Consumerism in healthcare should empower patients to make better medical choices. Instead, it penalizes them with higher hospital prices when making bad decisions and forces them to acquire extremely costly services. Leo Wisniewski, Co-Founder and CIO at Health Cost Labs, does not want such unethical practices to thrive in this space. In this episode, he joins Louis Bernardi to share the mobile application he and his team developed to address the consumerism problem in healthcare: Billy.app. He presents how it can help patients find lowest-cost medical alternatives in the market and confirm that they are not being overcharged, bringing back the buying power to the people. Leo also explains how they aim to disrupt the status quo through this app, turning the insurance industry around for the benefit of healthcare space and giving a competitive edge to independent facilities.
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How One Mobile App Aims To Eliminate Consumerism In Healthcare With Leo Wisniewski
Meet Billy.app Where Consumerism Meets Healthcare
We have a great episode for you. I’m going to bring Leo Wisniewski into the streamer. Leo, How are you?
It’s an exciting day. It’s a big episode. The title of the episode is Consumerism meets Healthcare. That might sound strange to a lot of people because the term consumerism has been used within the managed care healthcare space for a long time. We would agree and we’ll probably get to it in the conversation that true consumerism is beginning. Consumerism is empowering the consumer to make better choices.
It’s not penalizing them with higher out-of-pocket costs for making bad decisions and trying to drive them to certain facilities, where the system makes more money off of everybody. I’m going to do a little bit about your background and then you can add to it. This isn’t Hollywood so it’s not rehearsed that well. You’re fifteen years at Blue Cross Blue Shield. Those roles include actuarial analyst, contract analyst, payment integrity, and informatics. I need you to tell me what that is.
It’s data science. It’s modeling claims data.
You’re a numbers guy. There’s no question. Always been. Basically, in those rules, you modeled claims data to project spend, like claim spend for the individual market, the group market, or whatever. You created fee schedules, supported contract negotiations with the doctors and the facilities, and Identified incorrect claims. I’m assuming probably that we’re in favor of Blue Cross Blue Shield if you found claims.
If we overpaid, we keep their mouth shut, but if we were underpaid, it’s vice versa.
Everybody is trying to find a nickel these days. Also, payment policy impact. Did I do a good job? I feel like I did a pretty good job.
You did. It was funny because, when I worked at Blue Cross, I loved my job. You call me weird, but I loved going to work and I hated leaving. There’s nothing more fascinating than changing the way people get paid and watching how they react. There’s nothing more interesting than that.
How the consumer reacts?
No, it’s how the providers react. What I saw is in the beginning, it’s very complicated. I would pull lever A thinking I saved money. It wasn’t until three years later that I realized, “There’s something happening here. They’re changing their billing patterns.” Whenever I pull a lever, either the change in the policy, reducing the fee schedule rates, or calling money back, there was a reaction by the doctors to change the ways they bill to pick and choose codes that recover the money that I took from them. The air never went out of the balloon.
It was always inflating, getting bigger and bigger. Doctors and hospitals are changing the way they get billed because managed care companies are trying to call money back to hit their recovery goal. It was an unethical business practice. I didn’t know until 5 or 8 years into the job that there’s this cat-and-mouse game within managed care of this, “I’m going to get my money. I want to get my money,” and constant fighting while the consumer lost.
It was against my value system to participate in this unethical business practice. What happened was I showed management the reports that the doctors are changing their billing patterns to what you’re billing. The money you think you’re saving isn’t saving because you’re changing the cost somewhere else. It’s not coming down. They hated me for that. They put me in a closet and pretended I didn’t exist because they didn’t want evidence, data, or the story that this wasn’t working. They were in their silo. Their heads are down. This is what I do. That’s not my job. Get away from me. It was horrible. It made me miserable.
It’s funny that you bring that up because I talk about that quite a bit. I’ve been doing this for many years, and I was there at the beginning when managed care became the predominant form of health insurance and healthcare. The driver of the change has always been that the cost of the consumer has been going up. Managed care seemed like, in the early days, it was going to be the saving grace for the consumer because these insurance companies were able to create networks and force what at one time probably were true discounts. Getting discounts off of the true rate of care, but healthcare and health insurance is a huge business. No one sits there and says, “We’re going to make less money.”
At the highest level, both of these forces, healthcare and health insurance, are trying to use their leverage and the power of the pen. Those contracts are so important to earn more money. What I’m hearing from you now is you were changing the way that these contract negotiations were going. It seemed like a good thing. They could say, “We’re getting bigger discounts,” but the healthcare system was sitting there saying, “What are we going to do about it?” It was a manipulation of the numbers. They might make less money unit cost-wise, but now they’re going to change the codes and make them bill more units. They created more quantity, not higher quality.
Does anybody think a boo-boo is a level-four episode? It is. It’s funny because that boo-boo will bill a 99284, level four, at a very high acuity. Clinically, that doesn’t make sense. This level of acuity doesn’t line up with a boo-boo. Let’s think about what’s happening here. The insurance companies are calling money back where they shouldn’t be. The only thing that the hospitals and doctors can do is up-code and bill more units to get the money back that they need to be solvent and run a successful business. It’s unnatural to call money back from businesses. They should be allowed to operate as they do as long as they’re transparent. If they’re transparent, there should be no interference in how they run their business.
Have you come across Slingshot bills yet?
A little bit.
Their technology is based on reviewing all claims. They’ve discovered in a short period of time that they’ve been running their technology through TPAs and everything that 60% of claims include upcoding. That’s how predominant that is. Very little of it gets captured.
My point is that it’s not entirely wrong when you’re causing abrasion for the sake of hitting a recovery goal. Don’t interfere with their business, and they won’t upcode. Don’t poke the bear. That’s where I’m coming from. I don’t deny it’s there, but I’m saying the reason why it’s there is because the business practice of calling money back is unnatural. What Health Cost Labs is about diffusing the situation and putting transparent information in front of everybody so we don’t have this abrasion. When we don’t have the abrasion, the cost will come down. I’m not arguing that there’s upcoding there. I’m saying that the forces that are causing the upcoding aren’t being discussed. That’s the mission of Health Cost Labs.
Let’s talk about Health Cost Labs a little bit because you’re advanced in what you’re doing. You’re taking a tremendous amount of data. If you want to give a little bit of history of how you got into it, what Health Cost Labs does, and what they do with what they are able to attain, and then we’ll talk a little bit more about the vision and maybe the impact that you see that it may be having on the market.
Trump issued an executive order in May 2019 saying hospitals had to post their prices. Hospitals sued and the courts ruled in June that the prices must go forward. In October 2019, the appellate court ruled that it stands, prices will go forward. A few years ago, I was gearing up for building the database structures anticipating the files that will come online. I need to load them. I was doing homework, preparing the databases and the design, and anticipating these files that came online in January 2021.
Because of your background and your history, you already knew the massive amount of data that was going to be released. You have seen the data. You had spent fifteen years doing that already.
I knew exactly how I needed to prepare the database to ingest this data. I had inside knowledge, which I was using. That helped me out. When January 1st came in 2021, I started to open up these files. Of course, they were presented horribly, but it’s nothing no programmer can’t straighten out. That’s what I did. It was a lot of hard work during the first eighteen months of coding up all these scripts to ingest the data that was presented horribly but we got it done.
I thought the problem with healthcare was that there was no price transparency. If I put the transparent data out there, we can have a different conversation, diffuse tensions, and costs should come down. That’s not what happened. I built it. I thought they would come, and very few came. That’s when I realized the real problem isn’t price transparency. It’s a conflict of interest. It’s people making money doing something that made sense before price transparency, but they’re not changing their business practice to do business in a new way. They’re still doing reference-based pricing.The problem with healthcare was that there was no price transparency. If there is transparent data out there, it could defuse tensions and costs should come down. Click To Tweet
When you say they, who are you expecting?
Businesses, but I don’t want to name names. If the hospital says the lowest amount they accept is payment in full is $500, and maybe that $500 is 110% of CMS or Medicare. Why are you paying them 140% of Medicare if they take 110%? They’re not using the price transparency data to lower the cost because of your business practice, which made sense before price transparency. They’re not changing their business practice, which surprises me. People are not realizing that we don’t need to force plan designs, limited networks, and contracts when we have price transparency. That has been a real eye-opener for me. They’re not changing it. What we’re here now is we’re releasing a mobile app. It’s called Billy.app and it’s a direct-to-consumer tool to allow them to price shop to see.
I’ll demonstrate it in a few minutes, but it’s going to allow them to see lower-cost alternatives in their market, so they can get in their car or walk a block to a different hospital or doctor and pay a lower cost. It’s a different way of approaching healthcare. I feel that the only way we’re going to fix healthcare is to empower consumers to make different decisions. I’m not telling them what they should make. I want to make sure that they have the information so that they are empowered to do things differently.
They can become an informed consumer.
Yes. The businesses will have to adapt to the consumers on their buying powers because that’s how an economy works. Businesses react to a consumer’s buying decisions by buying power, not the other way around, which is what healthcare is.
One of the things again I talk about is that these two forces, the healthcare and the health insurance ecosystems, know about this. They know what’s happening. Probably, the people that were in the role that you had before are trying to determine the impact of new consumer behavior on their profits. What is the consumer and how quickly are they adapting to this now? We would not have a managed care system if it hadn’t been for the consumer. The indemnity companies that existed prior to managed care would still be in business if that’s what the consumer continued to purchase in the early ‘90s but all of them went out of business. It’s because the premium dollars went to managed care.
It wasn’t a heavy lift for advisors and plan sponsors to make that change because there was a lot of education around, “This is how managed care works.” Copays, directories, and a lot of new terminologies that didn’t exist before. We had people thumbing through directories. It’s like, “This plan sucks because my doctors aren’t in it.” I would literally have them chucked at me by business owners and CFOs because this plan sucked. The consumer made the decision ultimately. Now this is going to be a slow adoption, in my opinion. It surprised you that more people weren’t starving for this information. You’d admit, most people don’t even know about any of this stuff.
Most plan sponsors might hear the commotion, but if their advisors and their insurance companies aren’t talking to them about the power of transparency, what this data can actually help them do? These files, most people don’t know this. Hopefully, this whole show is called Benefits with Friends because it’s like me sitting around a coffee table with my friends on the weekend and talking to them about the things that I’ve learned about healthcare. I’m hoping the people that tune into the show are using it to become more informed because the information is power. Quick question. What percentage of hospitals have complied with this law so far?
In the beginning, I made some mistakes. I would pull a file down and see the negotiated rates. I say, “It’s compliant. Next file, compliant. Next file, not compliant.” I got myself into trouble because compliance has many checkboxes. Compliance isn’t one checkbox. It’s like, “Did you have this code? Do you have the cash rates? Do you have all these little plan names? Do you have every code?” I was not interrogating these files rigorously like I should label a hospital file as compliant or not. I removed myself from that. I say, “Here’s the file.” I’m not speaking about compliance. That’s a deep well. What I’ll say is that most files are full and robust.
One of the CMS 70 shoppable codes is knee surgery, DRG 470, and a new patient code, 99203. If a hospital doesn’t do knee surgeries, they’re not going to bill DRG 470. Technically, they’re not compliant. That file is not in there but they don’t have utilization for that code because they don’t do it. It’s a difficult thing to put a label on somebody when there are so many reasons why information may or may not be there. What I can tell you is that probably 88% or 90% of the hospital files are full and robust offering lower-cost alternatives.
You’re going to see the app pretty soon. You’re going to be blown away when you see the amount of pricing information in any part of the country. You’re going to say, “Why are we talking about compliance when we should be talking about why are we paying more than the lowest rate?” When I go on LinkedIn, people are not talking about why we are paying more than the lowest rate. We’re talking about 140% of Medicare or upcoding. They’re talking about all the wrong things, which is frustrating to me.
Let’s talk about that for a second because I know you get a little bit of pushback from the industry. We can’t assume that you can walk into a facility and say, “You accept this rate. That’s what I want to pay.” That probably won’t happen. The more people that walk in and do that, the healthcare system has to adjust. If people take their business elsewhere because another hospital, facility, or outpatient center says, “We’ll take that all day long,” the consumer is going to drive the market or the consumer behavior. If a hospital is required to accept Medicaid and Medicare because they’ve got the government that they’re dealing with, they either lose money at that rate.
If everybody came in and paid that rate, they’ll close their doors because they can’t turn a profit at that rate. That doesn’t mean it’s still not useful. What I’m saying is that the more people who are informed and have the power to negotiate a better price either on their behalf or maybe their plan is created in a way that uses this information to pay fairly. For me, I want to pay fairly. I don’t want my insurance carrier manipulating that rate because it drives their profits.
Let me speak to that. I don’t deny 99.9% of people will not know the code they need before treatment. That’s a post-treatment piece of information. What we can see is cheaper locations. Upon introduction, which I’ll show you in a few minutes, you are going to see lower-cost locations. Let’s start there. A map and you’re going to see it. When I get billed after treatment and I pick any code, let’s say it’s paid $900.
You can also use the Billy.app to say, “You are charging $900, but you’re accepting $300 from Blue Cross or Cigna. Maybe your cash rate is $300 but you’re billing $900.” There are two purposes for this app. It’s identifying the cheapest front door that you won if you do that and then you’re going to win again when you can confirm that you didn’t get overcharged. I don’t deny that hospitals have a patient mix where they expect revenue from there to generate this much money to pay their bills.
The numbers are going to move. Some are going to go up. Some are going to go down. Hopefully, in the future, you will have parity. You’re getting a fair rate. You’re not getting hosed. You’re not making a great deal. You don’t look like one. It’s a fair rate for everybody. We can stop this managed care nonsense of contracts and calling money back because it’s a direct payment. I wasn’t ripped off. I knew where I was charged before I got treatment. I’m not defrauded. Don’t call money back from a doctor or hospital who’s engaging in good faith.
One of the important regulations that stood up in court is that patients with insurance can still elect and the hospital has to allow them to pay the cash price instead of their insurance price. What’s really important is you can’t use your insurance. You can’t submit it through insurance if you have an insurance company that pays based on a network rate. Once that claim is submitted to your carrier, they’re going to take that code. They’re going to plug in the EOB, the billed rate, the allowed rate, and that allowed rate becomes your rate now.
Even if you agreed in advance to pay the cash price, submitting it through your insurance company is going to present a problem. I want to talk about the cash price because, for me, that’s probably the most interesting bit of information. People aren’t aware and you’ve seen these prices now for several years. I’m not using my insurance. I walk in and I don’t have insurance. How often is the cash price less than the insurance carriers negotiating discount rates?
I would say 90% of the time, the cash rate is not the highest rate. It may not be the lowest. It’s going to sit above and somewhere around the Medicare rate, but it’s not the highest. That’s what surprised me in the beginning when I saw cash wasn’t the highest rate. I’m like, “What is mass buying power if cash is the cheapest rate? Why am I paying premiums if you can’t even get me a good rate for your best mind power?” This is still messed up.90% of the time, the cash rate in healthcare is not the highest rate, despite it sitting above the Medicaid rate and somewhere around the Medicare rate. Click To Tweet
As an advisor who tries to build these plans using all of this information, this is data and technology. This Billy.app is going to be instrumental in getting the information out not only to the consumer. Think about the competitive nature this is going to create within the healthcare system itself for facilities and independent outpatient surgery centers like Oklahoma City Surgery Center, who post the cash price every day. There’s going to be more opportunity for companies that don’t want to gouge the marketplace to be able to say, “Come here, we’re an open book. Go on our website.” You could take their price right now and say, “Here’s the cash price.” I’m assuming their price is basically the cash price. That’s what they will pop up.
I want to speak to that. Clearly, there will be jobs no longer needed in the healthcare industry because price transparency replaces the need. I’m speaking to payment integrity, data analytics, and contract negotiators. That line of services is no longer needed but that doesn’t make the people’s knowledge. We still need your knowledge. The work you do has been replaced, but we still need you to help people shop.
There’s a massive consumer education effort that will be needed. The people who know how payments work will be needed to guide people to make these informed decisions. Your work product changed but we still need you. I’m asking you to like, “Let’s stop forcing this work product that’s no longer needed. Please stop doing that and get behind consumerism because that’s where we need you.” We still need you but in a different role.
Think about what you were doing. You could argue that you were on the dark side before you were working to help the insurance company. Now look what you’re doing with that massive amount of intellectual knowledge that you absorbed. You could still be doing that. I’m sure that that role pays pretty well. Once you have that a-ha moment and say, “None of this is being used.” I was naive. I was selling insurance for 26 years. I was a general agent. I have been helping hundreds of brokers and thousands of clients for a very long time. I thought that I was doing a great job. Based on the old standards, I was always negotiating the lower premium but I didn’t have a full deck of cards to work with.
I had no jokers. I had no picture cards. I was playing blackjack without anything above a nine. You could win. It could feel like a win, but is it a win if you know that there are people out there, members and patients, who are suffering and can’t afford their medical treatment and prescriptions because of the leverage of the healthcare system and the health insurance marketplace? They have to give the impression. If you go on any insurance company or any healthcare systems website, they’re going to talk about the good they’re doing for their communities.
That’s the impression. They have to do that. Once they lose any sense of goodwill that they’re providing for their communities, they’re done. They’re toast. They’re the enemy. I’m very conscious of that. I thought I couldn’t unsee what I’d seen so I got to make a decision. Do I get out of this business completely, or do I work harder and fight a fight that, to my surprise, thought that if you build it, they will come? Eventually, you’re going to get to that scene at the end of that movie where there’s a line of cars that goes past the horizon. It’s going to happen.
Everybody needs insurance for something catastrophic. I don’t deny they need to be there. They should honor the lowest amount the hospital or doctor accepts this payment in full. Let the member pay cash, take that receipt, mail it to the insurance company, and let them get reimbursed so they can apply that to the deductible. They can do that. There’s no law stopping them from doing that. They should have the decency to recognize that we’re in post-price transparency. These rates are unethical.Insurance companies should honor the lowest amount, let members pay cash, and allow them to get reimbursed so they can apply that to the deductible. Click To Tweet
I shouldn’t be forcing my members to pay ten times more than the cash rate. That’s wrong. Let’s stop the silliness and dishonesty and recognize that the contracts in a pre-transparency world don’t work. We need to reinvent ourselves to be relevant in the new marketplace and we’re going to do it by honoring the lowest amount. The hospital doctor takes full payment. We’re not going to call money back from them. Let them bill whatever they want. I don’t care as long as it’s a fair rate that the member paid upfront. I’m going to reimburse it and that’s it. That’s how insurance should work.
Who knows? Maybe years from now, both industries will be very different than they are now. I’m not sure that the networks now will still be here. They’ve shown that there’s no value. In my opinion, hospital systems are real estate companies. They own a massive amount of property and real estate. The tax advantage that they’re getting is astronomical. The goodwill that they’re doing for the communities isn’t nearly what they should be and what they are required to do. There’s one town. I think it was in Illinois, not too far from Chicago. It was Dr. Marty Makary who talked about this at one of the conferences I went to a couple of years ago, where 50% of the population of this one small town that was at the mercy of one hospital was in collections.
If I’m not mistaken, they brought a lot of public attention to that. I want to say it was wiped away, but that’s happening throughout the country. There was one time when most hospitals were independent, but to your point, what you discovered is they had access to the same data as you. The hospital systems were sitting there with their people in similar roles to where you were at Blue Cross, and they were crunching the numbers and said, “Probably at some point, if this continues, we’re out of business, so what are we going to do about it?”
What they had to do is they had to merge with other hospitals. They needed strength. They needed to be able to say, “You can’t sell your insurance product without our 5, 10, 15, 30, or 40.” There are networks of a hundred hospitals in this country. Do you think you can write enough insurance in a particular market if you don’t have the majority of the hospitals in that market? The consumer is still obsessed with the network.
I’m hoping Billy is going to change that real fast. Can I present it to you?
This is the Billy.app that’s going live.
It’s $10 a month and you can buy for one month and drop it or pay $100 a year for full unlimited access. We’re looking at New Jersey, New York, Philly and this is code 74177.
That’s 1713. That’s where I’m sitting right now. That’s Long Island.
We see here that the average rate in my visual is $1,507. We see a $457 amount and we see a $5,240. That $4,000 is probably a one-hour car ride with traffic between these two spots.
It’s a 1,200% markup.
I don’t know what the markup is but if I click on it, I can see it’s JFK Medical Center. What happens is when you click on the detail, it’s going to show you all the different cash rates and plan names.
For people who are reading, what we’re doing now is we’re searching for a code. It’s the CT of the abdomen and pelvis with contrast. The average rate over a pretty big market area is $1,559.
I’ll pick over your Long Island.
It’s 1713 there. That’s South Nassau Hospital in Mount Sinai. That’s in Oceanside, New York. The cash price is $1,700. The lowest insured price is $109, which I’m going to assume is Medicaid. The average insured rate is $808. Here’s a situation where the cash price is pretty high compared to the average insured price, but the highest insured price is $5,172. This is what this facility bills based on what type of patient you come in with and who’s your payer essentially.
There’s another hospital up on the Long Island Expressway, the South Shore University Hospital. The cash rate is $881. It’s 50% cheaper than the cash rate. Why would you pay $1,700 when you can pay $800?
This is particularly powerful for people without insurance or people with HSA plans on the marketplace or through their employer, where they might have a $17,000 family deductible. They’re paying $2,000 a month in premium here in New York for a plan that doesn’t cover anything except for preventative care until they’ve accumulated $17,000. You can use this. There’s a $447 up there on the top left if you want to drive that far. That’s a Manhattan cash price of $447.
You could call there. You get a prescription from your doctor, specialist, or whoever. You call them and say, “This is what you need. This is the code.” You get the code from them if you’re a savvy consumer. You go on this map and you say, “Where can I get this?” “Is it worth $1,000, $2,000, or $3,000 to drive an extra 30 to 40 minutes an hour?” Give them a call and say, “I’m coming in. I’m a cash patient. I want to pay. According to my resource, your cash price is $447. Can you double-check that? Book me for next Wednesday at 8:00.”
I get a good faith estimate with end-writing. That’s the law. Let’s go over to Houston.
People who purchase this app, they have access to the entire country. That’s not a regional thing.
Yes. It’s unlimited downloads. We found the cheaper front door. You can also do your payment integrity checks, but you’ll have access to the detail where you can simply check it. Let’s change the code.
While you’re doing that, for people who are reading, what Leo is doing with this app on the screen is he’s scrolling across the country. As he stops in a particular area, he zooms in, zooms out, or whatever you want to do, it populates all the prices in that area. Right now, we’re looking at Houston, Texas. We’re looking at a mammogram.
It’s a DX mammo. Here, we can see East Houston is $1,200 and Memorial Hermann is $135. Do you see all these little blue dots? These are your urgent care centers, your minute clinics, and imaging centers. We are informing you of other sites and services that you may not be aware of that you should be aware of. You can say, “Maybe I don’t need to go to a hospital for a bee sting. I can go to an urgent care center.”
The $1,242 and the $251, is that always the cash price that’s showing?
Yes. We have an asterisk. If the hospital didn’t post the cash rate in the file, we’re saying this is the average commercial rate. It’s a way of me forcing compliance on them if they didn’t post the cash rates.
If I have this subscription for this and I now click on it and show details, does it then show each individual insurance carrier’s price?
Yes, it does.
That’s really powerful for someone with insurance that wants to use it.
Once you click this, you would see the heat maps, which I post on LinkedIn. You’ll see all these prices. I love that we have all the clinics. Anybody without prices, we’re posting them here. We invite everybody to give me your prices and I will load them like clinics, urgent care, imaging centers, and HCA. We will load every price you make available to us, which will be available to the consumers, which will help you.
I know it’s going live. You’re releasing it. Is your vision to do this B2C or B2B?
Right now, it’s B2C, but in the Consolidated Appropriations Act, every employer has to give their employees a cost comparison tool, which is Billy. We can do a bulk discount. If an employer wants to give us money for their employees, we can figure out a price point discount so you can be compliant with the CAA. It’s B2C. We can do B2B, but this is about changing healthcare from a third-party payer to a first-party payer.
When the healthcare ecosystem realizes that businesses are going elsewhere because they’ve been caught with their hand in the cookie jar. It’s not going to happen overnight. We already agreed on that, but it doesn’t mean it shouldn’t happen. It must happen if this is part of the solution. I always bring it up. Educated consumers are our best customers. Markets will change. Just because you can’t make the same profit you were making before doesn’t mean that other people who are not in the business and weren’t used to making that amount of profit aren’t going to see this as an opportunity and say, “We can open up a facility. Post the cash price. We can disclose. We’ll accept the lowest cash price that you can find.” It can happen.
Jeff Bezos says it’s best, “Your margin is my opportunity.” Competition fixes all problems. Billy is about disrupting the status quo. Actors cannot survive. You cannot tell somebody, “I’m going to give you a great deal at 140% of Medicare,” when a cash rate is $500 cheaper. That makes no sense.
There are competent so that the consumer understands. Everybody has so been so groomed by managed care. Everybody thinks that the only system that exists is my insurance network. The BUCA networks, the Aetnas, the Cignas, the Blue Crosses, the Uniteds, the Humanas, or the Kaisers of the world. That’s what people think. Not only is their health insurance, they think about it as their healthcare.
There are companies already working, especially with self-insured groups. Once you self-insure, which we’re a big proponent of most companies out there that are large enough to be experienced rated in their market. That’s different in different states. There’s an opportunity in self-insurance. There are companies that are already working, especially with independent TPAs. We’re going to hear about them, today and tomorrow, at Health Rosetta.
I’m at the conference. We’re going to talk about companies that we’re able to significantly change the paid claims within their plan by using companies like cash pay systems. There are a lot of different types of systems out there, and people are having success with all of them. Reference-based pricing is probably better than insurance discounts in most cases but there could be pushback. There are people that are great at it. At the end of the day, it’s the consumer who’s going to decide, “What am I comfortable with? How much disruption am I okay with? How much change am I okay with?”
If you have a company working with your TPA that says, “We’re negotiating our own direct contract,” that’s a different form versus the published cash price. If you can pay cash at the time of service or even before the service is rendered, that is extremely valuable for that facility. When that person walks in the door with that $17,000 deductible and three weeks later finds out it’s $9,500, do you know how much of that gets unpaid?
Because I can bill $17,000, it doesn’t mean I’m ever going to collect $17,000. Maybe $4,000 is the fair price for that service. I’ll take that every day of the week. If everybody that came in paid me $4,000, my net is going to be better than I am trying to collect from people that I’m trying to bill $17,000 or $9,500.
I’m excited that we’re embarking on the mobile app. It’s been the mission of Health Cost Labs. It’s been hard getting here. We’re about disrupting. We have no investors. We don’t want anybody telling us who we can’t disrupt. I have no expectation of an ROI or no beating down my door. We’re here to do the right thing and bring consumerism to healthcare, and let the cars fall where they may.
Does Billy to be called Bill or Will?
It’s Sir William to a few people who I don’t like, but it’s Billy to everybody else.
My dog Brandy was Sir Brandon DeBrooke. When we lived in Minnesota when I was younger, you had to give it an official name. This is awesome.
Thank you so much. We also have the data from Direct, Scriptco, and Cost Plus Drugs. That’ll be coming in version 2 or 3. We’ll have direct ePharmacy prices so you can compare them in one screen so you can make your own informed decision.
That’s great. There’s going to be a lot. Are you going to Health Rosetta?
No, I’m not.
This is incredible. You’ve been working on this tirelessly since 2019.
I’ve been fighting healthcare for many years back at Blue Cross trying to get change things. It is been a long road for me, and I feel that this is where I’m going to hang my hat and say, “I’ve accomplished something.”
Good for you. I know that when I changed the course of my career in 2017, it was a scary time. I wasn’t sure. I found a new purpose in being able to help. I hate to use the word disruptive. What you’re doing is disruptive in a very positive way. When you’re selling insurance to consumers, they don’t like the idea of disruption. I know Dave Chase didn’t like that word as described what they’re doing either. Change is necessary. You can complain all you want or say, “This isn’t going to work. This information is not useful.” Any information that makes the consumer more informed is useful. The consumer will decide what they want to do with this. Hopefully, they’ll use it and they’ll use it a lot. Healthcare and health insurance have to change.
This is the GoodRx of healthcare and hospital prices.
Look how successful they are.
People are still going to need insurance for stuff they can’t afford. You said it earlier. Because you can bill $10,000 doesn’t mean I should pay you $10,000. Insurance is only for catastrophic care. Your major inpatient surgeries and cancer. That’s about it. Everything else, you can find at an outpatient center at a lower rate, and you’ll never hit your deductible.
I believe you’ve spoken to Marshall Allen when we connected. I’m thinking of this. Maybe someone doesn’t change their behavior or someone doesn’t know ahead of time necessarily, but they write on there when they go into the hospital and they have all that paperwork that you have to sign. Marshall is big about educating the consumer.
Letting them understand their rights and protecting them from a very predatorial healthcare system, unfortunately. It’s for something so important. It’s amazing how predatorial it is and how uncaring it is for the individual. If you knew in advance that you were going into that facility because you liked your doctor and your doctor hasn’t admit privileges to this one particular hospital, but you know that the cash price or the average price is X. You wrote on there when you signed it, “I agree to pay up to your average price as disclosed by Health Cost Labs, Billy.app.”
As disclosed per your machine-readable file.
I will stand up in court.
It will. This data is factual.
It’s my opinion. I’m not an attorney.
I’m not either. There’s no way anybody should pay more than the machine-readable file’s best price. I understand that the best price may be Medicaid or maybe too low, but we don’t want to get ripped off. Maybe it’s the minimum commercial rate.
It has to mean something. Take me to court and let’s see if the judge sides with you when they see the information and they’re sitting back there and says, “Your cash price is this. Your lowest price is this. Your average price is this. Just because they have that logo on their ID card, you’re charging them $5,200 when you accept $400. I rule in favor of the defendant. Thank you. You should refund them $970.”
That’s right. This whole medical bankruptcy and bill charges is all going to fall apart.
I think of myself as pretty forward-thinking and trying to be an advocate for our clients and their members, especially when they become patients and they enter the healthcare system. Having this information and saying, “Why don’t you use this? It’s $10 a month. Mr. Employer, let’s talk to Leo and his team and say you have 100, 200, or 500 employees. Maybe they’ll give us a discounted rate.” The TPAs are going to want this information and they might build it right into their platform, potentially. There’s so much possibility with this.
The more people that are aware of it and get upset by it, the better. The point of it is that we want the consumer to get on the edge of their seat a little bit and say, “Do you mean to tell me that my healthcare system or my insurance company has been taking advantage of me for these number of years with the insurance plan that I have now?” This very high out-of-pocket cost because of the manipulation of all the numbers and all of that contractual stuff that you used to do.
The problem in healthcare is ethics and there’s no moral compass. I hope the insurance companies will come to their moment and say, “This is wrong. We’re going to accept the lowest amount the hospital accepts as payment in full and reimburse the member that amount because this whole price rigging thing is false. Let’s stop pretending it’s a legitimate business when it’s not.”There is no moral compass in healthcare. The whole price rigging is false. Everyone should stop pretending that it is a legitimate business. Click To Tweet
Congratulations on this. I could see the excitement. Hopefully, six months or a year from now, you’ll be back on and be able to tell us, “We have 10 million subscribers.”
I would love to.
The stories, I got to get a panel together. There was a guest, and it’s terrible because I have my list with me, but I had a guest on probably about fifteen episodes ago. All this company did was the cash rate. We have a direct contract. We pay cash to the providers and facilities. This is great for those facilities that don’t have this feeding system of doctors and specialists that now are employees of the healthcare system that are driving people to where the care is the lowest value like high price with no better quality.
There are a lot of independent facilities that struggle because they don’t have the traffic coming in that do accept a lot less. That’s what’s powerful when you start talking about all of the independent facilities, clinics, labs, and things that. Once that data becomes even more abundant in your system, they’ll win because they are delivering equally.
That’s how capitalism works. It’s competition.
People don’t understand that their doctor, when they work for the ABC healthcare system, is an employee of that system. They’re told where to send people and they’re not told where to send people because this is where you can get at the lowest price. It’s where the healthcare system maximizes its profits.
This is going to change that conversation.
They don’t ask you, “How many of your seven medications are you taking? What’s your out-of-pocket cost ahead of time?” They want to know you’re out-of-pocket cost so that they can get paid because they know you’re coming in. When they’re referring you somewhere, they don’t say, “Let’s look at your plan. Your out-of-pocket cost for radiology is subject to your deductible and co-insurance and this is a $5,000 test with your insurance plan. There’s a facility next door that’s independent that’ll take $500 cash.”
I shouldn’t say no one but there are plenty of people helping. There are health plans being built and we’ll hear about them again. I like the plug Health Rosetta because it’s an amazing organization, but it’s not enough of it. That compass right now points towards Wall Street and private equity. We need to change that. We need to put the consumer in control. This is amazing. We’re coming right up on the hour. It’s awesome. Congratulations on everything and we’ll talk real soon.
I’ll talk to you then.
Thank you for your time.
About Leo Wisniewski
Leo Wisniewski, Founder of Health Cost Labs.
You’d hard pressed to find someone with more behinds the scenes insights of the health insurance ecosystem than Leo. Leo spent 15 years with Blue Cross as an Actuarial Analyst, Contract Analyst, Payment Integrity and Informatics Specialist.
Basically, it was his job to help the insurer understand the billing practices of the healthcare system in response to changes in contracts and Fee schedules. Bottom line, he helped the insurers maximize profits!!
Along the line he reported what he thought were unexpected behavioral changes that he reported to his supervisors. To his surprise, they weren’t interested and seemed to want to keep what he found silent. It was then that he understood that the driving force was profits over people.
Fast forward to August 8, 2023, the day his hard work of the past 5 years comes to life in the form of Billy.app. A new tool to empower the American Healthcare Consumer.
This is his story!