Redefining Cost and Quality: The Health Plan Opportunity Hiding in Plain Sight

By Dr. Matt Resnick, Chief Medical Officer | SVP, Health Plans and Partners, Embold Health

When we talk about rising healthcare costs, we almost always zero in on one thing: price. The assumption is that lowering costs means negotiating better rates. But what if that’s only part of the story - and not even the most important part?

As a physician, I’ve spent years living inside the very system we’re all trying to fix. And now, as Chief Medical Officer at Embold Health I see it even more clearly: the greatest opportunity to reduce healthcare costs lies in improving healthcare quality.

But to get there, we have to start by redefining what we mean by both “cost” and “quality.”

Why Price ≠ Cost

When I first started working closely with health plans, I realized just how differently cost looks depending on your vantage point. As a physician, I thought about care decisions. As a health plan partner, I started thinking more about the downstream impact of those decisions - how much they cost, where they happen, and whether they needed to happen at all.

What became clear is this: cost isn’t just about price. It’s about what providers choose to do, where they do it, and how often they do it. Cost is the sum of clinical decisions and care settings, both carrying weight, and shaping a patient’s journey in different ways. At Embold Health, we break it down into three distinct, and equally important, levers:

1. Clinical Decision Making: What a provider chooses to do has massive cost implications. Take a patient with knee pain. One provider may recommend physical therapy and weight management. Another may go straight to surgery. The difference? Tens of thousands of dollars and wildly different patient journeys and risks.  

2. Site of Service: An MRI at a hospital outpatient department can cost three times as much as the same scan at a freestanding imaging center. Same test, same patient, but very different cost.

3. Price: Yes, negotiated rates still matter. But they’re just one piece of a much bigger puzzle.

Cost, in other words, isn’t a fixed number. It’s a product of clinical decisions, settings, and contracts - all of which are driven by provider behavior.

The Hidden Connection Between Cost and Quality

Cost and quality are often treated as separate metrics, managed by different teams, using different tools. That’s a mistake.

Why? Because high-quality care is cost-effective care.

I’ve experienced this first hand. I contionue to treat prostate, kidney, and bladder cancer, working tremendously gifted colleagues, among them trainees.. Despite working at a top institution, I had (and continue to have) limited visibility into how my own clinical decisions compared to my peers. That’s not unusual - it’s the norm. And without meaningful feedback, there’s no way to improve.

When we start measuring clinical appropriateness, not just whether boxes were checked, but the quality of the decisions being made, we open the door to real improvement.  

To truly improve affordability, we have to stop thinking about cost in isolation. The better question isn’t just how much something costs, it’s whether it should be done in the first place, and how well it’s done when it is. Once we optimize on whether (appropriateness) and how well (effectiveness), we can also optimize on site of service and price, as a sustainable path to delivering value to patients and to those responsible for the health plans in which patients are enrolled.  

We define quality as care that is appropriate, evidence-based, and aligned with best clinical practices, not just completed tasks or box-checking. It’s about doing the right thing, at the right time, for the right patient. And when we improve quality in this way, we reduce waste, outcomes improve, and  costs fall as a result.

The Real Untapped Value in Healthcare

^Some estimates suggest that 30% of healthcare spending in the U.S. is unnecessary. Reducing that waste - even by a few percentage points - can have a far greater impact than any marginal improvement in negotiated rates.

The key is to bring cost and quality together, anchored in provider-level appropriateness data. When you measure the right things, you unlock smarter networks, more informed members, and a system that rewards high-value care.

At Embold, this is exactly what we’re building: credible, clinically grounded analytics that shine a light on the true drivers of both cost and quality.

Because the most powerful lever in healthcare isn’t price - it’s performance.

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