Introduction and Overview

[00:00:02] Stacey Richter: Episode 425, "Three Ways for Regular Clinical Practices to Take Cash When It's Cheaper for a Patient Than Using Their Insurance". Today I speak with Marshall Allen, 


[00:00:24] American Healthcare Entrepreneurs and Executives. You Want To Know, Talking. Relentlessly Seeking Value.  


The Current State of Healthcare and Insurance

[00:00:32] Stacey Richter: This show today isn't for the physicians or other clinicians or providers who are still taking insurance. Those who are going about their day being pretty normal. But at the same time, they're noticing one and or two things potentially going on. 


Here's thing one. They may be seeing patients struggling to afford care, especially patients with commercial insurance and huge deductibles. And, or thing two, they may have patients actually coming in and asking to pay cash. It's definitely becoming known in some circles that about half the time, the cash price for something is actually cheaper than the, in air quotes, negotiated rate with an insurance carrier. 


And this has really become an actionable insight for patients who haven't yet met their deductible bill. And some high percentage of patients, maybe upwards of 90 percent of patients won't meet their deductible in any given plan year.  


The Benefits of Cash Payments in Healthcare

[00:01:24] Stacey Richter: So all of this is probably some pretty obvious foreshadowing, but let's run through two maybe quick reasons why a practice might want to contemplate ways to make it easier for patients to pay cash when it is in fact cheaper for that patient to pay cash than it is for them to go through their insurance. Now, clarifying point here, we are not talking here about that patient always paying cash heretofore, like never using their insurance ever again, even if they get hit by a bus. No, we're talking about the patient coming in for some office visit or service, and today they want to pay with a wad of money they take out of their wallet and hands you. That is the end of the transaction that we're talking about here.

So here's the first of, let's just say, two reasons that a practice might want to entertain taking cash from insured, technically at least, patients. First reason, we have a situation in this country where 48 percent of insured commercial patients say that they are delaying or foregoing care due to cost or fear of cost. 


Sometimes I say this 48 percent number to a clinician and they will reply, “well, that's not in my practice or in my hospital. Our patients show up.” To which I reply, “yeah, because the patients abandoning care are not the patients that are coming in. They are abandoning. Care.”  


The Challenges of Implementing Cash Payments

[00:02:42] Stacey Richter: Now, the second reason a, in air quotes, normie practice might want to be thinking about how to help patients get the best possible price here is maybe less intuitive, but it's a financial motivation for the practice. 


I just saw Eric Vanderhoef. He wrote on a Listserv recently, and this is what he wrote. Here are some key findings from Tebra's report. Patient no shows and cancellations cost healthcare providers as much as $7,500 per month. That's a loss of $375 per patient.

Hmmm. Okay. Keep this in mind. The whole cancellations costing providers upwards of $7,500 a month. Coincidentally, I was talking to Dr. Paula Muto, she's the founder of UBERDOCs about this exact same topic the other day, just the crazy no show rates that many practices experience. 


And she made some really good points, which are exactly in-line. She said that if a patient knows exactly how much a physician visit is going to cost, because they're paying cash and the price is set between the doctor and the patient, so the price is the price, the end, no shows will go down. 


And this is especially true when the appointment is tomorrow and not six months from now when appointments are booking these days. It's kind of not normal for anybody to know what's gonna to be happening in lives six months from now. So no wonder patients fail to show. 


Dr Muto is recommending maybe having a couple of slots open every day for patients who want to pay cash. Doing this could help improve some, not all for sure, but some practice cash flow issues which are caused by the no show thing or the getting paid by the insurance carrier net, whatever, months later after a billing fight kind of thing. 


And it's also a win win for patients with high deductible plans, especially those patients who are coming in asking to pay cash.  


The Potential of Direct Contracting and Cash Prices

[00:04:46] Stacey Richter: In the conversation today, Marshall Allen, my guest, explains how to, in a simple enough way, how to operationalize the ability of a practice to take cash. There's a form that you'll need for insured patients. 


You'll actually need a cash price. It's also a marketing opportunity. For example, you can get listed with entities that connect consumers to practices that take cash, like UBERDOC. But there's also a growing movement of employers, especially in some parts of the country, who are looking around for providers who will do direct contracting or cash prices. 


Addressing Common Concerns and Misconceptions

[00:05:20] Stacey Richter: Alright. If I know you, you are thinking right now about all of the reasons why this won't work. So let me head you off at the pass. My guest today, Marshall Allen, solves for the most common issues that everybody brings up, including the big kahuna issue, the I am contractually forbidden by a health plan to allow patients to pay cash. 


You will need to listen to this podcast for the answer.  


The Complexities of the Current Healthcare System

[00:05:44] Stacey Richter: Now there are of course other hairballs to untangle that we do not address today. As Marshall Allen says, there are layers of dysfunction here. One bit of weirdness is something that David Schreiner told me about the other day. David is CEO of Katherine Shaw Bethea Hospital in Dixon, Illinois, and he's also the author of a new book entitled Be the Best Part of Their Day, Supercharging Communications With Value-Driven Leadership. Link in the show notes.  


David said that sometimes hospital payer contracts have the payer reimbursing the hospital for a percentage of overall charges. Yes, you heard that right? The hospital totes up using their charge master rates, the total amount of billings for the entire year, and the carriers pay a percentage of that total. 


So the hospital has a big incentive to keep charge master rates as high as possible. If some patients pay lower cash amounts than their carrier reimbursement, the hospital's carrier reimbursement will drop. Probably some math there, I guess, because if it's determined that patients aren't actually showing up for services due to cost, then they might be getting paid a percentage of zero by the carriers, but point taken still, there are for sure considerations to be thought through and for sure having contracts like this is one of them. 


Introduction to Marshall Allen and Allen Health Academy

[00:07:14] Stacey Richter: My guest today, Marshall Allen, probably needs no introduction, but 30 seconds from now, I ask Marshall for the skinny on how he started Allen Health Academy. 


And you will hear him introduce himself. So in the interest of eschewing redundancy, let's do this thing.  


My name is Stacey Richter. This podcast is sponsored by Aventria Health Group. And there are lots of links in the show notes to things that I already mentioned and many things to come.  


Marshall Allen, welcome to Relentless Health Value. 


[00:07:42] Marshall Allen: Thank you so much for having me here today, Stacey.  


[00:07:44] Stacey Richter: Before we start, you're doing so much with Allen Health Academy. Do you want to just give the short lowdown?  


[00:07:51] Marshall Allen: Yeah, definitely. So, I came into this through a really unexpected journey. I've done investigative journalism for about 20 years, about 17 years of that has been focused on healthcare. 


That led me to write the book, Never Pay the First Bill: And Other Ways to Fight the Health Care System and Win. The book is really a handbook and a guide for the working Americans and the employers to find their way out of this mess. And it's really like a how to book. That led me to launch Allen Health Academy because I saw this big need for healthcare literacy. 


And Allen Health Academy, the mission there is to equip and empower working Americans and employers to save big money on healthcare while getting better benefits. So I think the kind of amazing thing here is there's so much waste in our healthcare system, maybe a trillion dollars of waste a year that we don't need to keep taking more money from working Americans. 


We need the working Americans and the employers to assert themselves, demand a better deal, work with the vendors and the companies that are going to serve them well and serve them fairly. And when they do that, they can get better benefits at a lower price. So, that's what I call my audacious goal. 


I'll do webinars for employers. I have a video curriculum to train employees. When people apply these things, they can do it. They can get better benefits at a lower cost. 



The Importance of Health Financial Literacy

[00:09:17] Stacey Richter: We've always for eons talked about the importance of health literacy and what is becoming more and more clear with 48 percent of Americans abandoning or delaying care due to fears of cost. We're at this place where health financial literacy is completely underappreciated and potentially equally important, sad to say. Which leads us to it's interesting, Marshall, and heartening, I think, how there are individuals across the industry, these are the innovative ones or the ones looking patients face to face and actually seeing the turmoil and the trouble that this financialization of the healthcare industry is causing. And you had mentioned recently that you had a front desk person, I think, call you up and say that she wanted to help patients get the best price. 


And in her practice, she knew that if a patient paid cash, the cash price for the visit or labs or imaging, I'm not exactly sure what kind of practice it was. The cash price was cheaper than the insurance company negotiated out of pocket patient costs. Right? Before we dig in on that, do you want to, is there any background that you want to add on that conversation? 


[00:10:28] Marshall Allen: Well, about half the time, studies show, now that we have more price transparency, about half the time the cash price is lower than the insurance company's discounted price. And so this is exposing the scam or the fraud or the deceit of our insurance discount payment system. You see these prices and we believed that these big insurance companies were using their market power to get their members the best possible prices. 


That's their big selling point to the employers. Well, what we're finding now with price transparency is that's not true about half the time. Deductibles have now gotten so high across the board that about 90 percent of patients never meet their deductible for the year. And in some states now, we're seeing some policy changes where cash prices are able to be applied to deductibles, although that's not typically how it's worked. 


I had a woman who worked at the front desk for a psychiatry clinic who had emailed me to say, you know, I want to give the cash price to the patient, but I have these insurance company contracts that don't allow me to do it. How can I get around this? What can I do? And a lot of what I do is I help people hack the system by helping them see how the system works and then also how you can leverage different aspects of the system to accomplish what you need to accomplish. I mean, this is what has to happen now. Sadly, when you have a broken system, right, you have people having to navigate around the rules that are in place to accomplish what they want to accomplish.  


[00:12:03] Stacey Richter: You made a couple of really key points. 


One of them is if we're talking about commercial patients here, in other words, patients who have insurance through their employer. Yes. Something like 90 percent of patients never reach their really, really high deductibles, right? And what that's gonna mean is that the patient is bearing the full responsibility of whatever price the payer, their insurance carrier, negotiated for them. But you have this situation where, counterintuitively, the price that the insurance carrier negotiated, in air quotes, negotiated, I guess, is higher than the one that if the patient went in and said, hi, I'd like to pay cash, than that price. 


[00:12:48] Marshall Allen: It depends on the situation. Depends on the patient. Depends on the clinic or the clinician and what their billing system is. Depends on the insurance plan. It depends on a lot of stuff.  


The Potential of Cash Payments for Providers

[00:12:57] Stacey Richter: The conversation that we're going to have today is actually from the provider standpoint. If you're a provider and you're thinking to yourself, I would like to support this, I see the pain that these really expensive insurance plans with these really high deductibles are causing my patients, and I would like to do what I can in order to assist them. So I would like to enable my patient to pay cash in whatever way that I can. That's kind of what this conversation is about. 


And that's why this individual that worked at a front desk emailed you because she said, I want to help here, except I don't know that I can because I have these insurance contracts that forbid me from doing so, which is a funny thing to say. It's just, we as a society, and I was talking to Ben Jolley the other day about the same thing exactly happening in pharmacy, where you have these third parties who are, you know, as a society, we're enabling them to have immense power and control over transactions that they really have nothing to do with if they're not paying any portion of it, if it's entirely patient self pay, but that's probably a conversation for a different day. 


[00:14:03] Marshall Allen: Yes, I mean the, the layers and layers and layers of dysfunction here, but the one you're highlighting that the insurance companies are dictating a lot of what happens and then the clinicians feel controlled by the insurance companies and by their contracts. What I believe is this brokenness is really what's spurring the innovation and what's spurring the disruption and what's spurring the change. 


And so in a dark silver lining of the cloud kind of way, it gives me hope because I see that these clinicians don't like this either by paying the cash price, you can cut out that middleman, the patient and/or the employer pays less and the clinician gets more without all the hassle of filing claims with insurance companies, getting them denied, having to refile them, getting them pushed away, having all the clawbacks, the offsetting, all the other games that happen through the insurance payment system. 


I mean, it's estimated that system is wasting about $200 billion a year, just the complicated way that we pay for insurance claims. So again, if you could simplify this. Everybody would win, and by everybody I mean the people who are paying and the people who are providing the care.  


[00:15:14] Stacey Richter: So for more information on administrative waste and simplifying administrative waste, listen to the show with David Scheinker. That's episode 363. And there's also a show with Dr. Will Shrank. That's episode 413, but without further ado, what's this hack that you shared with the front desk administrator?  


[00:15:34] Marshall Allen: Usually I'm looking at this from the patient side, because patients hear all the time, if they're insured, they go to that front desk and they hear it all the time. 


Well, you're not allowed to pay cash because you have insurance. That is absolutely untrue. Just because someone has insurance does not lock them in a prison that requires them to use that insurance policy. We do have freedom in the United States of America. We can take cash out of our wallet or hand over our credit card and we can pay for things even if we have insurance. 


And my workaround for this from the patient point of view has been to cite the HIPAA law to prevent the clinician from sharing your insurance information with the insurance company. So that way they're actually not allowed because of the HIPAA privacy law to get paid by the insurance because you don't allow them to share your private information with the insurance company. 


And that's actually very effective from the patient side, of course, it puts you in a position where if this is non-emergency care, they might send you away, they could always deny you. But basically what you're telling them is, hey, if you want me to come here and if you want my money, I'll pay you cash right now, but I'm not allowing you under the HIPAA law to share this information. 


And if there's one thing we know, it's that clinicians and billing departments, they are afraid of violating HIPAA. That is like the nuclear option to cite HIPAA. And what I find is that this really makes them comply.  


So in this situation, I just turned it around. And I said, hey, front desk person, here's what you could do. Tell the patient to cite HIPAA so that you're not allowed to share their information with their insurance company. So I know you feel an obligation to these insurance company contracts. Well, the federal HIPAA law trumps insurance company contracts. Now, I'm not an attorney. So I ran this by a health care attorney and I asked the attorney, hey, is this really as clear as I think it is? 


And he says, absolutely. The federal law is very clear. You don't want to violate the federal law. And then what you tell the insurance company is if they ever asked, well, the patient would not allow me to share their private information with you, insurance company. So I offered them the cash price and they paid cash. 


[00:17:41] Stacey Richter: Yeah, I am actually reading here from a website which begins hhs.gov. Here's what it says you and it's speaking to the patient here you the patient can ask your healthcare provider or pharmacy not to tell your health insurance company about care you receive or drugs you take. If you pay for the care or drugs in full and the provider or pharmacy does not need to get paid by your insurance company. 


There you go. It's basically a HIPAA explainer on hhs.gov for patients. But it's so funny and ironic, honestly, to hear you evoke the HIPAA to be used by the provider on behalf of the patient in this case. Because usually it works the other way around, you know, usually HIPAA is wielded by carriers themselves. 


It's like this magic trick. If anyone asks an insurer for anything and the carrier wants to make it vanish, they don't say abracadabra, they usually say HIPAA and then, you know, everyone stands down and goes away.  


[00:18:43] Marshall Allen: Yes. I'm so glad that you and I'm sure a lot of your listeners to appreciate the irony in all this. Because, HIPAA has been used to hide information so often. So what I love is kind of the jujitsu kind of reversal, where now the patient and the clinician can use the HIPAA law for their advantage too, so that they can protect themselves from the shackles of the insurance company. It is kind of a fun little twist there. 


Practical Steps for Providers to Implement Cash Payments

[00:19:08] Stacey Richter: What makes it even more somewhere between ironic and ridiculous is that if you actually read HIPAA, like if you pull it up on your computer and it's easy to find, but spoiler alert, like 90 percent of it is actually a love note to the carriers themselves, and it governs the data that they must process and the structure of that data. 


Only about 10 percent of it is about the privacy of the data. And in that 10%, it really clearly specifies that the patient has a few rights. And of course, one of them is that nobody can be the boss of the patient when it comes to them being in charge of who can and cannot get their data, especially when it's self pay. 


[00:19:51] Marshall Allen: And by the way, just another side note, this technique also works really well to get an itemized bill. I mean, the first thing I recommend every patient do when they get a medical bill is make sure it's itemized with the billing codes so that you can check the prices and the accuracy of the bill. And you have to get an itemized bill. 


And citing HIPAA to the billing entity is extremely effective to get the itemized bill. And you can also get that information from your insurance company if you're insured,  


[00:20:17] Stacey Richter: Which is also really important to note if you're on the other end of that phone. I mean, most of the people that listen to this podcast, Relentless Health Value podcast are in fact in the healthcare industry or clinicians, you know, are sitting on the other side of the table facing patients. 


So all of this information is also really important if you are trying to figure out how to do the right thing by patients and get them that itemized bill or enable them to be able to pay cash. So again, let's just take this from the standpoint of a practice who's trying to figure out how to help patients who want to self pay. Do so. 


So one thing that we have, it sounds like deduced is you can do this and that there are some hacks. One of them being the evoking of the HIPAA, if we're thinking about how to do this more systemically though, right, like definitely know that it's certainly possible, what's your advice for a provider organization who may be thinking in this way? 


[00:21:19] Marshall Allen: Let's just finish with this HIPAA, citing HIPAA. I would have a form that the front desk can have. I would train the front desk on what the HIPAA law actually says and what's actually allowed. And then I would have a form that a patient could sign that says, I'm citing HIPAA and under HIPAA, I, the patient, am not allowing you, the clinic or the billing entity, to share my private information with my health insurance company. 


And so I would do that. I would keep it in the patient file, at least for this visit. It could just be per episode, you know, because it might not make sense for the insured patient to do that every time. But I would have that form already pre-written out so all they need to do is sign it, and then they can pay the cash price. 


I think that would protect the clinic in case the insurance company ever asks them questions about it. And it would also just make it a smoother thing to operationalize.  


[00:22:12] Stacey Richter: Yeah, that would seem like a dot the "I" cross the "T" kind of thing to do to have an in writing form and also could prevent misunderstandings just between the patient and the office. 


So for sure, having a form and thinking about things that Jerry Durham, who was a guest on the podcast several years ago that he has said relative to just making sure that the office is trained, and I don't mean that in any kind of pejorative way. I just mean, everybody's... 


[00:22:43] Marshall Allen: No. Of course not. This is complicated. 


[00:22:44] Stacey Richter: Yeah. Well, everybody also has to be singing off the same sheet of music. Like, there's just so many examples where a patient comes in, says, I want to pay cash. And then the front desk is like, you can't. Right? Like, because people aren't necessarily talking amongst themselves.  


[00:23:00] Marshall Allen: Part of it is that too many people are on autopilot. 


You know, we've been doing it this way for decades, so they assume that this is the only way it can get done. And so everybody cares about compliance. Everybody wants to do the right thing. And so it makes people more tentative or more insecure about doing something different. And I think part of that training for that staff of that clinic would include why we want to offer this cash price. 


This is obviously great for patients in many cases, but it's also great for the clinicians and the clinical side of this industry. I mean, you look at the opportunity here. You have, say, 160 million Americans covered by employer sponsored insurance plans. You have another 20 to 30 million who are uninsured. 


So you have a massive, massive market of people who might want to pay cash. If you go more toward cash or at least offer cash, the clinic also doesn't have to deal with all the insurance company denials that are associated with those cash payments. They get that money immediately rather than having to wait months for the insurance company to pay it. 


And there's also just a market for this. I mean, there is a demand out there that's growing and growing for people who want to as a patient control their own destiny and then as a clinician who want to control their own destiny. So I think a big part of that training would be to help everyone in the office be on the same page with why we want to not just sort of offer this, but why this is a great opportunity for us. 


[00:24:31] Stacey Richter: You bring up a couple of really, I think, very win win types of points. One of them is there is a market for this. Many people with just these high deductibles that we just discussed, they're never going to reach them. And the prices that they're paying are too high that they could actually pay a cheaper price if they were paying cash. 


And if you think about this from the provider side, just this whole, trying to get paid business on a good day, you probably get paid by the insurance company net, whatever it is, 30, 60, 90, right? Plus you have the issue of the prior-auths and the steps. I was talking to a clinician the other day, I was talking to two clinicians. 


One of them was trying to prescribe a drug. It was like a $19 drug, generic. And apparently it was prior-auth'd because just PBM shenanigans, right? So like the branded drug was actually on formulary, and the generic was prior-auth'd. And I said, why don't you just tell the patient to pay cash? Because the cash price for the generic was $19. 


The insured price was $19, as well as the, the cash price. And if the patient had just paid the cash price, then not only would you pay the exact same price, but there would be no prior authorization. Incredible. Right? But like, that same thing often holds true also for medical services. Again, I was having a conversation with somebody who needed like a very small cyst excised or something and it wasn't large enough. 


The insurance company will only pay if the cyst is above a certain size, like in millimeters or something. And this was too small. Well, what's the cash price? It was like $300 or something like that. But if you looked at what the patient copay would have been, it would have been like $500. Again, there's just these circumstances where it just makes sense for everybody. 


It saves so much time and it's not actually more expensive for the patient to just figure out how to do this cash business.  


The Future of Healthcare and the Role of Direct Contracting

[00:26:36] Marshall Allen: Right, and the big picture to me, Stacey, we need to have the more direct pay happening between the consumer, the patient and or the employer, and the clinician that's providing the care. 


The more we can do that, the more we pull these deceptive schemes out that are extracting money and adding cost without any value, the better healthcare system we can have. So it does give me hope that as this becomes more mainstream, we will see a transformation in our healthcare system that will be for the better of the public. 


[00:27:07] Stacey Richter: Ticking through our what now bits of advice for providers. Number one would be there is a hack, which is the HIPAA hack, if it's needed, but you're definitely going to want to operationalize that within the practice. So it would be really important to have the right paperwork for the patient to sign just in case it's needed. 


The other bit of it would be to make this a practice wide endeavor. You know, like this can't be some kind of skunk works going on at the front desk.  


[00:27:37] Marshall Allen: I think the next piece here is that you actually have to have a cash price, right? You have to set a price somehow and display it, you know, like a, like a menu of prices so that people can go in and they can see, okay, if I need this particular service, here's the price.  


Now that's obviously an internal conversation that any clinic or ambulatory surgical center or whatever needs to set. So the question is well, how would you set the price? What would you look at and there are a few places people can go and again? This is these are things that I show the patients how to do but the medical providers can also do these same things so for instance, if you want to see the average price that insurance plans are paying for different services in your zip code, go to fairhealthconsumer.org. That's a non-profit organization that's been collecting what insurance companies are paying, averaging it out, and publishing it. It's really easy to search that website. So you could look up the prices on fairhealthconsumer.org. That's the average insurance price. Just beat that or go below that for your cash price. 


You can also look at Billy, our friend, Leon Wisniewski has put together Billy with some partners and Billy again is scraping the hospital websites where they've been posting their prices and it's showing them on a really nice interface. It's like a visual map that shows you prices for different services and hospitals. 


So if you're wondering what the prices are out there in the market by insurance plan, they're right there for you to look at. Other websites that publish prices or do direct pay? colonoscopyassist.com does colonoscopy direct pay for cash prices? Jason Health, does cash pay for lab services? Green Imaging, does cash pay and direct pay for imaging services? And so you can get an idea of what prices are for different services that are provided out there and then you can see how your pricing should be competitive or would be competitive with these other prices you're seeing in your community.  


[00:29:36] Stacey Richter: You listed a number of resources there and we can put these in the show notes as well. 


You had mentioned fairhealthconsumer.org, billy.com, colonoscopyassist.com, Jason Health, Green Imaging, you also mentioned. And these are reference tools, research tools, that a provider organization, a practice could use to determine what patients are actually paying in your market and as long as you pick a price that's competitive, that should be good. 


It should be fair, I mean, you probably could also go all MBA and do cost-plus like how long did this actually take or whatever. So anyway, there's probably a number of different methodologies to do this and the simplest one is just go see what other people are charging.  


[00:30:20] Marshall Allen: Yes, and then the other thing about all these sites is that these provide an opportunity for the frontline people providing the care so they could go to Green Imaging. 


Green Imaging does direct contracting with imaging centers all over the country. They could become a partner with Green Imaging, and then Green Imaging is helping to market their services they provide to people out there who want to pay cash. Jason Health, you can do the same thing. I know with Billy, it started with just scraping the hospital websites and downloading all their price transparency, you know, spreadsheets and then making that easy to search. 


But now you're seeing other independent imaging centers and others sending their pricing data to Leon at Billy, and now he's getting that loaded into Billy. So now Billy's going to have more than just the hospital prices, it's also going to have prices from entities that offer people cash pay services. 


So these same places that you can go to check prices are also places that you could go to see if you could partner up to see if they would list your pricing. And you'd obviously have to work with each of them. I don't know exactly how each of those entities does that. You just have to reach out to them and work through it. 


But I think that's what's exciting now is that you're seeing more of these vendors find ways to operationalize this, to streamline it, to make it easier for the patients to find where they can get these services at a fair price.  


[00:31:49] Stacey Richter: The one thing that I'm just going to infer based on what you just said, that these, for example, Leon from Billy, the fact that these entities are getting the inbounds on this is a bit of a testimonial relative to innovators out there who are figuring out that there's a market for this. 


Patients are in fact, they want this. Everything that we're just talking about, I think it's a win win for patients, but it also should be a win win for practices as well. If we're talking about $200 billion a year, it was the figure that you mentioned of waste, and I mean, I don't think we ever can forget that somebody's waste is somebody else's profit, right? 


So there's $200 billion that's sloshing around on the table that some middleman is just picking up and sticking in their pocket. Like this is not a conversation about the overall value of insurance or anything like that. That's not what we're talking about here. What we're talking about are ways that the insurance system has been exploited for the benefit of these for profit entities who are scooping all that up and distributing it to CEO salaries and shareholders. 


Right? Like this is the wealth transfer aspect of insurance that we're talking about. And if patients and their doctors get together here, then the practice can have some advantages that you just talked about. They can get paid. They don't have to deal with prior-auth in certain circumstances. They actually, you know, if you just count all the clawbacks and fees, they may actually wind up making more money on a unit cost basis. 


But at the same time, the patient also can win here because they are actually paying less than they would pay if they went through the insurance negotiated rate from both a out of pocket standpoint, but also maybe potentially from a convenience standpoint, at the end of the day, I think what you're advocating for and what this all adds up to is how do you find the win win between a doctor and their patient, not only from a clinical perspective, but then also from a financial perspective. 


And there seems to be some opportunities to do so.  


[00:33:54] Marshall Allen: Yes, that's right. And I think the final kind of tier of partners here is these organizations that do a lot of direct contracting directly with the employers. So we've been talking about how to reach the individual patients, but I think ultimately when you have that direct contract between a health plan, like the whole employer sponsored health plan, or a TPA that works with a lot of health plans, and then they have a care navigator working for the TPA or working for the employer sponsored plan, that's then directing the patients to the places they have these direct contracts and I know like Dutch Rojas is the name that comes to my mind when I think about direct contracting gurus. I mean, there are others out there too, but this is something that is growing. It's a movement that I think we want to support. And the reason I say that is because the current system, as you just described so well, it's not set up for the benefit of the employers and the employees who are paying for the care and the patients who are receiving the care. 


It's really set up for the benefit of the middlemen who are trying to keep things under their control in a very opaque, overly complicated system, they're taking too much control and they're taking too much money without adding the value. We need to reward the entities as employers and as employees and patients. 


We need to reward the clinicians who are treating us fairly and giving us a fair price, high quality care at a fair price. And then we need to shun the ones that aren't. And as much as we can do that, I think we will be able to steer the market in the right direction and bring about really positive change. 


[00:35:36] Stacey Richter: I'm just going to ask one last question here. And this is a bit of a, I'm going to say in the weeds query, but it's a pushback that I hear a lot when anybody talks about taking cash. Are you ready? Fasten your seatbelts, but then I'll have to pay credit card fees.  


[00:35:53] Marshall Allen: You'll have to pay credit card fees. So I guess I would work that into the price, right? 


So that's part of the cost for any service that they're going to provide. So I would just build that into your cost. I mean, there is so much margin with these insurance company prices. And this is what's mind blowing when you look at it. The average working person on a commercial plan is paying two to three times the Medicare price. 


That's on average. So if a clinic wants to just look at their Medicare price, and I know they're going to say their Medicare price is too low, well, so build it out at 150 percent of Medicare or 180 percent of Medicare. If you did two times Medicare, that would be a great deal for most people on commercial insurance plans. 


So, I would just build all of those extra costs like credit card fees into your price so that you can, you know, absorb that when you get paid your cash.  


[00:36:44] Stacey Richter: And I think the point that you're also making it within that answer is it's still a win for patients still. Even if you add an additional 1 percent or 2 percent or 3 percent or whatever. 


[00:36:57] Marshall Allen: Absolutely it is. Add that percentage, the patient is still going to win and then it doesn't become a bigger loss for the clinic.  


Conclusion and Final Thoughts

[00:37:04] Stacey Richter: So, Marshall, is there anything I neglected to ask you relative to this topic that we want to wrap up with here?  


[00:37:10] Marshall Allen: This has been a really fun conversation and what's exciting to me, it's sometimes unexpected for me to get an email from a person in a clinic trying to figure out how to serve patients well. 


But I think one thing that we forget sometimes with all of the talk about the kind of nasty stuff that happens in healthcare, is that on the clinical side, they really do want to serve patients well, and they are also victims of this nonsensical insurance network system with these contracts and these restrictions, and so they're looking for a way out, too, and that's why I love this conversation. 


Because we're looking at it from the point of view of the clinician who wants to break free of these shackles and find ways out. This is a way out. And it's just a start now. So again, what the cynics will say is, this is never gonna work. This is not happening. This is impossible. Well, you know what? It's already happening. 


It's already working. And so we just need to build on what's working and keep making that more mainstream.  


[00:38:08] Stacey Richter: And that's just how innovation always tips, you know, if we're trying to find the tipping points, it always works this way, that there's a few people who figure out how to do it. These early innovators, early adopters, and then it spreads and promulgates from there. 


So it sounds like this is something which has started. And this is arguable, but as Malcolm Gladwell says, you only need 12 percent of a market doing something before the tipping point happens and it becomes completely widespread. And this is already starting. Marshall, where can people learn more about Allen Health Academy and take a look at the number, all of the resources that you have. 


And granted, most of them are for patients at this point, but where might I find them?  


[00:38:55] Marshall Allen: I put out a regular newsletter. That's a really good way to keep in touch with what I do. That's at marshallallen.substack.com. And then I also, if people want to learn more about Allen Health Academy, go to allenhealthacademy.com. You can also go to marshallallen.com to learn more about me.  


And also just one thing I always want to plug, I raise money through my newsletter to hire patient advocates for people who have especially complicated cases. So if you're out there, let's say you're an advisor, you're an HR person, or you're even a patient, who has been caught up in the real red tape nightmare of a billing situation, reach out to me. 


My newsletter subscribers have donated money so that I can hire patient advocates and I do that for free for people. I really enjoy doing it. So if people are in that nightmare situation that they can't get out of, reach out to me and let's see if we can get a patient advocate to help you.  


[00:39:49] Stacey Richter: We will put links to the Substack newsletter and the other resources that Marshall just mentioned in the show notes. 


Marshall Allen, thank you so much for being on Relentless Health Value today.  


[00:40:01] Marshall Allen: Thank you, Stacey.  


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