Gott's Gulch - Craig’s Substack Podcast

About Gott's Gulch - Craig’s Substack Podcast

My musings on bass fishing, writing, healthcare and life. gottwals.substack.com (https://gottwals.substack.com?utm_medium=podcast)

Publisher

Craig Gottwals

Category

business · sports

Language

en

Explicit

No

First episode

9 May 2023

Latest episode

13 Apr 2026

Latest episodes

16 episodes in the feed.

1. 

   13 Apr 2026

   Why does healthcare cost so much in America? More importantly, what exactly can we do to fix it?

   It is the single most common question I receive as a healthcare attorney and large group benefits consultant. On one hand, answer is frustratingly simple. The entire system is designed to extract maximum profit from your business. Every major player in the game makes more money when your healthcare claims go up. That includes the major insurance companies, massive hospital systems, Pharmacy Benefit Managers, and even your traditional broker. It is a rigged game. It is fueled by deeply misaligned incentives and the Iron Law of Bureaucracy. When the entities managing your plan get paid a percentage of the total spend, they have absolutely zero motivation to actually lower your costs.In this video, I break down the American healthcare machine. We pull back the curtain on the government agencies and Wall Street giants that dominate the current landscape. We examine how they intentionally keep you in the dark to maintain their profit margins. However, we certainly do not stop at simply admiring the problem. I provide concrete and actionable solutions that employers can implement right now to take control of their plans. This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit gottwals.substack.com (https://gottwals.substack.com?utm_medium=podcast&utm_campaign=CTA_1)

2. 

   12 Jan 2026

   When to Use High Deductible Plans & 2 Surprisingly Dark Downsides

   I've always been a proponent of high-deductible health plans for individuals, families, and smaller employers who cannot safely self-insure or partially self-insure. However, once an employer self-funds, there are a couple of surprising ways in which installing a high-deductible plan can have a very negative impact on your employees and their families.The referenced podcast from Stacey Richter (https://www.linkedin.com/in/stacey-richter-14b3234/) referenced: Episode 486 of Relentless Health Value (https://relentlesshealthvalue.com/blog/transcript-for-ep486-with-stan-schwartz-md). This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit gottwals.substack.com (https://gottwals.substack.com?utm_medium=podcast&utm_campaign=CTA_1)

3. 

   6 Sept 2025

   Overworked, Overtreated & Over It. A Doctor Speaks

   Handcuffed by the standard of care. Twelve minutes or less with each of her 2,500 patients. Pushed to prescribe drugs she knows aren’t the answer. This is the reality of primary care today. Dr. J, as we’ll call her, is a two-decade veteran of primary care, a good friend, and an amazing doctor. In this episode of Gott’s Gulch, she tells us what so many of her peers whisper about between exam rooms or keep bottled up until burnout incinerates them. She describes the difficult choices primary care docs face today: spending twelve minutes or less with each patient, frantically typing every CPT Code they can into electronic medical record systems, feeling pressured to prescribe medications that may not be the best option, and facing the harsh reality that homogenized protocols often lead to deadly overtreatment. She discusses what it’s like to be restricted by the so-called “standard of care,” overworked, sleep-deprived, and constantly forced to make difficult decisions between her conscience and the system. This is a raw, honest account from a physician who still loves medicine and her patients. But nonetheless, a doctor who’s had enough of pretending everything is fine. If you want to understand why primary care is collapsing, and why good doctors are leaving, you’ll want to hear this one. In This Podcast Medical errors are the 3 (https://www.bmj.com/content/353/bmj.i2139)rd (https://www.bmj.com/content/353/bmj.i2139) leading cause of death (https://www.bmj.com/content/353/bmj.i2139) in the U.S. In the United States, three in 10 people report having difficulty accessing primary care. A shortfall of more than 13,000 U.S. primary care clinicians today is expected to worsen in years ahead (https://keck.usc.edu/news/primary-care-doctors-are-in-short-supply-usc-family-medicine-is-doing-something-about-it), with the Association of American Medical Colleges predicting it could grow to as much as 40,400 by 2036. A 2008 study (https://pmc.ncbi.nlm.nih.gov/articles/PMC2765780) estimated that imaging services accounted for 14% of healthcare spending in 2005. Think Fast (https://open.spotify.com/episode/6bm6SZNWEEsHytI6D92shs?si=Q89KsMUYRSS-QEHiZI0PBQ). The 252nd Evolutionary Lens: DarkHorse Podcast Episode 252, released November 20, 2024. In that one, Bret and Heather describe completing a seven-day dry fast and discuss the biology and traditions around dry fasting. Timestamps 02:20 - Most patients don’t get to keep one doc anymore 05:32 – Dr. J still has a few primary care patients 06:45 – Primary Care docs in the system work more than 100 hours a week 08:30 – Primary Care docs are responsible for 2,500 patients/year 15:00 – The worst part of her job when a patient has an HMO 19:44 – Capitation vs. Fee for Service 24:00 – How I met Dr. J 26:50 – How much does the Standard of Care suppress creative medicine? 28:00 – Overtreatment kills 34:00 – Medical errors are the 3rd leading cause of death in America 36:52 – Did you ever feel pressure to overprescribe? 46:45 – How is/will AI impact primary care? 56:15 – Average doctor pay 01:07:00 – The Obamacare “free” annual physical 01:18:15 – How referrals work in modern medicine 01:21:30 – Compelled imaging 01:26:30 – Cost of malpractice insurance by specialty 01:27:45 – Vax schedules, how about those ingredients? 01:36:45 – The Iron Law of Bureaucracy 01:42:05 - Fasting and Dry Fasting This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit gottwals.substack.com (https://gottwals.substack.com?utm_medium=podcast&utm_campaign=CTA_1)

4. 

   26 Aug 2025

   AI & Russian/Ukraine with Jack Armstrong

   I’ve been making visits on the Armstrong and Getty Radio Show for sixteen years now. That is a crazy thought. It is always a treat to join the crew, and for me, an even bigger treat that I didn’t have to talk about what an utter nightmare American Healthcare is during this visit! This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit gottwals.substack.com (https://gottwals.substack.com?utm_medium=podcast&utm_campaign=CTA_1)

5. 

   19 Aug 2025

   From Big Medicine to DPC: Dr. Michelle’s $10K Startup Story

   Dr. Michelle-Linh Nguyen became a Direct Primary Care (DPC) doctor and launched her independent practice in a few short months, and nearly a year in, she’s spent less than $10,000 on the whole project. Yeah, it’s that doable. A DPC doctor is a primary care physician who contracts directly with patients or their employers for healthcare services, instead of billing insurance. Patients pay a flat monthly or annual membership fee, typically between $75 and $150 per month, that covers most routine and preventive care, including office visits, basic labs, and virtual consultations. Because there’s no insurance middleman, DPC doctors usually keep much smaller patient panels (often 300 to 600 patients compared to 2,500 to 4,000 in the legacy system). This allows them to spend more time with each patient, offer same-day or next-day appointments, and communicate directly by phone, email, or text. In this podcast, hear why doctor Michelle left a large healthcare system in the San Francisco Bay area to a DIY practice in the gold-laden foothills of Gott’s Gulch. * Dr. Michelle’s website: https://michelle-md.com/ (https://michelle-md.com/about/) * Michelle’s Substack: mtln.substack.com 5:00 DPC vs Concierge Medicine 12:20 Home visits and length of visit 31:00 Doctor burnout. 34:08 Pairing DPCs with self-funded plans 47:50 Ordering referrals 55:45 Malpractice insurance 56:20 How employees flood to DPC when available 58:08 Working with independent grocers 1:07:45 How to build your own health plan 1:15:30 How DPCs treat you when you’re hospitalized 1:25:00 DPCs can now be purchased with HSAs Build-Your-Own Health Plan article: https://gottwals.substack.com/p/build-your-own-health-plan (https://gottwals.substack.com/p/build-your-own-health-plan) Music by Marc “MIRV” Haggard. This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit gottwals.substack.com (https://gottwals.substack.com?utm_medium=podcast&utm_campaign=CTA_1)

6. 

   5 Aug 2025

   Stop-loss Insurance, RBP, Rx & Fasting | Daron Pitts

   Daron and I started in the industry within a year of each other, more than two decades ago. He’s about as guru-ee as gurus get when it comes to stop-loss insurance, underwriting, and self-funding. I had a fantastic time exploring all that and then some with him in this episode of Gott’s Gulch. 2:10 - MGUs, stop-loss, and reinsurance 9:00 - What is stop-loss insurance? 13:20 - Size of employers self-funding today 16:15 - Why self-funding is harder in Sacramento, California 16:55 - AI in underwriting. Does it help or hurt? Article on AI in claim underwriting, “HIPAA Is Dead. Long Live the Data Brokers. (https://gottwals.substack.com/p/hipaa-is-dead-long-live-the-data)” 25:40 - How a disgruntled employee could sabotage an employer’s self-funded health plan. 31:00 - How large should an employer be to self-fund? 31:25 - How captives work; pros and cons 42:25 - Three biggest problems in healthcare today? 49:45 - If hospitals don’t get in line, they’ll end up with Medicare for all. 52:50 - Fasting. Carnivore Diet. How long can you go without water or food? “A 27-year-old male patient fasted under supervision for 382 days and has subsequently maintained his normal weight. (https://pmc.ncbi.nlm.nih.gov/articles/PMC2495396/?)” He went from 456 pounds (207 kg) to 180 pounds. Episode 252 of their DarkHorse podcast (https://www.youtube.com/live/KPMYUyPCTxI?si=vtvdyU86MEJB5f0l) series, titled Think Fast, the two biologists recount completing a seven‑day dry fast—meaning no food and no liquids for the entire duration. 1:07:30 - the mythical, double secret TPA and BUCA carrier paying claims at 100% of Medicare? 1:19:50 - PEPM vs. % of billed charge in RBP? 1:34:30 - TPA reporting 1:38:00 - What’s coming in stop-loss? 1:44:50 - Ending with a case study. This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit gottwals.substack.com (https://gottwals.substack.com?utm_medium=podcast&utm_campaign=CTA_1)

7. 

   11 Jul 2025

   Pharmacy Deep Dive with DisclosedRx CEO Zack Robinson

   Oof. I knew it was going to be bad before I sat down with Zack this morning. But even with low expectations, I wasn’t prepared for just how dirty the PBM scams really are. Want to boast that you return 100% of rebates to your clients? Simple. Route the cash through a shadow intermediary in Europe, reclassify part of it as “appreciation dollars” or some other fictional nonsense, and voilà, you’ve technically returned 100% of “rebates” after you’ve siphoned off your tribute. The greed and money laundering transpiring in the pharmacy game would make the creators of Ozark blush. I needed a nap and a shower after this one. Zach Robinson (https://www.linkedin.com/in/zackrobinson/) is the co-founder and CEO of DisclosedRx - a truly transparent, fully disclosed PBM. This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit gottwals.substack.com (https://gottwals.substack.com?utm_medium=podcast&utm_campaign=CTA_1)

8. 

   21 Jun 2025

   RBP from A to Z with ClaimDOC Founder, Ben Krambeck

   Craig Gott interviews Ben Krambeck, Founder of ClaimDOC, about Reference Based Pricing (RBP) from A to Z, including its origins, benefits, and the future of transparent claim auditing.

9. 

   12 Aug 2024

   The 5 Most Critical Things Employers Must Uncover When Selecting a Benefit Consultant

   Whether I’m teaching HR and benefits, as an attorney, or an industry consultant, I’ve had the good fortune to assist several large organizations in selecting their employee benefits consultant. Having sat on both sides of this equation, I can tell you that businesses often focus on the wrong things. In this podcast, I walk through the five most important (and I also think most underrated things) a business must uncover when making their decision on a new insurance consultant to help them reel in their second largest expense. As usual, I hold NOTHING back! Enjoy. The Substack piece referenced: Second Large Employer Sued under ERISA & CAA for Failure to Manage Employee Benefit Program | Steps for Employers, VPs of HR & CFOs to Avoid This Looming Litigation (https://gottwals.substack.com/p/second-large-employer-sued-under). This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit gottwals.substack.com (https://gottwals.substack.com?utm_medium=podcast&utm_campaign=CTA_1)

10. 

    9 Apr 2024

    Healthcare Pricing on Trial: The Case for Reference-Based Pricing

    Dive headfirst into the wild world of Reference-Based Pricing, the game-changing strategy that's revolutionizing health plan cost containment like nothing else in the past two decades of employee benefits. Imagine stripping away the cumbersome layers of national carriers and their bloated PPO network fees, paving the way for a bold, new pricing model beyond the tangled web of the Government-Healthcare matrix. But here's the twist: without a pre-agreed pricing framework between healthcare providers and patients (or their health plans), how do we navigate the murky waters of billing disputes? Picture a scenario where, post-emergency service, a bill is slapped down with a staggering figure—900% above what Medicare might shell out for the same procedure. Sounds like the Wild West, right? Step into the arena with us as we embark on an exhilarating exploration of the legal intricacies of Reference-Based Pricing, alongside ClaimDOC’s Chief Legal Officer, the formidable Amy Pellegrin. Together, we'll unravel the mysteries of what it means for a repricer to take on the mantle of co-fiduciary for health plans, dissect the legal battles waged by providers against patients and plans, and spotlight the triumphant track record of reference-based repricers in the courtroom. This is not just a podcast; it's your front-row ticket to the future of healthcare cost management. This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit gottwals.substack.com (https://gottwals.substack.com?utm_medium=podcast&utm_campaign=CTA_1)

11. 

    13 Sept 2023

    Healthcare's Final Frontier: Navigating the Wild West of RBP with Industry Renegades

    Ever imagine healthcare could feel like the Wild West?  Welcome to the untamed lands of Reference-Based Pricing (RBP), the sizzling frontier where a select few employers unleash radical savings while giving the traditional PPO system a stiff arm. Unveil a world where only 3-4% of employers dare to tread, but where jaw-dropping 30-40% savings rain like gold and concierge-level service is the sheriff in town. Curious about RBP's magic? This isn't just healthcare. It's "Health-FAIR!" Here, employers "price-match" medical costs against benchmark prices, slicing their claims in half compared to big insurers. Projections say employer healthcare costs will shoot up another 7-9% in 2024. Yet Medicare Part D Premiums are projected to decrease by 1.8%.  All major insurers participate in both markets.  The lesson?  Employers with private insurance are subsidizing Medicare.  But hold your horses. With RBP, brace yourself for a 0-2% trend that turns the tables on traditional care. Jump into this roller-coaster ride of a podcast with your guide through this maze, joined by two titans of the trade—Omar Arif of ClaimDOC & Scott Schnaidt of HST.  They've both cracked the code, each in their unique ways, and the results? Nothing short of spellbinding. 🎯 What's on Tap: * The gears and levers behind RBP * Navigating the legal minefields * Secrets from Third-Party Administrators (TPAs) * RBP's performance across the geographical board * The art of handling balance bill claims * Litigation: When & How Often * Co-fiduciaries: The real deal or just smoke and mirrors? * Show Me the Money: Their pay structure dissected * Year-end Report Cards: The Good, the Bad, and the Profitable And just when you think it couldn’t get any cooler—did one of these guys actually play pro baseball in a global tourney, while the other rocked the stage with NIRVANA? 🎸⚾ Lock in your earbuds. Prepare for a mind-bending journey. You’re entering "The Repricers"—Healthcare’s Final Frontier! 🌌🛸 This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit gottwals.substack.com (https://gottwals.substack.com?utm_medium=podcast&utm_campaign=CTA_1)

12. 

    9 Aug 2023

    "The Best Thing to Happen to Healthcare in Modern Times" with A&G in 2019

    Yesterday, while live with Joe Getty, a wave of nostalgia swept over me. Together with Jack, we had been at the forefront, passionately deliberating the budding transparency regulations in one of their seminal Extra-Large Podcasts. My memory estimated it to be roughly four years ago. Digging deep into the archives, I pinpointed the exact date: March 14, 2019. That pivotal conversation laid the bedrock for today's burgeoning free-market revolution. These innovative solutions are now arming both employers and employees with a formidable weapon to shatter a system that's been systematically draining them for far too long. I invite you to revisit this episode, first broadcast here (https://www.spreaker.com/user/agshow/031419-extralarge-craig-gottwals). This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit gottwals.substack.com (https://gottwals.substack.com?utm_medium=podcast&utm_campaign=CTA_1)

13. 

    9 Aug 2023

    It's A Government Healthcare Complex: Craig Gottwals Talks To A&G

    Your health insurance costs and premiums have skyrocketed compared to the rate of inflation since Obamacare passed. Meanwhile, insurance carrier stock prices have grown by 1900% in the same timeframe. "They're making unimaginable amounts of money... off of you." -Joe Getty Craig Gottwals, aka "Craig the Healthcare Guru,” talks about that and more in a new episode of A&G's Extra Large Podcast. Listen to the Armstrong & Getty Extra Large Podcasts featuring Craig. Originally posted here: https://www.armstrongandgetty.com/featured/armstrong-and-getty/content/2023-08-08-its-a-government-healthcare-complex-craig-gottwals-talks-to-ag/ This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit gottwals.substack.com (https://gottwals.substack.com?utm_medium=podcast&utm_campaign=CTA_1)

14. 

    1 Aug 2023

    Casting a Legacy: The Rise of Dobyns Rods with Gary Dobyns

    Dive into the zany world of tournament bass fishing with Gary Dobyns – a true legend, a visionary entrepreneur, and the mastermind behind Dobyns Rods. Join us on a journey from a humble home bustling with a dozen foster kids in Olivehurst, California, to the glimmering heart of a 30,000-square-foot empire in Sulphur Springs, Texas. Along the way, explore the triumphs of 40 bass boat victories that dot this remarkable life's path. In this exclusive and intimate conversation, we'll delve deep into the uncharted waters of tournament bass fishing in the West. Discover the art and craft that went into founding Dobyns Rods, the intricate process of building rods in China and Korea, and the fascinating story behind the rise and fall of the Wild West Bass Trail. Gary's story isn't just about fishing; it's an inspiring American saga. Starting with only a high school education and a job as a $13/hour cable plant worker, Gary embarked on a dazzling 20-year tournament run, averaging two huge wins per year. And then, with a courageous spirit and borderline ambition, he launched Dobyns Rods. Now at the helm of one of the most respected brands in bass fishing, Gary's story continues to unfold. Don't miss this opportunity to reel in wisdom, passion, and insight from a man who has conquered not only the waters but also the business world. Whether you're an avid angler or simply seeking a tale of determination and success, this podcast is a catch you won't want to miss. This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit gottwals.substack.com (https://gottwals.substack.com?utm_medium=podcast&utm_campaign=CTA_1)

15. 

    12 May 2023

    One In Three Dollars You Spend on Healthcare is Squandered on Waste, Fraud or Abuse

    The labyrinthine American health insurance system, while ostensibly designed to safeguard our health care dollars, is rife with the specter of fraud, a malaise that stealthily siphons off staggering amounts of money. More than $1 trillion — one of every three dollars (https://www.cato.org/policy-report/july/august-2018/youre-being-overcharged) that passes through the health care system — is lost to fraud, wasted on services that don’t help patients, or otherwise misspent. With private insurance spending soaring to $1.2 trillion in 2019 (https://healthpayerintelligence.com/news/private-payer-spending-hit-1.2t-in-2019-as-spending-growth-slows), it's disconcerting that there's no systematic tracking of funds lost to fraud. Investigators and experts speculate that up to 10% of all healthcare (https://www.nhcaa.org/tools-insights/about-health-care-fraud/the-challenge-of-health-care-fraud/) spending may be devoured solely by fraudulent schemes. While insurance companies assure the public of their vigilance in monitoring and protecting these funds, the stark reality is alarmingly different: fraudsters find easy access to this system, and convincing insurance companies to shut them down is an uphill battle. Thanks for reading Gott's Gulch - Craig’s Substack! Subscribe for free to receive new posts and support my work. One egregious example reported in Marshall Allen’s fantastic book, “Never Pay the First Bill: And Other Ways to Fight the Health Care System and Win (https://www.amazon.com/Never-Pay-First-Bill-Health/dp/0593190009/ref=tmm_hrd_swatch_0?_encoding=UTF8&qid=1683831046&sr=8-1),” is the case of David Williams. Williams, a personal trainer who exploited vulnerabilities in the healthcare payment system to bilk millions from private insurers and employers. Williams, without any valid credentials, applied for a National Provider Identifier number (NPI), a requisite for medical providers to bill insurance plans, and was handed one with no verification. Equipped with this, he embarked on a fraudulent scheme, billing insurers for workout sessions under the guise of medical services. His victims included not only UnitedHealthcare but also Aetna and Cigna, with Southwest Airlines being the hardest hit through its self-funded benefits plan. By the time he was apprehended, Williams had successfully defrauded these companies for over four years, amassing about $4 million in cash from $25 million in fraudulent billing. This staggering case elucidates a stark reality: health insurers are woefully inadequate in protecting your healthcare dollars. Fraud like this thrives due to a lack of vigilance and urgency on the part of insurers, who often fail to validate the credentials of those submitting claims. Williams, for instance, was able to submit claims and receive payments, despite complaints and warnings about his fraudulent activities. His exploitation of the system was not an act of a criminal mastermind but rather a demonstration of the system's vulnerabilities and the insurance companies' laxity. When it comes to dealing with fraud, insurance companies often adopt a passive stance, primarily for two reasons.  First, as it relates to self-funded plans, prosecuting fraud cases is costly and challenging. In many cases, the approach is to settle or block suspicious providers rather than pursue costly legal proceedings. This practice raises serious doubts about the commitment of these corporations to stamp out fraud. Secondly, as it relates to fully insured plans, insurance companies are disincentivized to uncover fraud, waste, or abuse. The Patient Protection and Affordable Care Act (Obamacare) unintentionally created an environment where health insurance carriers have a reduced motivation to vigilantly monitor and control waste, fraud, and abuse. This is due to the mandatory minimum Medical Loss Ratio (MLR) rule (https://www.cms.gov/CCIIO/Programs-and-Initiatives/Health-Insurance-Market-Reforms/Medical-Loss-Ratio), which stipulates that insurance carriers must spend at least 85% of premiums on actual health claims, leaving a maximum of 15% for administrative costs, marketing, and profit. In theory, this regulation was designed to ensure that a substantial proportion of premiums go towards actual healthcare services. However, it also inadvertently created a scenario where carriers might benefit from higher claims. If the total claims increase, the 15% that carriers are allowed to keep also increases in absolute terms. For instance, 15% of $1,000,000 ($150,000) is less than 15% of $2,000,000 ($300,000). This means that the carriers' potential profit increases as the total claims cost increases, even though the percentage they are allowed to keep remains constant. As a result, the system incentivizes carriers to be less aggressive in controlling waste, fraud, or abuse because reducing these would decrease the total amount of claims and hence their portion of the profits. It is as if you tell your sweet-toothed twelve-year-old that she may only eat one-fourth of a bowl of ice cream. Her mathematically astute retort: “In that case, Dad, I’m going to need a larger bowl.” The widespread nature of healthcare fraud further diminishes the chances of smaller cases being pursued, with one investigator admitting to Allen in “Never Pay the First Bill (https://www.amazon.com/Never-Pay-First-Bill-Health/dp/0593190009/ref=tmm_hrd_swatch_0?_encoding=UTF8&qid=1683831046&sr=8-1)” that suspicious cases worth less than $300 were often ignored. The true cost of this laissez-faire approach is staggering when considering that these "small" cases can accumulate into millions of dollars, as exemplified by Williams' scheme. United Healthcare’s stock price since Obamacare became law illustrates that its lack of fraud control is having zero impact on its ability to profit staggeringly on American healthcare. Nobody Cares When It is Someone Else’s Money Here's an illustration of how third-party payments turbocharge the healthcare crisis, ultimately birthed by the stranglehold of political interference. Picture this story from Overcharged: Why Americans Pay Too Much For Health Care (https://www.amazon.com/Overcharged-Americans-Much-Health-Care/dp/1944424768/ref=sr_1_1?crid=2W5CSGIJW1XFP&keywords=overcharged&qid=1683832594&sprefix=overcharged%2Caps%2C171&sr=8-1), by David A. Hyman and Charles Silver - a friend, recently victim to a minor wound, suffers from a stitch malfunction. He finds himself at a nondescript, hospital-owned urgent care center tucked away in a strip mall. His ordeal - a mere 30 minutes of treatment. The bombshell lands soon after: a staggering bill of $3,000 - laughable, bordering on criminal. Yet, a miraculous reduction of $1,170 is granted due to a hush-hush agreement with his insurance company. The insurance, in a stupendous show of naivety or perhaps indifference, coughs up the "allowed" sum of $1,770. Our friend, slapped with a trifling $60 bill, shakes his head in bemusement and pays up. Now, ask yourself this: would he have been so nonchalant if the full, ludicrous amount of $1,830 had been his burden, not to mention the original, jaw-dropping $3,000? Would these healthcare providers dare to fire off such exorbitant bills if they couldn't hide behind the veil of third-party payments? Obamacare was trumpeted as a healthcare revolution, a monumental shift. But it was nothing more than a brazen reinforcement of the failed third-party payment strategy (https://gottwals.substack.com/p/we-all-needlessly-overpay-225-for). The payment system was already pumping obscene amounts of money into the healthcare sector. Obamacare did nothing but add fuel to the fire, pouring in subsidized insurance and an explosive expansion of Medicaid. At this juncture, you might be crying foul: Isn't insurance and government aid necessary because healthcare is too costly for us to shoulder alone? Occasionally, yes. However, history tells us it's not that simple. The skyrocketing prices of medical services are not the cause but the consequence of insurance. Prior to the meteoric rise of third-party payers during and after World War II, healthcare was affordable, and directly paid for by patients. It wasn't until the advent of Medicare and Medicaid in the 1960s that spending went off the rails. In Overcharged (https://www.amazon.com/Overcharged-Americans-Much-Health-Care/dp/1944424768/ref=sr_1_1?crid=2W5CSGIJW1XFP&keywords=overcharged&qid=1683832594&sprefix=overcharged%2Caps%2C171&sr=8-1), professors Ted Marmor and Jon Oberlander point out that in the first year of Medicare’s operation, the average daily service charge in American hospitals spiked by a shocking 21.9%. Over the next five years, this figure grew at an average compound rate of 13% (https://www.amazon.com/Overcharged-Americans-Much-Health-Care/dp/1944424768/ref=sr_1_1?crid=2W5CSGIJW1XFP&keywords=overcharged&qid=1683832594&sprefix=overcharged%2Caps%2C171&sr=8-1). Regrettably, the burden of health care fraud is often borne by the ordinary people paying for health insurance or benefits, as it's their money, not the insurers', being stolen. It's a sobering reminder that we need to be vigilant in checking our receipts, as we could be unwitting victims of fraud. The current health insurance landscape is a breeding ground for fraud, with its intricate system and lax oversight. It's a troubling reality that demands urgent and decisive action to protect the funds intended for our healthcare. Employers, There Is A Better Way Unleashing a HealthCost Revolution - Three Steps to a Jaw-Dropping 40% Cost Reduction Step 1: If your organization is too small to venture into self-funding or partial self-funding terrain, strive to purchase the bare minimum of insurance. The heftier the premium you shell out, the more you fall prey to an insatiable beast. It's time to break free from this rigged game. Opt for the highest deductible plan your insurer offers, then self-fund the amount beneath that deductible with a Health Savings Account (HSA) or Health Reimbursement Account (HRA). If your workforce is less than about 250, this strategy could be your golden ticket, contingent, of course, on your cash flow, industry, and geographic footprint. Employees spending their “own” money in an HSA or HRA will be more incentivized to ensure healthcare facilities are not fraudulently or erroneously billing them. Step 2: For those privileged to have a team exceeding roughly 250, it's time to consider a bold move - abandon the fraudulent system entirely, bid farewell to your insurers, and transition to a reference-based pricing (RBP) model. This system lets you pay a modest markup over the Medicare price - say, 120% to 140% of Medicare. It's a strategy that not only functions exceptionally well, but is also a masterstroke of legal creativity and acumen. This could pave the way to a future where your employees enjoy superior benefits, drastically lower costs, and unprecedented freedom. Yes, the initial step might be daunting, fraught with challenges, and demanding of extensive education. But once you take this leap of faith, you'll witness a staggering 20% to 40% reduction in your health plan costs. In 2020, I penned an article highlighting how this strategy might be our last, best hope for preserving private healthcare in America: "America will dramatically change the way it provides healthcare by 2030 (https://www.benefitspro.com/2020/04/06/america-will-dramatically-change-the-way-it-provides-health-care-by-2030-412-96023/)". More recently, I discussed the urgent financial necessity of evaluating this process in my piece, "The fiduciary imperative of reference-based pricing: A legal and financial analysis (https://www.benefitspro.com/2023/04/11/the-fiduciary-imperative-of-reference-based-pricing-a-legal-and-financial-analysis/)." You can also hear me dissect this issue in-depth on the Armstrong and Getty Radio program (https://www.armstrongandgetty.com/featured/armstrong-and-getty/content/2022-09-21-lowering-the-healthcare-gap-craig-gottwals-talks-to-armstrong-getty/). An RBP platform removes the laissez-faire carrier approach to fraud detection and replaces it with a reference base repricer. Many RBP entities audit every single bill your organization generates and, often, are compensated more the further they reduce your claims cost. This is in stark contrast to the perverse claim-inflation incentives created for carriers by Obamacare. Step 3: As you transition towards a self-funded RBP platform, it's crucial to seize control of your pharmacy coverage. Enter into a direct contract with a Pharmacy Benefit Manager (PBM), or one of the innovative consortiums that pool numerous employers under a singular contract, thereby amplifying your pharmacy discounts and rebates, benefiting you rather than the insurer. This strategy can slash your pharmacy bill by an impressive 25% to 50%. This is the road to revolution, employers. Will you dare to take the first step? I’m a healthcare attorney and senior vice president at McGriff Insurance Services. My full professional bio (https://www.benefit-revolution.com/p/bio.html). Thanks for reading Gott's Gulch - Craig’s Substack! Subscribe for free to receive new posts and support my work. This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit gottwals.substack.com (https://gottwals.substack.com?utm_medium=podcast&utm_campaign=CTA_1)

16. 

    9 May 2023

    We're All Paying More Than Double What We Should for Healthcare

    This podcast discusses my article, We're All Paying More Than Double What We Should for Healthcare - How America's Government Programs, Insurers & Hospitals Relentlessly Pilfer Private Plans. Article: https://gottwals.substack.com/p/we-all-needlessly-overpay-225-for (https://gottwals.substack.com/p/we-all-needlessly-overpay-225-for) This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit gottwals.substack.com (https://gottwals.substack.com?utm_medium=podcast&utm_campaign=CTA_1)

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