Shedding Light on Healthcare's Blind Spots (feat. Ann Lewandowski)
TRANSCRIPT
Click here to listen to the episode, published February 17, 2026.
John: Thank you all for joining us today for another episode of our podcast, Moving to Value Unscripted. My name is Dr. John Rodis, and I am a recovering ex-hospital president, and am proud to be the president of the Moving to Value Alliance. The Moving to Value Alliance (MTVA), a 501(c)(3) nonprofit, is a multi-stakeholder grassroots organization whose purpose is to foster a community that aims to create a value-based healthcare ecosystem, with high-quality outcomes at a reasonable cost for plan sponsors and their members, beneficiaries or employees. 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 and Kim Lynch. Steve, a nationally renowned arthroplasty surgeon, is one of the founders of MTVA, and is co-founder of Upswing Health. Kim is the founder and CEO of Metis Health Technologies, which creates health tech solutions to help organizations streamline operations, increase revenue and deliver better patient care. Our special guest today is Ann Lewandowski. Ann is a nationally recognized healthcare executive and fiduciary advisor dedicated to balancing cost control with high-quality benefit design. As a 2024 MarketWatch Top 50 Maven, Ann leverages over three decades of experience across health plans, providers, and the pharmaceutical industry to help employers navigate complex purchasing environments. Drawing on her dual perspective as an industry expert and a patient, she empowers plant sponsors to adopt a participant-first mindset that drives measurable outcomes, from significant cost savings to improved employee retention. Anne has been honored by HRSA and the Healthcare Advocates Summit for her work in pharmacy policy reform. She holds a Master of Legal Studies in Health Law and Healthcare Compliance from Arizona State University. Welcome to Moving to Value Unscripted, Ann.
Ann: Thank you so much for having me.
John: So, Ann, we like to start with just telling our listeners just a little bit about your journey, because I suspect if we rewound to 30 years ago, or maybe 25 years ago, I'm not sure you'd visualize yourself in the current position you're in. So, could you kind of share with us a little bit of how you got here?
Ann: Actually, John, that's such a great question, because it's absolutely true. I grew up in a healthcare family, so my parents both had healthcare practices. My dad was a physical therapist, my mom was a nurse practitioner who had independent practice in California. And I was answering phones and stuffing envelopes before I can even fully remember doing anything else. So, you know, my mom liked to talk about care delivery at the dinner table, and some of those primary care conversations were like, ew, yuck, I won't, torture your listeners like my mom tortured me, because I don't know where or when they're listening, but let's say, at the very least, there was a lot of unappetizing discussion at the dinner table. And then I think the other part that I saw that maybe a lot of your listeners don't appreciate was the impact on the family. So, because my parents both owned their own practice, there was a lot of times when they would get emergency calls, or had to interrupt whatever we were doing as a family to respond to their patients, which, as a patient now, I completely appreciate, but as a child, it was really, really hard. And so, I always said, ew, yuck, I never want to do healthcare. Fast forward a couple of years, as I was going away to college, I stayed at home for the first two years and did an associate's degree, and then I was launching into my first away-from-home college experience, and my mom ended up with an autoimmune disease, and I watched her flip from being a provider, being so well-respected, and then having to navigate the healthcare system on her own. And I saw just how broken it was. from a patient's point of view, right? I had always had the provider perspective, my parents' perspective. They could do anything in my eyes. But then seeing how difficult it was — my top talent is restorative, and if you do Clifton Strengths, you know basically that's like looking at a burning building and running in, rather than running away. And so, I — I got hooked on that side of things.
Steve: Good for you, Ann. You know, I'll tell you, I've been following you for quite some time now, and you're my hero, alright? I just admire, really do admire the guts it takes to take the position you have, and the personal — there always seems to be a personal why to these stories, that's why we like to ask this question, but I'll tell you a little secret — we're not supposed to prep for this, but I did.
John: You're such — you're such an overachiever.
Steve: I know. You know me, John.
John: It's unscripted, Steve. Unscripted. That’s the point.
Kim: I'm delighted to know that Steve breaks rules. This is good to know.
Steve: Okay, but listen, I'm transparent about it, right? There's no secret. All I did, John, was listen to her Stacey Richter —
John: Alright.
Steve: That's all.
John: I did that, too.
Steve: That's it. One of the points, and many points you make in that very impactful thirty minutes, is the whole issue of plan sponsors placing their trust in their advisors. And, you know, another person that I hold as my hero is Dave Chase, and we've had him on the podcast, and he said something that I — he said, you know, when the plan sponsor finds out how badly they've been screwed, so to speak, by their so-called friends and advisors, it's like marital infidelity. So, you know, it's pretty bad. It's powerful. You put all your trust. But from a plant sponsor's perspective, what are the, just the basic, simple guardrails that they should set up so that they can eliminate that concern about trust.
Ann: So, you know, trust is something that is hard to win, and it's easy to lose, right? I think that's the first thing.
Steve: That’s so true.
Ann: And then, I think the other thing that we in healthcare really need to think about is, what are the economics of trust? Because in every other area and aspect of our life trust is the driver, right? Like, I don't do business with people that I don't trust. But at the same time, we may be obligating people to go see healthcare providers that they don't necessarily trust, and all of these other things, so in terms of the guardrails, I like to look at the Consolidated Appropriations Act. I know it puts a lot of burden on plan sponsors, and I think there have been very reasonable criticisms that, just like HIPAA-regulated business associates, that, you know, the Consolidated Appropriations Act maybe should have regulated these vendors. At the same time, I do think it gives plan sponsors a North Star to start saying, these are things we must have from you, we cannot continue to contract. And so it's really interesting, because I talked with a friend of mine, and she was doing benefits for a fairly large company, well-known in the space, and right after the Consolidated Appropriations Act, or maybe about twelve months after, I was sort of asking her, like, hey, are you getting your disclosures? And she was like, hey, you know, my broker puts up his presentation, and they have a disclaimer that basically says we may get other compensation. And I was like, well, that's not really enough in my mind, right? I don't say this to her because you don't want to just, like, blow up your friendship. But I'm thinking to myself, okay, this is — so this is really interesting, this is exactly what we're examining. And I said, so why don't you push them for more information? Why don't you ask them for a full disclosure? And she said, well, I trust them. And so, I think that's the challenge, is you don't necessarily want to blow up this relationship, and you do think these people deserve your trust, and maybe they do, but I think anyone who is deserving of your trust should be able to reveal where they're getting their compensation and how they're getting their compensation.
John: Exactly.
Ann: And just be transparent about it.
John: not necessarily my political party, but I hear Ronnie Reagan in my ear saying, trust but verify.
Ann: Trust but verify, right?
Kim: Absolutely. And I love this point because it has lit me up for years, a boiling rage, working on the provider side, the number of times that I will hear or see agreements that specifically set up an asymmetry of information, that basically are like, I mean, these smart people in the room understand it, and I'm like, whoa! You're a clinician. If you don't understand what's going on, there's a very good indication that you're being screwed, right? Like, please, let's use that intuition, but I'm the daughter of a physician who got screwed.
Ann: Yeah.
Steve: Yeah.
Kim: Right? Like, and it was, like, those simple intuitions that we've broken in healthcare, and like you said — every other industry, we have transparency. I mean, I listen to an IPA that's well-regarded in a marketplace tell doctors, you get to see the whole dollar as it moves through, completely negating the fee structure that they have with the payer. And I was like, this is wild, you're saying this, and like, it is completely factually inaccurate.
Ann: Well, it's sort of like, you get all of your rebates, right? Okay, yeah, but, what about every other piece of that manufacturer payment? And, what I've come to is, plan sponsors — they're sophisticated, they're smart, right? So, what I try to remind them is, how would you approach this contract if it were anything but healthcare?
John: That's a great question.
Ann: If you were negotiating this —
John: It’s so true.
Ann: And you were looking at it as any other vendor —
Steve: It's so true.
Ann: What would you object to, right? Because I don't want to make people feel dumb or disempowered, right? My job is to get out there and empower them, help them understand, and navigate, sort of, the pitfalls that we all know are in there in healthcare. And even that one question is very transformative for them, and they're like, oh, if I saw this in a contract, in anything else, I would be raging. And it's like, yes, that's exactly what we need you to start understanding and activating.
Steve: Again, referring to Dave Chase, I like some of his things, I never forget them. But he said, when you ask a broker or a consultant a question, and you start… and they start with an excuse — I’ll never forget that. Brilliant. But there's another point, I mean, related to this trust, and it's apropos to my company, too, that I think employers think that they actually have access to choice, but in point of fact, they're not, really. I mean, most of the brokers, especially the BUCA brokers, are just distribution channels for the insurance companies, right?
John: Exactly. And that's who they get paid by. Two-thirds of their income comes from either them or the PBMs, right? I mean, that's — that's the truth.
Steve: So, how do they get that back, Ann? Where they really know what's… I mean, I know it's their responsibility, but how do they get that choice back?
Ann: Well, so I think it's really understanding and having a process, right? I think one of the things that I'm uncomfortable with is sort of the people who talk about fiduciary duty, like, it requires this really high bar. And what we know is it requires process, right? Like, are you running an independent RFP, for example?
John: Right
Ann: Can you point to that RFP and say, this is how we made choices? Those pieces are really important, and so it doesn't mean that you have to choose, say, the lowest cost vendor. That might be the outcome, if you see everything and can do an apples-to-apples comparison, which we all know is really hard. But, you know, you could potentially also say, we want to go with this more expensive vendor because they have really great quality, and they're gonna give our members a better experience. And all of those things are really reasonable, right? Like, if I were somebody making a decision, or if John were saying, hey Ann, I want to go with Steve's vendor because they're going to give us great quality, they're going to give us a warranty, they're gonna give us transparency — like, all of that seems very, very reasonable, right? And so I think it's that type of reasonableness that we need plan sponsors to adopt. You know, it doesn't have to be perfect, but they do have to say, like, okay, if we're getting Blue Cross Blue Shield versus United, we need to see, sort of, all of the fees, all of the pieces, and try to make this as apples to apples as we can, and then decide what our values are as a company. What are we looking for in a vendor? And that's what we need to establish, rather than sort of allowing somebody to say, oh, this is the cheapest, or, you know, this has the best clinical care. And those are all reasonable things to say, but we — the plan sponsor really needs to have some core values that they've established, and make decisions according to that.
John: Yeah, I totally agree with that. I think it's a great place to start. And you said something that — you know, and I think it's so true, and Steve said it too, there's this blind spot somehow with — healthcare seems like this — it's a weird, like, you know, I don't want to hear it, I don't want to see it, I just — even though it's my second largest spend, and Steve has heard me say this many times, but when I was the president of the hospital, I had five thousand employees, I had a billion dollars in annual revenue. My second leading expense, of course, was my healthcare, right? I had a $500 million payroll, probably $75 million spent in healthcare. And I could tell you, to the penny — because I had a great cost accounting system — to the penny, how much I spent on paper and toner. Ink, right?
Ann: Yeah.
John: And I could shop between, you know, W.B. Mason and Staples to get the best price. But if you ask me how much I spend for my employees, on joint replacement, something I knew a lot about — I knew how much it cost us to do a joint replacement, to the penny. Asked how much I spent on drug replacement, I had no clue. How much I spent on spine surgery, how much I spent on Humira, or high-cost drugs? Zero. And when we talk to employers, or at least when I talk to employers, I'll always say, is there any other part of your company — forget about the fact it's the second largest spend — is there any other party company that you actually don't know how you're spending the money, what you're getting for your money, and they kind of look at you with that blank look, and sometimes a light goes off. They're like, oh yeah, don't I know that? And then, of course, I point out, you know, by the way, it actually might be your legal responsibility, just like you manage your pension plan, or your 401(k) plan, you have the legal responsibilities to manage that. Somehow, with healthcare, they've got this crazy blind spot.
Ann: I actually wrote about this on my LinkedIn, earlier this week. Last week I met with a guy, and it was just a — he saw that I do fractional compliance stuff, which is great, and he reached out because he's also a fractional executive. He has a small company with fourteen employees, and he started off with, I hate healthcare.
John: Trust me, we're in the business of starting to feel the same way about it. It's kind of crazy.
Ann: So, I'm like, oh geez, what are we going to talk about? Because, honestly, you know, I have a few tricks, you know, but, like, really, they all kind of tie back to healthcare. I'm kind of a boring person in reality. And so, you know, we started this conversation, and somehow we ended up on his healthcare spend, right? And it was basically — I'm a small company, I told my broker that I am remote first, and then I hired these two people out of state, I pay 100% of the premium — which is amazing, by the way — and suddenly, my plan's not going to cover these two people in other states. And so, it's funny because no matter who you are as a business owner or executive, right, you're struggling with this. Even if you don't want to acknowledge the struggle, which I understand, right? Like, you're an executive, you're supposed to be sophisticated and a great decision maker, and a lot of the barriers we have in healthcare make that really, really hard. And so, I think it's this place where people feel like a failure because of their partners — rather than empowering them, they're disempowering them.
John: That's a good point.
Kim: I mean, you're really knocking me out, Anne, as I knew this conversation would. I've been so excited about it, because what I'm having as you're describing the emotional side for the employers, I'm picturing conversations I've had with clinicians, because it's the same disempowerment, it's the same shame when you say not to feel dumb, right? Your doctors, your nurses, you're brilliant humans, and you've been totally screwed over by these contracts you signed. You are totally screwed over by people you've trusted. You are not used to feeling dumb, you're used to being the smartest person in the room. I'm the daughter of an anesthesiologist and an economics teacher. So, like, I see you in the healthcare family where, like, your brain just is sort of forged in this, like, there's fair, there's transparent, and then there's healthcare. And hearing what you're describing on the employer side and this blind spot, I'm like, right, the clinicians have it, and then some. And so, to me, there's just this realignment of the table that we're setting, right? And that's the conversation today. But you — yeah, I'm picturing those shame-based conversations where a lot of my time gets spent saying, please don't feel ashamed. This is everyone, this is everywhere. This is not a personal thing, this is a systemic thing in medicine, and something that we have to fight back against. Money needs to stop being taboo for clinicians, because that's the blind spot that you are being hosed through, right there.
Ann: Yeah, I mean, I had a — I had an initial conversation with a Fortune 500 firm last fall and, you know, it started off with sort of some discovery, and I was on with a couple of other people, and we started talking about some of these shared savings programs, like Tiara Yachts, that has come up multiple times in the news. That's where Tiara Yachts sued Blue Cross Blue Shield for basically both processing the payments as overpayments and flipping them in and out of network and all of these things and then basically, being a party to that recovery, so then charging money to the plan to recover those payments that they inaccurately paid. So, we were starting to explore some conversations, and I said, hey, do you guys have a fiduciary committee? And they're like, oh, we pay, we pay some money to something. We pay a, like, a dollar or five dollars per employee per month for that service. And I didn't attack it or ask right there, like, what do you mean? The conversation continued, and so then it was — why do we need an independent review or examination of our things? And, you know, it was… I use the example of Tiara Yachts. It's, hey, you know, they have — they may have this shared savings program where they're paying the claims and then going back and — and the guy's face, you know, he's a sophisticated purchaser, he's not a dummy, and his face just kind of dropped, and you could see, wow, I am in this quicksand, and I just realized I'm up to my chin when I thought I was in at my ankles. And it was like, oh, they've designed their own incentives, huh? And I was like, yeah, that's exactly it. These big companies have gotten so large that they get to tell you exactly what they're going to do for you, and how they're gonna kind of take you out back to the woodshed, and maybe beat you over — over the head a little bit.
Kim: I mean, and I'll just give one more anecdote to mirror it on the provider side. I have worked in ACOs and risk groups across the country and seen how individual practices and clinics were saying, hey, you're not paying us correctly on that quality bonus. Hey, you're not paying us correctly on that quality bonus. Payer didn't give a hoot until we marched in the door with a risk pool, with all of those practices and clinics, and then they're like, oh, you're right! Was there any back payment? Of course not! But you had to roll that deep to get any feedback, I mean, and this was mammography screening, right? Like, that one matters, right? Like, we're not — we're not talking about long tail, we're talking about a huge measure that is of massive financial consequence, and it was an oopsie.
John: There's a systemic underpayment that we haven't really talked about much on this show, but I've had many people over the years tell me, you know, these third-party administrators, or quote-unquote insurance companies — which I even object to the term insurance company, it's not really insurance — they systematically underpay you some percentage. Now, that number ranges depending on who I talk to. But, you know, since we're talking about trillions of dollars, you know, a few percent here and there is hundreds of billions of dollars, and it's just enough to, like Kim said, they'll either just say, oh, well, we forgot to pay for that one, or, oh, we don't think you made the metric, and most people just go away and don't argue with them. It's kind of like people offering you, you know, oh, a full refund on the product they sell you, and, you know, but they could get away with it because they know most people don't bother asking for the money back, right? They nickel and dime you to death, but those nickels and dimes add up to hundreds of billions of dollars. It's just not right. If I can, let me segue a little bit back into — you mentioned the CAA. So, our friend Jeff Hogan, and Steve remembers this one, the CAA was passed back in January, or enacted, I should say, in January of 2021. Steve and I, I remember reading it, and we were like, wow, this is written so clearly of what the plan sponsor's responsibility is, and I perceived as a president of a hospital, you know, around that time, saying, okay, I get it, this is kind of my responsibility to know what the heck we're spending, just like my toner and paper analogy, I should know what I'm spending on these high-cost drugs. It was very specific. I needed to know the top fifty drugs I was spending, how much I paid, what I could get in the market, and I remember Jeff saying, oh, this is going to change everything. And I was thinking, I'm not sure, because I'm not sure the average employer, a) has any clue about federal law in general, and until there's any kind of litigation, I'm not sure anybody's going to do anything. Now, I said that now five years ago. And I know we're not going to talk about specific litigation today, but employers continue to just ignore the law. We had lawyers on this show saying the same thing, saying we don't understand it, because when ERISA laws came out, it actually took a few years, too, for employers to do it, but we're now five years in, and do you have a sense — I guess my question to you is, do you have a sense, since you're out in this marketplace, is there indeed legitimate movement towards compliance with the law, as we perceive compliance with the law?
Ann: So, I think employers are doing their best. I think that there's still a lot of struggle, so I tend to be very charitable in my thinking, generally. And I do think that there's a difference between the Consolidated Appropriations Act, which outlines the sort of minimum steps you need to take to start saying, we're compliant with our ERISA fiduciary duty.
John: Right.
Ann: And then there's the ERISA fiduciary duty that's sort of this broader concept that, you know, quite honestly, the courts need to talk about and decide and start defining on the health and welfare side, as they've done in the 401(k) side. So, you know, and then I think it's also — while the Consolidated Appropriations Act did give plan sponsors access to some data, there is still a lot of data that's considered proprietary, that could be what the plan is paying and all of that, which makes it hard for a plan sponsor to do all of the things you talked about. And so, as we're sort of thinking about what does compliance mean, like, I've looked at — because we have a data analytics platform, and we've actually worked on building the RXDC reporting tool that needs to take place. That's actually a fairly sophisticated report. And if you're sort of your average employer, I think it would be extremely difficult, without hiring an attorney, without an analytics firm, to be able to complete that report, because there's a lot of if-thens, where does this go, all of that is pretty complicated. So, I give, particularly your small groups, right? Your larger five thousand and above, I tend to think, well, you probably should have an ERISA attorney, they should be doing this for you, they should be checking what anybody's putting on the 5500. And I think that's a good practice anyway, because, let's be honest, paying an attorney up front and avoiding litigation is, you know, money well spent. But, it is more complicated than maybe us healthcare nerds think about. But I do think, generally, if people are aware of the law, they're trying to comply with it the best, but they may not necessarily know what is a gag clause. Like, oh, I think, you know, my broker tells me they're all taken out, my TPA says they're all taken out, I trust them, right? Back to that original conversation about trust. I trust them. And they tell me that my RXDC report is done as a part of the entire plan reporting, and they report my EIN, and so that's fine. I trust them. I may not even necessarily ask to see it, because I believe in these vendors that I've hired, because why else would I be hiring them if I think they're gonna screw me over?
Steve: You know, one of my quotes that I also carry in my — and I'm an orthopedic surgeon, as you know, so there's no love lost between orthopedic surgeons and the plaintiff bar, our best friends. John, I think you can resonate with that as a high-risk obstetrician, but — if you can't legislate, litigate. It's funny, my thinking on this over the past four or five years has changed. I mean, they may be the savior of our health system. You know, John and I looked at the CAA, and we looked at the J&J claim, and a kindergartner could understand that, and when it's dismissed for lack of standing, I scratch my head. Now, I'll further say I'm the only physician in my family. My grandmother was an attorney, so I grew up around the dinner table talking about law, and that's why I went into medicine, but —
Ann: So you’re the opposite of me.
Steve: I said, so you guys talk, talk, talk, I'm gonna work with my hands, but I did do some research on standing to understand that, and again, everything seems easy until you look at the nuances, like, you know, was the plaintiff injured, and is the causation fairly traceable? And redressability, all the stuff you know about it, it's just — it's not that clear. What's it going to take? Is it educating the court system, what standing really is? I'm fascinated by this.
Ann: Oh, I would not presume to educate the courts on what standing is. Absolutely not. I think they're the experts there. So, understandably, I am the plaintiff in the J&J lawsuit, so I need to be extremely careful, but what I do think — there's a lot of misunderstanding about insurance in this country. And I think one of the fundamental principles that people misunderstand is that by carrying a card with a major insurance carrier's name on it. that you're automatically getting the best deal. And I think that's probably the biggest uphill push that the plaintiff's bar needs to educate the courts on.
Steve: Yeah, as you know, ERISA covered 401(k) retirement plans and health care, and they would look at them in parallel, but standing was easier to establish, I think, for a retirement industry, because it's traced to numbers. Is that reasonable?
Ann: Well, I think — there was a very important case, and I think it was Thole in 2020, and so there was this sort of change in standing, that for these ERISA claims, there needs to be an individual injury. So, before Thole, you could say, hey, as a class, we have incurred these injuries. Instead, now, you have to find people who have individually been harmed, right? You have to have that individual injury, and then what you also need is the redressability to that person, so the court needs to be able to give them money back. And then, of course, you know, there's the, let's just presume that the injury is traceable to the plan sponsor or whatnot. So, you know, those are sort of the tensions and some of the moving pieces, right? Again, the courts have the ability to evolve their understanding of what is an injury, what does this mean, and all of that. And so, the concept of standing may also evolve as well. So, that's one of the challenges, I think, that is inherent with these cases.
John: So, I'm gonna push back a little bit on this carrying the card, and I think I'm getting the best deal. I actually don't think that myself, as a person with a card. I do think the average person does think when I go to the drugstore, and I give them my card, and they say there's a $0 copay, I think most people think, oh, there's no cost. And I think there’s a lack of transparency with the true costs. So, now, how do I segue this into this conversation, is that, as an employee — because who's paying the bills at the end of the day, right? We've said this many times on the show, who's paying the bills? It's not the BUCA players, right? Because we pay them, and they just administer the claim, right? It's the employees. It's the employers. It's the taxpayers for Medicaid, for state, it's the taxpayers for Medicare. We're paying all the bills, right? The $5 trillion is our money, so the harm, if you will, to me, and you know, listen, I'm part of the problem, right? As a hospital administrator. We raised our prices, double the cost of inflation for twenty-five years. And whose — whose money were we, at the end of the day, taking? And really, when you do the math, it's really the middle class, particularly if we talk about unions, and I know we've been — you do work with unions. It's their money that we're taking. It's the union members and their employers who we've taken their money from. And it's a big part of the problem of the middle class in America, frankly, because the rich people don't care, they have no problem, and the poor people, you know, get covered in another way, so it's the middle class that really suffered, so that's the folks who are quote-unquote harmed. And there's a monetary impact. There's cost there. That's kind of the damages. Damages is, hey, my employer wanted to give me a raise, or wanted to invest in the freaking company and hire more people, and they can't because they're spending so much money on healthcare. It's this — it's the follow the money component that is — that is always, I think, the big — there's so much subterfuge and confusion about the quote-unquote payers. I object to being called the payers, because they're not paying anything. Why do we call them the payers? We're the payers. So, push back on me, am I wrong?
Ann: No, I think that's really great, right? And so I think this is — this is the exact issue that people don't understand. So, first of all, there's so many graphs, and I go back to the KFF, the Kaiser Family Foundation, graph that I saw in, like, 2015, so this was ten years ago, when I was working at the Rural Wisconsin Health Cooperative, and we were doing our annual retreat. And we were basically looking at, you know, wages, pretty flat past thirty years. We're all pretty familiar with that, and then, you know, the healthcare line, and then basically spending for healthcare, you know, was this vertical line that was transecting, and it was like, hey, why are we all not getting raises? Well, this is why. Because your employer's literally spending all of this. Again, for courts, the lawyers have to have a really clear narrative and the ability to write that and persuade them, right? That’s what their job is, is to be persuasive and say, here's what we know about this company. That requires a pretty hard level of sophistication. Not that it can't be done, but I think there's a lot that's going to go into that. I think there's also fair — we've talked about information asymmetry before. I think there's a fair amount of information asymmetry. And then going back to sort of this concept of who's the end payer. This has been driving me crazy, so I'm glad that I get a chance to talk about this. We've seen, you know, some of these large PBMs now pushing back and saying, oh, Mark Cuban, you're so cute, whatever, you have this cost plus pharmacy, but don't you know it's going to cost patients more? And I actually resent this so much, because I'm like, okay, maybe it's gonna cost the patient more, but what we need to ask is, what is the total cost? And that is the key question that is always missing, right? It's not that we are the lowest cost — even lowest net cost, which is something that I object to, because, you know, rebates are basically just this thing that stays in the system, and you're paying more and more for healthcare, but, like, what is the lowest true cost? And, it drives me crazy every time I see that, because it's really, like — like you said, John, we are all the payers, even if our employer is picking up this tab. I'm gonna go on a little rant about high-deductible health plans, because I saw this question on Reddit.
John: Go ahead.
Steve: Go for it.
Ann: We missed the target collectively as people focused on healthcare when we invented a high-deductible health plan because we thought, oh, people are going to be shopping. First of all, I've had my own experience with trying to shop and find the lowest cost of care.
John: Good luck with that.
Ann: Going out of network is not a reason to save money. So, first of all, there's that statement, which is insane. Second of all, we also misunderstand the consumer motive. So as a consumer, this person had hit their family maximum out-of-pocket by January 7th of this year.
John: Wow.
Ann: Yeah, like, visit to the ER, a couple — a couple bad things happened.
John: Yeah, it doesn't take that much, actually, yeah.
Ann: Yeah. And so, what does this person do? They're a good American. They now think, like you said, John, everything is free to me now.
John: Exactly.
Ann: So they're on Reddit, literally asking, how do I maximize this time when I have free healthcare. And so people were like, go to the dermatologist, your kid has autism, get the ABA, all of the things, right?
John: Oh my god.
Ann: And, like, this is what we miss about Americans and free stuff, like once it becomes free, and there's no copay, there's no, you know — and, you know, I try to be really aggressive with this, but most Americans who have not been dealing with a chronic illness, you know, are not knowledgeable about the fact that the more you spend, the more your premium goes up the next year, are saying how do I get the best benefit? Because they may have been rationing healthcare for years.
John: Right.
Ann: And that's what people need to understand. So that's my rant on high-deductible health plans for the week. Thanks guys.
Kim: I think that's very necessary for people to hear, because you're right, as policymakers, and I have been one in a couple of ways, we've failed on so many fronts, and that is one of them. I guess to flip to the positive engagement side for patients, because we all are patients, right? As you go back to sort of your origin story of, like, when your mom experienced what the healthcare system actually looks like today, now, it's not great. And I think that is the righteous anger that I see patients, myself included, my family members included, and literally every healthcare insider I ask. I'm, like, taking a poll here in the end of 2025, beginning of 2026. How are you feeling about your healthcare? Just a quick, like, thumb dial situation. No one is feeling like they're getting great healthcare, even folks, you know, with the top, all the things. So my question is, where are the positive access points for patients and clinicians specifically, because I think both of those groups are yearning for a different way to mobilize in this system. And I love to say, we have only been paying for healthcare this way for fifty years. Medicine? Much longer than that. Like, this? We can wash away like a bad sandcastle. Because the other question I've been asking is, does anyone think fee-for-service is redeemable at this point? And again. Everyone's shaking their head no, right? Like, maybe there will be a phoenix-like moment. I worked for a Blues plan. I hope they do come back in a different form, but not like this. Perfecting or trying to improve the broken twentieth century healthcare system ain't it. What would you recommend to patients and clinicians, Ann, of how they can put their shoulder against this system in a meaningful way, and in a way that puts pressure for a realignment of the resources, the time and the money, because lord knows we spend enough, it's just going to all the wrong things.
Ann: I totally agree with that, and, you know, we're in 2026, we're more than a quarter century into the twenty-first century. Let's develop the healthcare system that we need in the twenty-first century, and you know, I think about the Jetsons and all of this — would they have tolerated a twentieth century model built on 1970s technology? God, no. So, I love my direct primary care provider. Many people know this. I'll explain a huge part of the reason why. I was going through a second autoimmune disease diagnosis myself. And when you have one autoimmune disease, you sort of fall into this trap of thinking everything is sort of responsible or justifiable by that disease. And so, I really had no thought that it was anything besides just this disease sort of acting up and being bad. And I took some shots of some skin issues that I was having, and I sent it to my doctor. And she actually called me the next morning, as soon as she was awake, and she's like, I need to see you, like, today. And I was like, I can't, I'm on a work trip, I can be there on Monday. And what's really interesting, and I want people to take away from this, is clinical judgment. I showed up, we talked, and she was very, very concerned, and I was very, very sick. I credit her with saving my life, with this particular situation. And rather than running an initial test that would have been very standard protocol, John. If she had run all of the tests that she ran, she would have not — she would have been violating clinical protocol, and all of these things in your hospital, and, you know, probably would have gotten her hand slapped. But because she knew me, and she knew my clinical history, and she knew that I had been sick for, like, for months, and I had not said anything, I had just sort of toughed it out, she ran sort of this gamut of autoimmune and autoinflammatory markers. And, weirdly, the one indicator that, like, would have just been run normally came back negative. But very specific markers came back positive. And so, that's where I think pushing back, trusting the physician to know the patient, and say, there is something really wrong here, and I don't want to just trust one indicator. I want to see them all, because my intuition is telling me there's something wrong. And, you know, for that reason, I trust her in a way — and so, like, I had breast pain because, you know, this is, you know, an inflammatory thing, and I never saw the radiologist. They basically said, everything's fine, you have a lump, walk out. When you've had sort of this weird body that has been sort of betraying you and throwing off bad things, you don't necessarily just believe that, and you don't trust somebody who just is like, oh, don't worry about it. Like, I called my doctor in tears, and I was like, hey, listen, I may be completely overreacting, but I need you to tell me it's okay. And that's what I think so many people miss is that you need to be able to say, I may be overreacting, and I may be, you know, not okay, but I just need you to tell me, because I trust you, and I know that you're going to look and know my body. And she was. She was like, hey, listen, I'm at a conference, I'm gonna look, and she called me back and she said, hey, Ann, like, I think, really, it's going to be okay. It's — it's not a problem. And that's what we're pushing against. That's what we're pushing for.
John: Yeah, I think we have to get back to that.
Steve: That’s a great story.
John: I think we would all agree, I think we have to get back to that.
Steve: I have so many more questions, Ann, we're not done, but yeah, that's a great story, Ann. We're here in Connecticut, and we don't have a very big DPC presence, and nor do we have a bunch of functional medicine, so my wife has some issues, and she saw a naturopath, spent an hour and a half with her. It really was a totally different experience. So, good for you. Yeah, so we've had some fabulously interesting guests on this podcast, yourself included, from very diverse backgrounds in the healthcare ecosystem. We like to sort of wrap up asking you to put your futuristic hat on, and sometimes we say, what do you see in five to ten years? But I'm going to shorten that, maybe just two to three years, and looking ahead, what do you think will be the most important shift that has to happen to really start to do the things that we know that needs to be done, you know, to really get rid of the opacity and pivot to an accountable patient-centered system?
Ann: I'm an optimist.
Steve: Me too.
Ann: I'm gonna say, I think the shift is already happening —
John: I used to be. I used to be.
Steve: Come on, John, come on.
John: Alright, alright, go ahead.
Ann: I don't think that you can continue to do this work without some level of optimism, right? Because otherwise, I think you'd probably just want to, like, curl up in a ball under your covers in bed. I think there's a lot of hope that I see. I give plan sponsors more credit. I think they're asking more questions. I think as they're asking these questions, they're going to start uncovering things. And I do think that over the next, say, three to five years, we will start to see a push towards fiduciary advice, or some sort of higher level than what we're getting now. We see this in the California PBM bill, that they can't be conflicted, that they are fiduciaries, and so I think that we are going to see continued push towards change. I think it's probably going to be slower than I anticipate, because I'm an optimist. But I do think that we are going to see a difference, and I think that difference is going to be really underestimated, because when you're talking 150, 160 million people who are covered under these employer plans, that's, like, half — half of the nation, and if you can change purchasing for half of the people in the United States, that's gonna be a massive shift.
Steve: That's true. Agreed. Beautiful.
John: Ann, thank you so much, and I'm with Steve and Kim. We have a lot more questions that we could talk about, but — you know, first of all, I just want to really thank you, not just for being on our podcast today, but for standing up for what you believe was a wrong, and I think it takes a lot of courage to do what you did. We really — we hold you up, as Steve said, as, you know, a hero in this space, and people should pay attention to this — it's not just employers who should pay attention, but employees should pay attention, people who run unions should pay attention, because at the end of the day, they're all getting hosed by this current system, and once you realize that, you're like, wait a minute, why am I getting hosed here? So, I'm gonna try to stay optimistic because you guys are telling me I should. But I think there's — I do think there's hope. I really do. I think the law, probably some litigation, to Steve's earlier point, and I think people just getting sick and tired of it, and shouting from the rooftops, saying, you know, I can't take it anymore. And I think employers are at that — at that breaking point, and employees, I think, are starting to figure it out, so thank you so much for joining us today. Kim and Steve, as always, thank you, and I wish you a beautiful day.
Ann: Bye, 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.
Listen to this episode. | All episodes of Moving to Value Unscripted.