They use those tactics to avoid shelling out money that they’re supposed to.

But how?

a = Premiums
b = Healthcare spend
c = Rebates
d = Revenue

b + c = (a x 0.8)

d = a - (b + c)
d = a - (a x 0.8)
d = a x 0.2

Therefore, no matter how much you drop b, d is still always going to be 20% of a.

Where does the extra amount in d come from?