marshall. I know he would, he'd love to, love to entertain some. So we've got somebody here with Mike.

You recommend small claims court for medical bills resolution. How many of the people that you've recommended that solution to have run into arbitration clauses to prevent small claims from being litigated?

None so far, but I've only helped, let's say, 15 or so people personally. So that's the. So I have a small personal.

Batch of cases I've worked with, but I haven't run into that at all. And what happens in every case is that the attorney for the hospital calls and settles the case in a way that's favorable to the patient.

They don't have a leg to stand on. And also, these bills for these episodic types of care are relatively small. It's in the thousands of dollars. And so you talk about the juice not being worth the squeeze. I mean, for the hospital to pay thousands of dollars in attorney fees to defend a bill that's worth hundreds or thousands of dollars doesn't make a lot of sense. I think they also don't want the accountability of a public case where a precedent is set. And so it creates a big expense and hassle for the hospital or the doctor. And again, it gives them the incentive they need to do the right thing. And so they come to the table, they negotiate it, and then the case goes away.

Who else? We've got some more questions.

Over here. Over here. Anybody else? Somebody who can put in the queue?

Thank you, Mr. Allen. So you have a lot of great.

Strategies here, tactics for individuals who are combating the healthcare system. Based on your experience, do you have any equal strategies for, like, the plan for the business side of it?

Yeah. So the first thing I always recommend is find an advisor who has the expertise to get you connected with the types of companies that are providing solutions like 4C is providing. And if you're a current advisor is not willing to do that, then start looking at their disclosures of their direct and indirect compensation and then ask who they're really working for. Because if your paycheck is coming from a big insurance company and PBM and tpa.

Who'S really, you know, I work for the person who pays my paycheck, and I am conflicted by any money I receive by definition. And the setup with brokers and advisors traditionally is just so backwards because all that money has been coming to them through the plan. And so now a lot of the more progressive advisors are doing direct pay arrangements with the employers where the employer pays them a direct fee. The advisors are worth the money. They are still making the money that they deserve to make. But now when they're paid directly by the employer, their incentives, you know, they're not conflicted. They're incentivized to go find these solutions. So that's the number one most important thing. And then look into things like, I mean, 4C is one here, there's others that do similar things, and there are, you know, there's vendors out here. Talk to any of them and examine those and see if they might be appropriate for you.

What do you think has given rise to that, that growth in that among those types of advisors and brokers?

What do you think it morally, they have been converted? You know, I mean, you talk to an employer or a broker and advisor or even a lot of the folks here that work for 4C that used to work in the industry, they've seen how things actually work. They've been even part of it and they've realized, wait a minute, this is not right. This is not actually, we're not serving the public here. We're not helping people. We might even be complicit with harming people. And so now they have a drive to change the way they do business and change the way the business is done and really work for what's right. But also they see an opportunity on the business side. So, you know, I think it's Jeff Bezos has that line. Your margin is my opportunity or my mission. There is so much fat in this system that you can have a profitable business by showing people how to reduce their costs. That's a great service that can be provided and it's a good business opportunity. And now with all the technology, all the data that's coming online and becoming more available, we're going to see more and more of this. So there's a lot of these companies providing these services that are extremely valuable and can save a lot of money while doing something that is actually better for the plan and for the patients.

What other questions.

Christy?

A lot of what we're talking about are market based solutions and some of the vendors. But market based solutions only can be as successful as the market in which they operate. And the market is highly dysfunctional. If you had a magic wand and could tell us one or two policy changes that would need to happen in order for the market to function more rationally, what would they be?

Wow, a magic wand.

There you go right there.

A magic wand. Well, I guess I would just say that prices need to be posted, you know, and that's under the hospital price transparency final rule. They're required to be posted. That compliance has been slow, but there's no reason why the prices shouldn't be posted up front so that people see what they're paying. Another thing I would love for employers to do is I think we need to reframe the way we communicate this to employees. We've talked about it like your employer is paying this share of your benefits and then you pay this share. And it's true that the employer funds 100% of the benefit. So I appreciate what the employers are doing, but when they make it seem like it's 100% employee compensation. So, you know, for my job, I get paid in wages. I get, you know, health care benefits, I get retirement benefits, I get vacation benefits. Well, that healthcare benefit is 100% mine. So the compensation pool is a limited amount of money that the employers are devoting towards overall compensation. I wish it would be better communicated that the employees need to know that this is all their money. And if the compensation that's, that their employer is allocating toward their health benefits is wasted and overspent, well then that's going to come, that they won't have the wage increases that they want, they won't have the other benefits they want. Because right now employees think, oh, I met my deductible, so now it doesn't matter what I spend for the rest of the year. Well, that's completely mistaken. And so I wish that employers, unions understand this much better actually, because they negotiate this. But I wish it would even show up on your paycheck. You know, like this is, this is what your compensation, this is how much of your compensation is going toward health care. And again, I appreciate the, of course the employers are funding it, but it creates a lack of understanding for the employees about they think it's their employer paying the bill. It's actually their, it's their compensation paying the bill.

We got Tom down front.

Oh, we have two minutes, two minutes.

Other questions.

George, expanding on that, would one of.

The policy solutions then out there be to remove benefits from its tax protected status and actually give employees that amount of money? Do you think that would drive course that's been changed.

I think it would. Now I have no expertise on the tax side of this, so that's, that's beyond my realm of understanding. But you know, as I've watched my own healthcare costs go up, you know, I've wished that I would be able to do that. And you do see a lot of people going to different types of plans, even like health sharing plans or other things that they can do to save money and still get the coverage that they need.

So I think that would also help people understand that this is their money and if they manage it more effectively, that would be a positive thing. Of course the counter to that is that most people don't really understand how the system works. And so that could create a problem, a lot of problems. You need to do a lot of consumer education so that people could have a better understanding of it.

Well, listen, Marshall, thank you. You know, my takeaway from all this is, is that you have to have people who are out telling stories, the real stories.

And how they affect businesses, self funded employers and how they affect actual real people. And that's what you're doing. And we're really grateful for that. And I think that you're a huge part of the effort that I think is going to ultimately bring healthcare costs into line with where they need to be, make employers stronger and make patients more. More healthy.

So thank you very much. Thank you.

Thank you.