The Healthcare Squeeze

RBP, Transparency, and the Rise of the Algorithmic Gatekeeper

I’ve spent the better part of a decade helping employers break free from the cage of bloated network pricing. Most of them didn’t even know they were in a cage.

Reference-Based Pricing (RBP) doesn’t need a sales pitch; it just needs a shot and an insurance adviser unwilling to bend the knee to Big Insurance and the easy button. Pay providers a consistent, benchmarked rate, typically tied to a multiple of Medicare. No backroom PPO faux discounts. No crossed fingers. Just transparent truth.

When it works, it works spectacularly. Employers save. Employees get real support. The system, what’s left of it, gets a dose of honesty. But let’s not pretend there aren’t moments of friction. Some hospitals push back. And lately, that pushback has evolved into something far more calculated and colder.

The future is here.

We’re at a Tipping Point

There are two tectonic shifts in play right now. And they’re on a collision course.

First, price transparency is finally growing. Thanks to federal disclosure mandates, we now have actual price data—not estimates, not ranges, but real, itemized numbers. ACL surgery in Northern California? Try $4,400 at one hospital and $63,800 at another. It's the same surgery, the same insurer, and a different zip code.

Second, AI is no longer science fiction in healthcare; it’s quietly becoming the new admissions director. Hospitals, especially those under private equity control, are using machine learning tools to filter patients based on projected profit. That’s not a conspiracy theory. I was recently approached by an insider working with healthcare-based private equity firms specializing in the revenue cycle management portion of health systems. They are working hard to weed out those pesky non-BUCA payers.

And what do the algorithms flag first? Patients on RBP plans. Medicaid recipients. Self-pay cash customers. Anyone not tied to a top-tier national insurer willing to cough up 500% of Medicare.

These patients get quietly rerouted. Or ignored. Or told there’s “no availability.”

The language is subtle. The impact is not.

Behind the Curtain: Nonprofit Hospitals and Selective Service

Here’s the part that should make your blood boil.

Roughly two-thirds of hospitals in the U.S. are tax-exempt nonprofits. They don’t pay federal or state income tax. They often don’t pay property tax. They receive charitable donations and tax-advantaged financing. All in exchange for one thing: serving the public.

Spare me.

That means the uninsured. The underinsured. And yes—the employer-funded, self-insured RBP plans that pay 140% to 180% of Medicare.

But if a hospital uses AI to exclude those patients because the margins aren’t fat enough, they’ve crossed a line. Actually, several.

They’ve violated the “community benefit” standard required under Section 501(c)(3).

They’ve endangered their tax-exempt status under Section 501(r).

They’ve opened themselves up to civil rights lawsuits if exclusion patterns align with race or income.

And they may be running afoul of the False Claims Act if they bill government programs while simultaneously ghosting those same populations under the hood.

In short, you don’t get to claim public service status while behaving like a private equity portfolio company.

What’s Next? A 10-Year Outlook

Here’s where I see this heading, unless someone grabs the wheel:

Years 1–3

• More employers move to RBP—some out of necessity, others out of principle.

• Hospitals sharpen their digital fencing tools. Pushback goes algorithmic.

• Legal teams at RBP vendors get busier. So do media consultants.

Years 4–6

• Leaked hospital documents start surfacing.

• State AGs and the IRS begin probing nonprofit compliance.

• Some systems quietly reverse course and start accepting cash pay and RBP again.

Years 7–10

• High-end systems go boutique—direct contracts only.

• Community hospitals either adapt to rational pricing or disappear.

• Employers who made the shift early will have saved millions. Others will be drowning in a system they no longer recognize.

If You’re Still Waiting, Don’t

Here’s what employers need to understand: if you’re still hanging your hat on a national carrier network, you’re paying retail for a product that’s been marked up six times before it hits your employees. Worse, you’re supporting a system that’s now willing to deny care to those very employees because your plan doesn’t ring the right bells on their AI dashboard. RBP isn’t a panacea. But it’s a statement. A first step. A refusal to keep feeding a system that hides its prices and then blames patients for not affording them.

If a tax-exempt hospital won’t treat your people because you refuse to pay 400% of Medicare, then it’s time to ask:

• Why are they still tax-exempt?

• Who are they really serving?

• And how long before their doors only open for platinum-plated plans and concierge networks?

We’re standing on the edge of something big. One path leads to a market that finally starts to act like a market, and the other leads to automated rationing disguised as patient prioritization.

I know which one I’m building toward. Do you?