Confronting Soaring Emergency Care Costs (feat. Al Lewis)
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'm a recovering ex-hospital president and am proud to be the president of the Moving to Value Alliance. The Moving to Value Alliance, a 501c3 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 who 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, Lisa Trumbull, and Kim Lynch.
STEVE: 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.
LISA: And I'm Lisa Trumbull, the president and CEO of Southern New England Healthcare Organization based here in Windsor, Connecticut, a physician-led clinically integrated network focused on population health and value-based care in Connecticut and Massachusetts.
KIM: And I'm Kim Lynch, founder and CEO of Metis Health Technologies, where we help clinicians and healthcare organizations streamline operations, increase revenue, and deliver better patient care. I'm originally from Michigan, now based in D.C.
JOHN: Our guest today is Al Lewis, founder of the Validation Institute and the gamified health literacy platform, Quizzify. Al has been called the troublemaker-in-chief of the wellness industry. He's a Harvard Law graduate, a prolific commentator, and author of several best-selling books, including Why Nobody Believes the Numbers, which Forbes named the 2012 Healthcare Book of the Year. As the founder of the Validation Institute, an organization that serves as the healthcare industry's most rigorous independent auditor, Al has spent years helping employers and CFOs separate healthcare snake oil from actual outcomes. He's a fierce critic of innumeracy, which he defines as the failure to apply basic logic and arithmetic to healthcare claims, allowing the healthcare and wellness industries to sell ineffective programs to unsuspecting employers. In an industry where many vendors promise a massive ROI in guaranteed savings, how do you know who's actually moving the needle and who is just moving the decimal point? Al joins us today to discuss how we can begin to answer that question. Welcome to Moving to Value unscripted, Al.
AL: Well, thanks very much for having me on, John.
JOHN: Al, you know, we like to start our podcast by, you know, kind of getting a little bit of background of our guests. And, you know, you have a very New England pedigree, you know, Philip Exeter Academy, magna cum laude from Harvard, Harvard Law School, somehow visualizing you should be running for office. I'm wondering how you got into — I know you studied economics at Harvard — how did you get into healthcare economics? And what's that early part of that journey to get you to write those books?
AL: Well, I didn't know the first thing about healthcare. And then I went to work at Bain & Company after Harvard Law School, because frankly, I didn't think I was going to be very good at law. And I was probably correct about that. And they just put me on a healthcare team. And after X number of years, you know, you learn the jargon, you learn the — you're sort of under the tent. And that's how I got into the field. And I used to think it was a calling, a mission. And then over time, it degenerated into first a business and then a racket. And I'm stepping back and saying, you know, it's my job to point out what a racket it is and get people to change — to realize that and change the way they look at things.
JOHN: You know, I often say I had an epiphany as a former hospital president. All of a sudden I realized one day it's like, you know, I thought I was part of the solution, but I'm actually part of the problem, to your point.
AL: Well, just to take that a step farther, I thought I was part of the solution when I was working in disease management, which I believe is where you and I and Steve first met in the aughts. And there was an actuary who claimed I was doing the numbers wrong. And then in fact, the savings were much greater than I was saying there were. So I went back and I looked at the numbers. And it turned out that not only was he wrong, but I was wrong. And in fact, there were no savings because we were miscalculating. We weren't counting the zeros. We weren't counting the zeros in the pre so that when someone who had no diagnosis had a heart attack, we weren't counting that. Okay, so I went to a conference, I presented a conference, and I pointed out, I said, you know, we've been doing the numbers wrong, turns out there's there's really not any savings here. And it was just a conference, you know, a couple hundred people, well, a guy blogged on it. And the headline of the blog was, founding father of disease management astonishingly declares, quote, unquote, my kid is ugly. So, so fine, you know, you put the warning on the cigarette packs, they still want to buy the cigarettes, I was perfectly happy to sell them. But I, you know, I crossed that, you know, I checked that box.
STEVE: AL, it's great to have you on. I've been following you for a long time, and the Validation Institute. I was introduced to the Validation Institute when I was running orthopedics at St. Francis under John when John was president. Brian Klepper introduced me to your organization. And we went through the validation process. And I was extremely, we had a very mature database at that time, maybe 10 years and 30,000 patients. And it still took your team about six months to validate. I was very impressed, very proud of that. I'm always guilty on these podcasts of admitting that I do a little prep. It's supposed to be unscripted. But I did listen to your podcast with Stacey. And it was about this issue we're going to focus on today, ER visits. And I think you said that ER visits are now running about six percent of total planned spend. So for the purpose of our audience, what does that mean in plain English? What does that mean in dollars and cents for small and middle market self-funded employers? And should that raise an alarm?
AL: Well, yes, it should raise an alarm because the price of ER is going up faster than any other thing in the hospital, or at least it was through 2024. And there's two things going on. One is that they are upcoding like nobody's business. And it's hard to stop that. I mean, we have some tools, but frankly, it's much squishier than one would think. But the other thing which is not hard is they're simply raising the price. They're using the Emergency Medical Treatment and Active Labor Act, which requires them to treat everybody, to say, look, we have to cover the cost of our uninsured people, so we have to charge a lot for the ER. So you get these four and sometimes even five-figure charges for something that in Maryland, where everybody is required to charge the same price, is $800 or $900. So it becomes a huge profit center for the hospitals, and they've taken this law that was supposed to protect patients and turned it into a profit center.
STEVE: So is it upcoding or are they just sicker patients? That's what I'm not — I’m thinking, maybe patients are sicker because we don't have any access to primary care. Is it upcoding or is it a bit of both?
AL: Okay. So that's a great question. The ER visit rate has actually gone up despite the presence of all, you know, urgent care, minute clinics and whatnot. However, what has not changed at all, and I mean literally at all, is the percent of people who go to the ER who get admitted. So you used to have about five percent people who would be coded at level 599285, which is the highest code. And now you have fifteen percent coded that way. You would expect that there would be more admissions and yet there aren't. But the visit rate, I do believe, goes up because of the lack of primary care.
STEVE: So it's a little bit of both. Yeah.
AL: Yeah.
LISA: I think it's a combination of a lack of primary care, absolutely, and patients not having access to someone to advise them of the most appropriate setting, right? Because what we see in our data is the vast majority of what's showing up in the ED, of course, the normal stuff, heart attacks and things like that. But what's grown the most is ambulatory care sensitive conditions, which is all manageable in some way, shape or form by primary care and getting upstream of the wellness part of it and the prevention part of it. And I wonder how you actually see that given what you know about our system, the uptick in emergency costs and kind of the direction that we're going. What do you think are the primary drivers? What do you think are the primary solutions?
AL: Well, there are definitely people going to the ER who should not be going to the ER because something was missed because they don't want to pay the doctor visit. But that's just one of many things driving the increase in ER visits. Is it cost effective to try to prevent people from having to go to the ER? Well, you know, that's an open question. I mean, it's certainly good for the people if they have access. But the question is, should employers be paying for it? And there have been articles that have said no, but there's new primary screening techniques now. There's a company we just validated called Hibiscus Health that you can look at your screen on your computer and in 30 seconds, it will tell you whether you're low risk, medium risk, high risk. They'll tell you your HbA1c. I had just had mine tested within a couple of weeks before. And just looking at the screen for 30 seconds, they got it within 0.1.
JOHN: Wow.
AL: So if you can reduce the cost of screening from $50 to literally $1, suddenly prevention becomes more cost effective. And having said that, I think they might have, I don't know, 20 clients or something. So there's still a ways to go. But there's going to be the kind of disruption in screening that there has been everything else. And that will change the economics. And if employers latch on to stuff like this, you will avoid a percentage of those ER visits. Shockingly, it is not a big percentage. I don't know the percentage that go to the ER. But I will tell you that what you would call ambulatory sensitive medical events, I think that's the official term. I call them wellness sensitive medical events, are only about five or six percent of all events. So that's all, you know, that's CHF, COPD, asthma, diabetes, CAD, hypertension, primary coded.
JOHN: That's interesting. I mean, I think there's two important parts in that. One is, and you know, when I ran the hospital, sometimes I'll admit I would call the offices that supposedly I ran at 4.29 p.m. And you know what I'm saying? What I'm about to say, right? And of course, the voicemail would already pick up. The office is open from 8.30 to 4.30. And I'm screaming at the voicemail, it's 4.29. So if doctors were available from 4 to 8, when people are flooding into the emergency department, that might help. So access is more than I have a primary care physician, right? It's access that I could talk to somebody from 4 to 8 p.m. So question number one, and maybe solution number one is, where's kind of those virtual visits fit into that cohort? But to your point, Al, you're right. That's only a relatively small, but I think important from a financial point of view for the hospitals, a source of patient visits. But that other group you just referred to, there's a lot of people coming into the ED that are dying. They're dying because they have end-stage heart failure, end-stage COPD, end-stage malignancies. And people used to ask me all the time, oh, why do you spend so much money on people's last 30 days of life? My glib answer would be, if I knew it was the last 30 days, I probably wouldn't have spent the money. The primary care — where does palliative care also play a role in that, preventing those visits? What's your thoughts on that?
AL: I'm not an expert in palliative care. As coincidence would have it, one of my best friends is a palliative care physician practicing in Connecticut. So I have some familiarity with it. But that's also not really what drives these ER visits because the ones you're describing probably end up being admitted. So they don't count as ER visits.
JOHN: Right.
AL: The sweet spot is, well, take my wife, for example. She thought she had Lyme disease, and I tried to convince her that she couldn't, because if there's one thing Quizzify covers, it's how to get Lyme, how to prevent it, where it comes from, yada, yada, yada. So against my better judgment, she went to urgent care. Now, this was in April of 2024, and it was April. That's another reason I told her that you can get it. It's extremely rare. So naturally, urgent care did not have the right titer at that point, because there was no Lyme disease. So they sent us to the ER. So we go to the ER and they're coding at level four. Now we used — and this is really the gist of this thing — we used the Quizzify — we call it the Quizzify Prevent Consent. Keeps you from getting financially ripped off by the ER. And so we write in, we agree to be billed a two times Medicare for correctly coded visit. In as many words. So we get a printout of the form. We wrote that in. We gave it to them. They could have objected. They did not object. They treat us without objection. So they should be billing us two times Medicare for a level two visit, which would be about, I don't know, $600, something like that. Medicare, whatever its other faults, is extremely good at limiting prices in the ER. So even when you want the tube, they're still quite low. So we get a bill for, I don't know, $4,000 or something. And it was in-network, so it got cut down to like $1,500. And so we wrote to them. We showed them the copy. We kept the copy. All the things Quizzify tells you to do. And they wrote back and said, well, we don't recognize that because we have a deal with your insurer. And so I get that in writing. This is not my first rodeo. We've been using this consent for six years. And newsflash, two parties to a contract cannot bind a third party against their will.
JOHN: Perfect.
AL: I don't want to be used. If I don't want to be under that contract, I don't have to be. So that's thing one. Thing two is federal law trumps common contract law. So we brought them to court and we were killing them. Like I say, I know all the lines that they're going to use, and I know how to cite even the case law for performance constituting a contract, for third party can't be bound, for EMTALA, yada, yada, yada. So then the person from Mass General Brigham says, well, what was your co-pay? And I said, it was $150. And they said, well, what would it have been if we'd done this? I said, well, it still would have been $150. Because Boston College — I won’t name them, actually, I shouldn’t name them — or, yeah, no, I don’t mind naming them because she’s retired. Boston College — I wrote to them. I said, you know, can we get a deal? Can we get something back from you if we get you a lower ER cost? Never heard back from them because I knew this was going to come. Judge said, well, you know, there's no damages here. And I said, yeah, there's no damages. I was hoping she wasn't going to raise that point, but it was absolutely right. So, you know, we're chatting on the way out. And she said, you know, we had to get the chief counsel involved in this case. And I said, just knowing that is better than winning.
JOHN: That’s great.
AL: So, yeah. So in any event, so if in fact the copay is not the same, if you have co-insurance, if you haven't satisfied your deductible, or if you have some kind of incentive from the employer, we win every case based on this consent. Now, there is one exception to that. Actually, I'm sorry, there's two exceptions. One is there was a hospital in Phoenix that had enough sense to reject our consent. So one hospital in six years had the good sense to say, we don't agree to this. We have to treat you anyway. That's EMTALA, but we're not agreeing to the price. The guy who did this could have a decent small claims case. They probably would have mediated, come up with something in between. They wanted like $3,000. He was offering $600. But he's like the same thing. He's like, you know, this is my wife's insurance. I don't really care. Let them have it. So yes, a hospital can reject the consent. It's not. And that just creates a mediation opportunity. So that was one. The other one, and this is the big one, is I suppose I can tell you who it is, Ohio Health, which is the largest health system in Ohio. So we had somebody go in, use the consent. They treated this person without objection and they sent a big bill. And we said, mind you, I've got this whole thing down to a science at this point. So they contact me and for a percentage of the savings, I help out. And usually it's easy. I write one letter and I get like five, $600. It took me half an hour, right? Well, this was a black swan event that made up for all the other easy wins. We wrote to them. We said exactly what I would say. We're going to, you know, we agreed to two times Medicare. You can either tell us what to — oh, the first thing is, as you know, because you ran a hospital, hospitals hate being contacted on email. So naturally, we contact them on email. So we, you know, we get the names of like seven or eight people in the C-suite and we write to them. So we write and we say, you can either tell us what two times Medicare is, or we will estimate it at $850 and we will send you a check for payment in full $850 on the 15th of October. Well, we never hear back. Now, and I say to these folks, write payment in full as agreed on the back of the check. Now, when I was in law school, you could write on the front. Now you have to write in the back. So they do that. Check gets cashed. So I write to them and say, great, that's the end. So we calculate my share and I say, okay, well, let's just wait till it shows up on your record and then you can sign the check. No, they cash the check and then continue to ask for more money, right? They wanted the other $4,000. We made a mistake. It was not a consequential mistake, but it was a mistake, which is we sued them and small claims court. We should have waited for them to sue us. We should have said, we're not paying, you need to take us to court for two reasons. One is it's much easier to be the defendant, burden proof is on them. But two, and more importantly, which is what I hadn't figured out because this was the first time this has ever happened, is that small claims court is supposed to resolve monetary issues. They painted our house badly. That's why we didn't pay them $3,000. Painter says, well, they owe us $3,000 more and the judge decides, just like Judge Judy on TV. Well, what we were asking for was equitable relief. It wasn't dollars. It was stop harassing us. They hired a big law firm to try to get the case dismissed, shifted to regular court, which would have been the end of it because we would have needed a real lawyer, yada, yada, you know, denying everything, motion after motion. Well, you know, the judge was having none of it. He says, no, this is a small case. It stays here. You know as well as I do that if I transfer it, it's dead. So, so far, we were, you know, we were doing well. I mean, this whole thing took place over months. and we're writing motions and they're writing counter motions, not costing us anything. I can do these things in my sleep. Meanwhile, they're racking up a bill that we now think is about $50,000 over a small claims case. But after a while, you get so far into it that you can't get out, you know, because if they try to get out, you win. This is like a Guinness Book of World Records small claims case.
JOHN: Sounds like it.
AL: Both for how much they spent and the length of the trial, the length of trial. I don't know if any of you ever been to small claims court. It's kind of he said, she said, it's over in 15 minutes. They usually handle 20 cases in two hours kind of thing. Well, this case took three and a half hours. And I would send you, if you could see the video, I would show you, there's a shot — it was all video — of the judge just going, oh, like this, listening to the — you can't see what I'm doing. I put my face in my hand, like, oh my God, listening to the defendant. The defendant blew it many ways. One was they had an expert witness who was an ER doc who said, yeah, you know, we're on the floor. We're treating these patients. We don't know. We don't know what's going on in the billing. That's another department. Well, if I had been there or even allowed to be on video, and that was the one motion they won was keeping me from being a witness, I would have said, yes, of course, it's another department. It's exactly what we're saying. It's the business department. They should have said something. That's what I would have said. Our plaintiff didn't know to say that. So that was thing one. Thing two was the — oh, the cashing of the check. So they had another witness. In addition to expert witness, they had a witness of fact, the person who ran the billing. And we're saying, look, you cashed the check. And they said, no, we didn't cash the check. Our bank cashed the check. And that's agency law. Agency Law 101, you know? Oh, and they said, they see 2,000 checks a day or a week or whatever, you know? So they can't be expected. Yes, they can. You know, yes, they can. They didn't catch that one either, you know? So I could not get in as a witness, but I had the bright idea of writing probably the first time in the history of small claims court, an amicus curiae brief, okay? So a friend of the court, I'd already waived my fee for these guys. I said, I can't charge anything because I kept telling you this was going to be over. So I had no financial interest in the case. But there were several points, both the checkpoint, the contract point. And then their other attorney kept saying, we were forced to accept this consent under EMTALA. We were forced to treat them according to this consent. And I'm writing to say, no, no, you're forced to treat them. You're not forced to accept the consent. And I got a letter from the guy at the other hospital in Phoenix who said, no, no, they rejected our consent. So it wasn't just I sent an amicus curiae brief because there was no governing law on this and they could have rejected it. In fact, the other side made a motion, you know, to keep it out. But so we put on, before we did the amicus curiae brief, we put on, look, we know this is unusual. We proactively waive any objection to them having an amicus curiae brief. So the judge accepted. And of course, they're not going to be able to find an amicus curiae brief. Well, and then the judge finally says he's getting really sick of them, especially because he us too, but especially them, because he says they kept saying, look, they consented. They came into our ear. They consented. And the judge says it says they didn't consent. And then the judge says, you people are in my court all the time with signed consent saying they consented, they consented, they consented. Well, here's a consent that was not signed. And you're still saying they consented. And he said, do you know what the law is? And their attorney says — this is all on video — says, well, I disagree with you on what the law is. You know, you don't say that to a judge.
JOHN: Oh, ouch. Never a good thing to say to a judge.
AL: No, no, no. So the final briefs, the judge finally says, both of you can put in a final brief by February 10th, no new facts, just the law. So we wrote a really good brief, put it in, they didn't even bother to write a brief. And we thought we would get a decision in a week, like every other small claims. Well, it's been almost two months at this point, no decision. And at first we thought, and we still do think, that the judge knows that Ohio Health is going to appeal. So instead of writing the typical one paragraph, you owe him for the paint job or, you know, whatever, he's going to literally write an opinion. He's writing an actual opinion because he does not want to be, no judge wants to be appealed. Certainly no judge wants to be overturned on appeal. I keep hoping, you know, the actual verdict will be in so I can actually, it's a decision, not a verdict. And yet the decision has not come in. So I can describe the case, but I can't tell you how it actually turned out yet.
KIM: Super interesting, Al. I mean, and the time, the effort, the Byzantine paths to navigate here. I'm feeling overwhelmed hearing you talk about this, right? And I can't imagine for our listeners that they're feeling otherwise. So maybe let's flip this dynamic to the country. Everyone in the country knows someone who will use an ER this year. Every employer in the country, right, is hoping that their employees are healthy and on the job or their retirees are healthy and on a beach somewhere. My question to you today in 2026 is, where can employers have more agency here? Where are the tells maybe? Some of the questions early on to help give them more confidence in, I'm pointing my people to the right kind of care, I'm purchasing the right kind of care, or, oh no, I need to make a change because something manipulative is going on here.
AL: Well, there's two things. And one of them is reasonably basic, which is teaching people, which we do with Quizzify. We have quizzes on proper levels of care, when you can use telehealth, when you use urgent, and when you use emergent. Now, one of the things, and this is not true in Connecticut or Massachusetts, in fact, I don't think anywhere in New England, but all around the country, they have these freestanding ERs. You don't have any of these, do you? They're all over Texas and Arizona and Colorado and Florida. And the whole business model is to make them look like urgent care until you get the bill. So one of the things we teach in Quizzify, we use visual pictures, you know, which one of these is urgent care and which is ER and which is going to cost you 10 times more than the other. So there's some level of knowledge that we impart at Quizzify. But where the rubber hits the road is when you go to the ER, number one, we teach people to write in, it's literally 18 words, but you have to know to ask them to print out their consent because they're just going to do it on a screen and write it in. So that's a step that loses a whole lot of people. We also have stickers that you actually peel off and put on that says the 18 words and then you sign. So that makes it a little bit easier. But the key thing, and this is done at the employer level, is we have what we call the auto consent, where depending on where you're located, we write to all the area hospitals and we have a letter that works perfectly because it says, unless we hear from you otherwise for this account number, you agree to two times Medicare. And then we say, and this was a refinement a couple of years ago, we say, look, you don't have to remind your ER intake staff of this, retrain them. That's a real pain. So we'll just know that if somebody signs the consent the way you've done it, that that doesn't count, that this is a consent. So that way, maybe some of you are old enough to remember those book of the month clubs, where if you didn't write back, you got the book on a thing. It was called a negative option. So we're basically giving them a negative option. And with the people we write to, because they are not the right people, we say forward the message. I don't even know how many of these messages get forwarded. So what we do is we have a little sticker that goes on the insurance card, or you can print the insurance card with a QR code that says see consent on file. And we have copies of all these consents. So in every case so far, and there haven't been a lot of cases where there's been a dispute. We just say, no, actually, you did consent to ours. And sometimes they'll write back and say, well, we didn't know this. And we write the letter back. We say, yes, you did. It's not on us that you did not leave the correct email on your website. So we had to write to you and ask you to forward it. And there's a little law school quote we use is that you are stopped from claiming that it's not your fault because of this. And I said, you can't, it's well-established in law that you can't murder both your parents and then ask the court for mercy because you're an orphan. And that's precisely what you do. You make it impossible to contact yourselves. We contact you. That's on you. And so far, all of those have worked. So you get 95% of people getting literally half the price that they would have otherwise gotten. The only 5% are done on the ones who forget to bring their insurance card. And frankly, even those who've consented, it's just a very gray area case that we don't feel like taking on. It's much easier if you give them the card that says the consent on file.
KIM: Very cool. And a follow-up, because you mentioned one of my favorite, in a sarcastic way, topics, which is the buying up of ERs by private equity and just the corporate practice of medicine broadly. I'm not an attorney, but this question, I'm really curious for, again, your practical advice as folks read headlines about their local ER being invested in by private equity or where they see these freestanding ERs. What's the discernment that the average customer and, again, the average employer can use to guide in those situations? And, you know, I'm making a presumption there that the outcomes are worse because that's the headlines that I've seen. So if you would like to challenge that, by all means.
AL: No, the outcomes probably are worse. There are a couple of options for patients here. One, they tend to buy the ER practices. Sometimes they buy the actual ERs. Now, if they buy the ERs, and this is another, I'm sorry, I guess I said there were two exceptions or three exceptions. If you go to an ER, a freestanding ER that is not part of a hospital, does not have a hospital license, they are not subjected to the Emergency Medical Treatment and Active Labor Act. Now, if you give them the consent and they accept it, you still win. But they can basically tell you to get lost. It would depend on the state. There's some states that have an equivalent of EMTALA, but there are others like Texas where literally they can tell you to get lost if you don't agree with them. So there are two parts there. One is that the private equity practices do tend to purchase the physicians, not the actual ERs, so that they can negotiate a much better deal as a group. And in fact, the funny thing is, you know, I've been doing this for years, and I also had investment in a private equity company that did healthcare. And so I go to their annual meeting and they're doing quite well. And they give these presentations on how they bought up all these practices for doing ER, radiology, whatever. And so they're able to get a much higher price. And I'm thinking, I'm in the den of iniquity here. Now, in all fairness to that particular fund, they divested those quite some time ago. But it was like the line in the movie Notorious, mother, I'm married to an American spy.
KIM: Yeah, no, that sounds like some of the rooms that I've been in as well. I don't think that that's the exception. I think that is in fact the rule.
AL: Yeah, it is. So now here's the thing. The EMTALA applies. It does not matter who owns the physician practice. You are signing, when you go to the ER, you are basically signing for everything. And it's between the ER and the providers, you know, what you get billed. But once the ER has accepted your consent, they have to do your consent. And we do have a, we have this great case where the providers of the, of the ancillaries, both the crutches and the reading of the, of the x-rays did adhere to the consent without being asked. So we got the x-ray read for $46 and the crutches were $18. And I have this, I have the screenshots because normally we only see the ones where, you know, we have to get involved. But this time the person was so amazed that they, they sent us these things, right? And so I said, I wrote back, say, it's almost as though you're in a foreign country. One of the very interesting things that happens here when the consent is used, and it happens a shocking number of times when there's a dispute, is they will write off the whole thing or they will just say, how about if we only charge you 500 bucks or something like that? And I used think, wow, I'm a great negotiator. No, it was because if they do charge two times Medicare, they've established a precedent. And that means every other time somebody comes in and asks for two times Medicare, they got to give it to them.
JOHN: Good point.
STEVE: Interesting. Hey Al, just quick question on policy. The No Surprise Act is surprisingly five years old and it took a year to get it out there. And I think it had good intent, like a lot of legislation, but missed the mark. I mean, it did eliminate the $5,000 COVID test, if you recall.
AL: It was $11,000, but yeah.
STEVE: It was $11,000? Okay. And all the other stuff, you know, about anesthesia and so forth. But it's kind of like the whack-a-mole. I mean, it had good intent, but there were holes in it. So what are your thoughts on a No Surprise Act, the downside, and how it can be improved?
AL: Well, yes, it did get rid of the headlines. It absolutely got rid of the headlines. We emphatically do not get involved in the No Surprise Act because it's more of a pain than you would think. And most of the decisions go in favor of the providers. We just do the whole EMTALA thing, and that has worked terrifically. And no hospital has ever said, wait, you have to do a No Surprise Act thing on this. Never. I mean, they may in the future, but they haven't.
STEVE: Yeah. So, Al, you know, you've been in the industry for a very long time. And I think of you as the yin and the yang. You're a staunch critic of nonsense, and I appreciate that. But I've also noticed you're a big advocate for things that actually do work through the Validation Institute or through other processes. And you've called out the fraud and the nonsense and the PEPMs and so forth. But where do you think health care, you know, I want you to swing hard here, Al. Where do you think health care is going in the next three to five years? How are we going to land? Are you optimistic about certain things? And where do you think the system is going to refuse to fix?
AL: That's a great question. And a couple of things. The Validation Institute — basically twenty percent of companies are pretty dishonest, but they have eighty percent of the business. And what the Validation Institute does is it finds the eighty percent of companies that only have twenty percent of the business because it's hard when you're honest, because you're not paying off the consultants. There's all sorts of stuff that's going on. And we try to dramatically raise their visibility in order to compete with the cartels. So that's thing one. Now, is it going to make a dent in health care? I'm going to use an analogy, and I'm going to not be particularly optimistic here. The problem with our health care is a little like when the typewriter was invented, they scrambled the keys because it was slow and they didn't want the keys to jam. Now, curiously, the top row of the keyboard jammed less than the lower rows. And so they hid the word typewriter in the top row so that when the salespeople were demonstrating it, they could type the word typewriter and it wouldn't jam. But that's just a trivia sidebar.
JOHN: That's a great trivia question.
AL: The problem with our healthcare system is that we're locked in to what we have now. And yes, there is a more efficient keyboard that nobody uses. It's called the Dvorak keyboard. And there is certainly a way more efficient way to do healthcare. Probably two or three more. Probably all government or all private or whatever, but we're stuck with the model we have. And all we can do is tweak around the edges, I'm afraid. And frankly, that's what Quizzify does with the prevent consent is, you know, we get that six percent reduced to three percent in the ER. We don't quite get that much, but close. That's what the Validation Institute does by finding, you know, say MSK providers that actually do something or diabetes reversal, instead of people who are trying to get you to use more meds. Those are going to take the edge off of the health care costs increase, but there's nothing that is going to change the system. There are companies, and they tend to be much smaller, that have, in fact, abandoned the cartel and do, in fact, go after these creative solutions. The problem is that you have to break eggs to make these omelets. And often large organizations are not willing to break those eggs in the way that small organizations are.
JOHN: Great answer, Al. Yeah, there's no doubt there's a lot of opportunity to reduce the five plus trillion dollar healthcare spend in this country. And you've certainly highlighted one very clear way to reduce it, that I think the average consumer who goes to the emergency department, just a little bit of not much chutzpah and 18 words can avoid getting a multi-digit bill, to your point, that often easily five. Somebody — I had a family member go to the emergency department last week, actually, and they said, what do you think the bill's going to be? I said, well, it's probably going to be five digits, you know, and it wasn't really a major thing, but just guessing. And I'm waiting to see it, actually. I'm guilty, Al. I didn't tell her to write the eighteen words, so we'll see what happens. But Al, thank you so much for being our guest on Moving to Value Unscripted. It's great to have you, and thank you so much.
STEVE: Thanks Al.
AL: Well, you're quite welcome, and thanks for having me on.
JOHN: To learn more about MTBA 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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