Insurance Giants are Running Out of Time (feat. François de Brantes)

TRANSCRIPT

Click here to listen to the episode, published June 9, 2026.

FRANCOIS [INTRO]: When does the wake-up call occur? When do people finally realize that they're being fleeced and fleeced again? These can turn into multi-billion-dollar lawsuits. I mean, you're looking at extinction-level events. The balance is shifting back, with employers starting to understand that they need to figure things out. This is not necessarily a red state, blue state issue. This is much more of a "what do you believe in?" If you cede the right, you have to find a way to reclaim it. You cannot compromise. It's difficult, but employers did it 25 years ago. There's absolutely no reason they can't do it today.

JOHN: Thanks for joining us for another episode of Moving to Value Unscripted. My name is Dr. John Rodis, and I'm a recovering ex-hospital president and president of the Moving to Value Alliance. Our mission is to advocate for a value-based healthcare ecosystem with the highest quality outcomes at a reasonable cost for our communities. I want to thank our members whose support makes this podcast possible. We'd like to give special recognition today to our trade member, Capital Rx. I'm joined by my fellow board members, Dr. Steve Schutzer and Donovan Pyle.

STEVE: Thank you, John. Good morning. I'm Dr. Steve Schutzer, orthopedic surgeon and co-founder of the Moving to Value Alliance. I'm also co-founder and chief medical officer of Upswing Health, a national virtual orthopedic company focused on improving patient access, clinical outcomes, and value in musculoskeletal care.

DONOVAN: I'm Donovan Pyle, CEO and founder of Health Compass Consulting, based in Orlando, Florida. I'm the author of Fixing Healthcare: How Executives Can Save Their People, Their Business, and the Economy, and senior advisor at the Validation Institute.

JOHN: Our guest today is Francois de Brantes, the Executive Vice President of Payment Innovation and Network Performance at XO Health. Francois is a leading strategist behind alternative payment models, arguing that the American healthcare system must dismantle the fee-for-service machine and fundamentally change how care is bought and paid for. Francois has pioneered the development of structured episodes of care and bundled payment models that shift financial risk away from employers, reward actual clinical outcomes over volume, encourage price transparency, and eliminate legacy insurance conflicts. By replacing fragmented systems with aligned value-based incentives, his models have reshaped how billions of healthcare dollars move through the economy, allowing employers to reclaim control of their healthcare spend. Francois joins us to discuss how employers can break through carrier roadblocks, fulfill their legal fiduciary duties, and start to transform healthcare in this country. Welcome to Moving to Value Unscripted, Francois.

FRANCOIS: Well, thank you, John. It's a pleasure to be here. The only — it’s not a correction , but nuance I'd put to what you said is: we're not shifting the risk to providers, but redistributing risk appropriately between employers and providers. Employers still carry, and should carry, catastrophic risk, like insurers do, because that's their role. But some of the risk — the management risk, the risk of managing patients — absolutely belongs in the hands of providers.

JOHN: Great. We all agree with that. Francois, our listeners like to hear a little bit of your story — how you got to where you are today. Your background, going back to your GE days, doesn't strike me as, "Oh, it's a natural thing that now you're in this healthcare transformation world." Tell us a little bit about how you got here. For many of our guests, we've noticed that there's been some sentinel event or epiphany that all of a sudden moved them. Tell us your story.

FRANCOIS: Look, over the past few years I've reflected on what you can think of as a wave of employer involvement in shaping — or reshaping — the U.S. healthcare system. In the early 2000s, that wave crested. And I just happened to be working for GE at the time. If you think of the different leaders of some of the larger U.S. companies in 2000 — literally 26 years ago — you had what we sometimes amusingly referred to as "the Generals": General Electric, General Motors, General Telephone and Electric Company (GTE), which became Verizon. Those companies had benefit leaders who were incredibly sophisticated individuals, oftentimes with two degrees — MD/MBA, or at least an MBA — who understood business, healthcare, and economics. They co-founded a large number of what ended up being foundational elements of the structural changes in the industry. For example, those three companies and a couple more agreed in the late '90s to create a common pool of de-identified claims data from their collective employees and retirees. There were millions of lives in that data pool because the companies were so huge. GE in 2000 provided care for 750,000 individuals — that's the population of Vermont. GM was significantly larger than it is today, because the number of manufacturing plants it had in the U.S. was significantly larger than what it has today. Those companies represented a bulk of purchasing power that was significant. They all decided: let's pool our claims together so we can understand what's going on between ourselves and create some normative values against which we can benchmark our performance individually and collectively. They hired a small company in Ann Arbor, Michigan called Medstat, which grew a little bit and got purchased 20 times. What you know as the Truven or the MarketScan database — that was the origin of MarketScan. We would get quarterly claims dumps from the carriers with zero restrictions, because we made it a condition of contracting. All of us did. There was no redaction, no gag clauses, nothing — 100% unredacted claims. And if they failed to give us the claims in a timely manner and in the format we required, we dinged them on their admin fees. So think of that. Today, we're arguing fiduciary responsibility, elimination of gag clauses, et cetera. And I'm there in semi-shock thinking, "But we had all that 26 years ago." So what happened in the interim? I'll get to that in a second. 2000 was also the birth of the Leapfrog Group. Those same people created Leapfrog. My team at GE — I worked for Bob Galvin, and my team was actually the Leapfrog team, because Suzanne Delbanco, who was hired as the first executive director of the Leapfrog Group, didn't have funding or a team. So my team supported Leapfrog. And Medstat developed the first Leapfrog survey. You remember, John. All of that was done by the employers. After Leapfrog, we created Bridges to Excellence — again, the same large employers, who said, "We've got lots of people in Albany. We've got lots of people in Cincinnati. We've got lots of people in Louisville. We've got lots of people in Detroit. Why don't we get together and measure provider performance? And then we'll pool our money together so we can give them checks for doing a good job." It was pay-for-performance before people even knew what pay-for-performance was. So in 2000, you had this incredible crest — the strength of the employers acting together to fundamentally change the way providers were paid, measured; transparency was a core tenet, et cetera. And then the ACA came along, and that wave subsided into a trough. Two real shifts drove that. One, many of the people in those companies started retiring in 2010. Two, many of them got hired by the carriers. The carriers smartened up: they went around and hired the head of benefits from Ford, from Delta — and so on. I'm not going to say they were co-opted, but the carriers were smart. They said, "You understand employers. Why don't you help us do a better job?" All of those medical directors became the medical directors who led the employer roundtables. So you had a brain drain at the top, coinciding with a realization by a lot of companies that with the ACA, it was maybe time to take the foot off the pedal a little bit. Why invest so much money in internal resources when you've got the ACA marketplace, you've got CMMI, all of the innovation in payment starting to materialize? In the interim, I left GE so I could continue working on Bridges to Excellence, Leapfrog, and what became known as the Prometheus payment model. It didn't make sense to do all that within one company, given that the scope was much larger. So we set up a nonprofit. With ACA and CMMI taking much more importance, and the carriers getting smart about taking people off the table, the strength and the power of employers subsided. I feel that we're on a wave back up. The elective abuse — you know, Jack Welch used to say, "You skate all the way to the edge of legality and you keep skating closer and closer to the edge until you get caught." That's just the nature of corporations. My sense is that the current carriers have stayed so far past that line that yes, they're getting caught, because it really leads to stupidity, and stupidity leads to jail. Inevitably, it happens. It's just a question of: when does the wake-up call occur? When do people finally realize they're being fleeced and fleeced again? And that ultimately, unless you stop going back to the people who fleece you, you're going to continue getting fleeced. It's a little like when I was young. My mother owned a restaurant in New York City, and we would pay for trash removal to a company that also offered "degrees of protection." Okay, we understand — we understand. And you didn't have a choice, right? Until you had a choice. That's what's happening in the carrier world and in the health plan world today. It's gone to that point of egregiousness, and now the balance is shifting back. You can feel the wave pressing back up, with employers starting to act in a more collective fashion, starting to understand that they need to figure things out — and companies responding to that. Capital Rx, one of the important supporters of MTVA and a company that XO Health uses as its PBM, is part of that change. It takes time, but once the pendulum has started to swing, it doesn't stop until it's reached its next peak, and then it'll subside again.

STEVE: But you know what, Francois, it was easier 20, 25 years ago, before the moats and the obstructions were built up. Now, you're right — we all feel that the pendulum is swinging. But the headwinds are much higher than they would have been when you did your work 20, 25 years ago.

FRANCOIS: I don't know, Steve. I don't know. I think there's clearly inertia — there always has been inertia. As a scientist, you know full well the power of inertia. But let's talk about the moats. The supposed moat is what? Information. Well, you now have regs in place that prevent the blockage of information. It doesn't mean they'll relent, but there's clear legal recourse. And that legal recourse is starting to play out. So what's the next moat? Networks? We all know what providers are being paid, because of the degree of transparency and the enforcement by the federal government — certainly on the requirements of hospitals and health systems. I run networks; I contract with providers; I supervise the pricing of claims, the building of fee schedules and alternative payment models. Physician fee schedules have never been the issue. It's the facility fee schedules that are the issue. And the federal lens on enforcing the rigorousness of transparency in the provider machine-readable files — mostly hospitals and health systems — is, believe it or not, the right move. They should do the same with the carriers. There's no question about it, and there's not enough enforcement on that front. So what ends up being the moat for the carriers? Network? I don't know that that's a moat. I don't think information is a moat. I don't think technology is a moat, either, because their technology is antiquated. It's clunky. It prevents them from actually doing things they should be doing. Sometimes it prevents them because they like to be prevented, and it's an excuse for doing nothing. But sometimes it's actually pretty legitimate — those systems are horrid, horrid, horrid, horrid. And rip-and-replace is a life-ending, business-ending proposition. So I don't think they actually have a moat. I think they've built themselves a castle that is surrounded by a desert, and they're running out of everything. They're running out of time. They're running out of food. They're running out of everything.

STEVE: Yeah, I'm really glad to hear that from you, Francois. We go back 15 years — from HCI3 to Remedy to Signify and now XO — and I've been a big admirer and follower of yours. So I'm really glad to hear you say that. I'm the ultimate optimist on the call here, but the structural abnormalities you referred to earlier — I have a company, and I'm still running into them, and they're pretty profound. The broker says, "Hey, love your product, love direct — but I've got to go with the TPA. The TPA has a network." That's at the BUCA level, but also at the independent level; they all have their networks. Is that true? And if it is, what is XO doing to fix that?

FRANCOIS: Yeah. Donovan certainly can speak to a lot of this. But that's a very different moat. You're correct that the broker/benefit-consultant line is currently a line of defense for the carriers — and because it's a line of defense for the carriers, it's also, as a result, a line of obstruction for many employers. But that line is breaking. It is breaking. It's breaking because when you have Willis Towers Watson, Aon, and Mercer being sued, the suits at the top are going to have to think differently. They don't have a choice. These can turn into multi-billion-dollar lawsuits. You're looking at extinction-level events, in much the same way as happened to the tobacco industry several years ago. This is not trivial. We all know the compensation schemes of brokers and benefit consultants. We know how much money they make on point solutions. We know how much they make on commissions. The same is true with the brokers. And the disclosure is not mandatory — that's a problem. The disclosure is only mandated if the employer requires it. So the lawsuits create a breach in that line — and it's a thin line. That's the issue. In military terms, this is not battalion strength; this is a thin line. And when it breaks — and it is breaking, because we've got a lot of independent brokers and consultants who have broken away already; not enough, but the lawsuits are a battering ram against that line — it's going to play out this year, and it's going to play out next year. Ultimately, it still boils down to the employers: you have to demand full disclosure. Again, I go back 25 years — and we had this. We had this.

DONOVAN: Yeah, just to comment on that: it's fascinating that 25 years ago, GE was successfully and voluntarily getting data rights and requiring zero gag clauses in their contracts. They didn't need an act of Congress to do that. Employers never did. And yet here we are — most employers don't ask for these things. So what's your take on that?

FRANCOIS: Well, they don't ask for these things — so again, I think history is always a good teacher. The rights to claims data are the employer's, because it's the employer's money. It always has been. Once the carrier realized they could start playing games — initially, a few cents here, a few cents there, but a few cents here and there on a lot of claims ends up being a lot of money — and when you realize the cents can turn into dollars, then you have a very different business. Entering into an agreement with a provider under the guise of "preferential pricing" naturally leads to, "Well, if it's preferential pricing, we have to keep it confidential." If St. Francis is going to give Anthem preferential pricing, then Anthem has to keep it confidential — because St. Francis is giving it to Anthem, not to Aetna, not to Cigna, not to United. Well, if Anthem needs to keep it confidential, then Anthem can go to its employer customers and say, "I can't give you the specific rates, the specific allowed amounts I'm paying on your behalf — even though it's your money — to St. Francis, because we have a confidential deal with them." Think of that arc, and that wave I mentioned. Employers at that time had retreated. The people like Bob Galvin, like me, who would have said, "Are you out of your mind? I don't care what kind of confidential agreement you have. We have a confidential agreement with you. These are our data. It's going into our claims data set" — they were gone. So you're left with benefit managers who said, "Okay." And that's the beginning of the end. So now you need the courts, you need regs and courts to reassert those rights — because the people who imposed those rights needed those rights. If you cede the right, then you have to find a way to reclaim it. That's what's happening. Slowly but surely, that is what's happening. And again, back to the brokers and benefit consultants, it's very frustrating. One of the things I've been exploring, and maybe this is something you guys can have conversations with the State of Connecticut's Attorney General, Department of Insurance, and others about, is this: brokers are licensed at the state level. Right, Donovan? Brokers are licensed by the state. There are certain regulatory requirements. It's a state license. Think about real estate agents and real estate brokers. They now have — and I recently had a real estate transaction; I sold my house in Newtown — an obligation to give us a piece of paper that disclosed all the fees, their fees, whether or not we would agree to pay the buyer's broker, what the split would end up being. Everything is fully disclosed on paper, and the seller has to sign it, and the purchaser signs it. Why don't we impose the same on insurance brokers? Why doesn't the Department of Insurance and the State Attorney General say, "We're going to impose the same reg on health insurance brokers that we have on real estate brokers"? When they sell a case — a case meaning an employer — they have a piece of paper that they put in front of the employer and disclose all the different commissions they're getting. And what I would suggest is comparative commissions: What would you have gotten if it was Cigna as opposed to Aetna, United as opposed to Anthem? Show me all the commissions you would have gotten, and why you decided on the one you sold. That obligation can then turn into a disclosure, because for the purposes of relicensing, the Department of Insurance can say, "I want, in order for you to be relicensed in '27, you to send me the sheet with the signature of the employer, for all the cases you sold, showing the disclosure you made." So again, once you get to a point where the authority has been ceded, you need regulation to rebalance some of it. The feds have done it with transparency and coverage and a few other things. I think this is an area where the states can enforce regulation that will explode that line of defense.

DONOVAN: Love that idea. Love that idea — "explode that line of defense." I think there are certainly opportunities in some states, and unfortunately in others, regulators have been captured, and it's not likely. But I love the idea. The reason this matters is that most employers don't have in-house resources that understand this stuff. They rely exclusively on the recommendations of their broker, not realizing that legacy brokers serve as retail distribution for insurance companies. That's their role. They're not in the business of providing the services that maximize employee benefits investments. It's a disconnect.

FRANCOIS: That's right. But look, most of us rely on financial advisors for a variety of things. If you have 401(k)s, whatever fees need to be fully disclosed. It's not as if the mechanisms don't exist — they're just not present in one area, which is health insurance. But they can be. Florida might be a while before it happens. But surprisingly, if you look at Indiana — red state — they passed legislation in '25 capping the price of hospitals for ACA and other government business. Not all commercial business, but it can be used as a yardstick. And it has worked. All the hospitals, including Indiana University and the larger health systems, have had to lower their prices to comply with the legislation. If you look at Texas, Texas has certain regs on the books related to fair market value and percent of Medicare when you're negotiating out-of-network bills. Texas was one of the states that instituted caps on liability for physicians. So this is not necessarily a red state, blue state issue. This is much more of a "what do you believe in?" If you believe in transparency, then asking for disclosure signatures of employers when your broker sells them health insurance is a transparency issue. If I were leading a Department of Insurance in a state, I'd say, "Well, the feds actually have a rule that says the brokers should disclose it if the employer asks. I'm just going to go one step further and say, it doesn't matter whether the employer asks for it or not — you have an obligation to disclose it, as a condition of licensure." And that would be it.

JOHN: Francois, let me shift back to when I first met you. It was related to our orthopedic program — our joint replacement program that Steve ran. We had one of the best orthopedic programs, honestly, in the country by every metric anyone can measure, and we had the data to prove it, as you know. You've spent a lot of your career, and you've taught me a lot, about episodes of care and bundled payments. When I think of the procedures done in America — once you get out of my field, obstetrics and C-sections; let's put those aside — hip and knee replacements and spine surgery are still always in the top three or four procedures done in this country. We're talking hundreds of thousands. When you think of it today compared to back then, what percentage are paid under a bundle? It seems to me most are still not. Is that not true, and why not?

FRANCOIS: I would say it has shifted pretty dramatically. Are most of the arrangements still on a fee-for-service basis? Yes. However — and I'm sure Steve is aware of all the different, I call them, marketplaces — Ortho Value Network is one, but there are quite a few in ortho and GI. Gastroenterology procedures are more common every year than joint replacements. Gastroenterology and orthopedics by far lead the way in volume of procedures. The number that are being paid on a case-rate basis is actually quite large. Now, that's not a full episode of care. Some of it is paid prospectively; some of it is not. But the orthopods and the GI docs have absolutely espoused that concept and have found a way to operationalize it. It goes back to the wave: if you make it simple, adoption increases. If you also make it not just simple but worthwhile — by "worthwhile" I mean, if the only deal I can make in the state of Connecticut is with the Joint Institute, okay — but I want to make 20 of those deals, not one. So how do I operationalize it? What's abundantly clear to me is that the challenge for employers now is not to convince them whether this is a good idea, because they all agree. We see it in RFPs from really large companies as well as medium-sized companies, and the format is all the same: a strong advanced primary care base — I've been saying that for 40 years; a high-performing network — a network, high-performing, not just the Joint Replacement Institute — that's eminently identifiable (contractable is a different issue, but it's identifiable); and as much predictability in pricing as I can get, and variable co-pays — or some variable cost-share structure — so I can execute on it. Those things run 100% counter to the business model of both providers and carriers. But they're in the sweet spot of any alternative health plan, any new health plan. The availability of data, the speed with which you can build today with the help of smart agents and artificial intelligence, the flexibility that gives you — you can stand up these solutions in a manner that is unmatched. I was telling a colleague of mine the other day that today I could do Prometheus version 10. We stopped at 5. I could do Prometheus version 10, which would be three times as good as version 5, in a week. It took us 10 years to build Prometheus. I could do it in a week. Some of that is because I have the subject matter — I've built it, worked with a number of different groups — but I could build it in a week, and I wouldn't need engineering help, medical help, anyone. The power of… you know, when people started talking about AI, I was like, "Jesus, can we just stop this?" Then came ChatGPT. Then came Claude. And now that is artificial intelligence. The stuff people were talking about before wasn't a joke, but it wasn't really changing anything from the perspective of the power these things unleash. Now you're in a different ballgame. The reason I mention that, Steve, is that when I was saying those guys are in a fortress surrounded by a desert, and they're running out of time and resources — the technology moat, the infrastructure moat that they have, is nothing. It's like a sandcastle that's being hit by wave after wave after wave of new versions of AI. That's destroying completely any advantage they might have. So that wish list that employers want, you can assemble. There are still some challenges, but you can assemble it and offer it up. Assembling it isn't a problem. Delivering it isn't a problem. We've got to break that last line of defense — the broker line. In our case, we can go to an employer with that full assembly. And the commissions we would pay a broker are a fraction of the commissions they get to retain the business for Cigna, Aetna, United, or the Blues. Until that employer has that information in front of them in a transparent way and says, "Wait a second — these guys can give me everything I want; these guys can't; but you're still pushing them on me. Oh, I get it: you're getting $40 PMPM from those guys, and you're getting $5 from these other guys. But that's not serving my interests." That's why I'm taking this on. I'm saying it everywhere I can and however strongly I can. Because until that line is crushed, we can assemble whatever solution meets the needs of employers and is truly, truly better than what the incumbents offer up — but we've got that last line of defense blocking us.

DONOVAN: Yeah, Francois, we just started a service auditing broker compensation disclosures for employers, and the things we're finding are just amazing. If your solution isn't offering loans and lines of credit to brokers, you might not be in the running. If they don't own equity in your solution, you might not be in the running. What's really fascinating is that a lot of these employers have never actually been exposed to the marketplace of strategies. They have no idea how dynamic and vast it all is. And you're exactly right — the brokers don't show them, because those aren't the vendors that pay them, or pay them the most. Compensation drives behavior.

FRANCOIS: It does. And it's got to get attacked at both ends — which is why I mentioned the Departments of Insurance, with regulation on the certification or recertification, the licensing or relicensing, of brokers. That'll hit the small market. At the top end, the lawsuits will do the job. The CFOs and CEOs of those three large benefit consultancies — the next time they have to sign the insurance for their liability coverage, their officer and director coverage, it's the premiums that are going to skyrocket. And they're going to say, "Time out, time out. We need to reconfigure the way compensation for our firm works." It's going to be painful. But it's either that, or we're in a lot of trouble.

STEVE: Francois, I want to come back to that structural anomaly. The TPA builds the network, and then the broker is supposed to sell it, and the broker says, "Well, I don't like this." It's just ridiculous. Why isn't it just one organization that's building it and selling it? It makes no sense to me at all. What is XO doing differently?

FRANCOIS: Oh, it can be. It's crazy. You could have asked me this question three years ago, and I would have had a very different answer. Three years ago, when I started working with XO, our only strategy was to assemble components. That's all we could do. To stand up a TPA, the only thing we could do was assemble components. We had to find a claims adjudication system, a provider directory and provider data management system — the list goes on of different technical solutions that would enable you to stand up a TPA. Because of all the different things we're doing in alternative payment models and variable cost share, it required degrees of customization and a lot of work just finding the vendors we could use. So now you have five or six different vendors, all with different platforms, all with different data systems, and you have to figure out a way — not to integrate them, because you can't integrate with, I'm not going to name the company, the other large companies. All you can do is manage the flow of data between them and work in a way that avoids degradation of the data as it goes, and make sure there aren't any errors. It's super complicated. By the end of this year, we will have built our own end-to-end, wing-to-wing, full claims ingestion, claims checking, claims pricing, and claims adjudication system internally. And we'll have done it in six months, because the world has changed. What was impossible three years ago is 100% possible today. So yes, for a TPA to try to stand up two or three years ago, the only thing you could do was assemble solutions — point solutions, other solutions — and try to integrate them as best you could. And the next piece you bring in is another nightmare. That has been the challenge — and I want to be clear, that has been the challenge. I built a fully functional claims pricing engine in six weeks.

DONOVAN: Amazing. Amazing. Francois, from your lens, what are the tactical steps that employers can take to move the big boulders? They're easily distracted by shiny objects and routinely step over dollars to pick up pennies. What can they do to pick up the dollars and put them in their pockets?

FRANCOIS: You can't compromise. I know that's difficult to hear, but I go back 25 years, and we never compromised. Never. What we needed is what we asked for, what we demanded, and what we contracted for. There was never any compromise between the determination of the benefits we needed for our employees and the data we needed to operate our plan. All of that consisted of requirements, and we never yielded on those requirements. We baked into our requirements the obligation of the carriers to collect and incorporate the Leapfrog data. We baked into our contracts the obligation of the carriers to implement things like Bridges to Excellence, so that it wasn't incumbent upon an individual employer to do that — it was the carrier's responsibility to do pay-for-performance. Super hard. Just a small anecdote: when we started Bridges to Excellence at GE, I called United, who was one of our TPAs at the time, and I said, "Here's what we want to do. Just write the doctor a check at the end of the year." "Well, we can't do that." "What do you mean you can't do that? It's our money. Isn't that your job? Isn't it your job to write a check and transfer funds to providers?" "We're not going to have a claim." "Okay, create an invoice. How complicated can this be?" They couldn't do it. They literally couldn't do it — which is why we set up an entire parallel process. Think of it: we set up an entire parallel process where we got the claims data from the employers. We did some matching to figure out how many GE employees were going to see Dr. Rodis, how many GE employees were going to see Dr. Schutzer, etc. At the end of the year, we knew how many GE, UPS, Ford, GM, Kroger employees had seen each doctor. And if Dr. Schutzer met the requirements, Bridges to Excellence — the not-for-profit — would send him the check. You cannot compromise. That's the point. Because if you don't compromise, then the brokers and benefit consultants don't have a choice, irrespective of their comp. The moment you compromise and say, "Next year, we'll add a couple of ortho bundles, and the following year we'll add a couple of GI bundles" — all of that is pennies. The total dollars accumulated in those layers of semi-value — at best, maybe you'll get to 10 or 15% of your medical spend, off of which you can maybe shave a couple of points. That's not going to make a dent on a 9-to-10% inflation rate. It doesn't slow inflation. The only way to double, triple, or quadruple that is if you don't compromise. I get it. It's difficult. But employers did it 25 years ago. There's absolutely no reason they can't do it today.

DONOVAN: As always, it starts with getting your data.

STEVE: I think what you just said perhaps works for a very large employer. I'm in a state that has a lot of employers with 100 or fewer employees; I think it'd be challenging. But to your point: get the brokers to disclose their fees. Start to understand what's in the landscape — to Donovan's point — and get your data.

FRANCOIS: At least two of you, and I still live in Connecticut — so the three of us live in Connecticut — the State of Connecticut compromised. The State Employee Plan of Connecticut compromised. They had a unique opportunity last year, when they issued their RFP for their medical plan, to do something really different that would create significant value for every taxpayer in the state of Connecticut who is funding the State Employee Plan. And they compromised. So until those purchasers — not just the private-sector employers, but state employee plans — stop compromising with our tax dollars, and until we demand that they stop compromising with our tax dollars, it's going to be a tough battle.

STEVE: Just to add — our good friend Jeff Hogan calls us the "Land of Frozen Molasses." You've heard that more than once. But, Francois, we're excited to have you on, and as always, you never disappoint. I have the honor of asking the last question. I took some notes. I love your enthusiasm. I think you're right — I just battle with it every day, and it's hard. But I like it: the moats are breaking down, the extinction-level events and the thin lines are starting to break down. We typically ask our guests to put on their thinking cap — blue-sky thinking — and project three to five years out. With you, I'm going to ask: what is it going to look like just at the end of 2027? What do you think is going to happen throughout next year to really make the non-compromising changes you were just addressing, by the end of 2027?

FRANCOIS: I do believe there will be at least one or two significant court cases that will shake up boardrooms — that will shake them to their core — on the benefit consultant side, but also on the employer side. Because companies, benefit managers, HR managers, they're all risk-averse. Once you've gotten sued, and a large company has been found liable for breach of fiduciary responsibility, the caliber of the people managing benefits will change very rapidly. The demands they make will change rapidly, and they'll stop compromising, because if they do compromise, (A) they'll get fired, and (B) they'll find themselves back in court. If you look at what's going on with the recent rulings, the fact that most of these suits have not been dismissed — they've found the defense wanting — that to me is the break point. And I hope that one state, one state, if we have one state that starts asking brokers for disclosure at the point of sale, more will follow. You need one, and more will follow.

STEVE: Thank you. Francois, thank you so much for joining us. We really appreciate it. You've been a staunch advocate for healthcare payment reform, and keep up the good fight, my friend. You said "when you were younger," but you're still young, my friend — you're still young, and you've got a lot of energy. Keep up the fight. Thank you so much for joining us today.

FRANCOIS: All right, guys.

JOHN: To learn more about MTVA and how to join our community, visit our website: movingtovalue.org. If you enjoyed this conversation, please follow us and leave a review on Spotify or Apple Podcasts. Thanks again for listening and for being part of this important movement.

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