Podcast Summary: Navigating Payer Challenges and Out-of-Network Policies with Jakob Emerson

Podcast: Becker’s Healthcare Podcast
Host: Scott Becker (Becker's Healthcare)
Guest: Jakob Emerson (Payer Industry Reporter)
Release Date: January 8, 2026

Episode Overview

This episode features Jakob Emerson, a leading reporter on the U.S. payer industry, as he unpacks two major current topics:

• The highly publicized debate between Mark Cuban and Optum’s CEO regarding pharmacy benefit managers (PBMs) and the opaqueness of pharmacy costs.
• Anthem Elevance’s new policy imposing a 10% penalty on hospitals for out-of-network provider usage—a move sparking widespread concern across provider and policymaker communities.

Key Discussion Points & Insights

1. Mark Cuban vs. Optum CEO: PBMs and Pharmacy Cost Transparency

[00:57 – 07:59]

• Background of the Event

  • Cuban and Optum’s CEO, Dr. Dirk McMahon (referred to as Dr. Conway in the transcript), held a lively and, at times, contentious conversation in Washington, D.C., moderated by a Johns Hopkins health policy professor.
  • The discussion centered around PBMs—OptumRx being one of the largest—and their role in driving up costs, maintaining opaqueness in how drug pricing works, and eschewing transparency for employers, plans, and consumers.

• Major Topics Debated

  • The Call to Break Up Conglomerates
    • Quote [04:09] (Jakob Emerson, paraphrasing Cuban):

      “Mark Cuban straight up just said, break up the big insurance companies so that they can't own PBMs, they can't own providers, they can't own their own technology. And to make them all independent companies…”

  • Pushback and PBM Defense
    • Dr. Conway (Optum CEO) responded that eliminating PBMs would shift costs directly to health plans, employers, and government bodies, as PBMs negotiate drug prices.
    • Pointed to the high cost of specialty drugs (e.g., GLP-1s) in the U.S. compared to Europe.
    • Claimed Optum contracts with 90,000 providers but only owns 10,000–12,000 directly.
  • Opaqueness and Employer Data Rights
    • Mark Cuban criticized the lack of transparency, especially for self-funded employers who cannot access detailed claims data from PBMs or insurers, even when they sue for it.
    • Quote [06:09] (Jakob Emerson):

      “…employers… it is very difficult, if not impossible to actually look through their claims data… they’ve sued for it and a lot of them have not won.”

  • Industry Disruption and Cuban’s Influence
    • Emerson highlights Cuban’s rapid rise in the pharmaceutical space since launching Cost Plus Drugs in 2022, and how his direct debate with Optum’s CEO signals both public appetite for reform and the industry’s growing openness to disruption.
    • Quote [07:40] (Jakob Emerson):

      “The fact that he's risen so quick, going head to head with one of the largest PBMs, I think, is… it says a lot about where the industry in general in pharmaceuticals is going.”

2. Anthem Elevance’s Out-of-Network Penalty Policy

[07:59 – 10:44]

• Policy Description

  • Went into effect January 1, 2026, for Anthem Blue Cross Blue Shield commercial plans.
  • Anthem can apply a 10% penalty on claims from in-network hospitals if an out-of-network provider (e.g., anesthesiologist) treats the patient at that facility.
  • Includes potential network termination as a penalty for hospitals.

• Industry Response and Rationale

  • Anthem claims this addresses unintended gaming of the No Surprises Act—a law set up to protect patients from unexpected out-of-network medical bills by mandating arbitration between providers and insurers.
  • Anthem alleges that some private equity and billing firms encourage out-of-network billing to secure large arbitration awards.
  • Providers are reportedly winning about 80% of arbitration cases, causing concern for payers.
    • Quote [10:44] (Scott Becker):

      “It’s amazing that providers are winning 80% of those claims. Is that what you said?”

    • Quote [10:46] (Jakob Emerson):

      “…providers are winning 80% of cases that reach arbitration under… the [No Surprises Act]. Simply absolutely fascinating.”

  • Major pushback from the American Hospital Association, Federation of American Hospitals, 14 physician-lawmakers, and provider groups, who argue hospitals can’t readily determine at the point of care whether all providers involved in a patient’s treatment are in-network.

• Concerns Raised

  • Likely to cause billing confusion and administrative headaches for hospitals and patients.
  • Could jeopardize provider-insurer relationships and network stability.
  • Reflects broader tension resulting from the No Surprises Act implementation and its arbitrage outcomes.

Notable Quotes & Memorable Moments

• Mark Cuban’s Directness:

  • [04:09] Jakob Emerson relaying Cuban’s prescription:

    “Break up the big insurance companies so that they can't own PBMs, they can't own providers, they can't own their own technology…”

• PBMs and Opaqueness:

  • [06:09] Jakob Emerson:

    “…self-funded employers… have sued for [claims data] and a lot of them have not won. But it is true that health insurers, pharmacy benefit managers… don't want to give up complete medical claims data…”

• Rapid Disruption by Mark Cuban:

  • [07:40] Jakob Emerson:

    “…he's already… sitting here on a stage with the CEO of one of the largest healthcare companies… That really spells just how quickly he's gained in influence within this industry…”

• No Surprises Act Fallout:

  • [10:44] Scott Becker:

    “It’s amazing that providers are winning 80% of those claims. Is that what you said?”

  • [10:46] Jakob Emerson:

    “…providers are winning 80% of cases that reach arbitration under… the No Surprises Act. Simply absolutely fascinating.”

Important Timestamps & Segments

• [00:58] — Introduction of key issues and Optum CEO vs. Mark Cuban debate
• [01:57] — Details on the Washington panel discussion, main points of contention
• [04:01] — How Mark Cuban and Dr. Conway would rewrite healthcare policy
• [06:09] — Employer frustration with “opaqueness” and lack of access to data
• [07:40] — Mark Cuban’s rapid rise as a disruptor in pharmacy
• [08:10] — Anthem Elevance 10% penalty policy on out-of-network provider use
• [10:44] — Arbitration under the No Surprises Act: 80% win rate for providers

Tone & Closing Observations

Jakob Emerson delivers his analysis with an even, highly-informed tone, often paraphrasing and channeling the bluntness characteristic of Mark Cuban. The conversation is briskly analytical, packed with topical data and clear-eyed observations about payer strategies and regulatory fallout. Scott Becker brings a sense of urgency and gratitude, emphasizing the value of insights shared in a compressed format.

Memorable Closing
[10:57] Scott Becker:

“I get more information in a shorter period of time on what’s really going on with payers and providers than with talking to you than anybody else.”

Summary Takeaway

This episode distills two of the most pressing ongoing controversies in U.S. healthcare:

• The future of PBMs and the intense pressure for transparency, driven in part by high-profile disruptors like Mark Cuban.
• The ripple effects of the No Surprises Act on payers and providers, now manifesting in potentially punitive network policies that risk adding complexity to both provider operations and patient experience.

Listeners leave with a deep understanding of the payer-provider battlefield circa early 2026, armed with quotes, context, and the leading-edge insights from Jakob Emerson.