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RosettaFest 2026: Highlights From Nashville
Fiduciary risk, arbitration losses, direct contracting, and what employers are doing with price transparency data.
Health Rosetta, a Public Benefit Corporation was co-founded by Dave Chase is Relocalizing Health to publish an open framework for how employer and union health plans can be built, and to certify the advisors who help build them. RosettaFest is its annual gathering, held this year from July 29 to 31 at the Gaylord Opryland in Nashville. A few dozen people came to the first event. This year's conference drew 1,230 registrants, including roughly 250 employers.
Employers, unions, public sector plan sponsors, benefits advisors, TPAs, solution companies, PBMs, and independent physicians were mixed through sessions for three days. What follows are highlights from some of the presentations I was able to learn from.
Matt Zachary's Journey and the Importance of Prioritizing Patients
Matthew Zachary told the main stage audience that he has spent years in rooms where patients get talked about constantly and almost never get an equal voice on the stage. He spent part of the event signing copies of his recently released book, We the Patients, and received the Marshall Allen Rosie Award for patient advocacy while he was there.
At 21 he was a classically trained pianist. In the fall of 1995, his left hand stopped moving across the keys the way it had, and he was told it was carpal tunnel, then told to carry his backpack on the other shoulder. By the time anyone scanned his head, he had brain cancer. Eight hours of craniotomy, then radiation, then a chemotherapy conversation he had no framework for. His father's best friend, a genetic scientist, intervened and found that the proposed regimen would have left him permanently deaf and permanently numb in his fingers and toes. That had not come up. He was given a 50 percent chance at five years and asked to choose between more time and the only thing he wanted to do with it.
He is 30 years out now and founded Stupid Cancer for a generation of young adults who had no category of their own. At one point Matt told the audience that employers are consumer protection, and that they are the seatbelts in the car for their employees.
Chris Deacon on the Difference Between Having Data and Tracing Money
Chris Deacon has spent nearly five years working with employers, unions, government entities, and purchaser coalitions on fiduciary process, and was the whistleblower in a case settled in December 2025 that returned $100 million to the state of New Jersey. Her session was titled "No Data, No Destination," and she opened by warning the room not to take it too literally.
Somewhere along the way, she said, the field started treating data acquisition as the goal, something you obtain and check off. Getting blueprints is not the same as being able to read them or build the house. Her working definition of data is how money moves from point A to point B, given how many parties take a cut along the route.
Funding mechanics: Almost nobody in the room could say whether their plan funds claims after the provider has been paid or just before the administrator issues payment. The gap between the two is the float, an interest-free window between the moment money leaves the employer's account and the moment it reaches the provider. Her framing of the range was one to three days, or 273 days, and it can run longer, because payment timeliness requirements often are not in the contract at all. Somebody holds that money and frequently earns interest on it.
Claims are not always final: There are 358 official claim adjustment reason codes and more than 1,100 remittance advice remark codes. A closed claim reopens through coordination of benefits, timely filing appeals, post-payment audit recoupment, bundling edits, subrogation, retroactive eligibility changes, duplicate reversals, and arbitration redeterminations. None of that is an anomaly. It is the documented design, and a claim can be adjusted several times before your next report.
Stop loss timing: When the same vendor administers claims and stop loss, a claim incurred in one policy year but paid in the next can trigger a second attachment point, and the plan pays up to it twice. Employers never offload risk, she said. They delay it.
Underneath all of them sits the reconciliation question, and this is the one I would put in front of any self-funded employer.
That comes from her expert witness work, and the $2 million gap went unexplained because nobody was comparing the two documents. While working at the New Jersey state health plan, she saw a $2 million claim from a New York City hospital where the plan paid column read around $675,000, and the spread in the middle was never explained. Being a fiduciary, in her framing, is exercising control over other people's money, which makes tracing that money the job.
Why Employers Lose Most No Surprises Act Arbitrations
Some of the most direct commentary of the week came out of an open question session with Chris Deacon, Lee Lewis, Marilyn Bartlett, and Russell DuBose.
No Surprises Act arbitration is baseball style, so the arbitrator picks one side's number and cannot split the difference. Volume is climbing fast, and claims that are not eligible are getting through the gate. Deacon walked the room through the arithmetic. A hospital bills $300,000. The plan's opening offer is $20,000. The administrator books $280,000 in savings on that gap and charges 30 percent of it, $84,000, before anything has been decided. The provider disputes, the case goes to arbitration, and the plan loses. The provider is now owed the full $280,000, which puts the plan at $364,000 on a bill it could have settled outright for $300,000. The $84,000 fee stays where it is.
The savings evaporated but the fee did not.
Unless an employer is reconciling its own records, nothing in a standard report shows that the fee was charged against savings that never materialized. Because the qualified payment amount is built from average in-network rates, there is little incentive to raise the opening offer, and the employer writes the check when the plan loses. In a case Deacon cited from unsealed litigation, the administrator kept more than the provider received on 79 percent of more than a thousand claims.
The employer loss rate came up in the room at around 90 percent, and federal reporting puts provider win rates in the mid to high 80s. Countermeasures from the discussion:
Require your carrier to attend every arbitration, then ask how many they attended. A no-show is an automatic loss.
Stop disputing anything under roughly $1,000, since the filing fee alone is about that much.
Carve IDR out to a specialist vendor for better win rates, several of which are winning in the 40 to 50 percent range.
Know where an award can be enforced. In Guardian Flight v. Health Care Service Corp., the Fifth Circuit held that the No Surprises Act gives providers no private right of action to enforce an award in federal court, and the Supreme Court declined to review it.
Following the Money Through a Hospital Org Chart
Marilyn Bartlett made a similar case through an accounting lens, starting with the corporate structure of a health system in Montana. Two critical access hospitals, one main hospital, and a sprawl of boxes around them, some of them disregarded entities that take on the tax treatment of their sole owner. Systems spin off the lab or the imaging arm, the subsidiary charges the hospital, and the hospital passes that cost along, so the payments an employer makes support a good deal more than the hospital. Her method is to follow the transfer payments between related parties.
Her walk through overpayment recovery clauses will be familiar to anyone reading administrative services agreements closely. An administrator identifies an overpayment and keeps 25 or 30 percent of the recovery as a fee. She showed a claim paid one day, reversed the next, held roughly six months, then repaid in the same amount with a fee taken on the way through. Her description of the mechanism was that the administrator becomes the bank.
On July 22 the Senate HELP Committee advanced S. 2355, the Patients Deserve Price Tags Act, by a vote of 21 to 1. It would put hospital price transparency into statute, extend disclosure requirements to ambulatory surgery centers, imaging centers, and clinical labs, and expand what plan sponsors can require, including the 837 claim file and the 835 remittance.
Price Transparency Data Producing Insight for Employers
A standard network discount analysis returns three numbers, and each of them hides something. Billed charges vary hospital to hospital, so a discount measured off them moves with the benchmark. A provider count says nothing about whether your members' own doctors are in the network. And one all-in savings percentage buries which service lines and sites of service drive the cost.
One session walked through a network comparison built entirely on published rate data, running one employer's claims against four networks' current rates in a single metro. A few of the findings:
Rates read differently by setting. The network with the lowest overall rate as a percentage of Medicare carried a real disadvantage on inpatient against another option in the same market.
Plan share and member share can point in opposite directions. One network came out ahead for the employer and behind once member out-of-pocket was included.
The effective discount becomes auditable. Every rate traces back to a disclosed fee schedule. In one example across four insurance carriers, the effective in-network discount ran from 47 to 52 percent.
Out-of-network leakage can be projected before the plan year starts. Expected out-of-network claims in one example ranged from about 4 percent to 14 percent depending on the network, and when two or three facilities drive most of that cost, they become the short list for a direct contract.
The answer changes market to market, which is how employers are building multi-market network strategies.
A couple of years ago, 20 to 50 percent of an employer's historical claims could be matched against the rates published in the machine-readable files. Based on this presentation and recent work being done by companies in the space, the current figure is closer to 80 to 90 percent. Match rate is what determines whether this analysis can be trusted. At 20 percent, you are pricing a fifth of the claims and extrapolating the rest.
Direct Contracting, and the Plumbing Underneath It
Cristin Dickerson MD, Certified Health Value Advisor of Green Imaging, a radiologist by training, walked through what it takes to buy healthcare separately from buying insurance. Independent imaging centers used to be the reliable low cost option and increasingly are not. The market has seen a run of private equity deals, with independent centers aggregated into a handful of national chains, and an acquired center generally moves onto the acquirer's contracted rates. The name on the building can stay the same while the price for the same scan changes.
Her practical advice centered on the plumbing. Know what the TPA earns on the arrangement, including alternative network fees, shared savings, and per-claim charges. Ask what conflicts they see, because an administrator with its own navigation vendor collecting referral fees has a reason to resist. And decide who holds the contract, since the employer holding it makes a future TPA change far less painful.
The utilization point is an important one because a solution nobody uses is noise on a plan. She sees 80 percent utilization in school districts, where scheduling support and word of mouth do the work and a modest copay against a zero dollar option is enough of a differential. She also noted that the average American spends around eight hours a month arranging care, most of it during working hours, which is a cost that never shows up in a claims file.
The Employer Results
Advisors bring clients to this event in part for the case study track, where they walk through the work behind an employer's return on its healthcare spend and its plan design choices.
An industrial employer with a blue collar workforce across nearly 30 states was already on reference-based pricing and still facing a projected 16 percent increase, with 330 ER visits and a home market where a new primary care relationship took ten months to establish. The rebuild layered direct primary care with an assigned physician and a real phone number onto transparent pharmacy sourcing and coordinated case management.
Member engagement reached 49 percent, and one specialty drug was sourced about $12,000 less per script with members paying nothing for it. The consultant's closing advice was to trust employees to make good decisions once they have the tools.
A panel on data access produced a third example. An HR leader for a manufacturer headquartered in Alabama described declaring data sovereignty with his medical TPA, on the argument that the law was on his side, the data belonged to the plan, and his administrator's job was to process claims. He now pulls medical claims, pharmacy, genomics, and seven years of EMR data into one platform and runs individual risk profiling on top of it. The same employer went straight to drug manufacturers instead of through traditional channels, removed member cost share entirely, and watched adherence climb from under 60 percent to around 95 percent.
Two Rosie Award winners made the same point at different scales. 32BJ SEIU, a service workers union, analyzed its own data, steered members away from a very high cost system, saved more than $30 million in a single year, and put the money into the largest raise in its contract history plus a one-time $3,000 bonus. In Alaska, the South Central Foundation, owned by the Alaska Native community it serves, where patients are called customer owners, has cut emergency room visits more than in half over two decades.
Nautilus and the Case for Shared Standards
The thread connecting the whole event was Nautilus Health Institute, a 501(c)(3) that Health Rosetta helped catalyze with roughly $4 million of donated intellectual property alongside contributions from many others. It is independent, with its own board, and its stated mission is to change health plan market norms in procurement, contracting, and data use by 2030. Everything it publishes is open source and free to use.
Three things to look at if you want to put this to work:
The model PBM contract language and Contract X-ray, at contractxray.com, for scoring a contract against the standard instead of reading 70 pages of legalese.
The CAA 2026 readiness report, for seeing where nine PBMs landed and how the rest of the market compares.
The advisor selection field guide, released this year for employers choosing or re-evaluating a benefits advisor.
Contract X-ray scores a PBM contract against 37 issues drawn from model language built with more than 30 experts. Nine of the 29 PBM contracts assessed earned a designation the group calls CAA 2026 ready, which requires a fiduciary alignment score grading good or better on every provision, plus data sovereignty. Roughly 80 percent of the market's business sits with contracts below the median.
Data sovereignty comes down to four questions. Do you own your data, can you use it to get better outcomes, can you prove the promises made in your contract, and can you take the data with you when the relationship ends?
Leah Binder of the The Leapfrog Group made the quality version of the same case. The Consolidated Appropriations Act put employers on the hook for monitoring cost and quality both, and not having been given the information is not a defense.
Core Themes and Takeaways
Data acquisition, accountability, and visibility are still the fight, and reconciliation sits right alongside them. Compare the claims file to the funding report to the 835 remittance and look at what does not tie. That gap is where the money is, and few plans are checking it.
The savings fee has moved to the front of the line. Shared savings used to mean the administrator negotiated an out-of-network bill down after the fact and kept a cut. Deacon's account is that the same fee now attaches to a software review before payment, to arbitration disputes before they resolve, and to recovery of overpayments the administrator made in the first place.
Price transparency data keeps working its way into employer workflows. Going from matching 20 to 50 percent of claims against the machine-readable files to matching 80 to 90 percent turns a compliance artifact into an asset that works as a network selection tool, an audit tool, and a direct contracting target list.
Direct contracting has become a plumbing problem. Nobody needed convincing that buying healthcare separately from buying insurance works. The open questions were administrator conflicts, contract ownership, and getting members to use what the employer bought.
The movement is trading boldness for repeatability. One of the founders said the boldness of the people who went first is opening a phase where the next wave will not have to be as bold. That is what the standards, the tooling, and the open resources are for.
The concluding line I would like to share, and the one still circling in my mind:
Employers are consumer protection, and they are the seatbelts in the car for their employees.
Great to see Jacob Little, Jennifer Leach, Dave Chase is Relocalizing Health, LynAnn Henderson, Michael Burmeister II MBA, Steve Schutzer, MD, Lee Lewis, Justin Leader, Julie Selesnick, Cristy Gupton, Renzo Luzzatti, Mark Hornung, Doug Geinzer, Dean Jargo, Rob Archibald, Leah Binder, joe lamantia, Katie (LaMantia) Wildman, Nelson Griswold, Chris Deacon, Marilyn Bartlett, Shawn Gremminger, Josh Butler, Kirat Kharode, Dawn Cornelis, Cristin Dickerson MD, Certified Health Value Advisor, Steve Ditto, Vidar Jorgensen, Matthew Zachary, Justin Manning, Ashley Bacot, Brian Talpos, Bill Miller, Patrick Blackaller, T.J. Parafioriti, Michael Havig, MD, Randa Deaton, Stephanie Porrino, Lena Chaihorsky, Michael Howard, Mark Galvin, Christapher Estep
Nice to meet Doyle Jensen, Miriam Paramore, Bradley Schleyer, Scott Conard, MD, Reid Rasmussen, Jason Beck, M.D., Rebeccah Randles, Jordan Stewart, Scott Dail, Nick Dinsmore, Bryce Heinbaugh, MBA - Healthcare Trailblazer, Brian Schram, Ben Hammond, Maggie Hammond, Elizabeth Bibeau, Jolene Rode, Russell DuBose, David Lechner, James Farley, Emily Fields, Justin Jasniewski, Sean Schantzen, Agnes Fasano, John Dean, Tracy Haymaker, Shehryar Siddiqui, Michael Howard, Timothy Gesicki, Rhett Bray, David A Saltzman, Matt McCord, MD, Tim Spooner, Katie Lozano, Jacob Long, Runako G., Tom Milam, Elizabeth Hodges, Jen Foley, Kat Cagle, Cara Kirsch, Ty Petty, MBA, Alex Sommers, MD, ABEM, DipABLM, Neil Phillips, Ellyn Howard, McCain Ashurst, Meagan Kearney, Matt Koppenhaver, David Kinsey, Jason K. Roussell, Rory Milne, Jennifer Kinley-Lawrence, Emily Davis, Jim Jusko, Adam Stadler, Alex Minney, MD, Carson Bartlett, Bradford Shepherd, Brian Kauffman, Annika Vogele, Ann Morrow Martin, Chris McCracken