November 17, 2025
Louis C. Bernardi, “The Benefits Whisperer”
The Healthcare Heist Newsletter – by Lou Bernardi, The Benefits Whisperer, Certified Healthcare Fiduciary Coach, Certified Health Value Advisor.
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Introduction We talk a lot about “reforming health insurance.” But what happens when reformers say: “We’re not tweaking the system; we’re tearing it up and rewriting the blueprint”? That moment may be arriving with the Patients Over Profit Act (POP Act), a proposed federal bill that signals a shift from incremental change to structural disruption in how insurers and providers interrelate.
What the POP Act Actually Proposes At its core, the POP Act would:
- Ban direct or indirect ownership or functional control by health insurance issuers over outpatient provider entities (physician practices, MSOs, MSAs) that bill Medicare Part B or participate in Medicare Advantage.
- Require divestiture timelines for existing arrangements (two years) and newer arrangements (one year) if the bill becomes law.
- Exclude hospitals, pharmacies, DME suppliers etc. from this prohibition.
- Impose enforcement via multiple federal agencies (DOJ, FTC, OIG) with potential False Claims Act exposure and court-ordered divestitures.
- Crucially: the definition of “control” goes beyond equity to include MSAs, reserved powers, veto rights and other non-equity levers.
- Notably, employer-sponsored health plans governed by ERISA are explicitly excluded from the definition of “health insurance issuer” under the bill, so self-funded employer plans may not be directly caught.
Why this matters now
- For years, the dominant industry narrative has been vertical integration (insurer owns/aligns with provider) = better coordination, lower cost, higher quality. The POP Act challenges that narrative, suggesting integration may instead drive market dysfunction, reduced choice, and higher costs.
- Even if the bill doesn’t pass, the mere introduction of structural separation as a policy tool sends a strong signal: regulatory appetite for structural reform is growing.
- For employer-sponsors, consultants and advisors, this shift is a reminder to avoid assuming the status quo will persist. Networks, contracts, analytics and incentive models may need to be re-thought now.
- As you build high-performance health plans (HPHPs) under the PLAN System (Planning, Leveraging data, Aligning incentives, Navigating the system), it emphasizes that “aligning incentives” and “transparency” aren’t optional, they’re increasingly essential.
Implications for Employer Health Plans
- Network design & provider relationships If insurer-owned provider entities are forced to divest or unwind, provider networks may become more fragmented and leverage may shift, and that can impact cost, access and contract terms.
- Risk-bearing and value-based contracting Many MA plans and integrated systems rely on vertically aligned models to drive star ratings, utilization control and value. If structural separation weakens those levers, performance-based models may need redesign.
- Transparency & fiduciary oversight With structural change on the horizon, employer-sponsors must ask: Do I truly know how ownership, referral practices, risk-adjustment and contracting incentives align, or misalign, with member interests?
- Cost of inaction (COI) As you emphasise in your work and in The Healthcare Heist, doing nothing is a choice—and increasingly risky. A major structural shift like this means that those who wait may get caught on the wrong side of cost, access and value surprises.
Next Steps
- Review your current carrier/provider ecosystem: Are any of your network partners part of vertically integrated models that may be affected?
- Perform a scenario-analysis: What if your primary insurers lose ownership/control of providers? How would that affect your plan’s cost structure, quality metrics, access and leverage?
- Promote transparency in your contracts: Insist on clear disclosures of ownership, referrals, and incentives that can influence care.
- Revisit your plan’s value-alignment strategy: How are provider incentives aligned with your corporate goals, employee health, cost containment, quality?
Conclusion The introduction of the POP Act is far more than another legislative moment—it’s a wake-up call. For too long, health plans have accepted opaque structures, hidden incentives and “integration” as a fix. As the regulatory winds shift, employer-sponsors and benefits advisors must shift with them. Your challenge, and your opportunity, is to position your organization not as a passive purchaser of insurance, but as an intentional architect of high-performance health ecosystems that put care ahead of profit.
If you’d like to discuss how this structural reform could affect your health plan design—or explore how to integrate the PLAN System’s next-level strategies into your roadmap—let’s connect.
Contact the author at lcbernardi@britepathbenefits.com
Schedule a call at calendly.com/lcbernardi
Visit our website at www.britepathbenefits.com