Emily Jacobson

If you're visiting my profile, just navigate to "Replies" for the good stuff.

*taking deep breaths* Hospitals aren't buying these ortho groups for the Medicare revenue. They want the doctors commercial patient panels. Independent docs get squeezed by Medicare, sell to the hospital and suddenly the hospital bills commercial insurers 250% of Medicare rates plus a massive commercial facility fee for the exact same knee replacement. Doctors aren't just trying to escape govt underpayment. Public underpayment acts as a feeder system for hospital monopolies to ingest independent providers and bleed commercial insurance plans entirely dry. Also although I read this source daily, please know this is biased ... by hospitals.

Why orthopedic groups are leaving Medicare and helping to make hospitals more money beckersspine.com/orthopedic/why…

And since your plan sponsor also pays this markup, guess what happens to your premiums??

Hey Mark, I've read more about cost plus wellness today and I have some questions. 1) So far the only companies that are participating in your CPW are your own companies, correct? So we are looking at less than 100 employees? 2) How are you handling stop-loss? What is your premium for stop-loss? Do they exclude individuals with pre-existing conditions? How will you handle stop-loss when you scale? 3) If you were subject to same rules as an insurer, would your network meet adequacy requirements?

Disagree. Still. They try to operate the same way every other insurance company does. Tell me what any of them did differently than the conglomerates ? Like I said. Costpluswellness.Com got lower prices than mid tier plans. Because we approached the whole thing differently. We negotiated prices to yield more for the provider , while costing us less. And this is just a few months old. Wait till we scale

Everything in the hospital could cost $1, and the insurance companies conglomerates would buy them, raise prices, and make sure their top and bottom lines grew I'm not saying hospital systems are innocent, far from it. But the big vertically integrated insurance companies create the annual plans that crush people's financial situation

Helpful review of the evidence on the relationship between health insurance coverage and mortality: annualreviews.org/content/journa…

@mcuban @DutchRojas @HEALTHCOSTtruth 70-75% of capital investments unrelated to care

Real estate/land. They buy independent practices and real estate to build a geographic monopoly that boxes out competitors and forces insurers to accept their pricing. ​It's the same reason PE is swallowing rural hospitals. They use leveraged buyouts to load the facility with debt, strip the physical real estate through sale-leasebacks to REITs, and leave the local community with a hollowed out asset trapped under fixed rent. ​The hospital system isn't structured or incentivized to be efficient. It’s structured like a capital holding company maximizing its real estate footprint.

It's kind of a fruitless argument. Should Physicians be allowed to own hospitals? Yes. Did AHA lobby to prevent them from owning hospitals so they could eliminate competition? Yes. Would allowing Physicians to own hospitals improve clinical outcomes? Not necessarily. Would allowing Physicians to own hospitals improve the financial ledger? Not necessarily. What would help is fixing the underlying CAPEX structure.

@DutchRojas @HEALTHCOSTtruth And these are Dr run hospitals in NYC I don’t think there is a way to take the position that this has led to lower healthcare costs in the city of NY ?

Absolute facts, Tim. To answer your question.. business that has legally separated its revenues from its liabilities. They privatize the massive monopoly margins through exec comp and CAPEX expansion, but socialize the operational costs through public donations and tax-exempt status. It’s an elite capital allocation magic trick.

@EmHealthStrat @mcuban @DutchRojas It is a series of structural issues that results in U.S. HC costs being $2T a year more than they should be. U make some good points about CAPEX but what business is able to pay for PPE with donations and then still have the highest costs in the World.

FDA regulations are better than systemic chronic disease driven by industrially engineered, hyper-palatable diets

That's precisely how UHC operates, except not to do better for the country and the world. Solely because the lawsuit always results in a financial penalty that is a slap on the wrist, a cost-of-doing-business. Because the profits always outweigh the penalty. If only us mere plebs could have that luxury...

@EmHealthStrat @mcuban @DutchRojas Emily - I think we should not be worried about lawsuits - let lawyers wear those suits - we can do better for the country and the world.

I could wait until you scale. Or you could just hire me to solve for the structural blind spots in your risk architecture right now. Your retail pipeline is great, but the macro catastrophe pool is a completely different beast. Let's fix it. Regionals can't do it differently, Mark. That’s the entire point of market architecture. They aren't emulating the conglomerates out of choice, they are structurally trapped by the physics of a risk pool. The conglomerates "do it differently" by hiding margin internally. When individual plan premiums get squeezed, United shifts profit into Optum, and CVS shifts it into Caremark. They use an internal pharmacy and provider network to absorb the losses. A standalone regional plan is a pure financial pass-through, they have no corporate shell game to play. By federal law, insurers must spend 80–85% of premium dollars directly on medical care (MLR). A regional plan can't magically price lower or "process" their way into a discount because their baseline cost of care is dictated by the hospital monopolies, who they have zero leverage against. They can't just shift profits around to artificially hit an MLR target. You cannot run a catastrophic risk pool on a retail philosophy. To even hold an insurance license, these regionals must maintain state-mandated financial solvency and statutory reserves to cover worst-case claims. If they just "did it differently" and ignored the baseline math of the hospital systems, state regulators would shut them down for insolvency. They didn't exit the market because they emulated the giants. They exited because they couldn't emulate the giants' vertical hedges.

@Tirth7777 @mcuban @DutchRojas Careful, that is how United ended up with a federal class action lawsuit.

@mcuban @EmHealthStrat @DutchRojas Insurance can be fast through AI - I can think about ideas and present it in next few days.

You should check out my own website, I made it entirely myself (with help of Claude code, of course) EmilyHealthStrat.org The Performance Architecture Simulator breaks down all the math for a hypothetical Medicare Advantage plan. There are two buttons about the simulator, if you toggle over to "How it works" it will breakdown all of the math for you.

I realize you sent me Cost Plus Wellness but the core concept remains the same. Direct contracting works for predictable, low-acuity outpatient care. But if an employee has a $500,000 ICU trauma stay or a NICU emergency at that monopoly hospital, a small employer cannot force them to accept a "wellness template." They get hit with raw, unhedged out-of-network chargemaster rates that instantly wipe out a small employer's self-funded risk pool. If a mega-hospital system controls 80% of the beds in a city, they have zero incentive to sign an open-source contract with a small employer. They don't care about a quick payment promise. They will dictate their massive commercial markups or just refuse to participate.

Regional plans do not have that kind of leverage. Easing administration achieves nothing for them. Not when the hospital board prioritizes profit over the administrative burden on their employees. Regional plans must contract with that monopoly hospital to meet legal Network Adequacy requirements to even exist. The hospital knows the plan has no choice but to sign, so administrative niceties buy exactly zero negotiating power.

@EmHealthStrat @DutchRojas As I’ve said before. I’m not saying the hospitals are good actors. And that they do t take advantage of market dominance. They do. How many of those regionals offered to pay on time ? To reduce denials ? To pay the contracted rate and not clawback ?

Small insurers who do it differently can price lower and they can get better pricing because they do it differently? That's blatantly false. In commercial contracting, volume drives discounts, not administrative politeness. A small regional plan with 20Klives has zero leverage walking into a monopoly health system that controls 80% of the beds in a city. The hospital isn't cutting them a deal just because they promise to pay faster. They will dictate the price or force them out of network, which kills the plan. The plan has to meet Network Adequacy. Smaller insurers actually get worse baseline pricing from hospital systems because they lack the market share to negotiate. Without volume, you take the price you are given. You are also confusing a retail cash transaction with a catastrophic risk pool. Direct contracting and cash pricing work beautifully for predictable, low-acuity care, like a generic drug or a primary care visit. But a standalone regional plan cannot "cash contract" away a $500,000 NICU stay or a $150,000 cancer treatment. Small insurers don't delay or deny claims to copycat the giants. They do it as a desperate brake-check because they don’t have a $160B internal cushion to absorb monopoly hospital billing. If a non-integrated regional plan just autopaid every hospital invoice to "do it differently," the risk pool would empty out and they’d be bankrupt by Q2.

Because they price to the market that the big insurers set , and they emulate the same processes. They late pay, under pay, deny , drag out peers to peers, etc. just like the big companies. The smaller insurers that do it differently, can price lower, because they can get better pricing , because they do it differently It’s the same reason cash and direct contracting pricing are lower

If vertical integration is driving the cost, how do you explain why standalone, non-integrated regional plans are seeing the exact same premium and deductible hikes? They don’t have $160B in internal transfers. They don't own a PBM or a provider group. Yet their numbers are also skyrocketing, while being legally capped for margin. The flaw in your logic is blaming a specific corporate structure for a system-wide inflation problem. Non-integrated plans aren't playing a shell game. They are just getting hit with the exact same monopoly hospital price tags as everyone else. The common denominator isn't the payer's structure, it's the hospital's baseline price. Just look at the Medicare Advantage volatility. Of all firms who totally exited Medicare Advantage in the past year, 100% were standalone, non-integrated regional or provider-sponsored health plans. BCBS of Vermont, Premera Blue Cross, BCBS of Arizona, Moda Health, UCare Minnesota, etc. etc.

@EmHealthStrat @DutchRojas No. The companies are vertically integrated. They can do 160b in intercompany transfers. It doesn’t matter which company the margin dollars are in. They all drive each other 70 pct of their revenues are from taxpayers.

Pay first and sue later means the cash is already out the door. If a regional hospital monopoly can invoice $5,000 for a $500 scan, pocket the money instantly, and force payers into endless lawsuits to claw it back, the risk pool collapses before the first court date. That just turns the insurance pool into an interest-free loan for mega-health systems. You are giving the entity with the rigged price tag all the cash and all the leverage. Worse, standalone regional payers could never survive that cash drain. You would instantly bankrupt the non-integrated plans, leaving only the giant conglomerates who have the capital to absorb that float. Your solution accidentally forces the exact vertical integration you are trying to stop.

@EmHealthStrat Claims aren’t bills. They are applications for billing. Yes they carry information. But if physicians were paid for their work, the invoice could carry the same data.

Talking to independent physicians, it's obvious that the big insurance carriers are doing to them, what their PBMs are doing to independent pharmacies. They deny, underpay, slow pay, clawback, and create administrative mazes, knowing their victims don't have the time or resources to fight. Why ? By putting financial pressures on physicians and pharmacies, it makes them more likely to sell their businesses to them , close their doors, or refer the business to their captive pharmacy or provider. All benefitting the biggest insurance companies We need to ditch the concept of "claims" and make every delivery of medications or care as a billable event that must, by law, be paid on a timely basis , with interest charges for any delays. If the physician or pharmacy doesn't deliver , the carrier has plenty of legal options already. As does the patient. This is not an efficient market. This is the big guy abusing the little guy. It needs to change to better the care we get in this country