My musings on bass fishing, writing, healthcare and life. gottwals.substack.com
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April 13, 202621 min
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
January 12, 202618 min
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 referenced: Episode 486 of Relentless Health Value. 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
September 6, 20251 hr 53 min
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 PodcastMedical errors are the 3rd leading cause of death 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, with the Association of American Medical Colleges predicting it could grow to as much as 40,400 by 2036. A 2008 study estimated that imaging services accounted for 14% of healthcare spending in 2005. Think Fast. 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.Timestamps02:20 - Most patients don’t get to keep one doc anymore05:32 – Dr. J still has a few primary care patients06:45 – Primary Care docs in the system work more than 100 hours a week08:30 – Primary Care docs are responsible for 2,500 patients/year15:00 – The worst part of her job when a patient has an HMO19:44 – Capitation vs. Fee for Service24:00 – How I met Dr. J26:50 – How much does the Standard of Care suppress creative medicine?28:00 – Overtreatment kills34:00 – Medical errors are the 3rd leading cause of death in America36:52 – Did you ever feel pressure to overprescribe?46:45 – How is/will AI impact primary care?56:15 – Average doctor pay01:07:00 – The Obamacare “free” annual physical01:18:15 – How referrals work in modern medicine01:21:30 – Compelled imaging01:26:30 – Cost of malpractice insurance by specialty01:27:45 – Vax schedules, how about those ingredients?01:36:45 – The Iron Law of Bureaucracy01:42:05 - 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
August 26, 202529 min
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
August 19, 20251 hr 26 min
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/* Michelle’s Substack: mtln.substack.com 5:00 DPC vs Concierge Medicine12:20 Home visits and length of visit31:00 Doctor burnout.34:08 Pairing DPCs with self-funded plans47:50 Ordering referrals55:45 Malpractice insurance56:20 How employees flood to DPC when available58:08 Working with independent grocers1:07:45 How to build your own health plan1:15:30 How DPCs treat you when you’re hospitalized1:25:00 DPCs can now be purchased with HSAsBuild-Your-Own Health Plan article: https://gottwals.substack.com/p/build-your-own-health-planMusic 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
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 reinsurance9:00 - What is stop-loss insurance? 13:20 - Size of employers self-funding today16:15 - Why self-funding is harder in Sacramento, California16:55 - AI in underwriting. Does it help or hurt? Article on AI in claim underwriting, “HIPAA Is Dead. Long Live the Data Brokers.” 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 cons42:25 - 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.” He went from 456 pounds (207 kg) to 180 pounds. Episode 252 of their DarkHorse podcast 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 reporting1:38:00 - 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
July 11, 20251 hr 42 min
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 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
June 21, 20251 hr 59 min
RBP from A to Z with ClaimDOC Founder, Ben Krambeck
Ben Krambeck is the Founder, CEO & Chairman of the Board of Directors for ClaimDOC, a third-party claim auditing and member advocacy firm focused on creating clarity and transparency in the facility claim space. Also available on YouTube. Hour 1* 00:00 Introduction & Co-Chair of the Board, Fritz the Giant Schnauzer * 09:28 How Did ClaimDOC Come to Be? * 10:42 Ben and Craig are INTROVERTS? * 26:18 The First Claims Giving Birth to ClaimDOC * 36:55 Why Might An Employer Offer RBP Alongside a PPO? * 44:55 The Customer Service Difference * 46:33 What is Pave the Way? * 49:50 Paving the Way Takes 10 Calls Per Doc * 57:05 The Downside of a Physician & Ancillary-Only Network * 58:40 100 Point Solutions? Hour 2* 1:02:30 The ONE Commandment of RPB * 1:04:00 MedCash * 1:11:52 Nearly All Competitors Are Private Equity * 1:14:00 Pricing for ClaimDOC * 1:25:51 Future of RBP? * 1:29:00 No Surprises Act & IDRs * 1:38:53 Single Case Agreements * 1:50:56 Where You Been Fishing? * 1:55:19 Golden Muscles 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
August 12, 202427 min
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. 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
April 9, 20241 hr 17 min
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
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