Why Are We Still Paying For Low-Value Care? (feat. Mark Fendrick)

TRANSCRIPT

Click here to listen to the episode published August 18, 2026.

MARK [INTRO]: If golf was fee for service, I would be Tiger Woods. I never, never get the ball in the hole. But if you're going to pay me every time I swing, I'm going to keep swinging. We know that we have enough money. It's just, do we have the courage to pull on the multiple constituents to actually align incentives with health production? The peanut butter side, or the payment, was never high enough for people to take it on. So we had a complete disconnect between payment, or peanut butter, and coverage, or jelly. Over 200 million Americans took advantage of a policy that existed because it amended our three paragraphs on preventive services should be free in the affordable care.

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 the 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, Quantum Health. I'm joined by my fellow board members, Dr. Steve Schutzer, Kim Lynch, and Donovan Pyle.

STEVE: Yeah, I'm Dr. Steve Schutzer, an orthopedic surgeon, and one of the original founders of the MTVA. Also co-founder and chief medical officer of Upswing Health, the national virtual orthopedic company. We're focused on improving patient access, clinical outcomes, and value in musculoskeletal care.

KIM: I'm Kim Lynch, founder and CEO of Metis Health Technologies, where we help clinicians and healthcare organizations align revenues and deliver better patient care. I'm originally from Michigan, now based in D.C.

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

JOHN: Our guest today is Dr. Mark Fendrick, director of the Center for Value-Based Insurance Design, known by the acronym VBID, and professor at the University of Michigan, professor of internal medicine and health management. Mark is the architect of value-based insurance design, and his ideas laid the foundation for the Affordable Care Act's preventative care provisions. His framework accounts for clinical nuance, shifting cost-sharing away from one-size-fits-all price tags, and tying out-of-pocket expenses directly to clinical value. He's here to discuss adoption. The framework isn't just theoretical, but the challenge is getting decision-makers to buy in. Mark brings a pragmatic approach to the C-suite, confronting the reality that high-value care is often cost-effectiveness rather than direct savings. By balancing every dollar spent on essential services with a dollar saved on wasteful ones, CFOs and leaders can make value-based designs scalable and sustainable. Mark joins us to discuss what that looks like, how to overcome adoption bottlenecks, and build benefits plans that truly deliver value. Welcome to Moving to Value Unscripted, Mark.

MARK: It's great to be here, John. I wish, as Steve and Kim knows, I've worked with them for decades. I wish it was moved to value as opposed to moving to value. So hopefully our next time we get together, we'll actually have said we've done it as opposed to trying it, as several of us have been attempting to do for decades now.

JOHN: Yeah. From your mouth to God's ears. So speaking of that, decades that you've been at this work, Mark. So you have to tell our audience exactly, our listeners, how you, oh my God, you go to an Ivy League school, you go to Ivy League medical school, you go to, most of your colleagues, I'm sure, ended up becoming cardiologists and orthopedic surgeons like Dr. Schutzer. How on earth did you get into this space?

MARK: Yeah. The motivation is quite an interesting journey, John. You know, I start every presentation since the year 2000 with a slide that says I published and I still perished. So for some reason, I have felt that writing grants and writing peer-reviewed publications for my colleagues to criticize was not enough for me. And my corollary clinical practice in primary care, it was becoming very clear from the mid-90s on that the things that I begged my patients to do, John, you know these no-brainer quality metrics. It turns out that even if my patients finally agreed to do them, their so-called generous insurance made it hard, not easy for them to get those services. And what I found is things were actually getting worse, not better. Certainly Steve and Kim know that I used to really complain about $50 co-pays for things like branded Lipitor. And then at the turn of the century came something, which is my ultimate scorn, which is the rise of deductibles, the ultimate blunt instrument that made it hard, not easy for patients to afford all good services, as opposed to what was intended with skin in the game to have patients shop better for the things they didn't need. So I kind of turned my clinical reality into a research and policy effort to try to spend our money better. Because as you know, just about every stakeholder agrees that $5 trillion estimated to $9 trillion at the end of the next decade is more than enough money. So we win the World Cup, so to speak, in terms of spending. But what aggravates my friend Kim very much so is we don't even make it to the knockout round for those of you who follow the World Cup in terms of outcomes. So for me, it's been all about spending our money better. And that means that we have to spend on different things, on different people, at different places, at different times. And in some situations, actually spend less on those things that are currently profitable, but don't have the moniker of the outcome that I care about, which is making individuals and populations healthier.

JOHN: All right, so how did you, okay, I get the motivation. That's clear. We all, we all, we all, we all, we all gone to that. We're all in the pews in the church. So for those who could see the video, you'll see that I have a forehead that's been banging my head against the wall for 40 years.

MARK: So no matter what the constituency, Republicans, Democrats, management, labor, health sciences companies, plans, people have always kind of agreed with this concept. And I agree with you pushing me further. And I think the core of my academic work is around incentives. And I like to say, never ask a barber if you need a haircut, in which I don't need, but I could find a barber to cut my hair every day in a fee for service environment. So what I've been trying to do, which is somewhat straightforward to talk about during your podcast, but difficult to implement, is align incentives around profitability and healthcare production. This sounds so much easier said than done. This is the driving force. But if you go back to the early days that I had a patient who supposedly had generous insurance provided by one of the auto manufacturers here in Michigan with a sister and a mother with early stage prostate cancer for which his colonoscopy was not covered. And then, so I realized the idea of aligning what coverage meant, which is a lot of really smart people, particularly those listening to this podcast who deal with benefit design, who need to integrate with people like Steve to understand that these are the things, regardless of their cost, should be covered generously. And some things that actually are covered generously because either their profitability or their low cost should be covered less generously. So, of course, this sounds relatively straightforward. And people do what you do, Steve. You're a bad poker player. You nod with your tells. And so, yeah, this kind of makes sense. But at the same time, implementation has proven to be very, very difficult. One of the earliest and best implementations were in the state of Connecticut. Steve was very much a role as implementing value-based insurance design for state employees. In Connecticut, an extraordinarily popular and relatively low cost intervention. This experiment is extended to six or seven other state employees and in many other private and public plans. So this is why attending this podcast and having your incredible reach allow other people to understand that we can create benefit designs that make it easy, not hard for patients and their clinicians to get the things that they should be doing. And in some situations, actually make it harder to do those things that may seem easy, may seem obvious, may seem demanded by patients, but just don't have the evidence to back up their use.

STEVE: Mark, I just want to let the audience know that we go back quite a ways here with the state of Connecticut health plan and Tom Woodruff in the good old days. And you were a keynote speaker at our first symposium in fall of 2018. I'll never forget, Suzanne Delbanco was on the panel as well. And you got a standing ovation. I mean, it just made, this is 2018, it just made, your presentation made so much sense. And that was, you know, eight years ago, so it would be nine, nine years ago. And where I'm going with this is, I recall from your presentation the definition of high and low value. And I'm always perplexed about how those decisions are made. Do you know Bill Besterman, Dr. Bill Besterman?

MARK: Of course, I know the name. I don't know him personally. 

STEVE: There's a lot of synergy between his messaging now. He just wrote a piece about metformin for rheumatoid arthritis versus methotrexate, about $4 versus thousands of dollars and so forth. But isn't the research kind of biased against low cost makers? And there's no margin to be made by the manufacturers. How do you reconcile that?

MARK: Yeah. You asked one of the challenging issues that again, tie to—

STEVE: Right down to it.

MARK: To incentives. And I like to tell the story, which I think Kim has heard before, of a conversation I had with Speaker of the House, Newt Gingrich, who was a very intelligent healthcare guy. And he asked me, in much more blunt terms than you did, so what's the problem here? To which I said, what is the most valuable thing a community-based pediatrician can do? To which he quickly answered, like everyone else, vaccinate kids. To which I said, what if I told you that half of community-based pediatricians in Michigan actually lose money vaccinating kids? And he took out his earplug, he put down his BlackBerry, and he closed his laptop. He said, say that again? I said, yeah, the most valuable things that pediatricians could do, cardiologists could do, primary care clinicians could do, are often money losers, but clearly are not the most profitable because the system goes. And I said to him, the problem is that money should follow health. But currently, in 1998, and now, in 2026, health follows money. So I'm not going to change the idea that people should make money in health care, nor do I want to. But I just want to have you all kind of help your listeners understand that we should not be spending money on things that do not make people healthier. And the profit alignment to things that are technical and resource intensive, if they don't make people healthier, I don't care. And I'm not going to pay for them. And there are people in Connecticut, now the state of Minnesota, and others taking your lead from a decade ago, are actually having the payers for the first time hold their providers accountable for, of course, doing more things that we want to do. That's been around for a very long time, as you know. But just starting to hold them accountable for not doing the things that we know they shouldn't be doing. And you know for sure that professional societies like yours and mine have been articulating the services that are likely widely overused for quite some time. Have we made great inroads in reducing their use? Not very much, which is why I continue to hopefully make my case for people like your listeners to really argue to spend those trillions of dollars better.

KIM: I want to just pull on that thread a little bit more, Mark, because you're right. This is what keeps me up at night. And I love hearing you say, we have more than enough money. I still think that that is surprising sometimes for folks to hear. We have more than enough money. The problem is how we spend it. And my question is, you know, the people winning in the last 50 years have every reason to keep us from answering that question clearly. And so I'm wondering how do we call that out honestly? And how do we help an employer or a patient tell the difference between a plan that is genuinely trying to buy health and one that's just sophisticated at extracting their dollar while looking like it isn't?

MARK: So you know, and what Metis does is the more we can align spending with health production, that of course is, you know, ideas come easy to me and implementation is very hard, which is why, you know, I rely and lean on you to make more of this happen. It's particularly problematic in the situations that we see. I don't know exactly what's happening in the Northeast with the trends. We all want to see some type of alternative payment model that goes away for fee-for-service that, as you know, Steve has been around longer than value-based insurance design and the implementation is staggered almost the same way. But it's these things that we know given the evidence base for a century, things that are extraordinarily high value. And as Steve mentioned in the previous comment, some of those things are incredibly low-priced and are, have minimal or no profits for which no one really cares about this thing. One example is the diagnosis and management of hypertension, which John and I know is just something that we don't need new diagnostic tools. In fact, we can now do this very easily from home with web-based blood pressure monitoring. The drugs, for the most part, are pennies a day. And I had the honor to chair a CDC NIH consensus conference on why, for the first time ever in 2024, we actually had a lower rate of blood pressure diagnosis and control than we had ever before, even though it was not the issue that some people claim, Steve, that it's just too expensive to diagnose and manage these things. So this is why it's so problematic and that I was invited to be involved largely because I said something that was controversial, which is no surprise to you, Steve, is that I said, what we need is an expensive branded antihypertensive drug to bring attention back to the condition like we have for these very rare cancers that we see advertised on TV during the World Cup, let alone being overwhelmed with the GLP-1s, which are, in my opinion, a very high, but very high cost breakthrough in the areas of many chronic conditions and unhealthy weight.

JOHN: Yeah, that's crazy. I struggle. You know, I understand what you're saying, Mark, and I think about when I ran the hospital and a lot of doctors employed and, you know, of course we have penalties and we have rewards both the hospital system and the physician system, right? You're rewarded for doing the right things, penalized for doing the wrong things. The penalties for doing the wrong things, you know, not getting out ideal outcomes, not managing hypertension, as you point out, less than half of people with hypertension who are seeing a doctor, not to mention all those who don't even see a doctor who don't even know they have hypertension, which is a huge cohort. We still manage less than half of them effectively, even worse for diabetes. So, as clinicians, it seemed like some of the problem was the penalties, if you will, came in and the rewards were about a year and a half after you provided the care. It was kind of like punishing your dog four hours after they did something wrong. Nobody, there's no connection with what you did to the outcome. Is that part of the problem?

MARK: It's really easy. I like to say to my colleagues and mentees that 90% of the field that I'm in, which is called health services research, so not basic or translation research, is actually bringing attention to problems in the system, which is why we have a multi-billion dollar and several hundred thousand people in this space because, as you know, John, it's not hard to find the problems. Why I rely on folks like you in the call is to develop solutions to these problems which are, A, not encouraged by academics and, B, really, really hard to do for the reasons that Kim raised about the financial motivator as the, instead of the, instead of the clinical outcome-based motivator. But I'll tell you that, you know, every three, four months there's some report about how much more we're spending on healthcare. And I've been very lucky to have a whole cadre of journalists that I talk to about these things. They call me when the CBO says healthcare costs will go up 8% or 12% or 2%, and they say, what do you think? And I've said every year since 2001, until you tell me what we're buying, I'm not going to be able to tell you whether that's good or not. And Steve, you know, this is long before 2018, when I told the key stakeholders in Connecticut about what I mean by that is that we'd have these CEOs and many of them were way ahead of the curve like Mike Critelli at Pitney Bowes is that, and he said, oh, we finally know how much we're spending on cardiovascular care and he was very proud of that. And I said, well, I really want to know is whether you're spending money on statins which prevent heart attacks or stents which treat heart attacks. So the amount of money that you're spending on those two is just a very straightforward thing to your listeners who really don't want to get into the weeds intentionally but they ultimately need to ask more questions about this. But regarding timing, so I'm now Medicare eligible and my kids call me artificially intelligent but I am smart enough to know that I have to really take a look and learn what I can about artificial intelligence or AI. And we could do a whole hour on AI and both the opportunities and challenges but one of the things that AI is very promising that I'm working on is real-time tools not telling us, Steve, that our EMR reminds us of things that we're going to do anyway that annoys us but provides real-time information regarding benefit design and out-of-pocket costs that pertain to actually what we're doing. And one of the things I'm very excited about even though it's taken some political heat recently is a model introduced by the Centers for Medicare and Medicaid Innovation or CMMI called the WISER model which is the first ever model that doesn't focus on those things that you mentioned, John, for us to do and be measured to doing the things we should be doing but in fact actually provides real-time AI-enabled prior authorization for those services that we have acknowledged for decades that we are doing too much of. Not that we would ever say we should never do them but we would need some additional information to know whether that it meets clinical guidelines for appropriate care. Skin substitutes is the hottest topic now on that. Nerve stimulators there's 11 current listed things and I think the idea of not telling you a year later that that knee arthroscopy probably shouldn't have been done but to basically say maybe you should try PT for six weeks before this knee arthroscopy is approved by this payer is likely appropriate. And I do see that combined with real-time cost-sharing information. So the most frustrating thing for my colleagues is they talk over with their patient about a very important innovation moving forward and let's say whether it's something like a GLP-1 for unhealthy weight or an anti-TNF one of these very sophisticated drugs for multiple autoimmune conditions as Kim knows I have studied not only the fact that people aren't getting the care that is best for them from clinical guidelines but there is a significant minority of patients who are actually prescribed and agree to those therapies and walk away from the pharmacy because their benefit design does not allow them easy or timely access to those services. So you see the forehead you know we're trying very hard as I said earlier it should be easy not hard for patients and their clinicians to access evidence-based care but because of the issues that you and Kim raised earlier about the incentives not being appropriately aligned around that concept is why I continue to try to march on and we're moving to value and hopefully we will be closer to have moved to value after some of your listeners kind of think hard about how not just the concept that Steve heard in 2018 but we have multiple implementations in both public and private payers kind of to make this idea of more of the good stuff and less of the bad stuff a reality.

DONOVAN: Mark, thanks for coming on. I wanted to double click on the demand side of the equation and get really tactical here — so you're a self-funded employer, you're in five states, you've got, you know, four generations in the workforce. What are the tactical things that you recommend purchasers do?

MARK: The first question, Donovan, that's a really good question, and I have to tell you a bit of an anecdote before I answer that — you might have to remind me the question again. So for years I would be invited to these self-insured employers, and I consider them my most important constituents, because they are the sleeping giant, as Uri Song just wrote about in New England Journal, of actually leading benefit design reform. And I give the state of Connecticut and Mike Critelli personally credit to have the courage to basically say, I'm going to cover high cost services at the level of generic drugs, because it's the right thing to do for my company. So I would go to visit these employers and I'd work all the way through about saying how important it was to do education, literacy, and benefit design to make sure that patients actually follow up on what their clinicians are recommending, particularly in those situations, like Steve mentioned, where the interventions were relatively low, low price — hypertension, type 2 diabetes, mental health, you know, PPIs, now basically pennies a day, all these other types of things. And we would, we would have these situations that we ultimately got all the way through the meeting till I was walking out to the car at the end of the day, to the CFO, who basically said, oh, remind me — how much, if we implement these interventions to increase the use of these high value services, will my spending go down and my premiums go down? And it was always the last meeting of the day. I said, you know, every meeting through, I said, I want to make sure that most people know that the things that John and I beg our patients to do are cost effective — he made that term in the introduction — and not cost saving. And for those of you listeners who want to believe that cost effective, which is high value, good spending for the health you get, is not cost saving. And one of the most important quotes on this topic come from my close colleague Mike Chernew, recent chair of the Medicare Payment Advisory Commission, who said, if you buy more things that don't save money, you will not save money. I love that quote. So some of you know that I worked on the $35 instant copay cap for Medicare that has helped patients by the hundreds of thousands manage their diabetes better, but it doesn't lower health care costs — it's just a very efficient use. And all the other things that you and I, John, would list on our, my high value list, it's very, very, very rare that we have an intervention that saves lives and saves money. It's my very strong opinion that it should not — you know, that health is worth paying for, like education and transportation and defense — but I understand, Donovan, your constituents are just saying I just don't have any more money to spend. Thus in 2010, much to my chagrin, the advisory board of the value-based insurance design center basically forced me to become a low value and no value care guy. And what I mean by that are services that we provide that the net health benefits actually are less than the risks or the costs — the things that I wouldn't buy even if they were free. And it turns out that luckily for us, and unluckily for those employers, Donovan, that your constituents are spending tens if not hundreds of billions of dollars a year, that things like those in the academy of orthopedics and those from the internal medicine society and infectious disease and nephrology and ER doctors say we should not be doing this at the rate we're doing it now — understanding that it's never, it's not never — is that services are also high and low value depending on the patient, the provider, the site, and the timing, which is why we need people like Kim to go through that detailed information to determine whether a CT scan in the ER for back pain or a prostate specific antigen for someone over the age of 70 — where most should not be done, but every once in a while some should be done, which is why I think AI can ultimately help. So here's the issue: we know that we have enough money, it's just, do we have the courage to pull on the multiple constituents to actually align incentives with health production. And if we could go one inch further with that, John, with this conversation, with your listeners, then I view this podcast as a significant success.

DONOVAN: So Mark, just to follow up — your recommendation is for a self-funded employer is to work with the supply side on aligning incentives, is that the core takeaway?

MARK: Yeah, exactly. And this has been — I knew I wouldn't answer your question fully, thanks for coming back — no, no, because it's, for me, you know, whether you work with a utility, where most of the employees are men who are going to stay with the plan for decades, or you work with the hotel industry, which I've worked with very closely, where the turnover is immense and primarily the employees are younger women — it's understanding the cultural context of a specific organization, identifying those things that are not — you don't need a clinical degree to say, what would you like to see among your employees, to have them do more of. And then you look at the primary health plan that's used by blue collar workers in both of those settings, and they have a deductible of thousands of dollars, sometimes tens of a thousand dollars for families, which, as of January 1st every year, makes it almost impossible for people to purchase those visits, diagnostic tests, and drugs — right, which is why, A, your employers should pull on what they can do in high deductible health plans, and less flexible in health savings account qualified high deductible health plans, saying these services are so valuable that I will make them at least pre-deductible, or what several employee lawyers, like Pitney Bow, said — these certain services are so valuable, I'm going to make them free. And as you mentioned in the intro, John, is that, Donovan, if these employers just say, that's insane, you know, I'm never going to make high value services no cost — please remind them, almost every employer I ever worked with, which one of the most popular aspects of their benefit, which are the 90 services that are mandated for them to cover at zero cost sharing because of the preventive services provision. So while John knows what value-based insurance designer, VBIT, is, your clients and your colleagues don't know what VBIT is. But if you ask them, what do your employees think about the fact that we could get mental health, cholesterol, for cancers, hepatitis C, and go down the list of things, at no cost — which is why even in the peak of repeal and replace of Obamacare, one of the few provisions that was staying in the 900 page law of the ACA, in the repeal versions, were the preventive services provisions, because they were so popular. And while they are not cost saving for the most part, they don't — preventive care, as Steve, as you know, there's practically no investment in that in the relative total pie of what we expend in the US on medical services.

STEVE: Mark, I see the bruises on your forehead, and I think you can see them on ours as well, because we've been at this for 20 years with you. But a question about the VBIT program — so you started, you and Michael started writing about this, I think 25 years ago, your landmark paper was 25 years — you didn't call it VBIT, that had another acronym. I'm here at the Rosetta Fest — your work has been within the traditional confines of insurance, making insurance better, and that goes back 20 years. I'm here at the Rosetta Fest — this is a, it's a movement to accomplish your goals but in a different way, it's basically throwing out the baby with the bath water and starting fresh, and it now has a movement — there were 1200 brokers and providers and consultants here, but it's based in direct primary care, fee based brokers and consultants, bundle payments, cash pay, direct contract, and so forth, so it's outside of the traditional insurance rails. And I was thinking about this, I was listening to this yesterday about this upcoming podcast — how does VBIT, as a program, morph into or fit into this new emerging framework? So this is kind of a back to the future question.

MARK: So Steve, thank you — exactly. And when I talked to you all on the prep call, we talked a little bit about why I'm known on Capitol Hill as the peanut butter and jelly guy. So because I don't get to speak to sophisticated audiences like this podcast very often, and speak to policymakers and fourth graders, I have to try to make these examples very relevant to them. So Donovan's question about the demand side is very, very important, and as you all know, I've kind of worked on the patient facing side, you know, since the last century. But as Kim very well knows, that the stronger arm is the supply side — you know that, Steve, as a provider, John certainly, you know, leading a hospital and working with hospitals now. Why I decided to work on the demand side — while it's hard, the supply side is much, much harder, because one person's revenue is another person's wasteful spending. And, you know, this has been very, very problematic to me. Ultimately what I would say in kind of moving this forward is, you know, talk to experts like Kim and yourself who talk about payment reform and how, you know, we've talked about rewarding value, whatever that means, because it's very subjective. But just imagine, back to this core principle of, of the things we should do more of and the things that we should do less of. So let's talk about the more of things — so for the more of things, these are quality metrics, been around forever, you know, there's tons of places with tons of acronyms with the word Q in it — National Quality Commission, NCQA, National Quality Forum, and several more of those — that say these are things that we should benchmark you on, and in fact we need to do more of those, and the more you do, the more you get paid — thus the, although recently visited by the courts, but the motivation behind the star ratings of the Medicare plan. So if you were to look at some of the things, I'll give you just an example that's outside your realm, but John would know this well — is the diabetes prevention program, something I worked on from the first day, when this was a — intervention that was designed in the YMCA of Indianapolis, Indiana — we're getting people who are at risk for diabetes to exercise and take metformin and potentially prevent the diagnosis of diabetes, which is horrible for John and me in terms of the clinical outcomes, you know, but for Donovan and Kim, the costs of diabetes are immense. So I worked very, very hard for the diabetes prevention program, whether in person or virtually, to be covered 100% by Medicare. So the demand side, or the jelly, was completely covered. But it turns out that the reimbursement for the diabetes prevention program — the peanut butter side, or the payment — was never high enough for people to take it on. So we had a complete disconnect between payment, or peanut butter, and coverage, or jelly. The converse of this is my leading high value service, which I studied long before — the benefit-based copay, which was the first acronym, Steve — but because there was an organization called the British Broadcasting Company, we had trouble with BBC, so Turner came up with value-based insurance design. But it turns out that diabetic retinopathy screening, on every quality metric that's been designed for 40 years, we know people with diabetes need to see the eye doctor. It turns out that while reimbursement for diabetic retinopathy screening is adequate, it turns out that it was not a generously covered benefit in just about every plan that we've looked at, until we, you know, had a executive order sign that made it predeductible coverage. So examples persist across the entire continuum of care of things that clinicians want to do that patients can't — currently the buzzword, of you know, end of July 2026, is GLP-1s. And we also have situations where clinicians are not able — I mean, that patients are not reimbursed at a level high enough for things that we know would be beneficial for patients to do more of. And hypertension, John, falls squarely in that arena.

JOHN: So you've done a lot of work in the public policy space, and where does public policy fit into some of this?

MARK: So you know, we have a population that has health illiteracy, they don't really understand half of what we're talking about — we obviously, diabetes is a great example, by the way, besides it being one of the top 10 causes of death in this country, it accounts for one fourth of the total spend, because it's not just about insulin, as you know, it's about amputations and diabetic retinopathy and diabetic nephropathy and diabetic cardiomyopathy, and all this equally — right, and dialysis. Where does public policy fit in — listen, I grew up in an environment where everybody used to smoke, nobody smokes today, at least most educated people don't smoke, and a lot of that was related to two things — one was public service announcements, and the other part was about finally taxing, basically put a syntax on cigarettes to make it particularly unaffordable for teenagers, which is when people start. Where does that commit to some of these other, other things we talked about — you raised two things, and thank you for raising my blood pressure, and that now you're going to have to manage to bring these things up. So, long before I visited Hartford in the teen 2000 teens, the flagship VBID medication was insulin for type 1 diabetics — so you don't, you could be a fourth grader or a congressperson to realize that if you're type 1 diabetic and you don't take insulin, you will die, right? So you could talk to any people with various backgrounds and say, why in hell would you ever put a barrier of any kind — so not just money, right, any kind — in front of insulin. We sit here on July 30, 2026, we have a copay cap for medicare beneficiaries of $35 a month, which is fine, but for some people on fixed incomes, that is still not affordable, and debate goes in congress today on the insulin act to extend the $35 copay cap to commercial plans, which unbelievably is not a reality. So when you keep talking to me and Steve and Kim about other areas, how we can move forward, how can I say, after 27 years, that my work basically say, if you believe that it should be easy, not hard, for clinicians and patients to get high value services, how can we not have access to insulin for type 1 diabetics? Steve and Kim and everyone else I would talk to would say, yeah, add different services to that list, and this is ongoing, and the administration is open to hearing about more services that should at least be pre-deductible, meaning you don't have to meet your deductible to get it — it doesn't always have to be free, but $5 or $35 is certainly better than $1,000 out of pocket for a service. The other thing I say as we wind down is when I meet people like maybe some of your listeners who never heard of EBIT before, I ask them what did they pay for their COVID shot or their COVID test during the pandemic, to which everyone who got a COVID shot or a COVID test for the pandemic said, I got that for free. So I want to leave kind of on a high note that even though people have never heard of VBID, or the idea that high value services should be free, over 200 million Americans took advantage of a policy that existed because it amended our three paragraphs on preventive services should be free in the affordable care. So I am not suggesting, like some people, that all healthcare should be free — I want all the listeners to realize that, in fact, I want some healthcare to be more expensive for patients, and more importantly, I want clinicians to be paid less for doing things that they know the evidence does not bear out benefits of health. And you're going to have to get back to me with your feedback about, is this something we can move forward incrementally or not, right, if we're just continuing to base what we do on what we spend as opposed to how well we spend, which is where we've been during my entire career — so be it. But if some of your listeners are actually saying, well, what if healthcare was like golf? If golf was fee for service, I would be Tiger Woods, I never, never get the ball in the hole, but if you're going to pay me every time I swing, I'm going to keep swing. And I'm not suggesting that we have strict capitation, right, that we just set a global cap — I'm just saying that we reward people for doing the things, particularly the low-lying fruit, or that fruit below the ground, those services that we just know that we should be doing more of, and especially those that we know there's no overuse — so why insulin is such a great example, is no one wants to be on insulin, right, you know, no one wants chemotherapy or the autoimmune drugs that Steve mentioned earlier. 

STEVE: So, you know, we continue to march on, and as Dan Quayle said, if we don't succeed, then we will fail. So, but we'll continue to kind of hopefully moving to value. And one of the reasons I love coming to Rosetta Fest is that I get energized for another year banging our head against the wall, but we do sense that there's momentum, and there's good momentum, and I think with a little help from our plaintiff bar, with some cases that are sitting, moving into 2027, it could start to really unfold — all of the background is there. So with your experience, Mark, and you've worked with policymakers and politicians and providers — what do you think is going to, how is this going to unfold in the next two to three years? Where do you see this going?

MARK: Yeah. The great Yogi Berra said predictions are dangerous, particularly those about the future. You know, I've been doing this so long, Steve, as you have, that I, I view myself as an infield singles hitter, not a home run hitter like yourself. So, you know, we see incremental change — we see the bridge model with Medicare beneficiaries this month having access to GLP-1s for unhealthy weight for $50 a month, we see the Medicare Part D out of pocket max at $2,100 a year, you know, removing these most vulnerable Americans out of situations where they have to make decisions whether to fill their drugs or see their clinicians or get their procedures or pay rent or buy healthier food. I love the movement, the broader approach to food is medicine, and understanding that the, you know, as we've all talked about for decades, the issue of social determinants of health coming more to the fore. But ultimately, if you could help these people at that meeting who basically look more at what we spend as opposed to how well we spend, to basically say, what if I told you, if we spent more on statins and less on stents, what if we spent more on anti-hypertension drugs as opposed to thrombolytic therapy for stroke, what if we spent more on weight loss as opposed to having scores of people coming into your practice every week needing knee replacements that are primarily driven by — not always, but driven by unhealthy weight. So the ideas are always been there, thankfully they've been accepted, but as I leave, I'd almost much rather have people who are listening, John, tell me that they think my idea is dumb, as opposed to saying they think our ideas are promising and not do anything about it. It's like my kids and taking out the trash — I'd much rather have them say, I'm not going to take out the trash, as opposed to have them say they're taking out the trash and see they haven't taken out the trash.

STEVE: That's a perfect, perfect wrap up.

JOHN: I'll let — every time I take out the garbage, I'll be thinking it was that. I know. Mark, thank you so much for joining us. And thank you — not just for joining us, but thank you for this decades of work in this space, and you've made some really profound, meaningful differences. And I know we're all frustrated, but think how much worse it could be, believe it or not, without some of the things you've already done in your career. We're spending most of our time making bad things a little bit better. And I'd love to come back on the sequel of Moved to Value podcast when we've actually been able to put some of these things in place. And I thank you, Kim, for all the work we've done together, and Steve, great to reconnect, and Donovan, let me know how I could help. Appreciate it. Thank you so much, Mark. 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.

Listen to this episode.  |  All episodes of Moving to Value Unscripted.