Wholesale vs. Retail Pricing — The Power of Transparency
Every rate benchmarked against Medicare (100%).
The Medicare Subsidy Gap
Hospitals lose ~20% on Medicare patients and shift those losses to commercial plans. With roughly two-thirds of patients on Medicare, employers end up charged 3–4× Medicare rates to make up the difference.
Vertical Consolidation
Carriers bought providers and PBMs (pharmacy benefit managers) to guarantee the 85% MLR (medical loss ratio) rule works in their favor. Vertically integrated conglomerates now control insurance premiums, hospital prices, pharmacy pricing, and care pathways — 80% of the market is controlled by four conglomerates.
The Problem in Numbers
- →Traditional PPOs pay ~254% of Medicare nationally — and over 300% in California, Florida, and New York (RAND Hospital Price Transparency Study).
- →Self-funding alone doesn't fix it. Rented PPO networks still pay ~250% of Medicare. Changing who holds the risk doesn't change the price of care.
Change the math, not the doctor.
Instead of paying a discount off an inflated "retail" charge, your plan pays the greater of Medicare + 25% or Cost + 20% — a fair, transparent margin above the provider's actual cost. In 2025, 99.5% of claims were paid at exactly these terms.
Three deliverables. Zero ambiguity.
Wholesale, pre-negotiated facility rates
Minimal employee disruption — your team keeps a top-five provider's card.
Advocate / Auditor / Litigator on your behalf
99% success rate in executing pre-negotiated rates in 2025 on behalf of clients across the US.
Full transparency
Complete access to your claims data — every payment traceable to a benchmark and a margin.
Ready to see your number?
We run the analysis on your own data — no charge, no obligation.