EP488: Mark Cuban, Cora Opsahl, Trust, Simplicity, and a Chicken—Today We Talk Healthcare

Episode Transcript
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Stacey Richter (00:00):
Episode 488.
"Mark Cuban, Cora Opsahl, Trust,Simplicity, and a Chicken.
Today We Talk Healthcare."

Tom Nash (00:16):
American Healthcare Entrepreneurs and executives
You Want to Know, Talking.
Relentlessly Seeking Value.

If you are listening to this prior to October 9th,
2025, go to the 32BJ Changing thePlaybook on Hospital Prices event
where Mark Cuban will be keynoting.
Cora Opsahl will also be speakingand I will be there listening
link in the show notes, sotrust, simplicity, and a chicken.

(00:45):
Yeah, this is where this wholeconversation with Mark Cuban
and Cora Opsahl winds up.
And it is a barnstormer becauseyou know what some really good
advice is for anybody trying to doright by patients and taxpayers and
plan sponsors, it will take trust.
It will take making thecomplicated as simple as possible.
And also if you could pay witha chicken, like in the good

(01:07):
old days, that would be messy.
I can say with confidence, having grownup in Pennsylvania, Dutch country where
there are many, many chickens, but alsobeing able to pay with a chicken could
also indicate that healthcare pricesare reasonably chicken proportionate
and that the doctor-patient relationshipis good enough to break bread.

(01:28):
Or have chicken.
That last part is really important,and Cora Opsahl sauce says this at
one point in the episode that follows.
It doesn't matter how wonderful thetransparency or the financing, if
the prices are insane and there'sno more reasonably priced options
in any given market, then yeah.
Shane Cerone says in an upcomingshow, he says, We do not have

(01:50):
a broken healthcare market.
We do not have a healthcare market.
There is no market.
Okay, so you could call thisconversation a continuation of the
episode with Ann Kempski, episode444, entitled "Two State Healthcare
Laws Often Don't Go As Planned".
But it's not just healthcare lawsthat often don't go as planned.
It's some very foundational constructsthat we have built the healthcare sector

(02:15):
upon that may also not go as planned.
The healthcare sector islike a game of Pachinko.
You chuck an input into the mix andit will bounce all around into all
the perverse incentives and humanbeings and the non-market that we
have, and who the heck knows whatis gonna pop out the other side.
It's like game theory atits most unpredictable.

(02:36):
So in healthcare, there are many,many examples of when the solution
to a problem arguably creates worseproblems than the problems the
solution was trying to solve for.
But we Mark Cuban, Cora, Opsahland I are gonna shake our fists
at two such solutions today.
High deductible health plans or justhigh deductibles in general, and then
self-insured employers trying to solve thecomplexity of the healthcare industry by

(02:58):
hiring consultants and middlemen, middlepeople, and other vendors to navigate the
Pachinko parlor, that is our $4.9 trillionhealthcare sector on their behalf.
Now, I am not in any way saying thespirit of these two endeavors, high
deductibles and hiring consultantsand middlemen weren't wholehearted.
They seem just like many otherwell-intentioned solutions,

(03:19):
very logical on their face.
What I am saying is there are many waysin the real world for even the most,
again, genuine endeavor to turn intoa money grab for those so inclined.
While at the same time I'm saying allthis, I'm also very much saying that
there are some amazing consultantsand middle folks such as independent
third party administrators, otherwiseknown as TPAs, and PBMs, pharmacy

(03:43):
benefit managers who are transparentand hold themselves accountable to the
fiduciary responsibilities that theirclients are held to in real terms.
Not just in marketing speak with40 pages of disclaimers following.
There are great folks out there, manyof whom listen to this podcast and
are part of our tribe on the regular.
And to you I say thank you for being here.

(04:04):
Because it takes all the knowledge andmore from every one of the guests featured
in these past 487 Relentless HealthValue episodes plus treating every day
like a school day to make sure that weall are not getting shanked from behind
by some innocent looking contract termthat turns out to be anything, but.
The conversation that follows starts outtalking about high deductibles, naturally

(04:26):
segues into how third party intermediariescan actually exacerbate the issues here.
Then we get into transparency,financing, clinical organizations,
taking on risk, and the benefitsand challenges of direct contracts.
Then Mark lays out avision for the future.
Okay.
I wanna get to this conversation.
If you are a new listener here, andyou might be because yeah, Mark Cuban,

(04:48):
let me just inform you that thispodcast is largely listened to by those
who work in the healthcare industry.
So you are going to encounter acronyms.
You will also encounter me referencingearlier episodes because surveys
say listeners really appreciatethese callbacks to go get additional
information about any given topic.
You can get what amounts to apersonalized Masters of Healthcare

(05:10):
Administration curriculum.
If you follow the episodethreads long enough.
And that was a directquote from a listener.
About the acronyms, they are holyterrors and we in the healthcare
industry are chock-full of them.
In the show notes, I will put alist of acronyms that come up so
that you can follow along at home ifthis is your first day at our rodeo.
Also in the show notes is a transcriptof this show, along with links

(05:33):
to all of the mentioned episodes.
Okay, here's my conversation with MarkCuban, who is, Mark Cuban and also CEO
and founder of Mark Cuban Cost Plus Drugs.
Also, we have Cora Opsahl, who is HealthFund director of the 32BJ Health Fund,
and an expert in many things healthcare.
My name is Stacey Richter.

(05:54):
This podcast is sponsoredby Aventria Health Group.
Today we are going to talk aboutsolutions where the proposed fix winds
up maybe, or maybe not being as bador maybe worse as the original problem
the solution was supposed to fix.
So today here to discuss thistopic, we have Mark Cuban.

Mark Cuban (06:14):
What's up guys?

And Cora Opsahl.

Cora Opsahl (06:16):
Hey everybody.

Welcome to Relentless Health Value.
So let's start with solution one.
High deductible health plans,just high deductibles in general.
You know, let's just talk about thewhy high deductibles got set up in the
first place, which was this idea that ifpatients had a little skin in the game,
that healthcare costs would come down.
That was the original rationale behindthe raising of deductibles in these

(06:38):
so-called consumer high deductiblehealth plans, CHDHPs, you know, make
people spend their own money firstand then they'll be smart shoppers.
How's that working out?

Mark Cuban (06:48):
Yeah, high is high.
I don't know whether to take highin the cost sense or high in the
smoke 'em while you got 'em sense.
Because if you can't afford yourdeductible, your insurance is worthless.
You know, if we're talking copaysof 5, 10, 15, 20, $25, okay?
A discussion can be had.
But if you've got a $4000, $5000deductible, and your max out of pocket is

(07:15):
$19,200 for your family, you're screwed.
You know, you really don't haveany healthcare protection at all.

Yeah.
We often talk about patients beingfunctionally uninsured because if
your deductible is more than you havein your bank account, then you can't
afford to use your own insurance.
How do you see that workingout on the ground Cora.

High Deductibles had a really solid reason behind it, right?
The idea was, people need to beable to have an understanding of
why they're using their insurance.
But functionally, I agree.
We're creating a class of uninsured folks.
On top of that I would argue it'sunethical because all you're gonna
do is cause people to delay care.

(07:59):
Delayed care just means moreexpensive care down the road.
It also then is gonna compound theissue of uncompensated care that's
going to the emergency rooms.
You're not seeing people atprimary care docs, you're sending
people to emergency rooms.
And so what is meant, I think, in anattempt to put quote unquote skin in the
game is causing employers to actually justincrease their costs across the board.

Mark Cuban (08:21):
And I don't even look at a skin in the game anymore.
I think it's really just a payrolldeduction from the employee and a cash
addition to the insurance company.
You know, the insurancecompanies aren't dumb.
They know that the higher thedeductible, the less likely it is to
be used, which means they get to keepthat money in their bank account.

(08:43):
And if this was a real world applicationswhere people really cared about patients,
then there would be a credit check.
Now that sounds counterintuitive, right?
To check people's credit before theycan get access to their insurance.
But if, you know, 40% of Americans onlyhave $400 or less in the bank, having a

(09:03):
1500 deductible, which seems reasonablein this day and age, is still as good as
having a $10 million deductible becauseyou can't afford it one way or the other.
And then you get into the ACA subsidieswhere the cash just goes right to the big
insurance companies, that are offeringthe plans that the Feds approved.
It doesn't make any sense.

(09:24):
This whole system is designedfor the big insurance companies,

Episode 482, with Preston Alexander called "Three
Surprising Ways Carriers Make Lots ofMoney", and it's all about the float.

I think Mark is absolutely right.
On top of that, we know that.
I think it's over 25% of folks, ifnot more, and Stacey, you'll probably
override with the correct number.
Go without care becausethey can't afford it.
Taking a side, we're talkingabout copays, outside of even
talking about high deductibles.
I know that my plan is very generous andI love the fact that I get to provide

(09:59):
benefits that are really affordable.
And I've still had folks call me andsay, I can't get my brand diabetes
drug because it's $40 or a $30 copay.
Now, if health insurance is there inorder to protect the healthcare of
members and your employees and thepopulation, we're not doing that if
we're not making it affordable for folks.

Mark Cuban (10:19):
Well, we've got this disconnect.
We're using health insuranceas a proxy for healthcare.

Absolutely.

Mark Cuban (10:25):
There's not a connection between the two at all.
I mean, you guys have heard me saythis before, healthcare is a really
easy business on the business side.
Doctors and hospitals do what they do,the miracles they offer, but on the
business side, it's how much does it cost?
How do you pay for it?
And who takes the riskfor people who can't pay?
Those are the only three questions thatneed to be answered on the business side.

(10:50):
Yet we don't try toanswer those questions.
We just presume that the health insuranceindustry is gonna take care of everything.

Mark, I wanna just do call-back back to something that
you said the other day, which isthat the higher the deductibles,
the more the providers themselves,in a way become subprime lenders.
Which basically also means, it's afunny, if you start thinking about it
paradoxically, the carriers who are oftenperceived as the ones taking risks, and
in the case of self-insured employers,it's the providers who may arguably be

(11:18):
taking more risk than the carriers..

Mark Cuban (11:21):
You're exactly right.
Think about what happens.
A member gets sick and needs togo to the doctor, and they have
just a thousand dollars, just, athousand dollars deductible, right?
The doctor refers them.
They went through their primarycare doctor, which is included in
their plan, let's say, and they'rerecommended to a hospital and they know

(11:43):
that it's going to cost them money.
You go to the hospitalwith your appointment.
First thing they want to do isask you for a credit card or
money to pay for your deductible.
Now the hospitals in aquagmire right there, right?
They have a paradox right there.
Because if they don't provide youfunding for your deductible, then they
can't get the money that would come fromthe insurance company post deductible.

(12:07):
And so, not only are they usingthird parties to fund uninsured
people, but they're using themto fund deductibles now as well.
What's the whole point?
Why do we need insurance companiesat this point at all, if they're
not truly taking the risk?

I mean, and I would also mention, I think, Mark, you're
spot on, but even beyond that, whenyou think about it, you've got the
provider who now is going to be actuallyin the debt collection business.
Right?
They're not in the healthcare business.
If you think about it, it's part of thereason that the solutions that are out
there, such as direct contracting, whereyou get to remove these cost share,

(12:45):
you know, components and remove this.
I mean, I think, Stacey, you were justtalking about the average is one, one
administrator for every two providers.

Listen to episode 486 with Dr. Stan Schwartz, where
we get into hotboxing patients forcopayments and also just how many
administrators that takes on theclinical organization side to manage what
amounts to a debt collection business.

If we can shift that where you've got the one administrator
for 10 providers, you're thenactually providing healthcare.
And you know, it stops people frombeing afraid to go to the doctor.

Debt collection, I think is also a really interesting
thing to start thinking about becauseif you are a large, consolidated
health system, huge endowment, lotsof people, rev cycle management, the
whole works, you may be well equippedto essentially be a bank, if you will.

Mark Cuban (13:36):
Even then, when you talk to their CFOs, they're saying they
have, you know, a 50% rate of debtof people not being able to pay, and
so they're losing 50% of that, whichcreates a not so virtuous cycle, right?
So they're increasing their interestrate, all playing all these games to
compensate for that, even if they're big.
And if you're small or if you'reurban or if you're rural, I think

(13:59):
to your point, you're stuck.

I will also just point out at the JPM conference,
there was a big consolidated healthsystem touting the credit cards that
they're offering to the patients.

Mark Cuban (14:07):
They should, that's not a bad thing.

They'll making more money off those credit cards than,

Mark Cuban (14:11):
I'm okay with that if it, you know, if the rates aren't usurious
right or just awful, then I'd be like,okay, they're gonna gimme credit.
And so I'll go to the doctor and aslong as it's something reasonable,
I'll just plan to go to the doctorand make an appointment there.
That works.

I mean, true.
I agree, Mark, it does work.
But I think what you're talkingabout is the reasonability,
it related to the credit card.
But let's talk about thereasonability of prices.
I mean, you gotta talk aboutboth hand in hand because right
now prices are unreasonable.

Mark Cuban (14:41):
If you know what they are.

If you know what they are at all.
You know, I think we can talk about howtransparency is potentially a solution,
but again, it's only if you understandhow it's actually gonna be billed.
If you really understand whatyou're supposed to be looking for.
I think we could call out wordslike DRG and CPT, but I'll tell
you, when I talk to my mother, shehas no idea what I'm talking about.

Mark Cuban (15:01):
And those are only relevant to insurance, right?
If there were no insurance companies.
Would we have DRG codes?

No.
It'd probably just say, youknow, inpatient stay for three
days or whatever it would be.
It's something that makessense to the normal person.
You know, but I think we have a, we havea fundamental reasonability problem.
If you look at the, all of the studiesright now that are coming out about
what they expect premium increases tobe our, you know, nine, 10%, I think the
funny thing I always find interestingis, the insurance companies are saying

(15:31):
their premiums are gonna go up 9%.
The insurance companies are theones who are negotiating the
prices that are also going up 9%.
I think what we should be replacingthe word premium with price.

Dr. Stan Schwartz was on the pod a couple of weeks ago and
one of the things that he said, whichI think is very apropros here, he said,
"So much of what we call expense inmedicine is simply pricing failure".

Mark Cuban (15:52):
Yeah, I mean, and it, you know, it's the all time question.
Why is it any schmo with the credit cardcan walk into a hospital and pay the
cash rate, which can be less than halfof the rate negotiated by the biggest,
most powerful insurance companies.

Listen to episode 425 with Marshall Allen, or there's a bunch
of shows about this topic, but just howcommon it is for it to actually be cheaper
for a patient to pay cash, then to paythe insurance negotiated price, right?
Going in with no insurance ischeaper than going in with insurance.

Mark Cuban (16:29):
Plus, you know, it's the whole cycle management of billing because
the amount negotiated is not what theinsurance company's going to pay anyways.
You know, they'll say that hipreplacement's, negotiated rate is 15,000.
Somebody gets their hip replaced,the bill goes to the insurance
company, and they pay 12,000.
Then they go to the hospital andthey say, that's what we're paying.

(16:50):
If you don't like it, sue us.
You know, or do whatever.
And so the hospital now has, whoknows how many administrators or
lawyers who just negotiate and sue.
And when you talk to a CFO aboutthat, they say three to 5% of
their revenue is lost because theinsurance companies just underpay.
And when they underpay, and when denialscome and denials, half the reason of

(17:13):
denials aren't to deny but to delay.
So they get the time value of themoney from the premiums, right?
And so you have denials,you have the underpayment.
So what do hospitals do in response?
They come up and they inventnew ways to generate revenue.
They increase prices,they do facilities fees.
You know, they do play all these games.

(17:34):
They acquire independent practicesthat were in the same building
as them, but now it's inpatientbecause it's the same building as
the hospital and they own them.
All the private equity gamesthat are played that way.
There's all this financial engineeringwhen we just need to simplify it.
And that's to your point, earlier Cora.
That's why we're doing a lot withdirect contracting and I'm as much as

(17:56):
I can, I'm pushing companies, directcontract, direct contract, direct
contract, and providers as well.
I mean, just think about it, if we justgot rid of, if, if the American Hospital
Association just created their own networkand just said, Hey, we want all of our
hospitals to join this network and offertheir cash prices to anybody willing to
pay cash, you know, including employers.

(18:18):
The whole system could change.

But I think this is one of the things is that it's easy, I think, to
think about it in a fully insured market,kind of what you're talking about, Mark.
But when we pivot to self-fundedemployers, right, I think it shifts
a little bit because the self-fundedemployer is ultimately paying the bill,

Mark Cuban (18:33):
And taking all the risk, and taking all and risk.

And taking all of the risk.
And I do believe there are self-fundedemployers, you know, 32BJ Health Fund,
being one who want to direct contract.
But that also means though,that you gotta find the hospital
and the provider who wants to.
And has the capacity to, because they'regonna say, drive all of my volume here.
But if you already cost more,I always think about it.
I don't wanna pay for an outfitif all I need is the T-shirt.

(18:56):
Right?

Mark Cuban (18:56):
I think about that all the time.

Right?
And right, or, or, or even a betteranalogy is why if I can get a white
t-shirt from Target, just as good asthe white t-shirt that I'm getting from
Macy's or the white T-shirt I'm gonnaget from Nordstrom, sending all of my
people to Nordstrom, who's getting me theMacy's price, when I could probably send
people to, you know, when I don't haveto get, engage and get the target price.

(19:19):
The problem we have is also, again,I don't know if that's the good deal.

Mark Cuban (19:23):
Yeah.
No transparency.
Yeah.
There's no transparency.

Episode 436 with Elizabeth Mitchell, or Episode
480 with Kimberly Carelson or theearlier show with Cora Opsahl.
Listen to those on just howdifficult it is to just go out
and buy healthcare services.
You can't get the datato assess the quality.
You can't figure out the prices.
You can't figure out what's beenbundled together or sold separately.

Yeah.
Even if you have your data, youwere saying, you know, there's
the underpayments to providers.
I don't know if that's happening.
I get my claims data.
I only know what I'm being billed.
I don't know what is thenbeing paid to the provider.

So we started out talking about high deductible health plans.
Well, we pivoted a little bit,but I'm hanging on for this ride.
So we started out talking aboutwhat the problems are with
high deductible health plans.
The high deductible health planswere created to solve one problem,
which is, you know, obviouslypatients cannot be moral hazard.
The whole nine you givefree healthcare to people.

(20:22):
People are gonna takeadvantage of it in ways.
We need them to shop.
We need them to be judiciouswith these dollars.
So let's give them someskin in the game here.
And what has wound up happening is thatwe have created a very obvious, this would
be really hard for anyone to argue againstthese days, that the idea may have been a
decent idea at the beginning, but it haspivoted to, let's cost shift to employees.

(20:45):
And insurance companies or carriers,let's just say, because many times
they, if they're dealing with aself-insured employer, they're not
insurance companies any longer.
They are administrating the risk forthe employer taking none themselves.
But in those situations then youhave the carrier who's like, Wait,
I can take advantage of this.
Because as Mark said, you've gotthe float, you've got all kinds

(21:06):
of things that can be happeningthere from the carrier standpoint.
Meanwhile, the self-insured employeralso, if you have a, and this was alluded
to by Mark as well, if you have a CEOwho's like, well, $5,000, like whatever.
I can find that in my couch cushions.
Then they are buying aplan for themselves, not
necessarily their $18 an hour.

Mark Cuban (21:27):
Yeah.
Its a core competency tounderstand their benefits at all.
And even though it's the secondlargest line item, expense line
item after payroll, as Cora knowsvery well, it's hard to dig in.
I was just as much of an idiot withthe Mavericks and my other companies.
I had no idea I was getting ripped off.
But for our employees and theirfamilies now, you know, as Cora knows,

(21:49):
we're doing all direct contracting.
All direct contracting.
And slowly but surely, we'readding more and more providers.
We're up to like 8,800 providersin our network right now.
And so we're getting there.
But what we tell them and the reasonthey're willing to give us their
cash price or something close to it.
Sometimes we work off ofMedicare as a reference.

(22:09):
We tell them, A, we'regonna pay you cash up front.
B, there is no employee deductible.
You know it is compensation forour employees one way or the
other, and their families, right?
And you can pay it up front, pay itvia healthcare, whatever it may be.
And so you're not takingthat collection risk.
You're getting paid the full amount, andwe'll do all of the pre-auth in advance.

(22:31):
By the time it gets to you, it'salready being been approved, and you
take no pre-authorization denial orpre-authorization or denial risk.
And they're like, no credit risk,no underpay risk, no pre-auth risk.
Where do I sign up?
Now the catch is and why some havebeen hesitant, I should add, is we're
also gonna publish those contracts.
And so, we're gonna create somethingcalled Cost Plus Wellness, and hopefully,

(22:54):
knock on wood, this, or next month orsoon, we're gonna start publishing those
contracts so every employer can see them.
So to Cora's point in terms oftransparency, we'll see what the hospitals
and doctors and dentists and et cetera arecharging with the MRIs are costing, what
the CAT scans are, whatever it may be.
And you can compare.

(23:15):
And we're trying to extend it further.
We're not quite there yet, so thatemployees and members can shop
and because we want them to go andfind the best doctor at the best
price, that's part of our network.
We want them to be able to be the mostconfident, but shopping in terms of
quality within our network as opposedto Okay, I'm gonna save my 25... this

(23:40):
one's a $25 copay, and that one's a 50.

With no relationship to quality.
Go ahead, Cora.

I mean, I was gonna say, Mark, I think what you though we are
hitting on is it is taking, I mean,and I've said this many a times.
We are asking people to understandhealthcare who are not healthcare experts.

Mark Cuban (23:57):
Nobody's a healthcare expert because it all changes every day.

Every day.
But I think it also though hits onthe fact that the current system
where self-insured employers go to acarrier, they go through an RFP, that's
a black box that they offload theirbrain to a consultant or a broker.
They go and hire a PBM or acarrier to go then get the network.
We need to start taking accountabilityfor some of this, because you're right.

(24:25):
I will say, look, 32BJ Health Fundremoved a hospital system in a way that
has really never been done, and still...

Mark Cuban (24:31):
You guys deserve a ton of credit for that.

And today, not a single employer probably could do
it themselves because they won'tbe allowed in their contracts.

Listen to episode 452 with Cora, where she gets into what she's
talking about here, just how hard it wasto kick a hospital out of their network.
Because of the contracts that theirTPA, third party administrator had made
that had nothing to do with 32BJ, butwhich 32BJ was stuck in the middle of.
This hospital, was costing them millionsand millions of dollars in excess charges.

(25:02):
Then 32BJ figured out a way to get ridof this hospital from their network.
And everybody, meaning everybodyin the union got the biggest raise
they had ever got, and employersgot a premium holiday for a time.
This is just how much thishospital was cha-ching, the union.
When there were other just as good optionsright down the road that members could

(25:23):
go to that were much more affordable.

We did it with almost no member noise because of exactly what
you said, we gave back to the members.
And I think that so often cutting costsin healthcare is about a bottom line and
less about the healthcare piece to it.
But if you give people a choiceand you can say, Here's access
to high quality docs and here'swhat you're gonna get out of it.

(25:46):
Because you're right, it's totalcompensation, whether you're
paying for it in your healthinsurance premium or in your wages.
And I don't know about you, I'drather have my money in my paycheck.

Mark Cuban (25:55):
Yeah, of course.

Than in a health insurance premium.

Mark Cuban (25:57):
Even if you have a doctor that you're currently using that's
not part of the network, right?
You can go to them and try tonegotiate with the doctor, or even
if they're part of a bigger systembecause they want to keep you.
Now, some will just say no.
If it's a market dominantnetwork, you're outta luck.
But if it's a specialist or somebody,they're always looking for patients
and they want to keep their patients.

(26:19):
And for the most part, we'vebeen able to negotiate.

Circling back to the high deductible health plan, which puts
a lot of indie practices in a reallybad spot, but also those indie practices
are probably some of the most agile andalso willing to do some of these things.
So the other thing that I just wannapoint out as a benefit of what we're
talking about here is that it doesgive some strength to these indie

(26:42):
practices who are currently suffering.

Mark Cuban (26:44):
But the crazy part is Stacey, like even when we talk to them
sometimes, they have like their oneor 2 billing people that have been
doing it the same way for 15 years,and it's hard to get them to adjust.
So you have to go talk to thesurgeon, their doctor directly.
You can't talk to their administrativepeople because they're like,
I don't want new paperwork.
I don't want to try new things.

(27:05):
But your bigger point is right on.
They are more agile and theyalso feel the pressure of all
the changes in the industry.

And also they feel the pressure of those, look at
me, I just keep, keep going back.
I keep going back here.
Of the high deductibles because they'rethe ones who don't have a huge endowment
and seven consultants who are at theready to try to figure out how to make
the challenge into an opportunity.
Indie practices just do not havethe wherewithal to be a bank.

Mark Cuban (27:32):
When I see hospitals, which is almost all of them with revenue cycle
management, consultants or employees,that's proof of failure, you know.
That means a system is a mess.
And again, it is always, it's who pays,you know, who, what's the price and
who takes on the risk for nonpayment?

I just read an article, I think in Modern Healthcare
about how the biggest private equityarea of investment these days is
in RCM revenue cycle management.

And I would say, who pays and what's the price?
And I would actually add a third P,which is, where does the power lie?
The idea was we wanted to put power backin the hands of the patient by having
choice through the high deductiblehealth plans, and it has now failed.

Mark Cuban (28:14):
And patients have no power.
None.

Right.
And you know, if we think aboutkind of other ways in which we can
talk through the concept of powerthat I think has really failed us
and this healthcare system, is thatthe power is not with the employer.
The power is not with the patient.
The power is oftentimes notwith the independent providers.
It's with the C-Suites.
It's with the large insurance companies.

(28:37):
It's with the hospital system.

Mark Cuban (28:39):
Well, yeah.
It's The C-suites don't even knowwhat power they have, and that's
where I spend a big part of my day.
Whether it's talking about directcontracting for medical or PBMs and you
know, pass through PBM transparent PBMs.
CEOs have no idea howthe whole thing works.
None.
And their HR people and their CFOs don't.

(29:00):
HR is just trying to survive becausethey have 15, depending how big the
company is, 15, 50, a hundred peoplewho got their, their pre-op denials.
And they can't even come towork 'cause their kids are sick.
Right?
And they have to deal with their kids.
And so that's what HR spendshalf their day dealing with.
Nobody wants to spend the time dealingwith, okay, how do I kick my BUCAH

(29:20):
out and go to direct contracting?

So let me use this as a segue, because a lot of what we have been
talking about in this first topic, is areally big foreshadowing and tee up to
the second solution to a problem where thesolution might be worse than the problem.
And that one is this, that one of thebiggest challenges for self-insured
employers is that healthcare and claims.
We have just spent the past 10 minutestalking about all the complexities here.

(29:47):
It's really complicated andthe whole payment system is
just ridiculously convoluted.
What the self-insured employer windsup doing for all the reasons that
we just talked about is hiring,is outsourcing, hiring layers
of vendors and administrators tomanage it all on their behalf.
But then again, you wind up with thislayer in the middle and we have just

(30:11):
talked at length about how that solutionmight be worse of a problem than the
original problem, which is, this is reallycomplicated and actually exacerbated
the complexity because you throw awhole bunch of consultants in the mix.
You throw the sprawlingbureaucracies in the mix.
You throw people who havespent the past 10 years,

Mark Cuban (30:30):
Well, why did all that happen?
The only reason that happens is to justifya lower level decision to HR, which then
justifies it to the CFO and or the CEO.
It's not that all thesethings are all that difficult.
I think, you know, what wetell companies is you need a
healthcare CFO or CEO, somebodywho just like, like Cora is right.

(30:53):
That you are the CEO of 32BJ's Healthcare.

Yes.

Mark Cuban (30:57):
You know, your whole mission is to optimize for outcomes for patients,
your members, and the economic side.
Any company with 500 or more employeesmay be smaller, can afford to pay somebody
$150,000 to do just that and get a returnof their money almost immediately because

(31:18):
they just don't realize just how muchmoney they're leaving on the table and
how badly they're getting ripped off.

Yeah.
Andreas Mang actually saidthat flat out on the podcast.
He said, look, any self-insured employer.
Whether they wanna face the truth or notis running a small insurance company.
Andreas Mang from Blackstone, episode 419,"The Financialization of Health Benefits".

Mark Cuban (31:43):
Yes.
Yeah, that's what Warren Buffet said.
You know, Ford Motor Companywas an insurance company
disguised as car company.

What were you gonna add, Cora?

I was just gonna say you need people who are healthcare experts.
And I agree with you, mark what you saidearlier, no one's a healthcare expert.
'cause every day I read a new article andlearn something new about healthcare, and
I've been doing this for almost 20 years.
Part of the challenge that exists,and one of the reasons we have, you
know, third party administrators andinsurance companies and PBMs, is that
we're asking people in HR whose jobshould be about the wellbeing of the

(32:14):
employee to be the healthcare CEO.
And their job, by the way, mostof the time is open enrollment.
They wanna make sure peoplesign up for the product.
Not ,is the product meeting their needs?
Not, are we making surethey have the right access?
Not what is the risk profileof our population, and should
we be caring about diabetes orshould we care about weight loss?

(32:37):
Or maybe we have a reallyhealthy population.
But what we're seeing is, there'sdifferent pockets and maybe you have
cancer problem and therefore youshould be focusing on screening.
Or you have, you're a teacher'sorganization and so you have a lot
of young parents and a lot of babies.
That is what the focus shouldbe on, and I agree with you.
I have always said, hire a healthcareanalyst and if they can find savings

(32:59):
worth their salaries, it means youhave a bad analyst, not a better plan.

Mark Cuban (33:03):
Right for sure, because there's plenty there.
I mean,

There's so much there.

Mark Cuban (33:06):
I mean, insurance companies are just stealing
companies, particularly self-insuredcompanies, stealing them blind.
I mean, that's why they continue tovertically integrate and buy up every
company they can, because that's howyou play hide the salami, you know.
That's how you hide all thenumbers from regulatory agencies.
I saw a stat that, I won't mentionthe name of the biggest insurance

(33:29):
company, but we can guess who it is.
Has over 2,500 subsidiaries and $161billion in annual intercompany transfers.
Now that $161 billion is 0.3% of theGDP of the United States of America.

0.3% of the GDP?
Episode 482 with Preston Alexandercalled "Three Surprising Ways
Carriers Make Lots of Money".
It's about the float, but alsothese intracompany eliminations.
Listen to that show if you didn'tunderstand what I just said.

Mark Cuban (34:05):
That's insane when you think about it.
But the bigger they get, theeasier it is to hide things.
So if you have an MLR of 80 to 85%.
But you get your PBM to chargeyou more, you're good, right?
If you're a carrier and you have a ratefor a provider and you gross it up some

(34:27):
for your self-insured sponsors, so thatthat balances their book of business for
Medicare and Medicaid and kind of worksin the interest of the carrier and the
provider, then, okay, but what aboutthe employer that's paying too much?
It doesn't matter, but they have,going back to what Cora says, it all
comes down to leverage and power.

(34:49):
There will be some networks that havemore power in certain markets, but more
often than not, the insurance companies,the reason they're so powerful is because
between the lives that they insure andthe lives that are on the formularies of
their PBMs, they effectively control allpatient and all revenue flows for the

(35:11):
entire $5 trillion healthcare industry.

I think I agree with everything you said.
And I'll say over the last, youknow, two years when we've gone
out to RFP and I've had a lot ofconversations with a lot of PBMs.
I've had a lot of conversationswith a lot of insurance companies.
On more than one occasion I havespoken to these consolidated entities.
And said, you are tryingto sell me a cost savings.
Here's a high performance network.

(35:36):
We're gonna drive this.
Do copay differentials.
And I finally raised my handone day and I said, you are
the one negotiating the price.
Why not negotiate a lower price?
We ended that section of theconversation and they moved on, right.
Because I think it fundamentally, ifyou are owning the provider or you
own the pharmacy in the PBM world,you are negotiating with yourself.

So I just wanna jump in here and say, we started out talking
about, and I think we have ended ina place which validates this with
three underlines and seven highlights.
That if you start getting multiple vendorsin the middle to solve complexity, you
wind up adding additional complexity.

Mark Cuban (36:20):
It doesn't have to be that way.
You don't have to work with the big PBMs.
And then the next question becomes,well, who does my medical right?
What am I gonna do therefor coverage there?
Direct contract, particularly ifyou're like one or two cities, you're a
union, right, that's limited coverage.
You can go all direct contractbecause you're self-insuring anyways.

(36:40):
You're effectively direct contractingis just disaggregating the different
functions from the insurance carrier.
You know, get your own TPA,that's what we've done, right?
Just have all thesethings done independently.
And then the biggest question is,what do you do for reinsurance?
Because once you've got the reinsurancecovered, particularly if you hire your

(37:02):
healthcare CEO, then you are good.
Like I think for our Cost Plus stuff, wepay less than $500 per family per month
with reinsurance, that starts at 50k.
So once that family, hits 50k, right?
Then the reinsurance clicks in.
And so for companies our size, we canafford that and it's not, we can take

(37:25):
on that risk, but for most self-insuredcompanies, that's the case as well.
We're a smaller self-insuredcompany, you know, with under a
thousand members that we cover.
So for anybody bigger, I would go rightto the hospitals and I, you know, you can
look at our stuff and we publish a CostPlus Wellness, but just sit down with
the hospitals and say, we don't wannapay premiums to an insurance company.

(37:47):
We wanna work with you.
They'll find a way.

And I think one of the things that you're really highlighting
here is one of the answers to all ofthis complexity in healthcare is that,
in the current market, employers,self-insured employers have been
convinced to buy discounts, whichare not actually buying healthcare.
And I think one of the things that youboth are saying is just go buy healthcare.

(38:10):
Just go buy drugs.
Just go buy what you need.
Listen to the episode 483 with JonathanBaran, where I go off for five minutes
at the beginning about how buyingdiscounts is the axle that a flywheel of
increasing healthcare prices spins upon.
And then listen to episode 483, parttwo, where Jonathan Baran offers similar

(38:32):
advice that Mark Cuban is about to offer.

Mark Cuban (38:36):
The only hard part at all is putting together a network.
That's it.
And in most cases, the carriers willsell you a wraparound network, you
know, for $18 per member per month.
And if they won't, you know, again,work with the biggest hospital system in
your town and they'll find a way to doit too, because they don't like working

(38:56):
with the insurance companies either.
It's just that they don't know howto go out there and sell direct
contracts and people typicallyjust aren't coming to them.
The business of healthcare,I can't say enough, is easy.
It's one of the easiest industriesI've ever seen, which is why there's
so much opportunity for us becauseagain, the doctors are gonna doctor.
The hospitals are going to hospital.

(39:18):
The only questions are howmuch does it cost, who pays for
it, and who takes on the risk?
And if you're self-insuredcompanies covering the 160
million people under your care.
You can afford to do those things.
You can take the risk.
You can ask for direct contractsand transparent pricing.
Your members will be athousand times happier.

(39:38):
Your biggest hassle is gonna bedealing with the TPA the first couple
times and just figuring out networksand transitioning some doctors.
It's not hard.

There's two things I wanna say to that.
I think it actually, it is reallyhard because we're asking people who
have never done it before to do it.

Mark Cuban (39:54):
Okay, fair enough.
Fair enough.

So I was gonna say, I think it's a little bit hard, but
I think there's two things here.
One, we're challenging peopleto do something different.

Mark Cuban (40:03):
Yeah.

Stacey, you and I were on a panel one day and she said this
brilliant thing that she claims shedidn't say, but I'm giving her a hundred
percent of the credit, which is weneed to stop talking about disruption.
Because disruptionmeans that it's working.
And it's not.
So we need to be talking about change.
And I think that's whatyou're talking about, Mark.
That's what I'm talking about.
We are trying to functionallychange the system.

(40:25):
And it's through thecollective action, right?
It's through employers comingtogether and saying, enough is enough.
If 160 million people are self-insured,or whatever the right number is,
if we all said timeout, I'm done.
Stop taking no for an answer.
Get a better consultant.
Get a better insurance carrier.
Get a better PBM.
Start with getting a better contract.

(40:47):
I've got a free contract for anyonewho wants one on a medical contract.
I'm gonna have a free PBMcontract to anyone who wants it.

Mark Cuban (40:54):
Perfect.

In the next coming months.

Listen to episode 453 with Claire Brockbank discussing
said contract, and also episode 484talking about Health Rosetta slash
Nautilus Health's open source contracts.
That last episode was with Dave Chase.

There is so much resource out there for employers
who wanna do something differently.
And I think that's really yourpoint, is that it's not that
hard to do something different.

Mark Cuban (41:19):
Yeah, and just think about it from a macroeconomic
basis, you know, we're saving10, 11, 20% in any given month.
That's a lot of money, that's alot of cash savings for everybody.
And trying to find ways tocompensate your employees more,
when healthcare is going up.
You can't do it.
It's Catch 22.
You're literally laying peopleoff so you have enough money

(41:42):
to cover your healthcare costs.
And then if we can get enough wholesalechange to Cora's point and things really
start to change, I mean, healthcare isthe biggest tax, healthcare insurance is
the biggest tax on the American people.
Like if you look, you know, somebodywho's under the ACA family of five makes
$125,000 a year for their healthcarewith the premium subsidies that are

(42:06):
still in place for this year are paying$1,500 a month, give or take, and
so that's $18,000 a year, over 120.
They're paying four or five timesthe amount in insurance premiums
that they are in federal income tax.
People really don't understand thatthe biggest tax that they pay are their
insurance premiums and that if they losethe subsidies, and we can argue whether

(42:30):
the subsidies should stay or go, but thatsame family is gonna pay $2,300 a month,
and that's before the $5,000 deductibleand the $19,200 max out of pocket.
A family of five making ahundred, can't afford any of that.
Most families, some hugepercent of them can't afford it.

(42:50):
So when employers start changing what theydo to Cora's point and going to the right
consultant, asking the right questions,even if it's a progression, you can't go
to direct contracts, you know, year one.
But slowly but surely you get involvedwith your own TPA, whatever it may be.

Listen to episode 485 with Cristen Dickerson, MD from
Green Imaging about how if you wannadip a toe into the direct contracting
waters, starting with imaging directcontracting is a decent way to go.

Mark Cuban (43:20):
Over time, that's how we'll change the system, and you're
changing it not only for yourmembers, but for the entire country.
Because we'll all learnthat there is a better way.
And that tax that we pay in healthcareinsurance, I mean, we've gotta start
realizing that's exactly what it is.
It's a tax that's put on, notby the federal government,

(43:41):
but by the insurance carriers.
It's paid directly from our taxmonies, that $1,500 a month with
the $800 ACA premium subsidy,that $2,300 a month now is paid
directly to the insurance companies.

It's a tax on both sides because you're paying the tax.
But then you're alsofunding taxpayer paid,

Mark Cuban (44:05):
Yeah.
You're getting hit twice, right?

Carrier.

Mark Cuban (44:06):
Your tax dollars, your tax dollars are, you know,
plus your insurance premiums.

Like half of the federal budget or something like that,
or even more is going to healthcare.
So yeah.

We've done similar math for our population that you were just
going through in the sense that over thelast 10ish years, wages went up 50% for
our union members, which is incredible.
Meanwhile, healthcare costs went up 230%.

Listen to episode 487 with Kevin Lyons about the state
of New Jersey Health Plan, which iseven worse if I'm remembering right.
A family health plan is now$67,000 a year for state workers
and members pay 35% of that cost.
That is a lot of money for ateacher or a firefighter or
a police officer or anybody.

And we know that had healthcare costs just gone up at the rate
of inflation, just the rate of inflation.
Our members would have more than$5,000 annually in their pockets.
That's groceries.
It's a vacation.
It's school books.
It's real things that allowpeople to have a life.
And I think that's the other piece is thatwhen we talk about high deductible health
plans, when we talk about the complexityof healthcare and all of these things,

(45:18):
is that these are choices then that everysingle everyday Americans have to make.
Do I put food on my table, gas in my car?
And we shouldn't have to put peoplein a position where they have to
pick between food and healthcare.

Mark Cuban (45:32):
Cora does a phenomenal job and I think what she's able
to do and the progression she'son can change the country.
And for my smaller companies, ifa union came to me and said, okay,
we'll negotiate wages, but in exchangefor us negotiating wages, collective
bargaining, we're gonna give you accessto our healthcare that core negotiated,
it would more than pay for itself.

(45:54):
You know, I'd end up probably savingmoney and most companies don't
understand that, but there's theselaws that prevent it from happening.
And who knows.

We should get Cora to be the CEO of healthcare.

Mark Cuban (46:05):
I agree with that.
I'm voting for that all day, every day.

I also think, Mark, there's probably a lot of union leaders who
really like what you just had to say.
So.

Mark Cuban (46:13):
Lot of 'em don't though.
I brought it up to a bunch of 'emand that's like too much work.
When you talk to doctors, right?
The core in nurses.
Not like their wages went up that much.

I mean, I think that goes back to the power piece
that we've been talking about.
Because let me be clear that when we'vetalked to hospitals, their first complaint
is the, it's the nursing wages that'sreally causing them to raise their prices.
But there's been, it's just not true.

Listen to the podcast with Vivian Ho, who has much to say in a very
well evidenced way about that comment.
Episode 466 with Vivian Ho, aneconomist who does all the math, and
concludes that clinician wages havenot by any stretch, gone up the same
rate as hospital prices have gone up.

Mark Cuban (46:55):
I did a study probably seven years ago.
I hired this company outta DC andI had just asked a simple question.
Hospitals will tell you theycan't live at Medicare rates.
You know, they need higher rates,which isn't true 'cause they
have to have pianos, they have tohave extra wings, all that stuff.
So I said, okay, medicine inCanada, let's start with Toronto.

(47:16):
Does the cost of a buildingin real estate cost more or
less Toronto versus Manhattan.
Cost more in Toronto.
Nurses.
Nurses and doctors, do they getpaid more in Canada or the USA?
Little bit more in the USA, butit's really, really, really close.
Band-Aids, you know, a hip implant,prosthesis, whatever, right?

(47:37):
The implants cost more inCanada, you about the same.
So why is it that Canadian hospitalsbreak about even and get paid 30, 40%
less than Medicare for the top 50, atleast back then for the top 50 procedures?
And they, some of them make alittle money, most lose a little
break even off their budgets.

(47:57):
What is it that's making it so that youknow American hospitals and these towns
can't at least break even at those costs?
It's because they just want to grow.
Right?
That's how, that's where the reward is.
The bigger you get, thegreater the rewards.
Whereas in Toronto, they're not justgrowing their hospitals left and right.
And so it's the incentivesthat are different.
It's not the ability to providethe care at a lower cost.

Yeah, and that's a really, really important point.
It's what are we trying to do here?
I mean, we could just goback to very much basics.
What is the point of havinga health plan at an employer?
Is it to get members better health?
And it's the same thing withhospitals, like what's a hospital
supposed to be doing here?
Is it adding beds and consolidating,or is it potentially improving
the health of the community?

(48:42):
Like if we really just wanna getvery De Novo about this whole thing.
And really start getting back tolike, what are we even doing here.

Mark Cuban (48:49):
And where do we wanna go, right?
Do we want universal healthcare orsingle payer or Medicare for all?
Well, you can't get from here tothere without transparency and costs.
What are all these hospitals going todo with all the digital technology,
robotic surgery, all that stuff?
How are they gonna get paid andstill advance the technology to the

(49:10):
point where we improve patient care?
And the only way to do that isto have complete transparency.
So that if the city of Dallas wanted tobe a single payer union, right, where
you cover all costs for all employees,well, if you knew what all the costs were
going to be based off your population witha little bit of actuarial projections,

(49:32):
right, or statistical analysis.
You could make that choice.
A state can make that choice.

I mean, the reality is healthcare is one of the only
commodities that you buy with neverknowing how much it's gonna cost.

Mark Cuban (49:42):
We we're changing that a little bit, but on on the healthcare side.
Exactly right.

We started out this conversation on the premise that
sometimes the solution is worse thanthe original problem, and we started
out talking about high deductibles.
Then we pivoted into, Hey,this is really complicated.
Maybe we should get some help here.
And I think what we have ended up withat the really highest level is that
these factors add up to these solutionshave resulted in a lack of transparency

(50:08):
at any way that you look at it.
It is so not transparent.
The unknown unknown is the biggestpart of the Venn diagram in some cases.
Then we also have pricingfailures at a magnitude, which
is to quote you, Mark, insane.
So if we're starting to think abouthow do we fix this, we've come up
with a number of different fixes.

(50:30):
One of them is direct contracting,but even, even before that, get a CEO,
get a leader of the small insurancecompany that many employers are
running off the sides of their desks.
You gotta be able to negotiate.
You have to be able to figure outwhat the strategic imperatives are.
I mean, this is reallya leadership position.
You have to, maybe you wanna havea doctor just saying who's weighing

(50:51):
in a medical director of some kind,who actually, you know, knows,

Mark Cuban (50:55):
Doesn't hurt

medicine.
So those are, I think, the main kind oftakeaways that I'm taking away from this.
I'm gonna ask Cora first, andthen I'm gonna ask Mark to bring
us home here and land this plane.
But Cora, do you haveanything that you want to add?

I would say you can't fix what you can't see, and
that is fundamentally one of thechallenges we've got in healthcare.
You can't see the rising prices.
You can't see.
Who's in network, who's out of network.
You don't always knowwhat you're gonna get.
You can't see quality, youcan't fix what you can't see.
But I really fundamentally believeit really is the collective action

(51:29):
of employers, of folks like Markand Cost Plus and what we're doing.
And some of you know Kevin Lyons anda lot of the guests you've had on your
podcast over the last few years, Stacey.
It is the collective action of thesevoices who are saying Enough is enough.
We have always said healthcarecosts are unsustainable.
I think it's about time we look, start tolook at things a little bit differently,

(51:50):
and that's what we're trying to do.

Mark Cuban (51:52):
Amen.
I would just tell you, if I wastrying to come up with a solution,
right, I'd go back to what I saidabout hospitals offering credit.
Think of it this way, if therewere no insurance companies.
Period.
End of story.
None, zero.
And everybody was responsible forpaying for their own healthcare
at some level and determining whatdoctors they wanted to work with.

(52:14):
If those providers were able to offercredit, but the pricing, let's just say
if they offered pricing that was Medicare,just to use that as a foundational number.
I think the solution then becomes, if thefederal government is willing to guarantee
that credit risk so that that provider,as long as they're charging Medicare or

(52:35):
under, and maybe some other establishedprice for services like MRIs, et cetera,
and taxpayers absorb that risk as longas the credit pricing was means tested.
Somewhat like Medicare does.
You know how the Medicarepremiums, it's 2%.
If you're FPL, you know one, or youknow 150% of FPL you'll pay 2% of et

(52:56):
cetera, up to eight and a half percent.
If we did something like that, thenproviders would all get paid so they
wouldn't have to play all these games withfacility fees and all the other garbage.
Insurance companies, insurance would nolonger be a barometer for healthcare.
They'd be out of the mix completely, andit'd be, you know, back to the future, you
know, 1955, where here's the price list.

(53:18):
You walk in if you want to have yourbaby at this hospital, it's this amount.
If you don't have the money,they'll provide you credit.
And if you're making, you know, Xamount of money, let's just, and
you could even pick a parameter thatsays if you're under 200% of federal
poverty level for individual or family,the government will cover it, right?
Because that's effectivelyMedicaid levels.
I think the system gets fixedjust like that, you know.

(53:41):
Now whether or not you can getproviders to work at a Medicare
level, to be determined.
Is there a different price point?
But that goes back to what Cora said.
What's the price?
Once we get that, who pays for it?
Pay for what you can afford to pay for.
Who takes on the risk of nonpayment.
The taxpayers can do it aslong as they have full audits

(54:03):
of all the providers, right?
Let the providers in this day of AIprovide their every general ledger entry
that they have so you can just look tosee what they spend all their money on.
If you're willing to be transparent likethat, so we all trust you, you'd cut
the cost of healthcare significantly.
Just the 20% that everybody saysis administrative costs, gone.

(54:24):
The simplicity, simple back to1955 where you can pay with a
credit card, cash or a chicken.

I like that.
Trust and simplicity was in thatlast sentence that you said, which

Mark Cuban (54:38):
Wouldn't that make sense though?
Wouldn't it make sense.

Stacey, Trust, Simplicity and a Chicken.

That's gonna be the title of this episodes.

Mark Cuban (54:48):
The question is, what's the question?

Mark Cuban and Cora Opsahl, I thank you so much for being
on Relentless Health Value today.

Mark Cuban (54:53):
Thanks so much, Stacey.
Great as always.

Thank you Stacey.

Mark Cuban (54:56):
Thanks, Cora.

Thanks, Mark.

Mark Cuban (54:58):
Hi, this is Mark Cuban of costplusdrugs.com, and not only
do I listen to every episode ofRelentless Healthcare Value, but it
is the most incredible, stupendous,amazing healthcare podcast in the
history of all healthcare podcasts.
So make sure to listen every single time.

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CrimeLess: Hillbilly Heist