EP529: How Stark Law, Stipends, and Noncompetes Drive Hospital Consolidation, With Eric Bricker, MD

[00:00:00] Episode 529, Facility Fees, Low Professional Fees, Stark Law, Stipends, and Noncompetes. The Chain Reactions, Wrecking Healthcare Affordability. Today I am speaking with Dr. Eric Bricker.

[00:00:23] American healthcare entrepreneurs and executives you want to know, talking, relentlessly seeking value. Hello, all you Relentless Tribe members. Hey, thanks for being here with me every week, some of you every single Thursday.

[00:00:42] Give yourself a little round of applause, maybe silently and in your own head, depending on where you are. But yeah, you matter. You being here matters. There's real power in this tribe of ours. And I'm not kidding to take a moment to thank yourself for being who you are and showing up in the way that you are. Many do not.

[00:01:01] And here's the problem with that. If we blame all of our problems on intractable, inevitable structural constraints, we lose our own agency. That is a brilliant insight from the episode with Dr. Lisa Rosenbaum from a couple of weeks ago.

[00:01:20] And it's not only important because you being here is also you taking back your agency and our collective, it takes a village opportunity to fix the healthcare industry in this country. But it's also the perfect lens for today's conversation because we are unpacking the exact action slash reaction chains.

[00:01:44] We talk about two today that were both very much a part of creating the healthcare mess that we're in and how we can actually take action to stop the chain reactions that are still actively chain reacting, still actively kinetically decaying or whatever the science word is.

[00:02:05] Having this information and understanding how these action reactions work is what it will take for us to figure out how to reverse the direction of these things, make healthcare more affordable, higher quality, better outcomes instead. This is Dr. Cristin Dickerson. Stacey not only unearths and distills the problems with the existing healthcare system, she also offers hope for a better future for healthcare and for restoring trust in the system.

[00:02:31] If you rely on this podcast as much as I do, please sign up for the RHV newsletter to stay informed. My guest today is the legendary Dr. Eric Bricker from A Healthcare Z. And together, as I just said, we are tracing these two distinct but very adjacent action-reaction chains that have collided to spark a fire of pretty staggering healthcare inflation and kind of the opposite of the quadruple aim. I'm Stacey Richter. This is Relentless Health Value.

[00:03:01] Thank you so much to Aventria Health Group, which is our founding sponsor. Thank you so much to our series Underwriter in 2026, Payerset. And I just want to let you know that Payerset just posted about 129,000 self-funded employers allowed amounts on their website for free. So do go over to Payerset's website if you want to check that out.

[00:03:25] Also, thank you so much to Patient Rights Advocate for a really nice donation this year. With that, let's get to it. Here is my conversation with Dr. Eric Bricker. Dr. Eric Bricker, welcome to Relentless Health Value. Oh, Stacey, thank you so much for having me. And thank you to everybody for listening and watching.

[00:03:45] So today, we're going to talk about how two kind of action-reaction chains have combined together to create a bigger action-reaction chain. So let's start with the first kind of tendril in our entwining rope here. And the first one I'm going to say is that there's two kinds of payments.

[00:04:12] One of them is facility fees. And then the other one is professional fees. You have said that it's interesting that facility fees are actually tracking with inflation, but professional fees are not. Do you want to dig into that? Yes. So important thing in healthcare finance to understand is that when you get a medical service, typically you don't just get one bill. You get multiple bills, right?

[00:04:38] And so at a very basic level, they separate out the bills for the physicians, that was called the professional fee, from where you had your service done, which is the facility fee. Which if it's done like at a hospital, it's for like the building and to keep the lights on and to pay for the nurses and the staff, et cetera, et cetera. It's two completely different billing and collection processes. And they operate actually fairly differently.

[00:05:01] And so specifically for traditional Medicare reimbursement, the payment for professional fees has relative to inflation is actually lower now than it used to be. Whereas the facility fee payment by traditional Medicare has largely kept up with inflation.

[00:05:24] And that has implications for things like Medicaid and commercial insurance as well, because a lot of times Medicaid and the commercial insurance, they kind of mirror what traditional Medicare does. And so a lot of the commercial professional fee reimbursement also hasn't been going up to keep up with inflation. And then on the facility side, a lot of commercial facility reimbursement is actually even outpacing inflation and it's rising even faster than inflation.

[00:05:53] So understanding the dynamic around how those you've got the two different bills and in terms of like how much is being paid, they're really separated. We often talk about how hospital charges are 50% of any given plan sponsors spend in any given year. And this is really an underlying component of that, which I really hadn't heard said in such stark terms before. That if you start thinking about it also, you've got two different organizations here, right?

[00:06:22] You've got the AHA who's lobbying for facility fees largely. And then you've got the AMA that's large, that's largely lobbying for professional fees. So it seems like to me, the AHA is quite a bit better at this. That's right. And so part of the, obviously, one of the largest, if not the largest lobbying forces in Washington, D.C. is healthcare.

[00:06:49] Between hospitals, the American Hospital Association, with physicians, with the American Medical Association, with health insurance carriers, with America's health insurance plans, with pharmaceutical companies, with pharma. I mean, they all do massive lobbying to the federal government. But really, at the end of the day, the American Hospital Association has been much more effective in having Medicare reimbursement to facilities, to the hospitals, go along the lines with inflation.

[00:07:15] Whereas the American Medical Association really has not been as effective. Look, tribe, this right here is a huge point that I have never heard dots connected on like this before. So I'm stopping right here, pausing, so that we all can let this sink in. And I'm going to add one more wrinkle here that I'm going to bring up again in a minute or so in the, actually, the original interview. Here's the thing. Hospital charges, facility fees are outpacing inflation.

[00:07:45] Part of the reason for this is kudos to the AHA for excellent lobbying. And fair enough. I don't know how big a part, but considering the millions spent by the AHA to this end, they are at least probably proud to take credit for a material bid of those increasing facility fees.

[00:08:07] Then you have professional fees, provider professional fees, which are not keeping up with inflation, flatlining, especially for like PCPs. But this is true for even in the air quotes profitable service lines like ortho, orthopedics. I've seen plenty of analyses showing real professional fee reimbursement for like total hip replacements, total knee replacements going down over time. I'm connecting this to the AMA. I don't know.

[00:08:36] Isn't the AMA supposed to be the big lobbying group in D.C. for doctors? I think so. Maybe I'm not sure because I'm thinking about the numerous conversations lately about how much money the AMA makes by selling ICD codes and about how only something like, I don't think 10 percent of doctors are members of the AMA. I will link to two videos from Dr. Elizabeth Potter about this. She's amazing. Follow her.

[00:09:03] But yeah, the AMA obviously has a $300 million business priority. That's how much they make annually off their code selling operations. But what's the problem with hospital payments skyrocketing in comparison to what an independent clinic, a physician can manage to get paid? What does this site of care variation incentivize? Longtime listeners already know where this action reaction chain is headed.

[00:09:32] And part of the reason for that, this is in my opinion, is that physicians are largely balkanized based upon their individual specialty. So you also have, you know, radiologists kind of have their own advocacy group and anesthesiologists have their own advocacy group and pediatricians have their own advocacy group. And so to a certain extent, the American Medical Association, as far as reimbursement goes, it's really hard for them to represent, quote unquote, all physicians. And so what's happened is that you've gotten these like these micro lobbying groups.

[00:10:02] And of course, because they're not coming together as a unified group, they tend to be less. Again, this is my opinion. They tend to be less impactful than the American Hospital Association, which is in a unified fashion representing America's hospitals. Just to underline that point. And then I've got my own opinion in all of this. I was reading a post by Dr. Grant Walker, offcall.com. And he said, for an appendectomy, the doctor's Medicare payment is $609.

[00:10:32] The hospital published charge is $48,126. Another one was inguinal hernia repair, doc Medicare payment $415. Hospital published charge $39,000. Right. So like this isn't just like sort of incrementally different. We are talking orders of magnitude. Those are orders of magnitude difference. And again, it's important to keep in mind that those numbers for the facility, that's the billed charges.

[00:11:01] That's not what they're actually getting paid by Medicare. But your point is still well taken for that appendectomy when the physician, when the surgeon is getting paid $600. The hospital might be getting paid probably $3,000 to $4,000. So you're still talking multiples of what the physician is getting. And that then translates over on the commercial insurance side where the oftentimes commercial insurance might reimburse maybe 20% above what Medicare reimburses the physician.

[00:11:30] So you're still talking like less than $1,000 for the surgeon for the appendectomy. But the way that the facility contracts with commercial insurance, it might be like $12,000. Right. So again, you're talking potentially upwards of 10X more than what the physician is being paid. The way that they get paid is very different.

[00:11:52] If we're thinking about the why there, also just kind of like relative to why the hospitals have been able to keep their reimbursement at the high levels that it continues to be versus the professional fee schedules being flat at best.

[00:12:12] It also could be that the AMA makes, I think I read a stat the other day, like 90% of doctors are actually not even a member of the AMA because the AMA makes most of its money off of the coding guides. The RUC, which you said the profession is balkanized. The RUC didn't help. Let's just put it that way. And if you want to go back and listen to a show all about that, listen to the one with Brian Klepper from a while ago.

[00:12:37] So the term site neutral payments is an attempt at fixing the current state, which is site unneutral payments. Right. Exactly. Because we wound up in a world where facility fees, hospital charges, are so much higher than professional fee schedules relatively and in comparison with inflation. So we have these big site unneutral payments.

[00:13:03] That's the bottom line here and the source of our first action slash reaction cascade. The very classic example is like an echocardiogram, like an ultrasound of the heart done by a cardiologist. If it's done in a cardiologist, Medicare pays a lot less than if it's done at a hospital. And so what that does is the site unneutral payments is just a scheme that hospital system use to maximize their facility fees, their facility payments.

[00:13:31] And what they do is they then buy the cardiology practice and they say, hey, cardiologist, now all your echocardiograms are going to be done at the hospital and not at your office anymore. And so we, the hospital system, are going to make a lot more money because we get all that volume of echocardiograms that used to be done in the office. And now they're done at the hospital.

[00:13:52] And we, the hospital system, are willing to pay you, the cardiologist, to buy your practice because of that future revenue stream of echocardiograms. The same echocardiograms are done. The same cardiologists are reading it. But then who's paying more are the taxpayers. All you've done is done the exact same service for the exact same number of patients and have it cost taxpayers more. That's all you've accomplished. And the hospitals will come back and say, well, we need to do all this because we have all these uninsured patients.

[00:14:21] They're going to have all these excuses around why they need to do this. That's fine. And some of those excuses may be legitimate. But the point is, it just increases the cost of care for the exact same service. Okay, so first action slash reaction. Chain site on neutral payments lead to consolidation. Consolidation leads to higher payments for taxpayers and plan sponsors, such as self-insured employers, as well as patients slash members themselves. So let's move on.

[00:14:47] Let's talk about the second action reaction, which is that the Stark Law happened, which gives rise to stipends. Right? So Stark Law and then we've got stipends. And I kind of want to define terms before we kick in on this. What is the Stark Law? Just to start out.

[00:15:10] Yeah, so decades ago, and again, the Stark Law actually only applies to federal programs. So it doesn't even apply to commercial insurance. It's just the federal government said, look, for any federal dollars, that hospitals cannot pay physicians for referrals. Because they used to do that. They're like, hey, you know, surgeon, if you want to do a surgery, if you do that surgery, you know, and the surgeon was independent.

[00:15:36] And the hospital would say, oh, surgeon, if you want to do your surgery over here at the hospital, we'll give you some money to do it over here, as opposed to our competing hospital across town. And so the Stark Law said, okay, well, you can't do that. That's illegal. All right? So fine. So the hospital can't do this quid pro quo. You do the surgery here, we'll pay you money for doing it. And look, certainly not advocating for doctors to get paid for referrals or anything that the Stark Law was trying to prevent.

[00:16:05] But in the land of unintended consequences, the Stark Law is one to study. Hospitals having an incentive to buy up local doctor practices we just talked about. And for a whole lot more on that topic, do go back and listen to the episode from last year with Dr. Bricker, where we really dig into all of the dirty and also lucrative little corners of that playbook, a link in the show notes.

[00:16:30] But not getting paid for referrals for those doctors, physicians not savvy enough or too balkanized, not organized collection action-y enough to get themselves into the stipend zone that we're going to talk about in a moment. Yeah. If these referrals were a source of revenue, now you have independent doctors having that source of revenue removed.

[00:16:54] At the same time that we have the hospital fee, professional fee disparity that we just talked about happening. So why not get bought or get hired by a hospital? It's just another point to ponder here. And so to your point around stipends is, I'm sure many of you are familiar with these stats where many physicians are now employed by hospital systems, but a lot of physicians and physician groups are not.

[00:17:19] And so when a physician groups goes to practice or see patients at a hospital, they sort of collectively as a physician group, it could be a group of surgeons, it could be a group of anesthesiologists, it could be a group of gastroenterologists, or a group of cardiologists, you get the idea. These tend to be physicians that actually do tests and procedures and see patients at a hospital, is they say, well, look, you, the hospital, it's against the law for you to pay me for referrals,

[00:17:46] but you need to give me a stipend, sort of a flat fee amount, to incentivize me to even have my patients go there at all. And so the hospital system might say, okay, sure, we'll give you as a GI practice or you as an anesthesiology practice, we'll give you a million bucks a year, $2 million a year, $10 million a year, $50 million a year. We'll give you, depending upon how big the hospital system is and how many physicians there are. And it's a contract.

[00:18:15] And the physicians agree to certain services, like they'll provide ER coverage and they'll provide inpatient consults, et cetera, et cetera. But essentially what has happened is that it's become a game of power and consolidation, where as the hospital systems have consolidated their power, there's not that many hospital systems in a town. I'm sure you've all heard the statistics before about how most metropolitan areas in America actually have very low levels of hospital competition.

[00:18:44] And so the physicians are like, oh, well, if we combine into larger and larger physician practices, then we'll have more bargaining power for larger stipends when we negotiate for coverage. And this has happened a lot with anesthesiology, right? So there's very large anesthesia groups now that say, oh, you want anesthesiologists for your OR? Then you need to pay us a very large stipend.

[00:19:10] And we have so many anesthesiologists in our group that if you don't pay us for this stipend, for us to sedate people for their operations, you're going to have a hard time finding any anesthesiologist to come sedate your patients for procedures. And part of the argument from the physician groups is like, look, you at the hospitals, you're getting a ton of money from commercial insurance and Medicare compared to what we get paid for our professional fees.

[00:19:38] So you need to give us some of that facility fee money, not in a way that would violate the Stark law in this quid pro quo way, but rather in the form of this sort of lump sum stipend. And these stipends have become very expensive for hospital systems. In some senses, some hospital systems are like it's one of our fastest growing expenses is actually to pay these stipends to these physician groups. I just want to back up for a sec just to kind of go through the chain of events.

[00:20:08] So we have the Stark law, which basically says you can't pay for referrals. You just can't. At the same time, we've got the action reaction that we were talking about before, which is that hospitals are now getting paid a ton more than the professional fees. So you could see if I was a physician kind of in that mix, I'd kind of be like, hey, what about me? So then, as you said, the idea of the stipend came up where a hospital says, well,

[00:20:35] I'm not going to pay you for referrals, but I'll pay you a million dollars a year for you to practice at my hospital. So that's how we're going to solve this issue compliantly. So then the idea of the stipends starts to happen. Doctors start banding together so they can preserve their stipends and negotiate with these hospitals. Then, of course, you've got private equity on the scene who's just like, hey, I sense an opportunity here.

[00:21:04] So then you've got the private equity kind of in the mix who's helping, I guess, roll up practices, not only so that they can get market power outside of the hospital, but also because there's an opportunity to raise the stipends. That's right. So we've got right now, we've got the impact of facility fees being high, professional fees

[00:21:34] being low, plus the Stark Act in these stipends. So all that's going on. If we're thinking about how, what that all adds up to relative to the patient, which by the way, we've been talking for, I don't know how long Dr. Berker and the word patient has, this is the first time it's coming up. That's right. That's right.

[00:21:57] If we're thinking about how all of this impacts patients, what would you start listing if I was going to ask you to tick off patient impacts right now? Yeah. So all of this just increases the cost of healthcare. And of course, one person's cost is another person's revenue. So basically the physicians in the hospitals are both acting to maximize their revenue, but somebody's got to pay.

[00:22:23] Yeah, the government pays, yeah, the insurance companies pays, but yeah, the patients pay as well. If you're traditional Medicare, you've got your 20% coinsurance that you're paying for all this. And if you've got commercial insurance, you've got your deductible and your coinsurance, et cetera, et cetera. So you've got higher patient out-of-pocket costs for these associated healthcare services. And so this is where the prices go up because the hospitals then go back to the health insurance carriers and negotiate higher rates for commercial reimbursement. Okay, so fine.

[00:22:50] Money, it's really not about the money. What it's really about is access in that anytime you raise the out-of-pocket costs for patients, you're limiting access for them. At the end of the day, like the quality of the healthcare, like doesn't matter at all if you can't access it in the first place. If everyone's just thinking about their own vested interest, at the end of the day, it is not a shock

[00:23:19] that care is not, as a trend, becoming more affordable. It's becoming incredibly unaffordable. That's right. That's right. And that's the famous, you know, Charlie Munger, you know, the vice chairman of Berkshire Hathaway, former vice chairman of Berkshire Hathaway said, you know, of course healthcare is messed up. The incentives are all wrong, right? And again, I like to say that, listen, Charlie Munger was on the board of directors for a hospital in Los Angeles for 35 years. The money is not aligned.

[00:23:44] It's not conducive to the physicians and the hospitals acting in the best interests of the patient. At the same time though, just because there is an incentive doesn't necessarily mean that everyone is acting in their own, you know, personal best interests. And you talk to a lot of, especially doctors and physicians that listen to this show, they're just like, you know what I did all day? Not make money. Like I did a number of different things every single hour, which I was not compensated for,

[00:24:14] but I knew was the right thing to do on behalf of my patient. And I think that one of the things that does become clear is that the further away you go from the patient, the more you start acting in alignment with exactly and specifically what the incentives are. The further from the bedside you get, the more the incentive is going to be predictive of behavior.

[00:24:43] If I'm kind of thinking through what the takeaways are here or what is the proactive action that can be taken, obviously we've got the issue with these stipends. We've got the issue, you know, consolidation of any kind. If we're thinking about the fact that this whole industry relies on market, the market to function in order for it to function. And then you've got this market consolidation that creates dysfunction in the market. However, that winds up happening

[00:25:13] is not a competitive market that's going to wind up rationalizing prices. It's becoming less and less fluid. You have less and less choice. And so unfortunately, I mean, you know, this isn't a great analogy, but that's why when you encounter healthcare, it kind of feels like going to the Department of Motor Vehicles. It's like, well, what are you going to do? You don't have any other options. This is where you get, you know, these issues of a physician burnout, et cetera, et cetera. Because what happens for the physicians is they're trying

[00:25:40] to do the best they can for the patient. And because they're employed by these hospital systems that don't have policies and procedures and priorities that are necessarily aligned with what's best for the patient. It's like, you know, decrease your length of stay, discharge the patient. Well, maybe I want them to stay for an extra couple of days, or maybe there's something else that I want to do. Maybe I want to do an inpatient service versus an outpatient service or what have you. And then when the physician is working at a location that does not align with how they want to

[00:26:05] best treat the patient, then they can't leave because they've signed a non-compete with the hospital system. So the physicians are stuck. It's kind of like the golden handcuffs. They can't, even if they wanted to leave, they couldn't. And there was a very good example of a group of physicians called the Tryon Medical Group in Charlotte, North Carolina, where that exact thing happened. They were bought by a hospital system. The hospital replaced their nurses in the clinic with medical assistance. And the physicians were like, no, we want nurses. We

[00:26:34] don't want medical assistance. And so they left and then they then had to sue the hospital to let them leave. And it was only because the hospital cried uncle and said, no, no, no, it's okay. And then the physicians called up every single one of their patients and said, we're leaving. And over 90% of the patients went with the doctors and didn't stay with the hospital system.

[00:26:59] And that Tryon Medical Group example is the exception that proves the rule. And the rule is the vast majority of physicians don't do that. They want to do that, but they don't have the organization or the courage or the gumption or what have you to do what Tryon did. So one of the things that would make it a lot better is if these non-compete agreements were like outlawed to say that, look, it's restrained trade. If the physician wants to leave, they can leave. And the hospital's like,

[00:27:26] well, we can't have them take all the patients and blah, blah, blah. Listen, at the end of the day, the most important thing that patients can do, that physicians can do is they can vote with their feet. It shouldn't take an act of Congress. Just vote with your feet and go somewhere else. And so things that are done that restrict patients from being able to vote with their feet and go someplace else are a problem, which is why we're talking about this.

[00:27:53] If we're thinking about advice here, what I'm hearing you say is to really harness the power that may exist for two sleeping giants. And I'm going to give the blunt version here, but for a lot of context, definitely go back and listen to the show from several episodes ago with

[00:28:19] Dr. Suhas Gandhi. I'll put the link in the show notes. The two sleeping giants of healthcare. So the first sleeping giant is the, it's almost a cliche at this point, self-insured employers who pay for healthcare, the ultimate purchasers for something like 60% of all Americans. You hear the term sleeping giant referring to them a lot, i.e. if the ultimate purchasers would actually harness

[00:28:42] the power that their dollars really should confer them, then things could change around here in the healthcare industry. This is where the large employers like Disney and Boeing and Home Depot and Lowe's, et cetera, et cetera, are like, we have to take matters into our own hands because these dynamics around physician

[00:29:05] and hospital price escalation and service escalation that the carriers have not been able to handle very well. We need to take, and my opinion is that's the right approach because no one is coming to save you. Okay. So the only, the only way you as an employer are going to address this is if you as the employer address it, nobody's going to save you. I'm sorry. I wish somebody was going to come and save you.

[00:29:35] That's the first sleeping giant. But the second one that, that has been coming up more often over here on Relentless Health Value is the idea of physicians, that what can be accomplished if physicians band together in a non-Balkanized way and advocate for themselves as well as their patients. And you gave one example just now. Another one might be what is going on in Eugene,

[00:29:59] Oregon with PeaceHealth. And there was emergency room physicians that were going to be replaced. Their hospital wanted to replace them with a private equity firm, locum physician group. The emergency room physicians banded together on behalf of their community, their patients, themselves, and fought that off successfully. Another example, I think there was a nurses union

[00:30:25] that did similar. Like, so there are examples these days of really compelling things which are possible if these groups are operating, you know, leveraging the power that they have, but also working together because you've got the ultimate purchasers, which are employers who have the potential to work with the ultimate deliverers, physician-led, independent ones, right? And really

[00:30:51] figure out what the optimal way is to, you know, kind of create a vice grip maybe on what's going on in the middle there. If I'm thinking about another piece of advice here, I'm going to say site neutral payments, site unneutral payments as a reason for, for example, hospital consolidation, independent practices being bought, et cetera. The important thing that I would say to the listeners of this podcast is that all of these

[00:31:19] games are very high stakes with lots of money involved. So site neutral payments is saying, hey, Medicare is going to pay for that echocardiogram in the physician's office or in the hospital. The same amount. And the hospitals don't want that at all. And then the commercial insurers are like, well, if Medicare is going to do site neutral, then we'll follow suit and we'll do site neutral as well. So quote unquote site neutral payments would be, would decrease the cost of healthcare

[00:31:49] for individuals and for employers and for governments. So those constituents all want site neutral payments and hospital systems do not want site neutral payments. Okay. So now we are in the advice portion of the show and we've got two pieces of advice so far. Number one, fix non-competes for docs and others so that folks can vote with their feet,

[00:32:14] which is what a market requires. Also fix site unneutral payments. That's a major driver in both our action and reaction chains of events leading to consolidation, which is the gas in a downward spiral of increasing on affordability, staggering healthcare inflation, market failures, pricing failures. Well, and, and this, and this is like specifically for employers, what they're doing today, like, cause it,

[00:32:41] cause it, cause it, you know, it's like what's within your control, right? There's your circle of concern and then there's your circle of influence. Okay. And so like, are you going to change Medicare policy when it comes to like site neutral payments? Like, no, like, but what you can do as an individual employer is this is where direct contracting has become a much more popular strategy for employers. Okay. So that's a real solution that our employers are doing today.

[00:33:10] I don't think a show goes by lately where direct contracting doesn't come up and yeah, it's a sea change and often logistically challenging, but there are also increasingly resources that help employers make direct contracts happen, including our sponsors, Upswing Health, Health Here, Zero Health, Line Marketplace, Green Imaging, and others. Here's Dr. Bricker with a third piece of advice. Dr. Bricker with a third piece of advice is really the, the entire fee for service model

[00:33:39] where just a doctor or a hospital system like does something and then gets paid. What that does is that doesn't create fee for health. It creates fee for service, just like it says. And so you're not incentivizing health, you're just incentivizing doing stuff. And everybody knows an ounce of prevention is worth a pound of cure. And that means treating conditions a lot earlier in the process in a much more proactive way as opposed to a very expensive

[00:34:07] reactive fee-for-service way. And so honestly, that's why I'm on the board of a direct primary care company because all direct primary care companies, they contract with employers on a fixed monthly subscription for unlimited use by the employees at zero out of pocket. So to the extent, and by the way, they've done this with specialist services as well. There

[00:34:30] was a group of urologists in Los Angeles that got fixed monthly payments to take care of specifically men with prostate cancer. And they found that the outcomes for those men with prostate cancer were better and more in line with urology guidelines when the urologists were not being paid fee-for-service, but instead were being paid on a subscription basis. So you as an employer,

[00:34:58] you don't have to, again, you don't have to switch all of your services to subscription-based. You can just start with primary care or just start with one specialty. And that is the beginning of breaking. You got to understand, listen, traditional Medicare, they keep moving the date by whether it's 2030 or 2035. They have no intentions of leaving traditional Medicare as fee-for-service. They realize

[00:35:25] that is not the future. That will bankrupt America and it's bad for America's seniors. So just know that the future of health care is not in fee-for-service. And, you know, and all the clinicians and hospital systems out there, I mean, there's going to be a lot that are going to go down kicking and screaming, but the future of health care is not the payment structure that it is today. Revisiting the top of this conversation, I just looked this up. The AMA has pivoted the narrative

[00:35:51] of CPT from a fee-for-service billing tool to a uniform data language necessary for measuring outcomes. According to AMA leadership, you cannot reward value or quality unless you can precisely track what services were actually provided. To this end, they have also launched a value-based care working group to shift how codes function so that they can be used for bundled care models and

[00:36:16] longitudinal and team-based care. It is, as aforementioned, a $300 million a year business, so you would expect them for sure to be protecting it. And so, again, I don't want to boil the ocean, but just look at what particular part of your health could you start paying on a direct subscription basis? I mean, there's gobs of employers that have

[00:36:42] already done this. This is not some weird hocus-pocus idea. If other people can do it, you can do it too. Go listen to the episode with John Quinn relative to treating Health Plan, the network, like I say, PlyChain. And then there's a short episode with Kristen Dickerson that was released in August 2026 about how, you know, in certain cases, especially if it's for radiology or something

[00:37:08] like that, fee-for-service could be fine, but then you can't have the same person in charge of driving volume who is also taking the fee-for-service payment, right? Because if the perverse incentive is volume and it's something like radiology where the radiologist can't be like, oh, we're going to do seven more tests, right? Then you're separating the incentive, that perverse incentive from who's got the power to abuse it. And in certain cases like that, sure. Right? So the show with Dr. Kristen

[00:37:36] Dickerson is a nice follow on there. Dr. Eric Bricker, is there anything that I neglected to ask you that you want to talk about right now? Stacey, you did a fantastic job as always. And thank you everybody for listening. And with that, I just, you know, keep plugging away. Stacey's not going anywhere. I'm not going anywhere. So just keep on keeping on. Right. And so if someone is interested in watching your videos, A Healthcare Z on YouTube, anywhere else you direct people.

[00:38:06] Yeah. Or follow me on LinkedIn. I think I'm the only Dr. Eric Bricker on LinkedIn. So either go to A Healthcare Z on YouTube or you can follow me on LinkedIn, both places you can see the videos. Dr. Eric Bricker, thank you so much for being on Relentless Health Value today. Thank you.

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