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[00:00:00] Stacey Richter: Episode 443. "Let Us Never Pay The First Bill In Honor of Marshall Allen." This episode is a tribute to Marshall and includes a few words from Dave Chase. 

American Healthcare Entrepreneurs and Executives You Want to Know. Talking. Relentlessly Seeking Value. 

The first time I figuratively, not actually, met Marshall Allen was the day he did not meet Dave Chase for lunch. Dave was in Manhattan and he was supposed to meet up with Marshall, but something happened and Marshall was unable to make said lunch, so I filled in for Marshall, who I had never met at that point.

I zipped uptown to have lunch with Dave instead. We simply could not have Dave Chase eating lunch alone in my home city, I guess, and I was extremely pleased to ensure that that did not happen. Anyway, of course I met Marshall after that. I mean, being his standby and all. This was, I'm going to say, 10 years ago or more.

So when I saw the beautiful words that Dave Chase had written about Marshall after his death in May of this year, 2024, of course I asked Dave if he wouldn't mind coming on Relentless Health Value and saying a few words about Marshall and his legacy. 

After Dave talks, I have teed up an earlier interview with Marshall that originally came out on Relentless Health Value after his book launch.

I am sure that listeners of this show have heard Marshall speak many times, but I'd encourage you to listen all the same because this is Marshall talking to the healthcare industry. By that, I mean he's talking to us listeners of the show, and it was a little cathartic for me at least, to actually revisit.

If anyone is interested in supporting Marshall's legacy, please subscribe to the content available at Marshall Health Academy and consider purchasing access for employees. This is likely the best way to honor his legacy and amplify his work as a catalyst for change and to empower patients. There is a link in the show notes.

My name is Stacey Richter. This podcast is sponsored by Aventria Health Group. And from all of us at Aventria Health Group, our hearts go out to Marshall's family. 

Dave Chase Remembers Marshall Allen

[00:02:17] Dave Chase: I was honored to be asked by Stacey to share a few memories on our friend. Marshall Allen, in my role as founder of Health Rosetta, had the privilege of working with Marshall quite a lot on different reporting stories that he did, and I was honored to be able to join his family and friends at the celebration of his life.

It was certainly a sad day for all of us on Sunday, May 19th, when we lost Marshall. Let me just share what I think about Marshall. He was a dedicated journalist and also a former member of the clergy. He had an unwavering commitment to investigative journalism that really left an indelible mark on the healthcare industry. He was really a relentless voice for the little guy.

He shed light on price gouging, sloppy billing, fraud, conflicts of interest, insurance denials, and unnecessary treatments that preyed on Americans in our most vulnerable moments of our lives when we're in the healthcare system. Marshall had a passion for justice and transparency, and it wasn't just a professional pursuit.

It was really a personal mission. Marshall's work was driven by a deep seated desire to help individuals and employers understand and navigate the convoluted healthcare system and really about empowering them to overcome its many injustices and win in the process.

Marshall Allen's Impact on Healthcare

[00:03:44] Dave Chase: His impact went beyond just great reporting and fascinating stories. He had a huge impact on healthcare legislation. One of Marshall's most significant contributions was his year long investigation into the health insurance brokerage industry, which culminated in the publication of a pivotal article in ProPublica.

That investigation caught the eye of Senator Lamar Alexander, who was leading the Senate HELP Committee at that point in time, as well as on the Democratic side, Senator Patty Murray. They were seeking areas of bipartisan agreement, and the insights from Marshall's work played a crucial role in drafting and eventual passage of the Consolidated Appropriations Act of 2021, really a key part of that, regarded by many as the most consequential employee healthcare legislation since 1943. 

Marshall Allen's Book and Legacy

[00:04:38] Dave Chase: He didn't stop there, he wrote a book. "Never Pay the First Bill” is a tremendous resource for patients navigating the complexities of the healthcare system.

It equips families and employers with the knowledge and strategies to fight back against unjust medical bills and practices. and promoting a sense of empowerment and advocacy in the process. He also edited two healthcare books by Dr. Marty McCary. This further cemented his legacy as a thought leader and communications leader in the healthcare industry.

After the success of his book, Marshall founded the Allen Healthcare Academy. This is a platform dedicated to educating and empowering individuals to take control of their healthcare experiences. This really reflects Marshall's enduring commitment to making healthcare more accessible and fair for everyone, especially the most vulnerable.

And anybody who knew Marshall knew that he was really on a moral mission rooted in his faith. It played a significant role. in shaping his character and his work. In his New York Times piece entitled, "The Biblical Guide to Reporting", he shared how his five years of Christian ministry enriched his journalistic practice, fostering a sense of compassion, integrity, and dedication to truth.

He wrote, his years in ministry made him a better journalist because he was a Christian, not in spite of it, is how he put it. It's soured him to see people, quote, getting beaten down by the system. Marshall Allen's legacy is one of courage, integrity, and relentless pursuit of justice. His work has not only illuminated the dark corners of the healthcare industry, but has also inspired countless individuals to stand up for their rights and demand better, not to mention many journalists following in his footsteps.

As we mourn his loss, let's celebrate the remarkable impact he had on the world and take solace in the lasting changes he brought about. Marshall will be deeply missed, but his contributions will continue to resonate for many years. 

One of the people that Marshall was closest to as a friend and as an editor was Dr. McCary, and I'd like to wrap up with what Marty shared in a post announcing Marshall's passing. In his final hours, this is what I told him. Marshall, we watched you fight tirelessly for the voiceless. and become a fierce advocate for the defenseless. A fight many will continue. At every step along the way, you reminded many of us what's really important.

Thank you, my friend, for being a role model to so many. We will miss you dearly. 

I'd encourage you to bring some part of Marshall into your day every day and it'll be a much better day and you'll have a huge impact on our nation. And once again, thank you for the opportunity to share a few thoughts on Marshall.

Thank you. 

Interview with Marshall Allen

[00:07:34] Stacey Richter: Today, I'm interviewing the incomparable Marshall Allen. His book, "Never Pay the First Bill and Other Ways to Fight the Healthcare System and Win", a book with that title being on the New York Times bestseller list, has implications to healthcare leaders. Marshall's book is an instruction manual for patients on how to fight back against unfair and or egregiously inaccurate bills.

This interview with Marshall Allen is different from others that you may be hearing. Because listeners of this show are healthcare executives, I wanted this interview to be relevant to you. What does this book mean for you? Doug Aldeen told me one time, unless something has a direct impact on the CEO or leadership team at a health system or insurance co., they're just bored. 

Let me sum up this interview in one sentence. This is not boring. If you want to skip to the exact examples of not boring, you can skip ahead to about the 30 minute mark. We go through the ways that health systems can and probably will be hurt by the financial toxicity that they create.

Here's the three-ish ways that Marshall and I talk about. Number one, doctors who no longer trust their employers, i.e the health systems they work for, leave. And then you have to recruit new doctors. Hashtag problematic and expensive on a number of levels, but I don't need to tell you that. 

Number 2. Reputational damage. When the slogan on the door becomes a joke, that's a problem. 

Number 3. Employers and taxpayers reading bestselling books like this one and Marty McCary's, which also is or was just recently on the bestseller list. 

[00:09:16] Stacey Richter: Marshall's book, by the way, is available wherever books are sold. There are links in the show notes.

My name is Stacey Richter. This podcast is sponsored by Aventria Health Group. 

Marshall Allen, welcome to Relentless Health Value. 

[00:09:27] Marshall Allen: Thank you.

Marshall Allen on Healthcare System Issues

[00:09:28] Stacey Richter: You obviously have a very unique point of view as an investigative reporter. Do you want to just kind of clarify where you're coming from here? 

[00:09:36] Marshall Allen: Yeah, definitely.

Thank you. For the last 15 years, I have been doing deep dive investigative stories. Looking at our system from the point of view of the patient and also the employers who are funding the healthcare and also the patients especially are the ones engaging with the system. And so when I look at healthcare stories, I'm looking at how does this affect the people who are paying for it and the people who are undergoing the care?

Your audience is a lot of healthcare insiders, and I'm always very aware of that my stance is from the outside reporting on how the system's affecting patients. My sources tend to be on the inside because maybe a patient will tell me about a story, I'll be featuring a patient story, but then it's the insiders who help me understand what's going on so that I don't make any mistakes and also so whatever I report is fair.

You know, like ProPublica, especially, we're naming names. We're highlighting, you know, some form of wrongdoing that's harming the public. But I always want to be very careful that I'm naming, if I name names, I'm naming the right names, right? For that, I depend on the insiders to help guide my reporting. And by the way, those insiders also give me a lot of my best story ideas too.

So a lot of my tips come from the insiders. There's a lot of good people working within this very messed up system, filled with all of its perverse incentives. Those folks, often get frustrated, and then they end up coming to me and helping me do my journalism. 

[00:11:04] Stacey Richter: The binary that you set up is really interesting, insiders and outsiders, and it's probably a statement in and of itself that patients are considered outsiders in a system that's supposed to be serving them.

[00:11:15] Marshall Allen: No, it is. It's unfortunately the way that it's set up, and I think that's one of the biggest problems, right? Like in my book, I talk about the five reasons why people should fight back, and one of the reasons that I mention is that in the United States, we have this fundamental belief that the customer is always right.

And when you're a patient in the healthcare system, you assume that you're the customer because you're the one paying for it through your taxes, through your premiums, and your out of pocket costs. And you're the one undergoing the care. So you would think that you're the customer in this equation. But what's happened in healthcare is that the stakeholders treat each other more as the customer.

So the insurance companies are more loyal to the hospitals and the doctors than they are to their own members in a lot of cases. I've helped a lot of patients contest inaccurate or overpriced claims to their insurance company, sometimes blatantly fraudulent, where they say, this did not happen.

But then the insurance company will say, well, if it's documented, it happened. And so we're going to pay for it. And so you're responsible for it. 

[00:12:16] Stacey Richter: Yeah, I have heard many times the healthcare industry described as the only industry in which one person orders the dinner, someone else pays for it, and a third person eats it.

[00:12:27] Marshall Allen: I like that, except I would also argue that ultimately the patient is also the one paying for it. So, yeah, even the portion that's paid by employers, they're funding employee compensation, but then it's 100 percent employee compensation that's funding all the healthcare that gets provided through the employer sponsored plans, or out of pocket costs for the patient.

[00:12:48] Stacey Richter: Yeah, you know what, you're totally right. And I think that that's becoming all the more clear, even to patients who may not quite understand the full impact, but they certainly understand the impact of their rising deductibles and whether they realize it or not stagnating wages, which is one of the things that you've talked extensively about.

[00:13:09] Marshall Allen: Right, I'm trying to help patients have a better understanding of how even if their plan is paying for it, or they see it as their employer is paying for it, it's still that cost gets passed on to them. It just may be passed on to them over time. 

[00:13:23] Stacey Richter: Yeah, certainly. And as taxpayers, you know, same rules apply.

[00:13:26] Marshall Allen: That's right. That's right. 

[00:13:28] Stacey Richter: So, you know, your book is rife with all kinds of egregious examples, some of them outright fraud, some of them maybe just egregious, of our healthcare system doing its worst to patients. But do you want to pick one to talk about? 

[00:13:45] Marshall Allen: We could talk about any number of egregious practices, but let's just talk about one that I see quite a bit, which is upcoding.

Where a patient goes in, let's say like a young woman I talked to recently who went into an emergency room to get three stitches on her finger. This is a very noncomplicated. It was a small slice from her cutting an avocado. The knife went awry. She needed three stitches. That's not a complicated case, but she was billed, you know, emergency room visits can be billed at level one to level five.

Level one is the least complicated, and therefore it's reimbursed at the lowest rate. Level five is obviously the most complicated. It pays the most. She was billed at a level three emergency room visit. The problem there is that you're not supposed to just put whatever code you want to put because you want to get better revenue.

A level three emergency room visit is only supposed to be used when there's moderate complexity in terms of medical decision making, where there's an extended examination of the patient that's performed. In this case, there was no examination. And where there's an extended problem focused history that's taken of the patient.

That was not done in this case. So this was an example of a very simple, noncomplex emergency room exam that she received that should have been billed at a Level 1, that was billed at a Level 3. That type of upcoding is happening every day. All the time. And I don't think anybody is even looking at it. I certainly don't think the big insurance carriers are looking at it.

Because I've documented cases of just absolute egregious fraud. That they are very slow to police. Very biased about intervening and holding people accountable for. And I'm talking about criminal behavior, not just some upcoding. 

[00:15:29] Stacey Richter: It really seems like the industry seems to have bypassed discrete up coding and they're now approaching coding like it's some kind of, you know, as much as you can stuff in your face, coding buffet.

[00:15:39] Marshall Allen: Yes. And there's, you know, and you know, there's, there's software, there's consultants, there's people who actually help guide this process, right? Well, if you could add this diagnosis to it, you could show more complexity to the patient. Are you sure that patient didn't have that diagnosis? 

[00:15:52] Stacey Richter: Yeah, I mean, and then there's, there's readmission penalties and higher reimbursements.

There's all kinds of reasons why from a revenue cycle management standpoint, you'd want to, you know, upcode the heck out of it. 

[00:16:02] Marshall Allen: Yeah, you want to goose it just a little bit, right? Just so that you can maybe have it be believable, but get paid a higher rate. I'll give you another example. And this is the other thing that's so crazy about this is that everybody has experienced this.

I once had someone ask me, how does the industry respond to your stories? And I'm like, well, they know it's true. You know, like I'm writing about things that everybody on the inside knows happen all the time. And I don't think it's always something where there's willful intent, like it's criminal. I think it may be that the incentive pushes people that way.

I also think there's a lot of chaos in the way the billing system is handled. And so sometimes it might just be mistakes. So I'm not trying to impute criminal behavior here. It isn't necessarily criminal, but these are mistakes that get made. And then when you try and correct the mistakes, it's hard to get them corrected.

[00:16:52] Stacey Richter: Yeah, indeed. I mean, just to even take it up a notch, because it appears that we're taking it up a notch, there was just a big article the other day about a health system in Virginia who in the ER put a trauma team. So some gentleman came in, again, he needed stitches. They activated the trauma team and charged $52,000 or something like that because all these trauma surgeons ran over.

[00:17:14] Marshall Allen: That's incredible. In the book, I also talk about these are schemes that have been created within the industry to increase revenue, even though they're not necessary. The healthcare industry, as I've found over the last 15 years, is so driven by profit. That it creates these schemes and some of them are very deceptive and some of them are very dishonest.

I've been documenting those over the years and I include a lot of them in the book, but that's kind of the fundamental starting point for my book is that this system is not set up for the benefit of the patient. In fact, it is filled with deceptive schemes that are designed to take more money from working Americans than it should.

And unless working Americans and employers band together and push back using the strategies I've documented in the book, using other strategies that are that people are also putting into place to fight back and win, the industry is not going to stop doing it. On the financial side, the industry is actually oppressing the American people.

And until we stand up to the bullies, and get savvy about how this industry has been exploiting our sickness for profit, until we do that, it's not going to stop.

Strategies to Fight Back Against Unfair Billing

[00:18:28] Stacey Richter: So, just to make sure that I'm understanding your advice, you're basically saying, look, patients, every time you go to the doctor, regardless of whether you get an egregious bill or not, you know, if you are highly healthcare financially literate here, just call up and ask for an itemized bill.

Because the more people that do that, the more somebody's going to scratch their head over in the hospital billing department and go, oh, maybe we should just give this to everybody. It actually would be easier. 

[00:18:51] Marshall Allen: That's correct. And like the title of the book is a provocative title, right? It's called "Never Pay the First Bill".

Well, I'm not saying never pay your bills. What I'm saying is never pay the first bill until you have gotten an itemized bill and checked it to make sure that it's accurate and to make sure that it's fairly priced, and if it's accurate and fairly priced, then of course, pay your bill. But what I'm saying is, we have been expected to pay whatever aggregate sum is thrown at us, and we have been sued for these amounts.

I mean, the stories of hospitals suing patients, one in six Americans has medical debt in collections right now. And I think a lot of that is because we have not pushed back, we have not demanded fair prices, we haven't demanded that they itemize medical bills so that we can make sure they're accurate.

And so what I'm trying to show patients and employers is that your passivity, and a lot of it is for good reason, right? I mean, it's not fair that a patient should have to basically practice financial self defense at a time that they're sick. I mean, this is not a fair situation. They're victims here, but I'm trying to empower and equip the victims to understand the system, understand how the incentives are stacked against them, and then understand the leverage points they have to get the system to treat them in a fair way.

[00:20:11] Stacey Richter: Do you want to just give like maybe some top line context here? Because what you said is striking. One in six Americans has medical debt, but yet we don't push back. Why, why are Americans blind to, I mean, you've used the word fraud, you've used the word deviant, you've used the word egregious. Right? Like, how does this happen?

[00:20:34] Marshall Allen: I think it starts with us being trusting of the healthcare system. And we put great trust in doctors and nurses and the other clinicians who take care of us and heal us. But what we don't realize is that on the financial side of the industry, they are glomming on to that trust. They're piggybacking on that halo effect that we have with the doctors, the nurses, and other clinicians.

Our love for our medical providers who care for us and heal us and who we trust. The financial side of the industry, the middlemen in the industry, are glomming on to that trust and using it to exploit us. And they're getting away with it because the system is so complicated that it's almost impossible for a layperson to understand.

And also because people are sick, they're in a vulnerable position where they're just trying to recover from whatever type of care they needed. And so in the book, I try and help people see here's how the system works, okay? Here's how it's set up to exploit you. 

[00:21:35] Stacey Richter: And I think this goes, just goes back to the question is like, you know, everyone's just got to sit back and ask how much is enough.

There's in fact a great quote from Hippocrates, which is “everything in excess is opposed to nature. 

[00:21:49] Marshall Allen: Hmm. 

[00:21:49] Stacey Richter: He's the Hippocratic Oath guy, the, the prenom non nocere, the first do no harm guy. It seems like we're going back to first principles here just because you can charge that amount. Does it mean that it's ethical to do so?

[00:22:04] Marshall Allen: Right. I think that's the difference between making a profit and profiteering. Because nobody's saying that the industry shouldn't make a profit, but the issue is that this becomes profiteering when they start extracting as much money as they can from people just because those people are sick and don't have a choice about whether or not they should pay for it.

[00:22:24] Stacey Richter: Let me ask you this, Marshall. So in your book, you've got anecdotes involving, I mean not good anecdotes, troubling anecdotes. Involving billing clerks, PCPs, surgeons, specialists, employer benefit departments, out of network ER docs, health systems, insurance carriers, first responders, supply middle people, brokers, all across the board.

These are human beings who, some of them went to medical school. Is this perceived as kind of like victimless? You know what I mean? Like, I know you're not able to see into people's heads, so this is inarguably not a fair question, but like, how many, how is it that so many good individuals either drink, you know, so much Kool Aid, or feel so powerless to not push back on obvious financial toxicity? 

[00:23:08] Marshall Allen: There are a lot of good people also who are working within these companies or within these systems. They don't always know themselves exactly how it all works. They're not all looking at the profit statement and the revenue statement for the company. They're not all examining the massive executive salaries.

I mean, certainly a lot of them are not making those massive salaries. A lot of them might also be people who have medical debt in collections. I mean, odds are they are. I gave a talk at a conference and it was a health benefits advisors conference. And I saw this guy in the audience and he was nodding his head, nodding his head.

And I could see, you know, and my, you know, my, my presentations are, are not, you know, I'm not shy about what I'm saying here. 

[00:23:47] Stacey Richter: Yeah I was going to say, you're not gentle, Marshall. You're not gentle. 

[00:23:50] Marshall Allen: I'm not gentle. I think I'm very, I think I'm exceptionally fair, but I am very clearly on the side of the public that has been being exploited here.

I'm basing it on sound reporting. Anyway, this guy is nodding his head rigorously during my presentation. I just noticed him out in the audience. Afterward, I bumped into this guy and I said, hey, I couldn't help but notice you nodding your head while I was talking. I was just curious, was there something I was saying that resonated with you?

And he told me that he had just recently left earlier this year from one of the big blues. And he said he was their top sales guy. Now, I don't know if that's true or not. I didn't verify any of this. This is just what he told me. But he said he was their top salesperson and he said, I sat in these meetings and I kept trying to show them how they could save money, how they could do better for the members.

And yet he kept running into brick walls, you know, there kept being obstacles put in front of him when he would suggest things that they could do to improve what they were doing until he finally realized that that was not their ultimate goal. That wasn't really what they were trying to do. And at that point then he came to this moral crisis personally.

Where he realized, I don't think I can continue morally to endorse what I'm doing here. Even though he was a top salesperson making piles of money, he had to leave and go become an independent benefits advisor and do things in a different way. And so I think, I think everybody kind of, they're in the dark.

They don't understand how things work. And then they might come to that point of moral crisis where they have to make a decision for themselves about, is the money I'm making justifying this type of behavior and how it's affecting the public? 

[00:25:29] Stacey Richter: Well, you know, that juxtaposes really interestingly with, there was an article on “Healthcare Dive” in May about It talked about both patient trust and physician trust, but it said physician trust in their health system employers declined over 30 percent during the pandemic.

And I'm not sure if it was in that article or other ones. There's been a lot of talk about how there's been an exodus, you know, for the first time there's more physicians who are leaving hospital employment than trying to get hospital employment. So I think that might in a hopefully, maybe I'm overly optimistic, but maybe that's a signal that, and maybe if enough physicians leave hospital systems that are doing not cool things, you know, if you're looking at it from a patient standpoint, that the cost of replacing physicians, which is huge, like there is a huge cost in losing physicians and then having to recruit new ones.

I mean, maybe that's the WIIFM, the what's in it for me for some of these, for health systems to maybe take a hard look, especially if they're interested in the long game, as you said. 

[00:26:36] Marshall Allen: I think that is a great point. And when you think about this particular gentleman I talked to, now, let's say what he told me was true and he is a top sales person, right?

Well, they just lost their top salesperson. And that is a cost for that insurance carrier. I know you've talked, I listen to your show a lot. I really enjoy it. But you've talked to people who are doing things like direct primary care or creating centers of excellence models. So where you see employers beginning to think outside of the buka box, you're seeing some really innovative, less expensive, and higher quality of care options that are being developed.

It is working. We are seeing it work all over the country where employers venture out in that way. So I think the what's in it for me, if I'm in one of the big insurance carriers or one of the big hospital systems, they're in the position that my industry, the newspaper industry, was in, say, 20 years ago. The industry was already on the decline. They did not see the disruption coming. Like, when I got into journalism in 2001, obviously the internet existed at that point, and newspapers started putting the stories up on websites. The websites for newspapers were derided internally by the old school journalists.

We didn't take the threat seriously. And next thing we knew our entire industry was disrupted and decimated. And I think an argument could be made that the healthcare system is in that same precarious position right now. They just are riding high. So they haven't come to grips with it yet. 

[00:28:07] Stacey Richter: Well, you know, so speaking of online, let me pull a bunch of these threads together.

We were talking about physicians losing trust in their employer health systems exiting, but that same study in “Healthcare Dive” also covered patients and their trust in the healthcare system declined equally precipitously. It was like 32 percent or something like that according to that article.

I mean, and maybe a good deal of it is the financial issues that we were talking about before. I've heard more than once about how patients are scared to death to go to an emergency room or get care for something because they don't want to bankrupt their family. 

[00:28:46] Marshall Allen: That's right. 

[00:28:46] Stacey Richter: So this trust and loss of trust in the system can create really some powerful second order effects, which we might be seeing.

[00:28:53] Marshall Allen: That's right. And our, our healthcare system has always been penny wise pound foolish when it comes to revenue and not investing in the short term for things that will save money in the long term. We're so focused on the short term revenue cycle and that violation of patient trust is a massive problem.

And I think that's also why the stories I do get so much traction. In my book, I point out we have 20 years of data to look back within working Americans, can look back over 20 years and show how their costs have risen year after year without any relenting pause. And the rise is not justified when you look at the amount of wasted spending.

I spent an entire year, 2017, just documenting the wasted healthcare spending. They estimate that up to 25 percent of all healthcare spending is wasted. 

[00:29:45] Stacey Richter: So if we take the lack of trust as kind of the underlying means, let's just say, the first order consequence of these behaviors, but it's going to be the second order consequences that actually drive change in the industry, right?

Because it's those second order consequences when the lack of trust transmogrifies into, you know. 

[00:30:07] Marshall Allen: Yeah. Action. 

[00:30:09] Stacey Richter: And well into some meaningful consequence that the leadership teams of some of these organizations start to realize that the rest of the country is getting wise to their ways. We've talked about one of them, which is if you have so many doctors and other professionals who work in these organizations who just exit, like, that obviously creates a consequence that might light up a CEO's, lift their eyebrows, right?

But you know, there's another one, reputational damage. You had a bunch of different examples of where just the threat of Marshall Allen's pen created behavior change. Do you want to talk about that? 

[00:30:46] Marshall Allen: When you tell the truth about what's going on and the way the hospitals or others are treating patients, they become so ashamed, and they don't want the public to know it, that they change their behavior.

And this is something you see all the time. Like, people can look at the Kaiser's Bill of the Month stories. I love that series. And I've done these stories myself.

But a patient can be getting just steamrolled by a hospital billing department. Or a doctor, or a dentist, or whatever type of provider it is. They can be being treated so unfairly, they can fight this battle on their own for years, getting ripped off, not being listened to. As soon as the journalist calls, that PR department makes it in the incentive for that hospital to correct the behavior, and the behavior can be corrected within minutes. So that when the story comes out, they can say, “oh, well, we did correct this problem.”

Well, it didn't get corrected until, you know, the patient had to go to a reporter and get, and get the report in and intervene. And I often have found that the system, some of these hospitals, the way they treat people, they seem to care more about the image of how they look than they do about the reality of how they actually treat people.

And I think that's another indication that the patient to them is not their most important customer. So the customer is always right, but the patient isn't actually the customer. 

[00:32:06] Stacey Richter: Sunlight is sometimes considered the best disinfectant. 

[00:32:10] Marshall Allen: That's right. 

[00:32:11] Stacey Richter: Again, if done at scale, we could be creating a situation where once again, a leadership team's eyebrows go up because, you know, if the marketing department has to work overtime to overcome all the negative publicity generated by, you know, patients in small claims court taking selfies or something, then I'm assuming just based on the effectiveness of get a journalist involved, that approach is that the potential damaging of the image.

The pointing out the hypocrisy of whatever slogan is written on the door, that seems like something that leadership teams think is important. 

[00:32:48] Marshall Allen: I think it is. The big giant, though, the sleeping giant is the employers. 

The Role of Employers in Healthcare Reform

[00:32:53] Marshall Allen: If the employers woke up and got engaged, they have so much power. Because they're the ones who really control the flow of all the money in these employer sponsored plans.

[00:33:05] Stacey Richter: Let me interject there, though, because this has been said many times, but one of the issues that these employers have is that their influence tends to be diluted. Like, you know, if you have a giant health system someplace and any given employer in that area has 100 patients, You know, 200 patients, right?

I mean, it could be a huge employer with thousands of patients across the country, but in any given geography, their influence could be considered weak. How do you counter that? 

[00:33:35] Marshall Allen: Again, when they wake up, they're going to have to think about how they can do this in a strategic way. But you see, like in Colorado, employers banding together to create greater, a greater force of all of them banded together to demand change.

Now, all healthcare is local, so I really think this has to happen at a local level. But if you had employers who gathered together, let's just say in a city or in a region, and said, you know what, we're going to start funding direct primary care for our employees in our little location here. Now, this would require a lot of employee education, right?

Employees need to understand how their compensation is unjustly being taken from them right now. So they can also be motivated to try something different.

But let's just say they did a direct primary care relationship for their employees in one area, and they started their own little clinic. Well then not only are your patients getting their primary care paid for at no out of pocket expense, but then they can also be directed, some of these employers are then hiring what they're calling like a benefits champion to help guide and steer the employee or employee to the most high value care. 

They could enter into direct pay relationships with doctors and surgery centers or in hospitals who want to charge them fair prices. It could be done, they just haven't ever tried it. They haven't had the motivation to do it, and I think what I'm trying to do with my book, I have chapters for individuals and chapters for employers, and I'm trying to spur things in the direction where people need to think about this in a different way.

We need to reframe the way we analyze this and then stop doing things the same way and start doing things in a more innovative way that's going to protect our money while still delivering the best possible healthcare. 

Conclusion and Call to Action

[00:35:18] Marshall Allen: Marshall, your book is "Never Pay the First Bill”. Can people find this book anywhere that books can be found?

They can find it anywhere books can be found. And I want to emphasize the subtitle because it's "Never Pay the First Bill and Other Ways to Fight the Healthcare System and Win". I'm really focused on not just the problem, but it's a how to guide about what people and employers can do about it. 

[00:35:40] Stacey Richter: Well, buy the book, I read it and I highlighted three quarters of the book.

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

[00:35:47] Marshall Allen: It's been an honor for me. Thank you. 

[00:35:49] Stacey Richter: So let's talk about going over to our website and typing your email address in the box to get the weekly email about the show that has come out. Sometimes people don't do that because they have subscribed on iTunes or Spotify and or we're friends on LinkedIn.

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Thanks so much for listening.