EP366: An In-Depth Dissection of Our Dysfunctional Healthcare Benefits Market, With Kevin Schulman, MD Relentless Health Value™

First of all, this is a 400-level discussion. If you think you already know all about our dysfunctional healthcare benefits market, then this show is for you. Before we begin, I just want to say something. I’m gonna refer back to David Muhlestein’s episode (), where he talks about the first step toward healthcare transformation. It is, let’s just say, for incumbent health systems and payers, people who work there, to step back and in the harsh light of day really contemplate their business model—see it clearly. If you’re listening to this show, then know that I love you; so this is not a condemnation of you or the great things that you are likely doing in your department. I see you as a changemaker. But contemplating your organization as a whole is like the first step of a 10-step program … to admit what friends and family were saying at the intervention. If you’re not yet at the—what’s it called?—contemplative stage in your journey toward transformation, you could skip ahead to the 23:00 mark approximately for some advice on what people who work at incumbent payers and/or providers can do right now. My one and only intent here is to see change happen. What I see currently are certainly efforts to improve quality at some level. But those responsible for finance, premiums, and the employer sales team are in a different part of the building. I mean, maybe a first step here is, Can you invite those guys and gals to your meetings? OK … so, there was a paper that came out in entitled “The Dysfunctional Health Benefits Market and Implications for US Employers and Employees.” It was by David Scheinker, PhD; Arnold Milstein, MD; and Kevin Schulman, MD, who is my guest in this healthcare podcast. David Scheinker, by the way, was on the show earlier (), so certainly go back and listen to that.   This paper (the “Dysfunctional Health Benefits Market” paper) showed that commercial insurance costs have gone up 4x the rate of other benchmark goods or services in price. So, bottom line, “It is assumed that insurers compete intensely to improve the value received by employers and employees by negotiating to keep prices down and advocating for employers and employees.” It turns out, though … not so much with that. My guest in this healthcare podcast, as mentioned, is Kevin Schulman, MD, an author on that paper. And he says this much more eloquently than I will, but the skinny is this: Because insurer profits are capped at 15%, that means that the more healthcare costs go up, the more possible profit in absolute terms that a health insurance carrier can make. After all, 15% of a bigger number is … a bigger number. If you look at how Wall Street responds to these bigger numbers all the way around—higher costs translating to higher profits, that whole thing—you will find that Wall Street likes this profit-generating formula … very much. Share prices go up when that 15% goes up. What does Wall Street like less? It likes less restructuring and pushing providers to deliver better care for less cost and then passing those savings on to employers and employees. Even if you increase quality and decrease costs really well and/or profitably as an insurer, share prices do not rise nearly as much as they rise if you phone it in with the “negotiations” with providers. Nonprofits, by the way, get no pass here either. Some of the most expensive hospitals in the country, which are nonprofit, are doing their thing in areas where nonprofit carriers are the big kahunas. Call it margins. Call it profits. Whatever … same thing. Listen to the show with David Muhlestein, PhD, JD () from two weeks ago. It’s all about the business models. And that business model is revenue maximization. Period. End of the sentence.  So, who loses in this equation? Oh, right … patients. And employers. Read anything by for more on how crushing this loss is that patients and employers suffer: middle-class wage stagnation, bankru