For shoppers, CEOs, and staffers
How not to get ripped off — and how to argue for reform.
Self-pay vs insured, self-funded vs fully insured, a cash-pay flagship, direct contracts, and a packet you can actually hand a policymaker. The building is on Flagship. If they ban you from the network, that fight is on Hostile world . How monopolies actually die is on Kill the monopoly . The full self-funded walk-through is on Self-funded. Sharing ministries vs the card is on Faith. Start with the consumer journey if you want premiums, deductibles, and who knows the price.
You, with a debit card
How to shop care with cash
Pretend insurance is not in the room. You are buying a defined episode. Ask for the prompt-pay cash menu — not the chargemaster.
Name the SKU
‘Knee replacement, primary, no revision’ is shoppable. ‘Orthopedics’ is not. Get the CPT/DRG. Compare the same SKU across a hospital, an ASC, and a second state.
Cash menu ≠ rack rate
Hospitals publish two opposite numbers. The rack / chargemaster is the shakedown list for people with no deal. The prompt-pay cash menu is often below what insurers ‘negotiate.’ Always ask which one you are looking at.
Shop quality and price on the same page
A cheap MRI with a sloppy read is not a bargain. Sort by quality, then pick the lowest cash among the places you would actually let cut you. Academic is not automatically better for a routine scope.
Get the extras in writing
Facility, surgeon, anesthesia, implant, pathology, and the saline bag. Surprise bills live in the lines nobody quoted.
CEOs, CFOs, benefits leads
Self-funded: the cost-benefit, without the brochure
If you have more than a couple hundred lives, you are probably already the insurer. The carrier is a rented claims desk plus stop-loss. Act like the buyer. The full walk-through is on Self-funded: two piles, who keeps a good year, why cash almost never shows up.
Self-funded — who keeps the leftover
What you actually buy today
Claims + TPA/ASO fees + PBM spread + stop-loss premium + broker. The ‘premium increase’ is mostly claims trend and admin, not a magical insurance product getting more valuable.
When self-fund wins
Wins when you can steer shoppable spend (imaging, scopes, joints, infusions) to posted-price sites, keep a real stop-loss for blow-ups, and stop paying two bureaucracies to argue about flu shots. Kaiser Family Foundation: most large employers are already self-funded.
When it does not
Tiny groups with one cancer case and no stop-loss. Or a TPA that still runs full prior-auth theater so you bought the risk and kept the hassle.
A one-page compare
Last year’s allowed claims on the shoppable SKUs on this site vs cash menus vs your ASO fees. If cash + stop-loss is cheaper, you do not need a federal program to start a 90-day pilot.
Households who heard about sharing
Faith: cheaper monthly, not a licensed card
A grandfathered church share can be about a third of the family job sticker. It is not a contract, not minimum essential coverage, and not a 2026 app. The full compare is on Faith.
Faith — ministry vs the card
What you are buying
Guidelines, a monthly share, maybe a cap. No legal duty to pay your bill. The hospital often sees self-pay. Jane still exists; Classic’s shareable cap is about $250,000 unless you add more sharing.
Why it is allowed
26 U.S.C. § 5000A: 501(c)(3), a common set of ethical or religious beliefs, continuous sharing since December 31, 1999. That date froze new clubs. State commissioners still treat a duck as insurance.
What they are freezing
Not 1999 Samaritan. New copies — Jesus or not — after unpaid bills and after the marketplace lost healthy lives. A Visa at a posted door is the secular share. That is Flagship, not a loophole.
Operators, CFOs, anyone who asked ‘then what building?’
A cash-pay flagship hospital
One sticker, a real hospital, not two lists on the old tower. Self-funded shops pay the wall. Stop-loss wraps the crash. You do not start with your own emergency department.
Flagship — Cost Plus with beds
The product
Cost Plus Drugs posted a vial. Surgery Center of Oklahoma posted a joint. The flagship is that formula with beds: birth, a small intensive-care unit, quality you would send your kid to.
Who pays
Not only the uninsured. The shop that already writes checks. A funded card so nobody wires the implant from checking. Medicare can sit on the same fee. Two lists — cash plus a secret United book — is Walgreens with beds.
The shovel
The plant is where the law lets you, and whether you grow into the night or catch a dying door. Flagship is the building. Direct contracts fill the schedule before the emergency-department sign goes up.
Operators who assume the Senate stays shut
Hostile world: no statute, no network seat
Assume they drop you from every preferred-provider list. Being banned is the product. The trap is signing United just to get patients. The full fight is on Hostile world.
Do not want their list
Direct-contract the employer. Funded card. Independent wrap. Two lists — cash plus a secret book — is how Walgreens wrote the check. Never bill the network.
Who still pays
A self-funded chief financial officer who can name last year’s knee count, or a closed pool. Not a Healthcare.gov family on day one. They keep Blue for 2 a.m. until the door is good enough to walk into.
The sequence
Posted SKUs first. Beds next. Inherit a dying emergency department or grow until the pool can carry it. Copy the campus. Congress is not coming.
Anyone who thinks a file dump is the plan
Kill the monopoly: three knives, a crowd
Transparency is the catalyst. Then three divisions the same morning: a path that does not use their door, supply they do not own, and a state that cuts the bottleneck. Sequence is how they pick you off.
Around the door
Telephone versus telegraph. PC versus mainframe. Wireless versus copper. A prepaid system that owns the night so the member is not on United’s card. Most common death.
New supply
Shale versus OPEC. Mini-mills versus U.S. Steel. Plant where certificate-of-need cannot veto, or catch a dying door.
Cut the bottleneck
Standard Oil, AT&T, Paramount. Rare. Famous. Maryland cut the hospital rate and the family card stayed $24,000. A slice is not the system.
Employers and clinic operators
Direct care contracts
Pay the OR a posted price. Card swipe or ACH. Stop-loss never sees the MRI. That is the whole product.
What a direct contract is
A defined bundle (knee, birth, colonoscopy) at a written price, no 837 claim, no denial cycle. Surgery Center of Oklahoma–style posting is the existence proof.
What to put in the PDF
SKU, inclusions, implant brand cap, readmissions rule, who pays if it converts to inpatient, cash vs employer-card rate. If it is not in the PDF it will be on a bill.
How not to get ripped off by the insurer layer
If the TPA ‘rents’ a PPO discount, demand the allowed amount vs the cash menu on the same SKU. If the PPO is higher than cash, the network is not a discount — it is a tax.
Anyone reading an EOB
Self-pay vs insured: the evidence pattern
On this model, commercial allowed is routinely above the cash menu. That is the opposite of the story insurance sells.
The story
‘We negotiate so you pay less.’ Sometimes true vs chargemaster. Often false vs a real cash price — especially imaging, scopes, and outpatient surgery.
What we show
Shop floor: prompt-pay cash vs commercial vs Medicare. Backend: hospital cost to deliver. The commercial−cash gap is labeled ‘insured markup.’ RAND: commercial hospital prices as a multiple of Medicare, with Arkansas near the floor and California flagships at the ceiling.
The other list
Uninsured patients who never get a cash quote can still be billed rack rate — worse than insured. Empowerment is knowing to demand the cash SKU, not wandering into chargemaster.
Staffers, governors, boards
A reform argument you can hand a policymaker
Do not start with feelings. Start with a SKU, a cost to deliver, a cash price, a commercial price, and a source. Then ask why the commercial number is legal.
Post usable prices, not 10GB dumps
Transparency files exist and are often unusable. Maryland all-payer shows a US state can keep commercial close to Medicare. That is in the state table on purpose.
Let cash skip the claims army
US admin intensity (~10 staff per physician in whole-system models vs ~2–3 in simpler-payer countries) is not clinical quality. A posted-price + card rail deletes eligibility, prior auth, and denial on those SKUs.
Stop-loss for the tail, not for saline
Catastrophe coverage is a real insurance product. Packaging it with routine care is how the saline bag becomes a claims event. Separate them.
What this site is not
Not a named-hospital chargemaster extract. Numbers are modeled from RAND-style state multiples, CMS-like wage indices, GPO acquisition ranges, and recipe costs. Each figure is tagged sourced / modeled / guess so staffers can see the floor.