Relentless Health Value

Exploring the Complexities of Pharma Rebates with Ann Lewandowski In this Summer Short episode of Relentless Health Value, host Stacey Richter converses again with Ann Lewandowski about the intricate dynamics of pharmaceutical rebates, or as Lewandowski prefers, post-sale concessions. The discussion delves into the nuances of these rebates, the impact they have on drug costs, and the hidden consequences for patients and plan sponsors. They highlight articles and insights by Austin Chelko and Peter Hayes, touching on how rebates can disadvantage the pursuit of lower-cost generics and biosimilars, and can obstruct pharmacogenetic testing that ensures drug efficacy and safety. The conversation also critiques the opacity of rebates, deemed trade secrets by pharma and PBM companies, and underscores the ethical and financial dilemmas posed by the current rebate-driven system. === LINKS === 🔗 Show Notes with all mentioned links: https://cc-lnk.com/EP480 ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter: https://relentlesshealthvalue.com/join-the-relentless-tribe 🫙 Support the podcast with a small donation to the Tip Jar: https://relentlesshealthvalue.com/join-the-relentless-tribe 📺 Subscribe to our YouTube channel https://www.youtube.com/@RelentlessHealthValue 🎤 Listen on Apple Podcasts https://podcasts.apple.com/us/podcast/feed/id892082003?ls=1 🎤 Listen on Spotify https://open.spotify.com/show/6UjgzI7bScDrWvZEk2f46b === CONNECT WITH THE RHV TEAM === ✭ LinkedIn https://www.linkedin.com/company/relentless-health-value/ ✭ Threads https://www.threads.net/@relentlesshealthvalue/ ✭ Bluesky https://bsky.app/profile/relentleshealth.bsky.social ✭ X https://twitter.com/relentleshealth/ 07:24 What is a pharmaceutical rebate? 08:15 Why are pharma rebates so opaque? 09:52 Texas lawsuit on insulin pricing. 10:18 Why is focusing on a singular type of concession difficult with current pharma rebate structures? 10:50 EP397 with Paul Holmes. 13:55 EP353 with Pramod John, PhD. 14:29 How does pharma genomics testing affect pharma rebates? 14:52 EP465 with Chris Crawford. 15:52 EP426 with Nina Lathia, RPh, MSc, PhD.

In this second discussion with Andreas Mang and Jon Camire of Blackstone, Stacey Richter has an advanced discussion on the intricacies of stop-loss reinsurance for high-cost claimants. This show today, for sure, it's for plan sponsors and anyone on or about plan sponsors; but also listen if you are serving high-cost claimants some other way. Because what you'll learn here today is some insights relative to how plan sponsors go about making sure that they can pay you—like if you work for, for example, some clinical organization. There's a, I don't know, 101 starting point of this conversation if you need it on stop-loss, which is episode 478 from a couple of weeks ago. This show is the, let's say, 201-level conversation that I'm having with Andreas Mang and Jon Camire about, as I said, stop-loss insurance and stop-loss insurance considerations. Emphasizing the importance of eligibility audits and aggregating buying power, the guests highlight best practices to avoid overpaying for coverage and ensuring comprehensive risk management. This episode is sponsored by Havarti Risk, which I am so thankful for. The show, Relentless Health Value, actually does cost an unexpectedly large sum of money to create and produce; so I always appreciate when somebody offers to sponsor a show or help sponsor a show. === LINKS === 🔗 Show Notes with all mentioned links: https://cc-lnk.com/EP479 ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter: https://relentlesshealthvalue.com/join-the-relentless-tribe 🫙 Support the podcast with a small donation to the Tip Jar: https://relentlesshealthvalue.com/join-the-relentless-tribe 🎤 Listen on Apple Podcasts https://podcasts.apple.com/us/podcast/feed/id892082003?ls=1 🎤 Listen on Spotify https://open.spotify.com/show/6UjgzI7bScDrWvZEk2f46b 📺 Subscribe to our YouTube channel https://www.youtube.com/@RelentlessHealthValue === CONNECT WITH THE RHV TEAM === ✭ LinkedIn https://www.linkedin.com/company/relentless-health-value/ ✭ Threads https://www.threads.net/@relentlesshealthvalue/ ✭ Bluesky https://bsky.app/profile/relentleshealth.bsky.social ✭ X https://twitter.com/relentleshealth/ 07:47 What are the best practices for plan sponsors to use for stop-loss coverage? 10:11 What are the "unknown unknowns" within stop-loss coverage? 15:25 What are some policy provisions that plan sponsors should be aware of? 19:02 Why is it so important to do eligibility audits? 20:41 What are some common mistakes made with stop-loss coverage among the self-insured? 23:21 What's a panel approach, and why is it important for negotiating stop-loss coverage?

Stacey Richter has a second take on the original episode 433 since it is so relevant right now. Stacey engages in a compelling conversation with Justin Leader, CEO of BenefitsDNA, about the opaque practices of third-party administrators (TPAs) and their impact on healthcare costs. They discuss the hidden fees tucked into weekly claims wires, including shared savings fees, prior authorization fees, prepayment integrity fees, pay and chase fees, and TPA adjudication fees. The episode emphasizes the need for transparency, understanding hidden costs, and ensuring fiduciary responsibility for self-funded employers. Additionally, Leader shares insights from a Health Affairs article and mentions ongoing legal cases that highlight the financial discrepancies in TPA practices. === LINKS === 🔗 Show Notes with all mentioned links: https://relentlesshealthvalue.com/episodes ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter: https://relentlesshealthvalue.com/join-the-relentless-tribe 🫙 Support the podcast with a small donation to the Tip Jar: https://relentlesshealthvalue.com/join-the-relentless-tribe 🎤 Listen on Apple Podcasts https://podcasts.apple.com/us/podcast/feed/id892082003?ls=1 🎤 Listen on Spotify https://open.spotify.com/show/6UjgzI7bScDrWvZEk2f46b 📺 Subscribe to our YouTube channel https://www.youtube.com/@RelentlessHealthValue === CONNECT WITH THE RHV TEAM === ✭ LinkedIn https://www.linkedin.com/company/relentless-health-value/ ✭ Threads https://www.threads.net/@relentlesshealthvalue/ ✭ Bluesky https://bsky.app/profile/relentleshealth.bsky.social ✭ X https://twitter.com/relentleshealth/ 06:32 EP457 with Cynthia Fisher. 06:56 How is the claims wire typically explained to a plan sponsor? 10:49 What is the whole point of self-funding? 10:58 Why is it so vital to understand what you're paying for? 11:53 What are the five "buried" items that wind up in these claims wires? 12:12 What is a shared savings fee? 16:14 "Rates are important, but so are your rights." 20:13 What's going on with prior auth fees? 22:44 What is prepayment integrity? 27:29 What is pay and chase? 28:46 EP428 with Julie Selesnick. 30:58 What is a TPA claim review? 33:21 EP285 with Dawn Cornelis. 34:16 EP379 with AJ Loiacono. 34:45 Is there medical claim spread pricing?

Host Stacey Richter discusses the intricacies of stop-loss coverage with Andreas Mang and Jon Camire from Blackstone. The episode focuses on defining stop-loss insurance and exploring its critical role in protecting self-insured employers from catastrophic financial losses. The conversation delves into the nuances of individual and aggregate stop-loss policies, laser claims, and the importance of selecting an experienced consultant to navigate this complex landscape. The episode is essential listening for those managing high-cost claimants and exploring self-insurance options. This is a two part show. The second show will cover major fails, mistakes that happen with stop-loss when somebody doesn't understand or do everything that we talk about. So, tune back in for the next part of this conversation, in two weeks. Thank you to Havarti Risk for sponsoring this weeks episode. Havarti Risk empowers healthcare leaders like you to make smarter decisions that increase quality and lower cost of care. https://havarti-risk.com/ === LINKS === 🔗 Show Notes with all mentioned links: https://relentlesshealthvalue.com/episodes ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter: https://relentlesshealthvalue.com/join-the-relentless-tribe 🫙 Support the podcast with a small donation to the Tip Jar: https://relentlesshealthvalue.com/join-the-relentless-tribe 🎤 Listen on Apple Podcasts https://podcasts.apple.com/us/podcast/feed/id892082003?ls=1 🎤 Listen on Spotify https://open.spotify.com/show/6UjgzI7bScDrWvZEk2f46b 📺 Subscribe to our YouTube channel https://www.youtube.com/@RelentlessHealthValue === CONNECT WITH THE RHV TEAM === ✭ LinkedIn https://www.linkedin.com/company/relentless-health-value/ ✭ Threads https://www.threads.net/@relentlesshealthvalue/ ✭ Bluesky https://bsky.app/profile/relentleshealth.bsky.social ✭ X https://twitter.com/relentleshealth/ 07:24 What is stop-loss? 08:27 What is reinsurance? 09:57 EP420 with Ge Bai, PhD, CPA. 10:10 Why has stop-loss been a barrier for smaller companies going self-insured? 13:55 Why self-insurance needs to be a joint decision between finance and HR. 15:38 What is aggregate versus individual within stop-loss? 19:51 Why is it important for companies to choose the right level of stop-loss coverage? 21:29 What is a laser claim? 29:28 Why is it important to know what your brokers are getting paid on your stop-loss policies?

In this episode, Stacey Richter explores the impact of trust on healthcare outcomes, drawing from listener contributions and prior episodes of Relentless Health Value. The discussion underscores how trust or the lack thereof affects patients, clinicians, and healthcare systems. Key points include the importance of building trusted relationships, the detrimental effects of antitrust behaviors, and the broader implications for healthcare delivery. Stacey also highlights a bonus show featuring Charles Green on earning and maintaining trust. The episode concludes with an uplifting message about the collaborative and giving nature of the Relentless Health Value community. === LINKS === 🔗 Show Notes with all mentioned links: https://cc-lnk.com/EP477 🔗 Bonus Show - Show Notes https://cc-lnk.com/Bonus477: ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter: https://relentlesshealthvalue.com/join-the-relentless-tribe 🫙 Support the podcast with a small donation to the Tip Jar: https://relentlesshealthvalue.com/join-the-relentless-tribe 🎤 Listen on Apple Podcasts https://podcasts.apple.com/us/podcast/feed/id892082003?ls=1 🎤 Listen on Spotify https://open.spotify.com/show/6UjgzI7bScDrWvZEk2f46b 📺 Subscribe to our YouTube channel https://www.youtube.com/@RelentlessHealthValue === CONNECT WITH THE RHV TEAM === ✭ LinkedIn https://www.linkedin.com/company/relentless-health-value/ ✭ Threads https://www.threads.net/@relentlesshealthvalue/ ✭ Bluesky https://bsky.app/profile/relentleshealth.bsky.social ✭ X https://twitter.com/relentleshealth/ 00:47 What is the new, emerging through line becoming apparent in healthcare? 01:54 Bonus Episode with Charles Green. 02:52 What is the impact of trust in healthcare? 02:55 EP475 with Peter Hayes. 03:11 EP473 with Kenny Cole, MD. 05:31 EP295 with Rebecca Etz, PhD. 06:07 EP326 with Rishi Wadhera, MD, MPP. 07:06 Why does trust grow through proximity, and why do providers need to integrate this into care models? 07:59 Why antitrust is so prevalent in healthcare. 10:00 What are two main contributors to the lack of primary care doctors? 13:27 Why collaboration builds trust.

In this bonus add-on to episode 477 of Relentless Health Value, host Stacey Richter revisits a decade-old conversation with trust expert Charles Green, founder of Trusted Advisor Associates. Green discusses the intricacies of building and maintaining trust in healthcare, emphasizing four key trust principles: client focus, collaboration, long-term relationships, and transparency. The discussion highlights the challenges within the healthcare industry, compounded by conflicts of interest and transactional dynamics. Green underscores the importance of individual actions and leadership in fostering trust, advocating for empathetic listening and genuine curiosity about others as foundational behaviors. === LINKS === 🔗 Show Notes with all mentioned links: https://relentlesshealthvalue.com/episodes ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter: https://relentlesshealthvalue.com/join-the-relentless-tribe 🫙 Support the podcast with a small donation to the Tip Jar: https://relentlesshealthvalue.com/join-the-relentless-tribe 🎤 Listen on Apple Podcastshttps://podcasts.apple.com/us/podcast/feed/id892082003?ls=1 🎤 Listen on Spotify https://open.spotify.com/show/6UjgzI7bScDrWvZEk2f46b 📺 Subscribe to our YouTube channel https://www.youtube.com/@RelentlessHealthValue === CONNECT WITH THE RHV TEAM === ✭ LinkedIn https://www.linkedin.com/company/relentless-health-value/ ✭ Threads https://www.threads.net/@relentlesshealthvalue/ ✭ Bluesky https://bsky.app/profile/relentleshealth.bsky.social ✭ X https://twitter.com/relentleshealth/ 01:45 Four trust principles that can help you earn your clients trust and come off as more trustworthy from first impressions onward. 04:31 Charles's words of wisdom for rebuilding lost trust. 05:46 Where does trusted leadership start? 06:38 Why trust in leadership is about embodying trust in actions, not words. 07:26 Why does personality have an outsized impact in leadership and trust? 08:21 "If we want to improve our trust, we just simply need to work on ourselves." 08:56 Why listening with a sense of curiosity and respect drives reciprocal behavior and improves trust. 09:14 What is the best technique to immediately improve your trust relationship?

In this episode, host Stacey Richter speaks with Ann Lewandowski about whistleblowing in the healthcare industry, focusing on a significant case involving a whistleblower at an employee benefit consultant (EBC) firm. This EBC allegedly pocketed their clients' pharma rebates, violating the Consolidated Appropriations Act of 2021. The discussion highlights the nuances of being a whistleblower, the ethical dilemmas faced, compliance challenges, and the significant financial implications for companies and individuals involved in illegal activities. Ann Lewandowski provides insights into documenting and protecting oneself legally and discusses the broader context of trust and transparency in the healthcare sector. Click through to the show notes below to access all of the mentioned links and prior episodes mentioned. === LINKS === 🔗 Show Notes with all mentioned links: https://relentlesshealthvalue.com/episodes ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter: https://relentlesshealthvalue.com/join-the-relentless-tribe 🫙 Support the podcast with a small donation to the Tip Jar: https://relentlesshealthvalue.com/join-the-relentless-tribe 🎤 Listen on Apple Podcasts https://podcasts.apple.com/us/podcast/feed/id892082003?ls=1 🎤 Listen on Spotify https://open.spotify.com/show/6UjgzI7bScDrWvZEk2f46b 📺 Subscribe to our YouTube channel https://www.youtube.com/@RelentlessHealthValue === CONNECT WITH THE RHV TEAM === ✭ LinkedIn https://www.linkedin.com/company/relentless-health-value/ ✭ Threads https://www.threads.net/@relentlesshealthvalue/ ✭ Bluesky https://bsky.app/profile/relentleshealth.bsky.social ✭ X https://twitter.com/relentleshealth/ 08:10 What does it mean to be a whistleblower? 09:05 What's happening in the current whistleblower case about pharma rebates? 14:24 What are the disclosure requirements, and how does this affect contracts in healthcare? 15:05 EP379 with AJ Loiacono. 15:11 The 5500 form. 15:36 EP397 with Paul Holmes. 16:46 Why having a "defensive health plan" is important. 17:31 Matt Ohrt's post about healthcare's soul. 17:42 Michelle Bernabe's post about how healthcare has lost its heart. 18:15 Why "trust and verify" is important when building contracts and relationships in healthcare. 18:42 Quote by W. Edwards Deming. 21:35 How has this case moved from state to federal court? 23:30 Whistleblower case on generic drug collusion. 24:01 What is a qui tam lawsuit? 28:08 What is an Upjohn warning and the issue of corporate Miranda rights? 30:01 What is Ann's advice to employees who might be whistleblowers? 31:41 EP438 with John Lee, MD. 33:31 What are some red flags that employees should look for to understand what kind of company they work for?

In this episode of Relentless Health Value, host Stacey Richter sits down with Peter Hayes to discuss the major forces driving change in the healthcare industry. Hayes outlines three critical factors: changing public opinion, heightened transparency, and new regulations such as the Consolidated Appropriations Act. He emphasizes the unprecedented convergence of these elements, creating a pivotal moment for healthcare transformation. The discussion delves into the erosion of trust within the healthcare system and the growing public unrest over high costs and inefficiencies. Hayes also highlights the role of state-level initiatives as experimental laboratories for potential national solutions. The episode concludes with a call to focus on root causes and collaborative approaches to restore trust and improve healthcare affordability and quality. === LINKS === 🔗 Show Notes with all mentioned links: https://relentlesshealthvalue.com/episodes ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter: https://relentlesshealthvalue.com/join-the-relentless-tribe 🫙 Support the podcast with a small donation to the Tip Jar: https://relentlesshealthvalue.com/join-the-relentless-tribe 🎤 Listen on Apple Podcasts https://podcasts.apple.com/us/podcast/feed/id892082003?ls=1 🎤 Listen on Spotify https://open.spotify.com/show/6UjgzI7bScDrWvZEk2f46b 📺 Subscribe to our YouTube channel https://www.youtube.com/@RelentlessHealthValue === CONNECT WITH THE RHV TEAM === ✭ LinkedIn https://www.linkedin.com/company/relentless-health-value/ ✭ Threads https://www.threads.net/@relentlesshealthvalue/ ✭ Bluesky https://bsky.app/profile/relentleshealth.bsky.social ✭ X https://twitter.com/relentleshealth/ 05:28 What things are adding to the urgency in this moment of healthcare? 05:55 The three things that have brought us to a tipping point in healthcare. 07:05 Why is now the real moment for this tipping point? 10:35 EP458 with Komal Bajaj, MD. 13:01 Article by (and tribute to) Uwe Reinhardt. 13:27 Hospital ratings by The Leapfrog Group. 14:08 EP358 with Wayne Jenkins, MD. 15:07 EP474 with Yashaswini Singh, PhD. 16:29 How is regulation changing in healthcare? 21:48 How the "trifecta" of change is working together to create this movement of change in healthcare. 23:54 What do we need to look at to address the problems pushing this change in healthcare? 25:44 EP465 with Chris Crawford. 30:04 Why is federal and state collaboration going to be important to this healthcare change? 31:51 EP455 with Beau Raymond, MD.

In Episode 474 of 'Relentless Health Value', host Stacey Richter interviews Dr. Yashaswini Singh, an economist and assistant professor at Brown University, about the growing influence of private equity (PE) in healthcare. The conversation delves into the corporate transformation of medicine, highlighting the potential misalignment between business interests and patient care. Dr. Singh discusses the diverse strategies PE firms use to drive profitability, such as increasing negotiated prices, consolidating market share, employing real estate leasebacks, and emphasizing performance metrics that may not align with patient benefits. The episode also examines the significant impacts these strategies have on physicians, including increased turnover and changes in practice patterns, as well as the broader implications for patients and communities. Dr. Singh stresses the importance of informed leadership, education, policy enforcement, and transparency to ensure that private investments ultimately benefit healthcare systems without compromising patient care. === LINKS === 🔗 Show Notes with all mentioned links: https://cc-lnk.com/EP474 ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter: https://relentlesshealthvalue.com/join-the-relentless-tribe 🫙 Support the podcast with a small donation to the Tip Jar: https://relentlesshealthvalue.com/join-the-relentless-tribe 🎤 Listen on Apple Podcasts https://podcasts.apple.com/us/podcast/feed/id892082003?ls=1 🎤 Listen on Spotify https://open.spotify.com/show/6UjgzI7bScDrWvZEk2f46b 📺 Subscribe to our YouTube channel https://www.youtube.com/@RelentlessHealthValue === CONNECT WITH THE RHV TEAM === ✭ LinkedIn https://www.linkedin.com/company/relentless-health-value/ ✭ Threads https://www.threads.net/@relentlesshealthvalue/ ✭ Bluesky https://bsky.app/profile/relentleshealth.bsky.social ✭ X https://twitter.com/relentleshealth/ 05:53 What is the tension between business and medicine? 07:05 What is the impact of private equity on healthcare? 08:46 How does healthcare change when private equity invests in medical facilities? 10:54 What are the intuitive impacts of private equity in healthcare? 12:28 What are the less intuitive effects of private equity on healthcare? 13:36 EP472 with Eric Bricker, MD. 14:15 What are the misconceptions about private equity investors acquiring healthcare facilities? 16:17 The Steward saga. 16:24 The death of Hahnemann Hospital in Philadelphia. 19:27 Are there any positive outcomes to private equity investment in healthcare? 21:17 EP445 with Tom X. Lee, MD. 22:45 EP420 with Ge Bai, PhD, CPA. 22:47 EP465 with Chris Crawford. 22:49 EP460 with Rushika Fernandopulle, MD. 22:55 Is there ever a need for private investment in healthcare? 25:40 How do the changes private equity firms create affect patients? 27:20 Study in Health Affairs on physician turnover rates following private equity acquisitions. 29:30 How can private equity disrupt physician employment as well? 34:13 What remedies might there be for consolidation in healthcare and private equity investing in medicine?

This episode of Relentless Health Value features Dr. Kenny Cole from Ochsner Health System. The discussion emphasizes the critical role of trusted relationships and excellent primary care teams in keeping patients out of the emergency room, thus reducing healthcare costs. Stacey Richter revisits this conversation to highlight the importance of care teams building trust with patients and the concept of primary care as an investment in health and wellness. The episode outlines four key points for delivering great primary care, including accountability for outcomes, belief in clinical goals, standardized care flows, and building patient trust. Dr. Cole also discusses the real-world challenges and strategies for achieving clinical and financial success in primary care. The episode serves as a guide for plan sponsors, clinicians, and healthcare executives looking to improve primary care delivery and align it with financial viability. The discussion is further enriched with insights on digitizing care pathways and the importance of measuring and sharing best practices to achieve high standards of care.I Stacey revisits, in a take two, this episode with Dr. Kenny Cole because she's listening to it this time with a new focus. That focus is the theme that keeps coming up over and over and over again on Relentless Health Value these past few months. === LINKS === 🔗 Show Notes with all mentioned links: https://cc-lnk.com/EP473 ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter: https://relentlesshealthvalue.com/join-the-relentless-tribe 🫙 Support the podcast with a small donation to the Tip Jar: https://relentlesshealthvalue.com/join-the-relentless-tribe 🎤 Listen on Apple Podcasts https://podcasts.apple.com/us/podcast/feed/id892082003?ls=1 🎤 Listen on Spotify https://open.spotify.com/show/6UjgzI7bScDrWvZEk2f46b 📺 Subscribe to our YouTube channel https://www.youtube.com/@RelentlessHealthValue === CONNECT WITH THE RHV TEAM === ✭ LinkedIn https://www.linkedin.com/company/relentless-health-value/ ✭ Threads https://www.threads.net/@relentlesshealthvalue/ ✭ Bluesky https://bsky.app/profile/relentleshealth.bsky.social ✭ X https://twitter.com/relentleshealth/ 07:35 Is there an optimal care pathway where there might be a lot of treatment variability? 10:52 EP412 with Robert Pearl, MD. 12:32 Why is it important to start with the end in mind? 15:44 How do you scale clinical excellence? 18:18 EP315 with Bob Matthews. 19:12 EP242 with Marty Makary, MD. 21:29 Why is it important simply to demonstrate what's possible for better health outcomes? 22:33 EP427 with Rik Renard. 23:18 How do we reinvent the business model of healthcare? 24:51 EP466 with Vivian Ho, PhD. 25:06 EP415 with Rob Andrews. 26:51 EP391 with Scott Conard, MD. 30:14 EP455 with Beau Raymond, MD. 34:22 Dr. Cole is published in various healthcare journals; check out his most recent article.

In Episode 472, Stacey Richter speaks with Dr. Eric Bricker about the impactful strategies hospital systems use to maximize revenue from high-cost patients. They explore the financial complexities and contracting tactics that enable hospitals to profit significantly from a small percentage of high-cost claimants. Key points include the negotiation of provider stop-loss contract provisions, strategic adjustment of charge masters, and the intentional steerage of patients to high-revenue service lines. This episode highlights the intricacies of hospital finance and the hidden mechanisms that drive healthcare costs for self-insured employers and other plan sponsors. We could have 0.5% to 1% of total plan members costing upwards of 40% of total plan dollars. And I bring this up just to highlight the magnitude of the money here. In that show from last week, we take the issue of high-cost claimants from the standpoint of the plan sponsor. Today, however, we're gonna be looking at this from the standpoint of the hospital system. If we were to come up with a motto for the show today with Dr. Eric Bricker, it's that all costs are somebody else's revenue. And when it's revenue and profit of the magnitude that we're talking about with many high-cost claimants, it starts to be less of an accidental "Oh, wow! How did that CABG patient wind up in our clinic? What are the odds?" and more of a "Whoever is not steering patients is letting someone else with a big profit incentive lock down that steerage in deeply embedded ways." === LINKS === 🔗 Show Notes with all mentioned links: https://cc-lnk.com/EP472 📺 Dr. Bricker's AhealthcareZ Channel www.youtube.com/@ahealthcarez ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter: https://relentlesshealthvalue.com/join-the-relentless-tribe 🫙 Support the podcast with a small donation to the Tip Jar: https://relentlesshealthvalue.com/join-the-relentless-tribe 🎤 Listen on Apple Podcasts https://podcasts.apple.com/us/podcast/feed/id892082003?ls=1 🎤 Listen on Spotify https://open.spotify.com/show/6UjgzI7bScDrWvZEk2f46b 📺 Subscribe to our YouTube channel https://www.youtube.com/@RelentlessHealthValue === CONNECT WITH THE RHV TEAM === ✭ LinkedIn https://www.linkedin.com/company/relentless-health-value/ ✭ Threads https://www.threads.net/@relentlesshealthvalue/ ✭ Bluesky https://bsky.app/profile/relentleshealth.bsky.social ✭ X https://twitter.com/relentleshealth/ 05:06 From a hospital revenue perspective, where do high-cost claimants fall? 08:45 How do hospitals structure their stop-loss provisions so that they ensure they're always maximizing their revenue? 12:15 How hospitals acquire providers to steer as many patients as possible through specific service lines. 20:21 Why do carriers let hospitals get away with these rates and stop-loss negotiations? 21:06 How do Medicare Advantage and Medicare rates play into all of this? 22:00 What should a benefit consultant be doing here? 23:37 What are the keys to direct contracting? 27:21 Why is it important to get trusted relationships set up ahead of time? 28:04 The Company That Solved Health Care by John Torinus Jr. 29:23 What needs to be the clinical consideration for specialists? 30:46 What is the advantage that employers have in all of this? 33:06 Dr. Bricker's video on 32 examples of healthcare deception.

Recently on Relentless Health Value, we've been tinkering around with a few recurring themes—recurring through lines—that are just true about American healthcare these days. In this episode of Relentless Health Value, host Stacey Richter speaks with Dr. Christine Hale about high cost claimants and the implications for healthcare plans in 2025 and beyond. They discuss the importance of trust in patient care, the financial incentives behind patient steering, and the critical role of timely and comprehensive data analysis. Dr. Hale emphasizes the need for an integrated approach to medical and pharmacy claims data to avoid expensive consequences and improve patient outcomes. She also shares strategies for plan sponsors to effectively manage high cost claimants through evidence-based care, appropriate treatment settings, and creative problem-solving, while underlining the importance of patient engagement and satisfaction. Don't miss next week's episode with Dr. Eric Bricker for a deeper dive into these topics. === LINKS === 🔗 Show Notes with all mentioned links: https://relentlesshealthvalue.com/episodes ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter: https://relentlesshealthvalue.com/join-the-relentless-tribe 🫙 Support the podcast with a small donation to the Tip Jar: https://relentlesshealthvalue.com/join-the-relentless-tribe 🎤 Listen on Apple Podcasts https://podcasts.apple.com/us/podcast/feed/id892082003?ls=1 🎤 Listen on Spotify https://open.spotify.com/show/6UjgzI7bScDrWvZEk2f46b 📺 Subscribe to our YouTube channel https://www.youtube.com/@RelentlessHealthValue === CONNECT WITH THE RHV TEAM === ✭ LinkedIn https://www.linkedin.com/company/relentless-health-value/ ✭ Threads https://www.threads.net/@relentlesshealthvalue/ ✭ Bluesky https://bsky.app/profile/relentleshealth.bsky.social ✭ X https://twitter.com/relentleshealth/ 05:22 What is a high-cost claimant, and how is the definition changing? 07:42 Why buy-and-bill pharmaceuticals can be so costly for plan sponsors. 10:19 What are plan sponsors getting wrong about this situation? 11:28 What do you need as an employer to understand your plan data fully? 13:41 EP462 with Scott Conard, MD. 17:35 What are plan sponsors currently doing that they should not being doing? 19:54 Why starting small is important. 23:02 EP468 with Matt McQuide. 25:37 What are the steps employers should take to improve their high-cost claimant spend? 31:02 EP371 with Erik Davis and Autumn Yongchu. 33:46 EP467 with Stacey. Recent past interviews: Click a guest's name for their latest RHV episode! Nikki King, James Gelfand (Part 2), James Gelfand (Part 1), Matt McQuide, Stacey Richter (EP467), Vivian Ho, Chris Crawford (EP465), Al Lewis, Betsy Seals, Wendell Potter (Encore! EP384), Dr Scott Conard

In this episode, host Stacey Richter revisits a conversation with Nikki King, CEO of Alliance Health Centers, discussing the critical issues facing rural hospitals and healthcare systems. They delve into the impacts of Medicaid cuts, the financial struggles of rural hospitals reliant on commercial insurance, and potential solutions like freestanding emergency rooms, telehealth, and the expanded roles of nurse practitioners. The conversation also covers the complexities of maternity care and mental health services in rural areas, emphasizing the urgent need for systemic reforms to ensure equitable access to healthcare. === LINKS === 🔗 Show Notes with all mentioned links: https://cc-lnk.com/EP470 ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter: https://relentlesshealthvalue.com/join-the-relentless-tribe 🫙 Support the podcast with a small donation to the Tip Jar: https://relentlesshealthvalue.com/join-the-relentless-tribe 📺 Subscribe to our YouTube channel https://www.youtube.com/@RelentlessHealthValue 🎤 Listen on Apple Podcasts https://podcasts.apple.com/us/podcast/feed/id892082003?ls=1 🎤 Listen on Spotify https://open.spotify.com/show/6UjgzI7bScDrWvZEk2f46b === CONNECT WITH THE RHV TEAM === ✭ LinkedIn https://www.linkedin.com/company/relentless-health-value/ ✭ Threads https://www.threads.net/@relentlesshealthvalue/ ✭ Bluesky https://bsky.app/profile/relentleshealth.bsky.social ✭ X https://twitter.com/relentleshealth/ 08:14 How dire is the rural hospital situation right now? 08:33 How could freestanding ERs be a potential solution for rural hospitals? 09:56 Advice from CHQPR: Rural hospitals should not be forced to eliminate inpatient care. 11:22 Why is broadband a roadblock to telehealth as a solution for rural health access? 14:52 What are other potential rural health access solutions? 15:37 The "hot potato" of nurse practitioners in the healthcare world. 16:34 "The number of residencies for physicians each year is not increasing, but the population … is increasing." 20:28 EP312 with Douglas Eby, MD, MPH, CPE, of the Nuka System of Care. 22:00 What's the issue with maternity care in rural America? 24:09 "As healthcare becomes more and more specialized, [the] ability to treat high-risk cases is better, but access gets worse." 27:57 How is mental health care affected in rural communities? 28:29 "Rural communities are trying very hard to hang on to what they have." 29:52 "When you look at the one market plan that's available in a rural community, you probably can't afford it." 31:37 What's the single biggest challenge to moving to a model that incentivizes keeping people healthy? 32:32 "The easiest low-hanging fruit … is having national Medicaid and have that put under the same hood as Medicare."

In part 2 of episode 469, host Stacey Richter discusses the implications of Medicare site neutral payments and Health Savings Account (HSA) reforms with James Gelfand, president and CEO of the ERISA Industry Committee (ERIC). The episode details how plan sponsors should adapt to Medicare's site neutral payment policies aimed at curbing hospital consolidation and inflated prices through facility fees and markups. Gelfand provides insights into how HSA reforms currently in Congress could expand the scope of preventive care covered before deductibles are met, benefitting both employers and employees. The conversation also touches on the challenges high deductible health plans pose and the potential benefits of codifying recent IRS guidance to allow greater flexibility in pre-deductible coverage. The discussion underscores the importance of plan sponsors staying ahead of Medicare policies to avoid higher costs. === LINKS === 🔗 Show Notes with all mentioned links: https://relentlesshealthvalue.com/episodes ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter: https://relentlesshealthvalue.com/join-the-relentless-tribe 🫙 Support the podcast with a small donation to the Tip Jar: https://relentlesshealthvalue.com/join-the-relentless-tribe 🎤 Listen on Apple Podcasts https://podcasts.apple.com/us/podcast/feed/id892082003?ls=1 🎤 Listen on Spotify https://open.spotify.com/show/6UjgzI7bScDrWvZEk2f46b 📺 Subscribe to our YouTube channel https://www.youtube.com/@RelentlessHealthValue === CONNECT WITH THE RHV TEAM === ✭ LinkedIn https://www.linkedin.com/company/relentless-health-value/ ✭ Threads https://www.threads.net/@relentlesshealthvalue/ ✭ Bluesky https://bsky.app/profile/relentleshealth.bsky.social ✭ X https://twitter.com/relentleshealth/ 05:42 What does Medicare site-neutral payments mean? 08:59 How do markups play into the dynamics here? 09:52 Upcoming episode with Christine Hale, MD, MBA. 10:36 What does the "narrow" start for these changes mean? 11:42 What action steps should plan sponsors be taking? 13:01 What options do plan sponsors have in highly consolidated markets? 14:27 EP371 with Erik Davis and Autumn Yongchu. 14:53 EP448 (Part 1 and Part 2) with Shawn Gremminger. 15:46 Will this bill potentially make changes to HSA plans? 17:40 Why has the thinking behind healthcare usage changed since the inception of HSAs? 18:42 INBW41 with Stacey. 23:24 How are preventive care and first-dollar coverage connected within the context of HSAs? 25:48 Why would it be difficult to completely get rid of a high-deductible health plan and offer HSAs without them?

In part 1 of this two part episode, Stacey Richter speaks with James Gelfand, President and CEO of the ERISA Industry Committee (ERIC), about the potential effects of proposed Medicaid cuts on plan sponsors and their members. They explore ways plan sponsors can prepare for the changes, including Medicaid's four major areas of possible cuts: reducing waste, fraud, and abuse; implementing work requirements; reeling in provider taxes; and addressing the 'Cornhusker Kickback' from the ACA. The conversation also delves into how state governments and hospitals might respond to these cuts and suggests actions for plan sponsors to mitigate potential impacts. The episode is part one of a two-part series, with the second episode covering Medicare site neutral payments and HSA reforms. === LINKS === 🔗 Show Notes with all mentioned links: https://relentlesshealthvalue.com/episodes ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter: https://relentlesshealthvalue.com/join-the-relentless-tribe 🫙 Support the podcast with a small donation to the Tip Jar: https://relentlesshealthvalue.com/join-the-relentless-tribe 🎤 Listen on Apple Podcasts https://podcasts.apple.com/us/podcast/feed/id892082003?ls=1 🎤 Listen on Spotify https://open.spotify.com/show/6UjgzI7bScDrWvZEk2f46b 📺 Subscribe to our YouTube channel https://www.youtube.com/@RelentlessHealthValue === CONNECT WITH THE RHV TEAM === ✭ LinkedIn https://www.linkedin.com/company/relentless-health-value/ ✭ Threads https://www.threads.net/@relentlesshealthvalue/ ✭ Bluesky https://bsky.app/profile/relentleshealth.bsky.social ✭ X https://twitter.com/relentleshealth/ 05:22 What's happening with Medicaid cuts? 06:47 What are the four main things congress is actually looking at in cutting Medicaid? 09:12 What is the Cornhusker Kickback? 16:46 What should plan sponsors be doing right now to prepare for these potential Medicaid cuts? 20:04 What's going to happen to hospitals with these proposed Medicaid cuts? 20:48 EP464 with Al Lewis. 23:41 How does hospital consolidation affect the potential future with these Medicaid cuts?

In Episode 468, host Stacey Richter engages in a conversation with Matt McQuide, CEO of Synergy Healthcare. This episode delves into the critical assumptions surrounding member engagement within the healthcare industry. Key points discussed include the role of employers in steering plan members, the importance of member engagement for navigating the healthcare marketplace, and Matt's three major misconceptions about health plan membership. Matt also presents real-life examples of how engagement significantly impacts health outcomes, emphasizing that relationships and trust are paramount. The episode concludes with practical strategies for employers to enhance engagement and manage employee health effectively. === LINKS === 🔗 Show Notes with all mentioned links: https://cc-lnk.com/EP468 ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter: https://relentlesshealthvalue.com/join-the-relentless-tribe 🫙 Support the podcast with a small donation to the Tip Jar: https://relentlesshealthvalue.com/join-the-relentless-tribe 🎤 Listen on Apple Podcasts https://podcasts.apple.com/us/podcast/feed/id892082003?ls=1 🎤 Listen on Spotify https://open.spotify.com/show/6UjgzI7bScDrWvZEk2f46b 📺 Subscribe to our YouTube channel https://www.youtube.com/@RelentlessHealthValue === CONNECT WITH THE RHV TEAM === ✭ LinkedIn https://www.linkedin.com/company/relentless-health-value/ ✭ Threads https://www.threads.net/@relentlesshealthvalue/ ✭ Bluesky https://bsky.app/profile/relentleshealth.bsky.social ✭ X https://twitter.com/relentleshealth/ You can learn more at Synergy Healthcare and by following Matt on LinkedIn. Matt McQuide is the founder and CEO of Synergy Healthcare, a role he has held since launching the company in 2012. Under his leadership, Synergy has made significant strides in improving member health, enhancing the health insurance experience and the financial integrity of health plans. 06:28 What are Matt's three common assumptions that employers make about member engagement? 07:08 "Health is actually hard." 08:19 Why is it important to meet people when their need for healthcare sparks their interest in their health? 11:29 "It didn't take much … it just takes time." 13:53 Why are relationships and trust more important today for employee health and member engagement? 16:04 Do people actually want optimal health? 17:44 Why is it important to meet people where they are today? 22:38 "Employers don't want to fix healthcare." 24:10 Why it's important to remember that claims are real people. 24:38 Quote from Steve Schutzer, MD, about EP463 with Betsy Seals. 26:44 How do you solve the "middle way"?

In this solo episode of 'Relentless Health Value,' host Stacey Richter dives into the intricate relationship between increased emergency room (ER) visits and the lack of access to effective primary care. Discussing insights from recent episodes featuring experts like Matt McQuide, Dr. Christine Hale, and others, Stacey explores how inadequate primary care leads to skyrocketing ER costs, which now account for 6% of total healthcare spending. Key points include the systemic issues driving this trend, the incentives misalignments within hospitals and insurance carriers, and the importance of establishing trust and relationships in primary care. The episode also discusses perspectives from healthcare professionals and thought leaders on potential solutions to realign healthcare incentives and improve patient outcomes. === LINKS === 🔗 Show Notes with all mentioned links: https://cc-lnk.com/EP467 ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter: https://relentlesshealthvalue.com/join-the-relentless-tribe 🫙 Support the podcast with a small donation to the Tip Jar: https://relentlesshealthvalue.com/join-the-relentless-tribe 🎤 Listen on Apple Podcasts https://podcasts.apple.com/us/podcast/feed/id892082003?ls=1 🎤 Listen on Spotify https://open.spotify.com/show/6UjgzI7bScDrWvZEk2f46b 📺 Subscribe to our YouTube channel https://www.youtube.com/@RelentlessHealthValue === CONNECT WITH THE RHV TEAM === ✭ LinkedIn https://www.linkedin.com/company/relentless-health-value/ ✭ Threads https://www.threads.net/@relentlesshealthvalue/ ✭ Bluesky https://bsky.app/profile/relentleshealth.bsky.social/ ✭ X https://twitter.com/relentleshealth/ 02:16 Connecting the dots between the last six shows. 05:34 EP466 with Vivian Ho, PhD. 05:53 EP463 with Betsy Seals. 05:56 EP384 with Wendell Potter. 14:38 Where does the primary care through line connect to carriers? 17:13 Health Affairs study showing ER cost increases. 19:19 Kevin O'Leary's Health Tech Nerds newsletter. 19:40 EP407 with Vivek Garg, MD, MBA. 20:47 How are hospital board directors affecting hospital price increases and why? 21:49 Upcoming episode with Matt McQuide. Also mentioned in this episode are Matt McQuide; Christine Hale, MD, MBA; Kenny Cole, MD; Al Lewis; John Lee, MD; Rushika Fernandopulle, MD; Scott Conard, MD; Vivian Ho, PhD; Betsy Seals; Wendell Potter; Tim Denman; François de Brantes, MBA; Jeff Charles Goldsmith, PhD; Mick Connors, MD; Primary Care for All Americans; Rob Andrews; Alex Sommers, MD, ABEM, DipABLM; Ann Lewandowski; Steve Schutzer, MD; Sergei Polevikov, ABD, MBA, MS, MA 🇮🇱🇺🇦; Kevin O'Leary; Health Tech Nerds; Vivek Garg, MD, MBA; Suhas Gondi, MD, MBA;

Healthcare costs keep rising, but what's driving those increases? In this episode, Stacey Richter speaks with Dr. Vivian Ho, a health economist at Rice University and Baylor College of Medicine, to break down the real reasons behind skyrocketing commercial insurance premiums. Are insurance premiums rising faster than wages—and why does it matter? What's the biggest driver of premium increases? (Spoiler: It's hospital prices.) Are hospital price hikes justified by rising costs—or is something else at play? Dr. Ho shares data-backed insights on hospital consolidation, executive incentives, and how health system pricing impacts self-insured employers and plan sponsors. If you're a healthcare executive or a jumbo employer managing benefits, this episode is a must-listen. === LINKS === 🔗 Show Notes with all mentioned links:https://relentlesshealthvalue.com/episodes ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter:https://relentlesshealthvalue.com/join-the-relentless-tribe 🫙 Support the podcast with a small donation to the Tip Jar:https://relentlesshealthvalue.com/join-the-relentless-tribe 🎤 Listen on Apple Podcastshttps://podcasts.apple.com/us/podcast/feed/id892082003?ls=1 🎤 Listen on Spotify https://open.spotify.com/show/6UjgzI7bScDrWvZEk2f46b 📺 Subscribe to our YouTube channel https://www.youtube.com/@RelentlessHealthValue === CONNECT WITH THE RHV TEAM === ✭ LinkedIn https://www.linkedin.com/company/relentless-health-value/ ✭ Bluesky https://bsky.app/profile/relentleshealth.bsky.social ✭ Threads https://www.threads.net/@relentlesshealthvalue/ ✭ X https://twitter.com/relentleshealth/ 05:12 Are insurance premiums going up?05:59 What is the disparity between cost of insurance and wage increases?06:21 LinkedIn post by Byron Hugley.06:25 Article by Michael Strain.06:46 How much have insurance premiums gone up for employers versus employees?09:06 Chart showing the cost to insure populations of employees and families.10:17 What is causing hospital prices and insurance premiums to go up so exponentially?12:53 Article by (and tribute to) Uwe Reinhardt.13:49 EP450 with Marilyn Bartlett, CPA, CGMA, CMA, CFM.15:28 Are razor-thin operating margins for hospitals causing these rising hospital prices?16:56 Collaboration with Marilyn Bartlett and the NASHP Hospital Cost Tool.19:47 What is the explanation that hospitals give for justifying these profits?23:16 How do these hospital cost increases actually happen?27:06 Study by Zack Cooper, PhD.27:50 Who typically makes up a hospital board, and why do these motivations incentivize hospital price increases?30:12 EP418 with Mark Cuban and Ferrin Williams, PharmD, MBA.33:17 Why is it vital that change start at the board level?

The Hidden Costs of PBMs: How Aggregate Discount Guarantees Inflate Drug Prices. In episode 465 of Relentlessly Seeking Value, host Stacey Richter interviews Chris Crawford, CEO of RxSaveCard, about the inflated costs within the pharmacy benefits industry. The discussion centers around a lawsuit involving J&J, highlighting how large PBMs can significantly overcharge for drugs that are available much cheaper through cash-pay options like Mark Cuban's Cost Plus Drugs. Crawford explains how Aggregate Discount Guarantees, a common contracting mechanism, often fail to control spread pricing effectively and instead may lead to higher costs for plan sponsors and employees. The episode also covers how RxSaveCard can help employers and employees access these lower cash prices, circumventing the inflated costs from traditional PBMs. === LINKS === 🔗 Show Notes with all mentioned links: https://cc-lnk.com/EP465 ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter: https://relentlesshealthvalue.com/join-the-relentless-tribe 🫙 Support the podcast with a small donation to the Tip Jar: https://relentlesshealthvalue.com/join-the-relentless-tribe 🎤 Listen on Apple Podcasts https://podcasts.apple.com/us/podcast/feed/id892082003?ls=1 🎤 Listen on Spotify https://open.spotify.com/show/6UjgzI7bScDrWvZEk2f46b 📺 Subscribe to our YouTube channel https://www.youtube.com/@RelentlessHealthValue === CONNECT WITH THE RHV TEAM === ✭ LinkedIn https://www.linkedin.com/company/relentless-health-value/ ✭ Bluesky https://bsky.app/profile/relentleshealth.bsky.social ✭ Threads https://www.threads.net/@relentlesshealthvalue/ ✭ X https://twitter.com/relentleshealth/ 07:12 EP365 with Scott Haas. 07:17 EP397 with Paul Holmes. 07:19 EP439 with Luke Slindee, PharmD. 07:20 EP379 with AJ Loiacono. 07:44 What is the Aggregate Discount Guarantee? 13:49 Why do the divergent list prices and the perverse incentives prevent the Aggregate Discount Guarantee from really limiting cost spread? 17:55 Why is it important for plan sponsors to check these drug cost prices, and how can employers check them? 23:56 What drives cost lower, and why does it change everything? 25:09 How does RxSaveCard work? 25:44 EP461 with Chris Crawford. 30:01 Do you need a PBM's permission to use RxSaveCard? 30:37 How does it look for employers/employees to use the RxSaveCard? 32:39 EP356 with Ge Bai, PhD, CPA.

Emergency room costs now make up 6% of total healthcare plan spending—why? In this episode, host Stacey Richter welcomes Al Lewis to break down the data behind rising ER expenses, separating fact from fiction. They discuss whether increased patient acuity or widespread upcoding is driving costs, the impact of the No Surprises Act, and why plan sponsors struggle to negotiate fair ER rates. Plus, Al shares actionable strategies for employers to push back against inflated charges. If you want to understand the hidden forces behind escalating ER bills, this is a must-listen. You can find the charts and links mentioned in the show notes in the link below. === LINKS === 🔗 Show Notes with all mentioned links: https://cc-lnk.com/EP464 ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter: https://relentlesshealthvalue.com/join-the-relentless-tribe 🫙 Support the podcast with a small donation to the Tip Jar: https://relentlesshealthvalue.com/join-the-relentless-tribe 📺 Subscribe to our YouTube channel https://www.youtube.com/@RelentlessHealthValue 🎤 Listen on Apple Podcasts https://podcasts.apple.com/us/podcast/feed/id892082003?ls=1 🎤 Listen on Spotify https://open.spotify.com/show/6UjgzI7bScDrWvZEk2f46b === CONNECT WITH THE RHV TEAM === ✭ LinkedIn https://www.linkedin.com/company/relentless-health-value/ ✭ Bluesky https://bsky.app/profile/relentleshealth.bsky.social ✭ Threads https://www.threads.net/@relentlesshealthvalue/ ✭ X https://twitter.com/relentleshealth/ 00:00 Introduction 08:32 What is going on in ER visits, and how big of a deal is the total spend? 10:16 Why is the price of ER visits going up when it should be going down? 11:59 What is the major source of unexpected medical debt? 13:27 What is code creep, and why is it happening? 16:26 Why are plan sponsors unable to negotiate emergency room services? 19:22 EP415 with Rob Andrews. 25:53 Why is it important not to agree to consent when you go in to visit the ER? 27:47 EP386 with Al Lewis. 31:28 What steps can plan sponsors take to be proactive about limiting ER spending for their employees? You can learn more at quizzify.com and by emailing [email protected]. You can also follow Al on LinkedIn. Recent past interviews: Click a guest's name for their latest RHV episode! Betsy Seals, Wendell Potter (Encore! EP384), Dr Scott Conard, Stacey Richter (INBW42), Chris Crawford, Dr Rushika Fernandopulle, Bill Sarraille, Stacey Richter (INBW41), Andreas Mang (Encore! EP419), Dr Komal Bajaj

In this episode of Relentless Health Value, host Stacey Richter engages with Betsy Seals, CEO and co-founder of Rebellis Group, to analyze the future of key Medicare Advantage policies amidst a changing political landscape. They delve into four critical areas: 1. Medicare Advantage Stars Program: Examining potential changes due to recent lawsuits and the new administration's stance on quality measures. 2. Risk Adjustment and Government Oversight: Discussing the focus on recouping improper payments and how oversight might evolve. 3. Use of Artificial Intelligence: Considering appropriate oversight for AI applications in prior authorization processes and ensuring they benefit patient care. 4. Agent and Broker Oversight: Exploring increased scrutiny over marketing practices and the dissemination of accurate information to beneficiaries. Betsy emphasizes the importance for Medicare Advantage plans to prioritize patient value, maintain compliance, and proactively utilize data to navigate these evolving policies. This discussion provides valuable insights for stakeholders aiming to understand the future of Medicare Advantage. === LINKS === 🔗 Show Notes with all mentioned links: https://cc-lnk.com/EP463 ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter: https://relentlesshealthvalue.com/join-the-relentless-tribe 🫙 Support the podcast with a small donation to the Tip Jar: https://relentlesshealthvalue.com/join-the-relentless-tribe 🎤 Listen on Apple Podcasts https://podcasts.apple.com/us/podcast/feed/id892082003?ls=1 🎤 Listen on Spotify https://open.spotify.com/show/6UjgzI7bScDrWvZEk2f46b 📺 Subscribe to our YouTube channel https://www.youtube.com/@RelentlessHealthValue === CONNECT WITH THE RHV TEAM === ✭ LinkedIn https://www.linkedin.com/company/relentless-health-value/ ✭ Bluesky https://bsky.app/profile/relentleshealth.bsky.social ✭ Threads https://www.threads.net/@relentlesshealthvalue/ ✭ X https://twitter.com/relentleshealth/ 05:09 Will the Star Ratings program stay in this new administration? 08:08 How will the lawsuits against CMS policies play out with this new administration? 10:24 Why is it hard for Medicare Advantage plans to survive, let alone thrive? 16:22 How does AI directly impact beneficiary lives? 21:38 What's going on now with the override payments? 27:08 How is non-collaboration going to impact Medicare beneficiaries moving forward? 31:45 Why is it important to become more technologically savvy in compliance?

In this episode, Stacey Richter explores how the demands of shareholders influence the actions of publicly traded health insurance companies with guest Wendell Potter. Drawing from Milton Friedman's assertion that a business's primary responsibility is to its shareholders, we examine the implications of this philosophy in the healthcare sector. The discussion highlights concerns about fraud allegations among major insurers and the lack of open competition due to market consolidation. We delve into the concept of the "medical loss ratio," a key metric for investors, and how it pressures insurers to prioritize profits, often at the expense of patient care. Our guest, Wendell Potter, a former health insurance executive turned advocate for healthcare reform, provides insider insights into these dynamics. He discusses the challenges insurers face in controlling costs, the impact of rising premiums, and the broader consequences for patients and the healthcare system. This episode offers a critical look at the intersection of corporate interests and patient care, shedding light on the systemic issues that arise when profit motives drive healthcare decisions. All mentioned links can be found in the show notes. === LINKS === 🔗 Show Notes with all mentioned links: https://cc-lnk.com/Encore384 ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter: https://relentlesshealthvalue.com/join-the-relentless-tribe 🫙 Support the podcast with a small donation to the Tip Jar: https://relentlesshealthvalue.com/join-the-relentless-tribe 🎤 Listen on Apple Podcasts https://podcasts.apple.com/us/podcast/feed/id892082003?ls=1 🎤 Listen on Spotify https://open.spotify.com/show/6UjgzI7bScDrWvZEk2f46b 📺 Subscribe to our YouTube channel https://www.youtube.com/@RelentlessHealthValue === CONNECT WITH THE RHV TEAM === ✭ LinkedIn https://www.linkedin.com/company/relentless-health-value/ ✭ Bluesky https://bsky.app/profile/relentleshealth.bsky.social ✭ Threads https://www.threads.net/@relentlesshealthvalue/ ✭ X https://twitter.com/relentleshealth/ 08:31 What is the medical loss metric? 11:33 "The reality is, insurers have been jacking up premiums … for a long time." 12:48 "It's a short-term game." 15:39 "You're seeing that these companies are not doing a very good job … of controlling costs because they don't have the incentive." 20:19 EP366 with Kevin Schulman, MD. 22:45 How do payers ensure that they're controlling utilization? 25:53 "It's death by a thousand cuts." 31:51 "Just like independent practice physicians are endangered, so are community pharmacists." 33:17 Who runs our healthcare system?

This podcast today is with Dr. Scott Conard, founder of Converging Health. You might remember him from the earlier episode (EP391). First of all, I enjoyed how it came to be. Brian Uhlig, an employee benefit consultant of some acclaim, came to me and offered to sponsor a show for someone else. Not himself. I gotta say, it's stuff like this that warms my heart. It's this village that we have here, this tribe of Relentless folks trying so hard to stand up for and help patients. So, thanks again to Brian Uhlig. Right now, Dr. Conard is doing a bunch of work with Mike Adams from 7-Eleven, helping their plan members. A lot of this work is centered on and about a few pretty striking but very common insights that many plan sponsors will find in their own data. It turns out about 70%, give or take, of people who wind up costing the plan whatever the high-cost threshold is in any given plan year. These higher-cost claimants didn't fall out of the sky unexpectedly, 70% of them. They were actually high risk but low cost in prior years. So, the trick is to find these individuals and help them not fall into the high-risk and high-cost part of the graph. If the goal is how to best manage a population of members, a lot of that is, again, identifying high-risk patients who are currently in the low-cost zone, who, any given plan year, are gonna go out of that zone and get into the high-cost area. So, if we're thinking about best practices to avoid this, I'm gonna run through Dr. Conard's list that we mostly run through in the show that follows. Lastly, we touch a little bit in the show today on community-run primary care. This is a community paying for primary care for community members, just like they pay the fire department and the police department. There's a town in Rhode Island doing this that Dr. Conard talks about today. In fact, Michael Fine, MD, is part of this effort in Rhode Island. === LINKS === 🔗 Show Notes with all mentioned links and articles: https://cc-lnk.com/EP462 ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter: https://relentlesshealthvalue.com/join-the-relentless-tribe 🫙 Support the podcast with a small donation to the Tip Jar: https://relentlesshealthvalue.com/join-the-relentless-tribe 🎤 Listen on Apple Podcasts https://podcasts.apple.com/us/podcast/feed/id892082003?ls=1 🎤 Listen on Spotify https://open.spotify.com/show/6UjgzI7bScDrWvZEk2f46b 📺 Subscribe to our YouTube channel https://www.youtube.com/@RelentlessHealthValue === CONNECT WITH THE RHV TEAM === ✭ LinkedIn https://www.linkedin.com/company/relentless-health-value/ ✭ Bluesky https://bsky.app/profile/relentleshealth.bsky.social ✭ Threads https://www.threads.net/@relentlesshealthvalue/ ✭ X https://twitter.com/relentleshealth/ 07:10 How do we think about data wrongly, and how does that affect our healthcare spend in regard to population health? 09:43 What needs to be done with population health data once it's collected. 14:48 Community in Rhode Island doing effective proactive care. 16:09 EP449 with Marty Makary, MD, MPH. 16:44 A real, successful case study. 24:08 How do we define high-cost patients? 24:14 What do we know about high-cost patients in regard to population health spend? 29:02 Why avoiding prevention in primary care only harms yourself in the future.

In this inbetweenisode Stacey Richter dives into the complexities of benefit design in American healthcare. Highlighting insights from recent episodes with Bill Sarraille (EP459) and upcoming episode with Scott Conard, MD, Richter explores the impact of cost containment measures and the moral hazard of insurance, emphasizing the importance of creating balanced and efficient benefit plans that align with plan values and avoid unintended consequences. She discusses the challenges and implications of high deductible health plans and copay maximizers/accumulators, urging plan sponsors to strive for pareto optimality and practical solutions. This episode is a call to carefully consider patient behavior, healthcare utilization, and the broader impacts of financial incentives in healthcare. Going black and white or over-indexing to prevent outlier kind of stuff is probably not gonna end well. Not seeking a middle way can easily result in a solution that is possibly worse than the problem. Moral hazard is actually a thing. There are lots of implications to patients not being able to distinguish high-value and low-value care. But if we know this, then, philosophically at least, how do we conceptualize a solve? What should we be doing? If we're not doing black and white, what does the gray in the middle look like? === LINKS === 🔗 Show Notes with all mentioned links: https://cc-lnk.com/INBW42 ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter: https://relentlesshealthvalue.com/join-the-relentless-tribe 🫙 Support the podcast with a small donation to the Tip Jar: https://relentlesshealthvalue.com/join-the-relentless-tribe 🎤 Follow on Apple Podcasts https://podcasts.apple.com/us/podcast/feed/id892082003?ls=1 🎤 Follow on Spotify https://open.spotify.com/show/6UjgzI7bScDrWvZEk2f46b 📺 Subscribe to our YouTube channel https://www.youtube.com/@RelentlessHealthValue === CONNECT WITH THE RHV TEAM === ✭ LinkedIn https://www.linkedin.com/company/relentless-health-value/ ✭ Threads https://www.threads.net/@relentlesshealthvalue/ ✭ X https://twitter.com/relentleshealth/ ✭ Bluesky https://bsky.app/profile/relentleshealth.bsky.social 00:00 Introduction to the Rabbit Hole 04:05 Where did Stacey's rabbit hole spiral start? 05:40 What is the moral hazard of insurance? 09:31 EP358 with Wayne Jenkins, MD. 12:49 Why isn't moral hazard mitigated in insurance? 18:16 EP459 with Bill Sarraille. 20:51 "How do we conceptualize a solve?" 22:24 Why should we be striving for Pareto optimality? 25:20 What is the theory of second best?

This episode with Chris Crawford, CEO of RxSaveCard, is not about the when, why, or how of GLP-1s for weight loss or best-practice prescribing. This episode very, very specifically is about the how and why of the pickle plan sponsors get themselves into often enough where if they impose formulary restrictions to limit the volume of meds that they are paying for, then unit prices go up, which is a thing for GLP-1s. And this is critical just given how the costs associated with GLP-1s for weight loss contribute to some pretty significant increases in pharmacy trend for plan sponsors who choose to cover the GLP-1s for weight loss. Chris Crawford and Stacey Richter discuss the challenges plan sponsors face with the rising costs of GLP-1 medications for weight loss. They explore how plan sponsors' efforts to manage pharmacy trends often result in a tradeoff: lowering unit costs by increasing volume or vice versa. Chris also introduces a potential solution leveraging the growing cash marketplace, where employers can bypass traditional PBM contracts to achieve cost savings. Tune in for actionable insights into the perverse incentives in the pharmacy supply chain and innovative ways to navigate them. (Continued below the links) === LINKS === 🔗 Show Notes with all mentioned links: hhttps://cc-lnk.com/EP461 ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter: https://relentlesshealthvalue.com/join-the-relentless-tribe 🫙 Support the podcast with a small donation to the Tip Jar: https://relentlesshealthvalue.com/join-the-relentless-tribe 🎤 Listen on Apple Podcasts https://podcasts.apple.com/us/podcast/feed/id892082003?ls=1 🎤 Listen on Spotify https://open.spotify.com/show/6UjgzI7bScDrWvZEk2f46b 📺 Subscribe to our YouTube channel https://www.youtube.com/@RelentlessHealthValue === CONNECT WITH THE RHV TEAM === ✭ LinkedIn https://www.linkedin.com/company/relentless-health-value/ ✭ Threads https://www.threads.net/@relentlesshealthvalue/ ✭ X https://twitter.com/relentleshealth/ ✭ Bluesky https://bsky.app/profile/relentleshealth.bsky.social Bottom line, there are some really impactful and not frequently delved into perverse incentives at play here. And we're gonna talk about these today. And these are really key for anybody on or about the pharmacy supply chain in the U.S. to know about. This is very actionable insight. So, again, there's an unfortunate tradeoff, as it stands right now, for many plan sponsors. Lower your volume and raise the unit price or vice versa. This episode is sponsored by RxSaveCard, and a big thanks for that. I really appreciate RxSaveCard for its financial support because this episode covers a really important topic that we probably would have covered anyway over here at Relentless Health Value. And so, RxSaveCard standing up and offering their financial support to cover it was a really nice thing to do. And I thank them for their generosity. 07:57 What are the two pieces going on with GLP-1 PBM prices and rebates for employers? 10:00 Is the cash price for these name brand drugs currently less than the rebated PBM price? 11:49 Why does the rebate for GLP-1s disappear if employers try to put restrictions on who can receive access to these drugs? 15:07 Where does RxSaveCard come in to play here? 19:55 "We exist to save people money." 20:45 EP456 with Brian Reid. 21:16 EP356 with Ge Bai, PhD, CPA. 21:37 EP439 with Luke Slindee, PharmD.

In this Relentless Health Value episode, Dr. Rushika Fernandopulle discusses with Stacey Richter his four-prong theory of change for transforming the American healthcare system. Key topics include the necessity of new payment models, process innovation, employing a relational technology infrastructure, shifting the cultural mindset towards team-based care, and emphasizing the importance of long-term partnerships. The conversation underscores the urgent need to move away from the current status quo to ensure better health outcomes and affordable care for all Americans. This is one of those episodes where we consider top-line strategic imperatives and key drivers. There was no better person to do this with than Rushika Fernandopulle, MD, who, in case you were unaware, was the founder of Iora Health, an advanced primary care group that was sold to One Medical and then to Amazon. They discusses his four-prong theory and as Stacey says, "I can't leave well enough alone, so I plucked one more prong from our conversation and stuck it on the end." For a summary of this 5 prong approach, visit the show notes page where we also list all of the links mentioned in the episode. === LINKS === 🔗 Show Notes with all mentioned links: https://cc-lnk.com/EP460 ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter: https://relentlesshealthvalue.com/join-the-relentless-tribe 🫙 Support the podcast with a small donation to the Tip Jar: https://relentlesshealthvalue.com/join-the-relentless-tribe 🎤 Listen on Apple Podcasts https://podcasts.apple.com/us/podcast/feed/id892082003?ls=1 🎤 Listen on Spotify https://open.spotify.com/show/6UjgzI7bScDrWvZEk2f46b 📺 Subscribe to our YouTube channel https://www.youtube.com/@RelentlessHealthValue === CONNECT WITH THE RHV TEAM === ✭ LinkedIn https://www.linkedin.com/company/relentless-health-value/ ✭ Threads https://www.threads.net/@relentlesshealthvalue/ ✭ X https://twitter.com/relentleshealth/ ✭ Bluesky https://bsky.app/profile/relentleshealth.bsky.social 06:39 How Dr. Rushika Fernandopulle found himself where he is now. 08:06 Dr. Fernandopulle's conversation with Kenny Cole, MD. 10:33 Why is it important to have new payment models? 12:21 EP453 with Claire Brockbank. 14:50 EP455 with Beau Raymond, MD. 16:19 Why it makes sense to change as quickly as possible. 19:55 How to be proactive and not be reactive and achieve value-based reimbursement for good care. 21:41 Why team-based care is so important for change. 23:37 Why is it important to have a different set of technology tools? 24:38 EP391 with Scott Conard, MD. 25:24 Why changing the culture is important. 27:01 "Getting doctors to do things they don't like is a waste of time." 33:22 "Healthcare is local." 35:31 EP364 with David Muhlestein, PhD, JD. 35:43 Study by Zack Cooper, PhD. 36:53 EP404 with Suhas Gondi, MD, MBA. 39:04 Why long-term partnerships are the only way to make things better.

In Episode 459, host Stacey Richter speaks with healthcare attorney Bill Sarraille about co-pay maximizers and accumulators, mechanisms designed to extract maximum co-pay support dollars from pharmaceutical companies. They discuss the financial implications for patients, plan sponsors, and pharmacy benefit managers (PBMs), emphasizing the legal and ethical issues and potential patient harm due to high out-of-pocket costs and surprise expenses. Sarraille provides five key pieces of advice for plan sponsors and highlights the importance of transparency and proper utilization management to minimize patient access problems and legal risks. Listen or read the show notes on our site for the full list. (continued below the links) === LINKS === 🔗 Show Notes with all mentioned links: https://cc-lnk.com/EP459 ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter: https://relentlesshealthvalue.com/join-the-relentless-tribe 🫙 Support the podcast with a small donation to the Tip Jar: https://relentlesshealthvalue.com/join-the-relentless-tribe ===CONNECT WITH THE RHV TEAM === ✭ LinkedIn https://www.linkedin.com/company/relentless-health-value/ ✭ Threads https://www.threads.net/@relentlesshealthvalue/ ✭ X https://twitter.com/relentleshealth/ ✭ Bluesky https://bsky.app/profile/relentleshealth.bsky.social Co-pay maximizers and accumulators are programs designed to capture maximum co-pay assistance from phara. Maximizers spread pharma co-pay support evenly throughout the year, ensuring plan sponsors benefit while, in theory, patients face minimal costs. More on how that can go wrong in the episode. Accumulators, however, design their plan to deplete pharma dollar support quickly, surprising patients with significant out-of-pocket expenses mid-year when they go visit the pharmacy. These programs usually exclude pharma assistance dollars from deductibles, potentially causing financial hardship because when pharma is paying your co-pay, those payments don't count against your deductible. 09:31 What should plan sponsors be aware of right now? 14:01 What is the justification for maximizers, and why is this at odds with the purpose of insurance? 18:05 Where does the issue of "fairness" land within cost containment? 20:00 Brian Reid's LinkedIn post on insurance company access challenges. 21:30 What are the real legal issues presented by some of these co-pay maximizers and co-pay accumulator programs? 27:06 How are these programs creating perverse incentives? 29:28 EP450 with Marilyn Bartlett, CPA, CGMA, CMA, CFM. 32:16 "If you're covered by the ACA, I think this is unlawful." 32:57 What advice does Bill have in regard to these programs? 33:49 What potential litigations does Bill see coming in the near future in regard to these co-pay maximizers and co-pay accumulator programs?

In this Inbetweenisode titled 'End of Year Wrap Up and My Personal Charter Encore,' Stacey Richter extends heartfelt thanks to listeners and healthcare workers for their dedication. She reflects on the challenges of maintaining personal integrity in a profit-driven healthcare system and introduces her personal charter. This charter, focused on ensuring net positive outcomes for patients, acknowledges that achieving transformational change in healthcare requires a collective effort. Stacey discusses the complexities of balancing ethical decisions, financial constraints, and the broader impact on patient care, urging others to reflect on their own guiding principles. Here's her manifesto which she is now calling her Personal Charter below which she breaks down in this podcast episode: "If the thing results in a net positive for patients, then I will do it. The timeframe is short-term or medium-term. And the assumption is that it will take a village and I am not alone in my efforts to transform healthcare or do right by patients." === LINKS === 🔗 Show Notes with all mentioned links: https://cc-lnk.com/INBW41 ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter: https://relentlesshealthvalue.com/join-the-relentless-tribe 🫙 Support the podcast with a small donation to the Tip Jar: https://relentlesshealthvalue.com/join-the-relentless-tribe === CONNECT WITH THE RHV TEAM === ✭ LinkedIn https://www.linkedin.com/company/relentless-health-value/ ✭ Threads https://www.threads.net/@relentlesshealthvalue/ ✭ X https://twitter.com/relentleshealth/ ✭ Bluesky https://bsky.app/profile/relentleshealth.bsky.social 06:52 "It's a zero-sum game." 07:02 Is the amount of profit fair? 07:13 What is an inescapable fact of the healthcare industry? 07:30 What does the financialization of healthcare mean? 07:55 Why does the self-interest in healthcare matter? 09:54 "It's basically up to us as individuals to do the right thing." 13:39 What is the first part of Stacey's personal charter? 13:54 How does Stacey calculate the net positive of an impact? 14:17 What are two major upsides/downsides that Stacey contemplates? 17:08 Why are incremental change and disruptive change not mutually exclusive? 21:16 "I always try to keep in mind that it will take a village." 22:55 Why finger pointing is killing innovation in healthcare.

Are you on the board of directors of a company? Or are you a shareholder of a publicly traded company? Or are you a CEO or a CFO or in-house counsel who reports to a board of directors or these shareholders? Well, this show is for you. And it's about how the healthcare industry has become financialized at the same time that providing health benefits has become the second-biggest line item after payroll for most companies. We talked about that in a recent encore with Mark Cuban (EP418) also, as well as the show with Cora Opsahl (EP452) and Claire Brockbank (EP453) from 32BJ. In this encore episode of 'Relentless Health Value,' Stacey Richter interviews Andreas Mang from Blackstone about the financialization of health benefits for boards of directors and C-suites of self-insured employers. They discuss the unseen financial layers in healthcare benefits and how companies can save significantly while improving employee satisfaction and health. === LINKS === 🔗 Show Notes with all mentioned links: https://cc-lnk.com/EP458 ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter: https://relentlesshealthvalue.com/join-the-relentless-tribe 🫙 Support the podcast with a small donation to the Tip Jar: https://relentlesshealthvalue.com/join-the-relentless-tribe === CONNECT WITH THE RHV TEAM === ✭ LinkedIn https://www.linkedin.com/company/relentless-health-value/ ✭ Threads https://www.threads.net/@relentlesshealthvalue/ ✭ X https://twitter.com/relentleshealth/ ✭ Bluesky https://bsky.app/profile/relentleshealth.bsky.social 04:55 Why Andreas starts every conversation with the question, "How's your healthcare company?" 07:38 Why is it important, as a self-insured employer, to treat your business as a small healthcare company? 09:16 Why is it unnatural for companies to be providing health insurance? 10:47 What can be achieved when there is alignment between employers and insurers? 12:41 What things can a company do to reduce spend by 10%? 14:14 Why is it better to have CFO engagement in the benefits plan throughout the year? 16:25 Why does self-insurance save 5% to 9% for companies automatically? 18:14 "The funding isn't a healthcare thing; it's a CFO thing." 18:27 Why is it vital to have a reliable, trustworthy broker? 25:12 When is the last time your company has RFP'd their health plan? 27:39 Why does changing a health plan feel scary but is necessary? 28:31 What is a dependent eligibility audit? 31:20 Why are employers better together? 34:34 How do employers truly get a flat-fee model with brokers?

In Episode 458 of Relentless Health Value, host Stacey Richter speaks with Dr. Komal Bajaj about innovative strategies for addressing staffing shortages in the healthcare sector. They explore the importance of cultural alignment within organizations, emphasizing trust and shared values to retain staff. Dr. Bajaj shares surprising findings from surveys indicating that healthcare workers are motivated by the goal of providing high-quality, planet-friendly care. The discussion highlights the interconnectedness of environmental sustainability and healthcare quality, presenting tangible ways to engage and empower healthcare workers while addressing both local community health and broader environmental concerns. The episode underscores the strategic importance of aligning organizational goals with the aspirations of the workforce to foster trust and mitigate staffing shortages. Stacey's guest today is Dr. Komal Bajaj. Dr. Bajaj is an ob-gyn who serves as the chief quality officer for a couple of hospitals in the Bronx, New York, that are part of the municipal health system of New York. She also now serves as medical director of sustainability for the municipal health system NYC Health + Hospitals. === LINKS === 🔗 Show Notes with all mentioned links: https://cc-lnk.com/EP458 ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter: https://relentlesshealthvalue.com/join-the-relentless-tribe 🫙 Support the podcast with a small donation to the Tip Jar: https://relentlesshealthvalue.com/join-the-relentless-tribe === CONNECT WITH THE RHV TEAM === ✭ LinkedIn https://www.linkedin.com/company/relentless-health-value/ ✭ Threads https://www.threads.net/@relentlesshealthvalue/ ✭ X https://twitter.com/relentleshealth/ ✭ Bluesky https://bsky.app/profile/relentleshealth.bsky.social 08:20 How do we quantify the issue of staffing shortages? 11:18 Why do we need to look at the root cause of the shortages? 11:51 Deloitte survey on staffing shortages. 11:54 Why is trust one of the core problems when it comes to staffing shortages? 13:59 "Healthcare workers have choice." 15:34 What are the strongest correlations that influence healthcare workers' desire to stay? 18:17 What things give healthcare workers the most pause? 19:36 The U.S. Department of Health and Human Services Health Sector climate pledge. 20:20 The Commonwealth Fund survey on what health systems can do to address climate change. 22:29 What do we do about sustainable, climate-friendly healthcare being a driving factor in staffing? 27:28 How do you meet the desires of healthcare workers where they're at?

In this episode of 'Relentlessly Seeking Value,' host Stacey Richter is joined by healthcare entrepreneur Cynthia Fisher to discuss the crucial issue of medical spread pricing and the need for contract transparency. Fisher explains how hidden fees and spread pricing by middlemen are leading to substantial overcharges for employers and patients in the U.S. healthcare system. The conversation delves into recent lawsuits that highlight these practices, the legislative strides made to enforce price transparency, and how transparency can potentially transform the industry. Look, this is a thing now, medical spread. And similar to how PBM spreads adds up to millions, billions of dollars, medical spread is not change in the couch cushions. Did you see the lawsuit against Cigna? Cynthia Fisher mentions it in the conversation that follows. Spoiler alert, here's the numbers: Self-insured employer paid $4 million for a claim. There's a slide on this Cynthia Fisher gave me, by the way, if you want to see all this written out. So, the employer pays $4 million. The provider was paid—drumroll, please—$876,000. I'm pausing so that sinks in: $4 million paid by the employer; $876,000 of that makes it across the trench to the provider. To view the meme we created for how carriers are learning to do spread pricing from the PBMs, visit our show notes page below. (continued after the links below) === LINKS === 🔗 Show Notes with all mentioned links: https://cc-lnk.com/EP457 ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter: https://relentlesshealthvalue.com/join-the-relentless-tribe 🫙 Support the podcast with a small donation to the Tip Jar: https://relentlesshealthvalue.com/join-the-relentless-tribe === CONNECT WITH THE RHV TEAM === ✭ LinkedIn https://www.linkedin.com/company/relentless-health-value/ ✭ Threads https://www.threads.net/@relentlesshealthvalue/ ✭ X https://twitter.com/relentleshealth/ ✭ Bluesky https://bsky.app/profile/relentleshealth.bsky.social Fisher emphasizes the importance of employers and unions demanding accountability, using existing laws to unveil true pricing, and advocates for a revolution in healthcare to ensure fair, equitable, and transparent billing. Insights are also shared from industry experts who were previous guests including Chris Deacon, Justin Leader, and Andreas Mang. You can find the links in the show notes on our site. 09:03 What is the goal of PatientRightsAdvocate.org? 10:28 Is American competitiveness being affected by healthcare spend? 13:47 Why is transparency a root cause to healthcare costs? 15:11 What's going on across the country to empower transparency in healthcare? 19:31 "I think people are fed up." 21:22 The Cigna lawsuit in California. 26:36 How do employers navigate contracts against anti-steering? 28:54 EP419 with Andreas Mang. 29:33 EP452 with Cora Opsahl and EP453 with Claire Brockbank. 29:45 EP433 with Justin Leader. You can learn more at PatientRightsAdvocate.org.

In this special Thanksgiving episode of Relentlessly Seeking Value, Stacey Richter discusses the significance of being 'givers' in healthcare, advocating for collaboration over transactional relationships to deliver real value to patients. She touches on the challenges and necessary shifts in healthcare market dynamics, emphasizing that true value is determined through bi-directional conversations between providers and end-users, like patients and plan sponsors. Stacey concludes with a call to action for listeners to reflect on their support networks and consider supporting valuable media and publications. I want to drop a thank you right here to those who have left a tip in our tip jar and/or offer up a monthly contribution. From the bottom of my heart, thanks for the support. Thank you to Dr. Scott Tromanhauser, Marilyn Bartlett, Ann Kempski, Dr. Matthew Bunte. Also, thank you to Brian Uhlig, Dr. William Gailmard, Dr. John Lee, Dr. Paula Muto, and Linda Krebs. Plus everyone else who left a lesser amount. You guys are my village, and this matters because, as it's been said by me and others a million times, it will take a village to transform healthcare. So, if you haven't already done so, because … yeah, Thanksgiving, consider who is on your own list of villagers to thank right about now in your world. So, yeah, long story long, all the more thanks to everyone who has donated to our tip jar, who has written a nice review on Apple Podcasts or Spotify, or who interacts with our posts on LinkedIn. Thank you. This is how pods like this and any of the publications that you like are able to continue. It's also, if you want to get really "why do givers succeed" about it, it's through these interactions that like 99% of guests I'd estimate who get invited on a podcast, probably any podcasts, come from, or who likely get their name in any publication come from. As I said, this is true for this pod at least. But I would say that who are most hosts or most reporters going to reach out to when they need information or insight and are looking to quote somebody? It's gonna be somebody that they know. It's gonna be somebody that they like. So, giving, the healthcare industry. This is the actual point I wanted to make before I completely distracted myself. And I talked about this at length actually at a recent thINc360 panel about delivering better patient outcomes. So, collaborate, give. And thank you to all of you who do both of these things every day, despite the cognitive dissonance and corporate forces and the lack of time and resources that may plague your efforts. I appreciate you very, very much. And it is this gang—the Relentless Tribe, that listens to this show—it is you who will transform healthcare. It's really you. And again, from the bottom of my heart, I thank you. === LINKS === 🔗 Show Notes with all mentioned links: https://cc-lnk.com/INBW40 🔗 Healthcare Industry Acronyms and Terms https://relentlesshealthvalue.com/healthcare-acronymns ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter: https://relentlesshealthvalue.com/join-the-relentless-tribe 🫙 Support the podcast with a small donation to the Tip Jar: https://relentlesshealthvalue.com/join-the-relentless-tribe 📺 Subscribe to our YouTube channel https://www.youtube.com/@RelentlessHealthValue 🎤 Listen on Apple Podcasts https://podcasts.apple.com/us/podcast/feed/id892082003?ls=1 🎤 Listen on Spotify https://open.spotify.com/show/6UjgzI7bScDrWvZEk2f46b === CONNECT WITH THE RHV TEAM === ✭ LinkedIn https://www.linkedin.com/company/relentless-health-value/ ✭ Threads https://www.threads.net/@relentlesshealthvalue/ ✭ Bluesky https://bsky.app/profile/relentleshealth.bsky.social ✭ X https://twitter.com/relentleshealth/ 01:33 How do you calculate the number of people you've helped? 02:46 Why is giving so important within healthcare? 03:16 Interview with Adam Grant. 05:47 How can you be a better giver? 07:50 Who is in charge of the bidirectional conversation of value? 11:35 Why is collaboration so important to value and being a giver? 12:58 Why is it important that plan sponsors are a part of all this giving and collaboration? 13:22 Encore! EP415 with Rob Andrews. 14:34 Summer Shorts 8 with Larry Bauer, MSW, MEd. 15:08 INBW39 with Stacey on the narcissism of small differences. 15:12 EP399 and EP400 with Stacey.

In this encore episode, Mark Cuban discusses his insights and experiences on disrupting the healthcare and pharmacy benefits landscape with Stacey Richter. This show from last year was one of the most popular episodes of the past year. And it's also extremely relevant right now, given all of the PBM (pharmacy benefit manager) goings-on, as well as ongoing litigation like the J&J lawsuit, etc. Listen to the show with Julie Selesnick (EP428) for more on that one. Joined by Ferrin Williams from Scripta, Cuban stresses the importance for CEOs and CFOs of self-insured companies to get actively involved in their healthcare plans to avoid overpaying. The conversation tackles the opaque practices of PBMs, the financialized nature of the healthcare industry, and introduces Mark Cuban's Cost Plus Drugs model which aims for transparency and cost reduction. Key topics also include the potential legal implications for employers, the importance of trust in healthcare transactions, and the real-world savings and benefits achievable with greater involvement and transparency in healthcare management. What do all of these numbers have in common: $140,000, $3 million, $35 million, and $3 billion? These are all actual examples of how much employers, unions, and some public entities saved on healthcare benefits for themselves and their employees. The roadmap to saving 25% on pharmacy spend and/or 15% on total cost of care in ways that improve employee health and satisfaction always begins when one thing happens. There's one vital first step. That first step is CEOs and/or CFOs or their equivalents roll up their sleeves and get involved in healthcare benefits. === LINKS === 🔗 Show Notes with all mentioned links: https://cc-lnk.com/Encore418 🔗 Healthcare Industry Acronyms and Terms https://relentlesshealthvalue.com/healthcare-acronymns ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter: https://relentlesshealthvalue.com/join-the-relentless-tribe 🫙 Support the podcast with a small donation to the Tip Jar: https://relentlesshealthvalue.com/join-the-relentless-tribe 📺 Subscribe to our YouTube channel https://www.youtube.com/@RelentlessHealthValue 🎤 Listen on Apple Podcasts https://podcasts.apple.com/us/podcast/feed/id892082003?ls=1 🎤 Listen on Spotify https://open.spotify.com/show/6UjgzI7bScDrWvZEk2f46b === CONNECT WITH THE RHV TEAM === ✭ LinkedIn https://www.linkedin.com/company/relentless-health-value/ ✭ Threads https://www.threads.net/@relentlesshealthvalue/ ✭ Bluesky https://bsky.app/profile/relentleshealth.bsky.social ✭ X https://twitter.com/relentleshealth/ 06:29 What was Mark Cuban's own journey as a self-insured employer with Cost Plus Drug Company? 07:44 What did Mark find when he decided to go through and look through his company's benefit program? 09:12 "When you think it through, you start to realize that money is being spent primarily by your sickest employees." —Mark 10:02 How do you get CEOs and CFOs of self-insured employers to realize that their sickest employees are the ones subsidizing their checks? 13:00 What is the role of insurance in healthcare? 14:30 "If you can't convince them, confuse them and hide it." —Mark 15:24 The reality behind getting a rebate check. 16:21 Why are rebates going away, and why isn't that changing PBM earnings? 19:05 How do you get CEOs and CFOs to dig into their benefits plan? 20:59 Does morally abhorrent move the needle? 21:33 "What we're trying to do is just simplify the [healthcare] industry." —Mark 24:19 What's been changing in consumer behavior? 25:04 "Transparency is a huge part of building that trust." —Ferrin 25:19 Why CEOs and CFOs really have the power to change healthcare. 32:29 What are Cost Plus Drugs' plans to expand? 39:21 Where is the future of the prescription drug market going? 42:09 What will happen to the prescription drug market in 10 to 20 years? 48:40 The wake-up call self-insured employers should be acknowledging now. 52:02 Where is the real change in the healthcare industry going to come from?

In this episode, Stacey Richter speaks with Rob Andrews, CEO of the Health Transformation Alliance (HTA) and former Congressman, about the strategic steps jumbo employers can take to achieve improved health outcomes while reducing cost. They delve into the importance of using data to discern effective practices, negotiate contracts, and hold intermediaries accountable. The discussion highlights maternal health as a critical area of focus, with successful interventions shown to reduce NICU admissions and overall healthcare costs. Andrews emphasizes the role of self-insured employers in driving systemic changes that align financial incentives with health outcomes. This encore is very relevant after the shows with Cora Opsahl (EP452), Claire Brockbank (EP453), and Marilyn Bartlett (EP450). Getting better health for the 160 million Americans covered by commercial insurance is all about rates, rights, and power. === LINKS === 🔗 Show Notes with all mentioned links: https://cc-lnk.com/Encore415 🔗 Healthcare Industry Acronyms and Terms https://relentlesshealthvalue.com/healthcare-acronymns ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter: https://relentlesshealthvalue.com/join-the-relentless-tribe 🫙 Support the podcast with a small donation to the Tip Jar: https://relentlesshealthvalue.com/join-the-relentless-tribe 📺 Subscribe to our YouTube channel https://www.youtube.com/@RelentlessHealthValue 🎤 Listen on Apple Podcasts https://podcasts.apple.com/us/podcast/feed/id892082003?ls=1 🎤 Listen on Spotify https://open.spotify.com/show/6UjgzI7bScDrWvZEk2f46b === CONNECT WITH THE RHV TEAM === ✭ LinkedIn https://www.linkedin.com/company/relentless-health-value/ ✭ Threads https://www.threads.net/@relentlesshealthvalue/ ✭ Bluesky https://bsky.app/profile/relentleshealth.bsky.social ✭ X https://twitter.com/relentleshealth/ 07:34 How did Rob get to his current role? 09:08 The problem of maternal health and mortality rate, and how self-insured employers wind up directly and indirectly paying for this. 10:27 Why economic consequences move the needle, and why sometimes they don't. 12:26 Why the best way to address costs isn't to re-shift costs but to address them directly. 13:22 Why compensation that isn't dependent on outcomes is a problem. 16:23 "Strategy's not what people say; it's what they do." 18:21 How do you operationalize saving money with better outcomes? 26:26 How do employers turn conflict into collaboration? 28:20 What is the win-win-win structure among employers, payers, and providers in Rob's eyes? 30:53 To whom should the task of risk adjustment fall? 34:43 "Better contracts do improve outcomes."

In this comprehensive episode host Stacey Richter sits down with Brian Reid to discuss pivotal aspects for the pharmaceutical industry. Key topics include understanding product value from the perspectives of plan sponsors, patients, and society, and the significance of benefit design in improving patient affordability. The discussion delves into the complexities of drug pricing, the roles of Pharmacy Benefit Managers (PBMs) and brokers, and the impact of healthcare consolidation on costs. Reid emphasizes the importance of transparent communication among stakeholders, the detrimental effects of cost containment strategies, and the necessity of considering policy and reputational impacts. Throughout the conversation, examples such as the Hepatitis C drug illustrate the broader implications on drug access and affordability. Listeners are provided with critical insights into how pharmaceutical companies can better engage with ultimate purchasers to ensure patients receive necessary, cost-effective medications while navigating a changing healthcare landscape. === LINKS === 🔗 Show Notes with all mentioned links: https://cc-lnk.com/EP456 🔗 Healthcare Industry Acronyms and Terms https://relentlesshealthvalue.com/healthcare-acronymns ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter: https://relentlesshealthvalue.com/join-the-relentless-tribe 🫙 Support the podcast with a small donation to the Tip Jar: https://relentlesshealthvalue.com/join-the-relentless-tribe 📺 Subscribe to our YouTube channel https://www.youtube.com/@RelentlessHealthValue 🎤 Listen on Apple Podcasts https://podcasts.apple.com/us/podcast/feed/id892082003?ls=1 🎤 Listen on Spotify https://open.spotify.com/show/6UjgzI7bScDrWvZEk2f46b === CONNECT WITH THE RHV TEAM === ✭ LinkedIn https://www.linkedin.com/company/relentless-health-value/ ✭ Threads https://www.threads.net/@relentlesshealthvalue/ ✭ Bluesky https://bsky.app/profile/relentleshealth.bsky.social ✭ X https://twitter.com/relentleshealth/ 08:29 Why is it important to understand the term "value" in respect to medicine? 10:07 Why is it important to consider all the players affected by the idea of this "value"? 11:06 Who are the ultimate purchasers in Pharma? 12:23 Findings of the Kaiser Employer Health Benefits Survey. 14:52 Why does it matter that we consider what value looks like to all players affected by Pharma? 16:46 EP300 with Bruce Rector, MD. 18:38 EP448 (Part 1) with Shawn Gremminger. 20:04 What does Pharma need to do to showcase their value when PBMs are often "locked in" at the moment? 23:11 Why Brian is celebrating companies that put their prices in their press releases. 32:31 Why does Pharma have an obligation to explain their value? 33:16 EP426 with Nina Lathia, RPh, MSc, PhD. 33:39 Why is it important for Pharma to keep an eye on hospital monopoly behavior? 35:55 EP370 with Erik Davis and Autumn Yongchu. 37:44 Why Pharma needs to capitalize on alignment.

In this conversation, Stacey Richter engages with healthcare leader Dr. Beau Raymond from Ochsner Health Network to explore the blueprint for better patient care through enlightened leadership, data-driven strategies, and localized health initiatives. The discussion covers shifting from 'sick care' to preventative healthcare, integrating technology and data tools like glucometers for health coaching, and addressing health equity through accurate data and regional strategies. The conversation explains the importance of stakeholder engagement, setting clear goals, financial incentives aligned with patient care, and continuous improvement through feedback loops. Practical steps such as weekly huddles for primary care teams and the role of digital health in managing chronic conditions like diabetes and hypertension are also highlighted to improve healthcare outcomes and operational excellence. A rate critical to attain better care for patients, I'm gonna say, is enlightened leadership—maybe dyad leadership—at a clinical organization. I am saying this because without enlightened leaders, it'd be harder to build from the blueprint that Beau Raymond, MD, talks about today on the show. === LINKS === 🔗 Show Notes with all mentioned links: https://cc-lnk.com/EP455 🔗 Healthcare Industry Acronyms and Terms https://relentlesshealthvalue.com/healthcare-acronymns ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter: https://relentlesshealthvalue.com/join-the-relentless-tribe 🫙 Support the podcast with a small donation to the Tip Jar: https://relentlesshealthvalue.com/join-the-relentless-tribe 📺 Subscribe to our YouTube channel https://www.youtube.com/@RelentlessHealthValue 🎤 Listen on Apple Podcasts https://podcasts.apple.com/us/podcast/feed/id892082003?ls=1 🎤 Listen on Spotify https://open.spotify.com/show/6UjgzI7bScDrWvZEk2f46b === CONNECT WITH THE RHV TEAM === ✭ LinkedIn https://www.linkedin.com/company/relentless-health-value/ ✭ Threads https://www.threads.net/@relentlesshealthvalue/ ✭ Bluesky https://bsky.app/profile/relentleshealth.bsky.social ✭ X https://twitter.com/relentleshealth/ 10:44 Why is it important to be flexible while keeping your goals in sight? 11:48 Dr. Eboni Price-Haywood's article on disparities in COVID. 12:29 How is equity a data point to achieving overall care improvement? 15:01 "If you can't measure it … accurately, you're not going to be able to do anything differently." 20:52 What strategies have been successful in using data to improve healthcare outcomes? 23:17 Why did Ochsner Health avoid looking at the individual physician standpoint in regard to an equity standpoint? 30:40 Why engaging patients in their healthcare actually improved patient visits and did not necessarily reduce patient visits. 34:49 "It's really about engaging with the patient."

In this episode, host Stacey Richter and guest Brendan Keeler dive deep into the significant legal clash between Epic and Particle over electronic health record (EHR) data access and market competition. This episode examines the broader repercussions on healthcare data exchange, including antitrust concerns, data liquidity, and the ethical considerations around secondary use of treatment data. The discussion brings to light how the outcome of such lawsuits could influence data transparency, interoperability, and the rules governing data sharing among plan sponsors, employers, and healthcare providers. Notable points include the shift to a judicial era impacting health tech companies and the potential for regulatory and judicial actions to improve data access and efficiency within healthcare networks. The episode emphasizes the critical need for clear pathways, accountability, and structured regulations to enhance patient care and reduce fraud in the healthcare data ecosystem. === LINKS === 🔗 Show Notes with all mentioned links: https://cc-lnk.com/EP454 🔗 Healthcare Industry Acronyms and Terms https://relentlesshealthvalue.com/healthcare-acronymns ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter: https://relentlesshealthvalue.com/join-the-relentless-tribe 🫙 Support the podcast with a small donation to the Tip Jar: https://relentlesshealthvalue.com/join-the-relentless-tribe 📺 Subscribe to our YouTube channel https://www.youtube.com/@RelentlessHealthValue 🎤 Listen on Apple Podcasts https://podcasts.apple.com/us/podcast/feed/id892082003?ls=1 🎤 Listen on Spotify https://open.spotify.com/show/6UjgzI7bScDrWvZEk2f46b === CONNECT WITH THE RHV TEAM === ✭ LinkedIn https://www.linkedin.com/company/relentless-health-value/ ✭ Threads https://www.threads.net/@relentlesshealthvalue/ ✭ Bluesky https://bsky.app/profile/relentleshealth.bsky.social ✭ X https://twitter.com/relentleshealth/ 07:21 Who can gain access to EHR data? 10:31 Are there limits to how EHR data can be used secondarily? 11:36 Can EHR data be shared secondarily? 15:47 Part one and part two of Brendan's comprehensive account of the Epic/Particle dustup. 15:57 What was the dispute that started Epic v Particle? 18:21 What are the two viewpoints in this dispute with Epic's actions? 26:16 What progress has been seen since this lawsuit began? 28:00 Who else will be impacted by the likely rule cementing from this lawsuit?

In this episode, host Stacey Richter delves into the complexities of the Third Party Administrator (TPA) Request for Proposal (RFP) process with guest Claire Brockbank from 32BJUnion. The discussion highlights the critical role of contracts in managing health plans effectively and the potential pitfalls of accepting contracts crafted by TPAs without thorough review. Drawing from Claire's experience, they explore tactics like starting with your own contract paper in RFP processes to gain negotiation leverage, and the benefits of employer coalitions in navigating health care complexities. Real-world examples underscore the financial impacts of poorly negotiated contracts and highlight successful strategies for health plan sponsors to optimize costs and services. The episode aims to empower employers with tools and insights to negotiate effectively and ensure their health plan contracts align with their strategic goals, ultimately paving the way for better population health management and cost-effective care delivery. As but one example—and Cora Opshal spoke about this last week and Claire talked about this today—it's about how allowing upside-down payments, for example, that are in a lot of ASO contracts, this allowing of upside-down payments. I mean, it turns out that 32BJ spent around $10 million paying more than the bill was for one year. If somebody signs that contract as handed to them by the carrier, then the plan is now contractually obligating themselves to pay more than the price the clinical practice was charging. So, doc sends bill for $100, and the carrier pays that practice $200 on behalf of the plan sponsor. So now the plan sponsor is paying $200 for a $100 bill. Is this conflict of interest? Is it imprudent? Is it not reasonable? Said another way, is that a bit of a fiduciary breach on the plan sponsor? So it's understandable why the team at 32BJ pushed back and pushed back hard. We all can see why the leading edge of plan sponsors and more and more C-suites are hotfooting it into conference rooms to plan their RFP process and doing it in the way that Claire Brockbank talks about today. For an open-source contract and some other free tools, please do head over to the 32BJ Insights Web site. Links in the show notes. === LINKS === 🔗 Show Notes with all mentioned links: https://cc-lnk.com/EP453 🔗 Healthcare Industry Acronyms and Terms https://relentlesshealthvalue.com/healthcare-acronymns ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter: https://relentlesshealthvalue.com/join-the-relentless-tribe 🫙 Support the podcast with a small donation to the Tip Jar: https://relentlesshealthvalue.com/join-the-relentless-tribe 📺 Subscribe to our YouTube channel https://www.youtube.com/@RelentlessHealthValue 🎤 Listen on Apple Podcasts https://podcasts.apple.com/us/podcast/feed/id892082003?ls=1 🎤 Listen on Spotify https://open.spotify.com/show/6UjgzI7bScDrWvZEk2f46b === CONNECT WITH THE RHV TEAM === ✭ LinkedIn https://www.linkedin.com/company/relentless-health-value/ ✭ Threads https://www.threads.net/@relentlesshealthvalue/ ✭ Bluesky https://bsky.app/profile/relentleshealth.bsky.social ✭ X https://twitter.com/relentleshealth/ 05:36 How does the initial contract writing affect how events in your healthcare plan will go? 06:56 What happens if a plan sponsor or employer doesn't do the contracting right? 10:42 How much could be saved by doing contracting right? 11:01 EP433 with Justin Leader. 12:22 How do you start an RFP process with your own contract? 14:06 What Claire Brockbank recommends doing to do a TPA RFP process in a way that's best for you. 19:46 What factors do carriers need to get an ASO or TPA to respond to using your contract? 21:11 Open-source contract available from 32BJ. 21:57 Why it's important to really probe brokers, despite loyalty to your broker/consultant. 24:30 Who are the reliable agents and experts when carriers are looking to start this process? 26:24 EP428 with Julie Selesnick. 27:56 What's the silver lining to this effort? 29:17 Why is it important to make it clear why you're doing what you're doing for your lawyers and any other support team you need? 31:39 What does "good" look like in this process? 34:15 Why is it important to continue to hold your ASO accountable?

In this episode I interview Cora Opsahl from the 32BJ Health Fund to examine the intricate dynamics between fiduciary duties and the entrenched status quo in healthcare. The discussion focuses on the challenges employers face when dealing with anti-competitive contracts and their responsibility to ensure plan expenses are reasonable. Cora Opsahl, my guest today, is the director of the 32BJ Health Fund, serving over 200,000 folks. Their ability to kick NewYork-Presbyterian, a big, consolidated, very expensive hospital, out of their network in 2018 enabled them to offer maternity benefits for $40 in total out-of-pocket for members. And also, employees got their biggest raise ever; employers got a premium holiday and a 3% rate increase for a bunch of years after that; and yeah … this is where we start the conversation today. Furthermore, you will find links to a template health savings calculator for plan sponsors and also a template contract (again for plan sponsors) that 32BJ has made available, in our show notes. === LINKS === 🔗 Show Notes with all mentioned links: https://cc-lnk.com/EP452 🔗 Healthcare Industry Acronyms and Terms https://relentlesshealthvalue.com/healthcare-acronymns ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter: https://relentlesshealthvalue.com/join-the-relentless-tribe 🫙 Support the podcast with a small donation to the Tip Jar: https://relentlesshealthvalue.com/join-the-relentless-tribe 📺 Subscribe to our YouTube channel https://www.youtube.com/@RelentlessHealthValue 🎤 Listen on Apple Podcasts https://podcasts.apple.com/us/podcast/feed/id892082003?ls=1 🎤 Listen on Spotify https://open.spotify.com/show/6UjgzI7bScDrWvZEk2f46b === CONNECT WITH THE RHV TEAM === ✭ LinkedIn https://www.linkedin.com/company/relentless-health-value/ ✭ Threads https://www.threads.net/@relentlesshealthvalue/ ✭ Bluesky https://bsky.app/profile/relentleshealth.bsky.social ✭ X https://twitter.com/relentleshealth/ 06:16 Why is it imperative for employers to do something differently when it comes to being plan sponsors? 09:22 How analyzing claims data allowed 32BJ Health Fund to reshape their benefit design. 12:09 What anticompetitive rights did 32BJ run into that limited 32BJ Health Fund from managing their benefit design? 14:12 How do these anticompetitive rights have quality implications as well as cost implications? 18:43 How did 32BJ Health Fund remove NewYork-Presbyterian from their network, and how much did it save 32BJ Health Fund per year? 19:46 What did the healthcare savings allow the unions and employers to do? 20:46 Study by Zack Cooper, PhD. 21:26 Why rising healthcare costs has pushed 32BJ Health Fund to move beyond benefit design to manage healthcare spend. 24:15 Why 32BJ Health Fund wants to control the contracting process. 26:00 EP419 with Andreas Mang. 27:18 What are 32BJ Health Fund's four non-negotiables? 33:17 Wall Street Journal article on health insurance contract. 35:30 Upcoming episode with Claire Brockbank. 36:14 What is the challenge that exists in our current healthcare environment? 37:43 Cora's advice on how to get high-quality healthcare at an affordable price.

In this Spotlight Episode host Stacey Richter discusses the management of oncology side effects with Dan Nardi, CEO of Reimagine Care. Highlighting the challenges cancer patients face, especially following chemotherapy which often leads to nausea and readmissions, the conversation delves into how Reimagine Care facilitates at-home integrative cancer care. Their services focus on proactive and reactive support via AI-driven tools like 'Remy' to assist patients outside of clinical environments. This approach aims to reduce emergency visits and improve patient outcomes while easing the workload on healthcare providers. The discussion underscores the role of patient reported outcomes and the integration of technology with human care to improve the quality of oncology treatment pathways. Note from Stacey Richter: Pulling off a show like this one is not cheap, and my Aventria business partner Dave Dierk and I are happy to fund the vast majority of it. But yeah, breath of fresh air, and thanks much to the team over at Reimagine Care for their sponsorship. My one disclaimer is that I have not personally vetted the solution, but there is a white paper (link in show notes) available where you will also find some insights from Reimagine Care's work with Memorial Hermann Health System. === LINKS === 🔗 Show Notes with all mentioned links: https://cc-lnk.com/Spotlight1 🔗 Healthcare Industry Acronyms and Terms https://relentlesshealthvalue.com/healthcare-acronymns ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter: https://relentlesshealthvalue.com/join-the-relentless-tribe 🫙 Support the podcast with a small donation to the Tip Jar: https://relentlesshealthvalue.com/join-the-relentless-tribe 📺 Subscribe to our YouTube channel https://www.youtube.com/@RelentlessHealthValue 🎤 Listen on Apple Podcasts https://podcasts.apple.com/us/podcast/feed/id892082003?ls=1 🎤 Listen on Spotify https://open.spotify.com/show/6UjgzI7bScDrWvZEk2f46b === CONNECT WITH THE RHV TEAM === ✭ LinkedIn https://www.linkedin.com/company/relentless-health-value/ ✭ Threads https://www.threads.net/@relentlesshealthvalue/ ✭ Bluesky https://bsky.app/profile/relentleshealth.bsky.social ✭ X https://twitter.com/relentleshealth/ 03:38 Why is it really important to keep track of oncology patients and their side effects? 04:27 Why is cancer treatment such a complex care journey? 05:57 Are there outcome and financial issues that compound when an oncology patient is left to navigate their care journey on their own? 08:53 What is difficult in navigating cancer treatment care pathways, and what does Reimagine Care tackle within that? 09:55 EP157 with Ethan Basch, MD. 10:17 How does Reimagine Care proactively check in with oncology patients to help them navigate their care pathways? 12:41 How does Reimagine Care measure their performance, and how did their work affect patient outcomes? 13:28 The Reimagine Care white paper. 14:57 How do providers feel about Reimagine Care services? 17:37 Where can technology really make a difference in cancer care?

In Episode 451 of Relentless Health Value, host Stacey Richter converses with Dr. Spencer Dorn about the implications of AI in healthcare, referencing lessons learned from EHR implementations. They discuss Kranzberg's first law of technology, which advises against labeling a technology as inherently good, bad, or neutral, emphasizing instead the importance of its application, configuration, and the human decisions surrounding its use. Dorn and Richter explore both the potential benefits and drawbacks of AI, drawing parallels with past experiences in healthcare digitization. The first takeaway from this short show focused on artificial intelligence is gonna be the same, really, as it was in episode 446 about EHRs. Do not ascribe any given technology a label of, as good, bad, or even neutral. That is Kranzberg's First Law of Technology; and it applies here, too. Second major takeaway—and again, this is the same as in that earlier show about EHRs, but today we're talking about AI—if you're thinking about the ultimate impact of the people and the processes that have some technology in their midst (technology, again, such as AI, artificial intelligence), the ultimate impact will not be a black-and-white binary. We talk about some of these nuanced not binaries in the 10 minutes that follow, but for more, I've put some links in the show notes on our epsiode page for some newsletters et cetera to check out. === LINKS === 🔗 Show Notes with all mentioned links: https://cc-lnk.com/EP451 🔗 Healthcare Industry Acronyms and Terms https://relentlesshealthvalue.com/healthcare-acronymns ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter: https://relentlesshealthvalue.com/join-the-relentless-tribe 🫙 Support the podcast with a small donation to the Tip Jar: https://relentlesshealthvalue.com/join-the-relentless-tribe 📺 Subscribe to our YouTube channel https://www.youtube.com/@RelentlessHealthValue 🎤 Listen on Apple Podcasts https://podcasts.apple.com/us/podcast/feed/id892082003?ls=1 🎤 Listen on Spotify https://open.spotify.com/show/6UjgzI7bScDrWvZEk2f46b === CONNECT WITH THE RHV TEAM === ✭ LinkedIn https://www.linkedin.com/company/relentless-health-value/ ✭ Threads https://www.threads.net/@relentlesshealthvalue/ ✭ Bluesky https://bsky.app/profile/relentleshealth.bsky.social ✭ X https://twitter.com/relentleshealth/ 05:23 What could happen with AI in healthcare if we aren't thinking about how we're deploying it? 05:58 How could the lessons from digitizing healthcare help us with employing AI? 08:25 How could artificial intelligence make things better and simultaneously worse? 10:55 Why is it important to look beyond the hype and pessimism and make a clear-eyed assessment?

In Episode 450 I speak with Marilyn Bartlett, a renowned CPA in the healthcare field, about her remarkable achievement of transforming the state of Montana's employee health plan from $9 million in debt to a surplus of $112 million within three years. Marilyn discusses the steps she took, including identifying financial inefficiencies, targeting high-cost areas, and implementing data-driven strategies to produce quick wins and sustainable results. The conversation delves into the importance of having the right team, communicating effectively with stakeholders, and staying focused amidst challenges. Listeners will gain valuable insights into strategic change management and actionable advice for improving healthcare plans. Yeah, I made a meme for the show with Marilyn Bartlett. My very first meme ever (link in show notes). In this meme, I picture that Olympic silver medalist shooter from Turkey who showed up in a T-shirt and his hand in his pocket versus the others with all their fancy equipment that, turns out, may or may not be necessary, regardless of who might swear up and down that complexity requires even more complexity and plenty of expensive gear to shoot straight. Point being, it's amazing what a dedicated CPA with a spreadsheet and their eye on the target can accomplish in the real world when they just do their thing and follow the dollar. And with that, Marilyn Bartlett has entered the chat. Marilyn Bartlett isn't called the "Queen of Healthcare" for no good reason, and nobody is joking when they say this. She was probably the first person (or one of the first, at a minimum) to truly identify the amount of money getting sucked out of the wallets of taxpayers and employers and plan members and into the pockets of the healthcare and insurance and consulting industries. She is a through and through numbers person but also deeply cares. She is truly a senior stateswoman in our field. === LINKS === 🔗 Show Notes with all mentioned links: https://cc-lnk.com/EP450 🔗 Healthcare Industry Acronyms and Terms https://relentlesshealthvalue.com/healthcare-acronymns ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter: https://relentlesshealthvalue.com/join-the-relentless-tribe 🫙 Support the podcast with a small donation to the Tip Jar: https://relentlesshealthvalue.com/join-the-relentless-tribe 📺 Subscribe to our YouTube channel https://www.youtube.com/@RelentlessHealthValue 🎤 Listen on Apple Podcasts https://podcasts.apple.com/us/podcast/feed/id892082003?ls=1 🎤 Listen on Spotify https://open.spotify.com/show/6UjgzI7bScDrWvZEk2f46b === CONNECT WITH THE RHV TEAM === ✭ LinkedIn https://www.linkedin.com/company/relentless-health-value/ ✭ Threads https://www.threads.net/@relentlesshealthvalue/ ✭ Bluesky https://bsky.app/profile/relentleshealth.bsky.social ✭ X https://twitter.com/relentleshealth/ 06:45 What gave Marilyn the confidence to fix Montana's state health plan? 08:11 Why Marilyn knew she would have enough power to make the changes needed in Montana's state health plan. 09:11 What Marilyn achieved in her time as the administrator of the Montana State Employee Health Plan. 10:38 What were the "quick wins" Marilyn was able to achieve when she first took over as administrator? 17:33 Stay tuned for an upcoming episode that covers RFP in detail. 17:50 How Marilyn structured her plan for the Montana State Employee Health Plan. 21:21 What's the key to setting yourself up for success when doing what Marilyn was able to achieve? 25:02 Why putting together your own team is so important. 29:07 What happened when Marilyn left the Montana State Employee Health Plan? 31:08 Have the costs of the plan gone up since Marilyn's time working on it?

So, I had a chance to read Dr. Marty Makary's new book, which is called Blind Spots; and here's why I wanted to get him to come back on Relentless Health Value and talk to you, people of the healthcare industry. It's because of something that he said on page 127 and which I've been mulling over for probably years, actually. It's this idea of what is appropriate care and how good are we at ensuring that patients/members get said appropriate care. Lots of people are of the same minds because appropriate care has come up in the show with Ben Schwartz, MD, MBA (EP434); John Lee, MD (EP438); Spencer Dorn, MD, MPH, MHA (EP446); Tom Lee, MD (EP445). I mean, an estimated 21% of all medical care is potentially unnecessary. And unnecessary is, of course, one category of things that are not appropriate. This is according to a national survey of physicians: 25% of diagnostic tests, 22% of all medications, and 11% of all procedures are unnecessary/inappropriate. This is billions of wasted dollars doing stuff that shouldn't be done, and it's not appropriate care. But think about this: How many visions for how to fix healthcare and how to reduce waste depend upon a broad-stroke assumption that we will materially ensure that patients are getting best-practice (ie, appropriate) care? That we cut down on over-medicalization and surgeries on the back end and add appropriate preventative stuff and optimal medical therapy to the front end? Dr. Makary and I delve into the challenges of ensuring patients receive appropriate care, touching on medical dogma, financial, business, and legal incentives, and the importance of measuring practice patterns. Dr. Makary provides practical advice for clinical leaders, payers, and plan sponsors on promoting transparency, improving health literacy, and steering members towards higher performing providers. === LINKS === 🔗 Show Notes with all mentioned links: https://cc-lnk.com/EP449 🔗 Healthcare Industry Acronyms and Terms https://relentlesshealthvalue.com/healthcare-acronymns ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter: https://relentlesshealthvalue.com/join-the-relentless-tribe 🫙 Support the podcast with a small donation to the Tip Jar: https://relentlesshealthvalue.com/join-the-relentless-tribe 📺 Subscribe to our YouTube channel https://www.youtube.com/@RelentlessHealthValue 🎤 Listen on Apple Podcasts https://podcasts.apple.com/us/podcast/feed/id892082003?ls=1 🎤 Listen on Spotify https://open.spotify.com/show/6UjgzI7bScDrWvZEk2f46b === CONNECT WITH THE RHV TEAM === ✭ LinkedIn https://www.linkedin.com/company/relentless-health-value/ ✭ Threads https://www.threads.net/@relentlesshealthvalue/ ✭ Bluesky https://bsky.app/profile/relentleshealth.bsky.social ✭ X https://twitter.com/relentleshealth/ 07:32 What is appropriate care? 10:19 Why what we think might be appropriate care might not be appropriate care. 10:34 Why is medical dogma damaging to appropriate care? 12:45 Why we need less absolutism in medical practice. 13:37 How is groupthink prevalent in medicine? 14:02 Why do we resist new ideas? 17:43 How do providers figure out what to believe and what not to believe? 20:59 "If you leave it to the medical profession to fix itself … so far, it's not going well." 22:33 How does supporting health literacy affect appropriate care? 30:23 "People need to find their care based on quality and price." 34:28 What proportion of medical care is deemed unnecessary right now?

Maybe you've already caught Part 1 of my conversation with Shawn Gremminger, and if so, you're ahead of the game. But if not, no worries—here's the deal: I decided to split this deep dive into the 340B program with Shawn into two parts. So, feel free to jump into one or both—it's totally up to you. These episodes don't have to be listened to in order, so you're good to start here with Part 2. Let's get into it!" Right now, we are going to talk about how 340B impacts employers and commercial plans and other plan sponsors. So, if all you want to hear about is the why—as in, Why do employers care about what amounts to a program that is or was supposed to be for low-income Americans and Medicaid?—you are in the right place. As just one example of the why should employers care if you are teetering on the edge of proceeding, did you know that if an employee or a member of a commercial plan gets a drug at a contract pharmacy participating in 340B, the employer does not get the rebate? The employer is gonna pay the list price for that med. Wait, what? Yeah, details follow because Shawn Gremminger is gonna get into this and many other reasons why employers or anyone in the commercial market (or taxpayers, really) should care about this, as some may call it, Medicaid program. The fact is, 340B is currently so gargantuan that it creates market distortions that bleed into the prices and possibly the quality of healthcare for everybody, all Americans. And that could really matter to employer or Taft-Hartley plan sponsors. After you listen to this show, if you want to drill in a little deeper on the "what the what" and the history of 340B, head back and take in Part 1 of this episode 448. Shawn Gremminger gives the skinny on how the program morphed over the years into a $53 billion juggernaut and is credited (or blamed) for all kinds of healthcare market consolidation and many other weird and unusual consequences that make me admire some of the folks who are truly gold medal winners in the sport of financial engineering. === LINKS === 🔗 Show Notes with all mentioned links: https://cc-lnk.com/EP448-2 🔗 Healthcare Industry Acronyms and Terms https://relentlesshealthvalue.com/healthcare-acronymns ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter: https://relentlesshealthvalue.com/join-the-relentless-tribe 🫙 Support the podcast with a small donation to the Tip Jar: https://relentlesshealthvalue.com/join-the-relentless-tribe 📺 Subscribe to our YouTube channel https://www.youtube.com/@RelentlessHealthValue 🎤 Listen on Apple Podcasts https://podcasts.apple.com/us/podcast/feed/id892082003?ls=1 🎤 Listen on Spotify https://open.spotify.com/show/6UjgzI7bScDrWvZEk2f46b === CONNECT WITH THE RHV TEAM === ✭ LinkedIn https://www.linkedin.com/company/relentless-health-value/ ✭ Threads https://www.threads.net/@relentlesshealthvalue/ ✭ Bluesky https://bsky.app/profile/relentleshealth.bsky.social ✭ X https://twitter.com/relentleshealth/ 09:11 Why do employers care about 340B, which is a Medicaid program? 11:30 Why do I care as an employer, even if I'm not Pharma? 12:44 Why is 340B causing employers to pay significantly more for healthcare? 14:36 Study by Zack Cooper, PhD. 15:06 Why are there distorted pricing models at 340B hospitals? 21:22 Why do employers need to stop playing the blame game?

So, after some pondering, I decided to release this conversation with Shawn Gremminger about 340B in two parts. So, listen to one, listen to both, pick your poison. Shawn Gremminger came up with three really important takeaways relative to 340B, which is a feat unto itself, considering how sprawling this conversation can be. So, if you came here for some concise and actionable takeaways, you have come to the right place. This first part you are listening to right now zeros in on Shawn's first takeaway: whether or not the original intent, or the presumed original intent, of the 340B program has actually been met. Many do not realize that 340B began life as a caterpillar. It originally, actually, was conceived as a lowly bureaucratic fix. But over the past 15 years, it has gone into a chrysalis and emerged into a 500-pound gorilla that sits in the corner of a lot of rooms, actually—probably more than many people realize. All of that being said, when you're done listening to this first part of the convo, you should be able to competently assess whether or not 340B does, in fact, adequately help underserved communities get better healthcare—because 340B is supposed to help safety-net healthcare providers stretch scarce resources. The second part of the show, which is a separate episode called Part 2, is how all of this impacts employers and commercial plans. And there's two more takeaways there. So, if you already have the gist of how we got from the beginnings of 340B to where we are in 2024 already and all you want to hear about is why do employers care about what amounts to a low-income program or was purported to be a low-income program, feel free to zip over to the second show and cut to that chase. === LINKS === 🔗 Show Notes with all mentioned links: https://cc-lnk.com/EP448-1 🔗 Healthcare Industry Acronyms and Terms https://relentlesshealthvalue.com/healthcare-acronymns ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter: https://relentlesshealthvalue.com/join-the-relentless-tribe 🫙 Support the podcast with a small donation to the Tip Jar: https://relentlesshealthvalue.com/join-the-relentless-tribe 📺 Subscribe to our YouTube channel https://www.youtube.com/@RelentlessHealthValue 🎤 Listen on Apple Podcasts https://podcasts.apple.com/us/podcast/feed/id892082003?ls=1 🎤 Listen on Spotify https://open.spotify.com/show/6UjgzI7bScDrWvZEk2f46b === CONNECT WITH THE RHV TEAM === ✭ LinkedIn https://www.linkedin.com/company/relentless-health-value/ ✭ Threads https://www.threads.net/@relentlesshealthvalue/ ✭ Bluesky https://bsky.app/profile/relentleshealth.bsky.social ✭ X https://twitter.com/relentleshealth/ 05:25 Shawn's three takeaways from the 340B program. 06:04 What is the intent of the 340B program? 08:22 Read the full 32-page report of the Energy and Commerce Committee. 09:17 Why does Medicaid have to get the best price? 13:26 Why was there a shift in how the 340B program looked starting in the mid-2000s? 15:11 Why do more than half of acute care hospitals now qualify for 340B? 18:18 How has hospital consolidation affected 340B? 20:37 What is the misalignment between how a hospital qualifies for 340B and how it benefits said hospitals? 24:11 How is a 340B designed for hospitals to make a profit? 28:45 Why isn't there a real patient definition in 340B? 31:46 Why is 340B still popular among policymakers? 33:05 Are 340B dollars being used in underserved communities? 33:57 EP394 with Vikas Saini, MD, and Judith Garber, MPP.

In this Summer Short Episode of Relentlessly Seeking Value, host Stacey Richter discusses the hidden costs and inefficiencies of value-based care with Elizabeth Mitchell, President and CEO of the Purchaser Business Group on Health (PBGH). They uncover how value-based care, often touted as the ideal system, can be manipulated by middlemen to extract more money from plan sponsors without delivering real value to patients. Through a critical conversation involving examples and insights from various experts, they explore the disconnect between financial incentives and actual care quality in American healthcare. Elizabeth argues for for-real alternative payment models that are transparent to the employer plan sponsors. She wants prospective payments or bundled payments, and she wants them with warranties that are measurable. She wants members to get integrated whole-person care in a measurable way, which most health plans (ie, middlemen) either cannot or will not administer. Elizabeth says to achieve actual care that is of value, cooperation between employers, employees, and primary care providers is crucial (ie, direct contracts). She also says that this whole effort is really, really urgently needed given the affordability crisis affecting many Americans. There's been just one article after another lately about how many billions and billions of dollars are getting siphoned off the top into the pockets of the middlemen and their shareholders. These are dollars partially paid for by employees and plan members. We have 48% of Americans with commercial insurance delaying or forgoing care due to cost. If you're a self-insured employer and you're hearing this, don't be thinking it doesn't impact you because your employees are highly compensated. === LINKS === 🔗 Show Notes with all mentioned links: https://cc-lnk.com/SUMS9 🔗 Healthcare Industry Acronyms and Terms https://relentlesshealthvalue.com/healthcare-acronymns ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter: https://relentlesshealthvalue.com/join-the-relentless-tribe 🫙 Support the podcast with a small donation to the Tip Jar: https://relentlesshealthvalue.com/join-the-relentless-tribe 📺 Subscribe to our YouTube channel https://www.youtube.com/@RelentlessHealthValue 🎤 Listen on Apple Podcasts https://podcasts.apple.com/us/podcast/feed/id892082003?ls=1 🎤 Listen on Spotify https://open.spotify.com/show/6UjgzI7bScDrWvZEk2f46b === CONNECT WITH THE RHV TEAM === ✭ LinkedIn https://www.linkedin.com/company/relentless-health-value/ ✭ Threads https://www.threads.net/@relentlesshealthvalue/ ✭ Bluesky https://bsky.app/profile/relentleshealth.bsky.social ✭ X https://twitter.com/relentleshealth/ So, yeah … with that, here is your Summer Short with Elizabeth Mitchell. 10:36 What are members and providers actually asking for in terms of value-based care? 10:56 Why won't most health plans administer alternative payment models? 12:17 "We do not have value in the US healthcare system." 12:57 Why you can't do effective primary care on a fee-for-service model. 13:30 Why have we fragmented care out? 14:39 "No one makes money in a fee-for-service system if people are healthy." 17:27 "If we think it is not at a crisis point, we are kidding ourselves."

My conversation today is with Will Shrank, MD. Dr. Shrank led the evaluation group at CMMI (Center for Medicare and Medicaid Innovation). He has spent time in the private sector, first at CVS Health and UPMC (University of Pittsburgh Medical Center) as chief medical officer of the health plan in Pittsburgh, and then as the chief medical officer for Humana. Now he is a venture partner at Andreessen Horowitz and doing some consulting for CMMI. We start out this conversation talking about waste in healthcare. In fact, Dr. Shrank was on a team who did a study (link in show notes) about waste in the US healthcare system. (The article is, unfortunately, paywalled.) In that study, it says estimates suggest we have upwards of a trillion dollars of waste a year. This waste can be categorized into administrative and clinical failures. Dr. Shrank emphasizes the need for aligning incentives with higher quality care, paying for patient outcomes, and highlights the potential rising power of PCPs. The discussion covers the progress made towards value-based care, the challenges faced by the current fee-for-service model, and the future landscape of primary care and healthcare delivery. In sum, we have a waste problem in this country. Aligning incentives might be one way to curb that waste. === LINKS === 🔗 Show Notes with all mentioned links: https://cc-lnk.com/Encore413 🔗 Healthcare Industry Acronyms and Terms https://relentlesshealthvalue.com/healthcare-acronymns ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter: https://relentlesshealthvalue.com/join-the-relentless-tribe 🫙 Support the podcast with a small donation to the Tip Jar: https://relentlesshealthvalue.com/join-the-relentless-tribe 📺 Subscribe to our YouTube channel https://www.youtube.com/@RelentlessHealthValue 🎤 Listen on Apple Podcasts https://podcasts.apple.com/us/podcast/feed/id892082003?ls=1 🎤 Listen on Spotify https://open.spotify.com/show/6UjgzI7bScDrWvZEk2f46b === CONNECT WITH THE RHV TEAM === ✭ LinkedIn https://www.linkedin.com/company/relentless-health-value/ ✭ Threads https://www.threads.net/@relentlesshealthvalue/ ✭ Bluesky https://bsky.app/profile/relentleshealth.bsky.social ✭ X https://twitter.com/relentleshealth/ 06:54 Can we cut healthcare waste while improving patient care? 07:33 What does "healthcare waste" consist of? 07:46 What are the six categories of "healthcare waste"? 10:23 EP363 with David Scheinker, PhD. 10:37 How much money does Dr. Shrank estimate is wasted each year in healthcare? 13:09 Where is that healthcare waste going, and why does it happen? 20:07 Uncaring by Robert Pearl, MD. 21:18 "We've built a backbone of extraordinary waste on a fee-for-service chassis." 22:16 EP409 with Larry Bauer, MSW, MEd. 24:24 EP359 with Dan O'Neill. 26:02 Dr. Shrank's warning to providers out there. 30:03 Summer Shorts 2 with Scott Conard, MD. 31:41 Why there might be a generational shift among younger providers looking to work with different models.

In this encore episode, host Stacey Richter speaks with Dr. Amy Scanlon, Chief Medical Officer of the Clinically Integrated Network, a joint venture between Intermountain Health and UC Health in Colorado. They discuss the complexities of transitioning to value-based care, including the need for infrastructure, data, technology, and team collaboration. Dr. Scanlon emphasizes the importance of listening to practices, fostering medical culture change, and addressing the powerful influence of fee-for-service incentives. They also explore the necessity of strong interpersonal relationships and the critical role of leaders in facilitating effective care integration. Despite the challenges, Dr. Scanlon offers valuable advice for those embarking on the journey toward clinically integrated networks. === LINKS === 🔗 Show Notes with all mentioned links: https://cc-lnk.com/Encore402 🔗 Healthcare Industry Acronyms and Terms https://relentlesshealthvalue.com/healthcare-acronymns ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter: https://relentlesshealthvalue.com/join-the-relentless-tribe 🫙 Support the podcast with a small donation to the Tip Jar: https://relentlesshealthvalue.com/join-the-relentless-tribe 📺 Subscribe to our YouTube channel https://www.youtube.com/@RelentlessHealthValue 🎤 Listen on Apple Podcasts https://podcasts.apple.com/us/podcast/feed/id892082003?ls=1 🎤 Listen on Spotify https://open.spotify.com/show/6UjgzI7bScDrWvZEk2f46b === CONNECT WITH THE RHV TEAM === ✭ LinkedIn https://www.linkedin.com/company/relentless-health-value/ ✭ Threads https://www.threads.net/@relentlesshealthvalue/ ✭ Bluesky https://bsky.app/profile/relentleshealth.bsky.social ✭ X https://twitter.com/relentleshealth/ 06:35 How is Dr. Scanlan thinking about the transformation process and the shift to value? 09:16 "It is really trying to think about, how do we help practices get there?" 11:48 "The hard part is the in-between spaces." 13:21 EP407 with Vivek Garg, MD, MBA. 14:12 "Team-based care done badly is really just a series of handoffs." 15:52 "We have to get to that point where the culture of collaboration is more pervasive." 19:58 "How do we as healthcare providers step in and solve this problem?" 20:06 Why do providers have a responsibility to step in and try to fix the healthcare system? 20:22 Article (unpaywalled) by Eric Reinhart, MD, PhD. 21:51 Why do physicians need to be accountable for the cost of care as well as outcomes? 23:38 Why does physician burnout give Dr. Scanlan hope? 24:26 What is the solution to changing fee-for-service incentives? 25:43 What are some of the challenges facing changing incentives? 27:16 Why is data so important? 28:54 EP393 with David Muhlestein, PhD, JD. 30:13 "It's important to understand that we are in the middle of this change." 31:18 Dr. Scanlan's advice for those trying to stand up a CIN.

In Episode 447, Stacey Richter interviews Ashleigh Gunter, president of Translucent Healthcare Consulting, to discuss the indispensable role of change management in healthcare transformation. They emphasize that creating an effective change strategy involves great leadership, a clear case for change, influential change champions, over-communication, and continuous measurement and celebration of successes. The conversation highlights the importance of understanding and aligning with the 'why' that drives healthcare professionals and the necessity of a multi-faceted approach beyond just implementing technological solutions like EHR systems. Before we kick in to the show today, let me remind you, if you haven't done so and you appreciate the show, could I ask you to please leave a rating and review on Apple Podcasts or Spotify? We haven't had any of them this month, and it is important for the show to get found and for me and the team to stay motivated over here. While you're there, be sure to Follow the show. === LINKS === 🔗 Show Notes with all mentioned links: https://cc-lnk.com/EP447 🔗 Healthcare Industry Acronyms and Terms https://relentlesshealthvalue.com/healthcare-acronymns ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter: https://relentlesshealthvalue.com/join-the-relentless-tribe 🫙 Support the podcast with a small donation to the Tip Jar: https://relentlesshealthvalue.com/join-the-relentless-tribe 📺 Subscribe to our YouTube channel https://www.youtube.com/@RelentlessHealthValue 🎤 Listen on Apple Podcasts https://podcasts.apple.com/us/podcast/feed/id892082003?ls=1 🎤 Listen on Spotify https://open.spotify.com/show/6UjgzI7bScDrWvZEk2f46b === CONNECT WITH THE RHV TEAM === ✭ LinkedIn https://www.linkedin.com/company/relentless-health-value/ ✭ Threads https://www.threads.net/@relentlesshealthvalue/ ✭ Bluesky https://bsky.app/profile/relentleshealth.bsky.social ✭ X https://twitter.com/relentleshealth/ 09:22 How does change management go wrong in healthcare? 09:56 "Communication [of change] in and of itself isn't change management." 10:53 How does change management work on the provider organization side? 15:33 "You want to ensure you are educating the operational folks." 16:35 What is change management? 17:36 What does great leadership look like in change management? 18:55 "Leadership sets the tone." 19:04 What makes change management so hard? 19:31 "What's the company reason to make this change happen?" 20:51 What are change champions, and why do you need to create them when changing your benefit plan? 21:57 Crossing the Chasm by Geoffrey A. Moore. 23:21 Why is it important to overcommunicate change? 26:47 Why is it important to measure your successes and communicate those after a change?

In Episode 446, "Hey, Let's Not Talk About EHRs," host Stacey Richter engages Dr. Spencer Dorn, vice chair and professor of medicine at the University of North Carolina, in a comprehensive discussion about the implications of healthcare technology, specifically electronic health records (EHRs). The conversation emphasizes the necessity of understanding technology as a tool that neither possesses inherent goodness nor badness but delivers results based on its implementation and usage. They discuss the paradoxical nature of technology in healthcare, highlighting how EHR systems can simultaneously empower and overwhelm healthcare practitioners. Dr. Dorn and Stacey delve into the effects of digital technology on patient-doctor and clinician-clinician relationships, stressing the importance of proper deployment, operational excellence, and continuous improvement to optimize healthcare outcomes. In essence, the episode sheds light on the necessity of viewing technology as a means to an end rather than an end in itself. === LINKS === 🔗 Show Notes with all mentioned links: https://cc-lnk.com/EP446 🔗 Healthcare Industry Acronyms and Terms https://relentlesshealthvalue.com/healthcare-acronymns ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter: https://relentlesshealthvalue.com/join-the-relentless-tribe 🫙 Support the podcast with a small donation to the Tip Jar: https://relentlesshealthvalue.com/join-the-relentless-tribe 📺 Subscribe to our YouTube channel https://www.youtube.com/@RelentlessHealthValue 🎤 Listen on Apple Podcasts https://podcasts.apple.com/us/podcast/feed/id892082003?ls=1 🎤 Listen on Spotify https://open.spotify.com/show/6UjgzI7bScDrWvZEk2f46b === CONNECT WITH THE RHV TEAM === ✭ LinkedIn https://www.linkedin.com/company/relentless-health-value/ ✭ Threads https://www.threads.net/@relentlesshealthvalue/ ✭ Bluesky https://bsky.app/profile/relentleshealth.bsky.social ✭ X https://twitter.com/relentleshealth/ 06:15 Breaking down Kranzberg's Laws of Technology. 08:16 How do EHRs go right? 12:49 "EHRs empower us with information, yet they also overwhelm us with information." 16:00 How do EHRs bring healthcare workers closer together? 19:35 The Digital Doctor by Robert Wachter. 21:33 "The whole point of healthcare is to help people live healthier, happier lives." 22:41 How the same EHR deployed in different places can be more or less efficient. 25:51 Why the problem is not necessarily the EHR but actually operational. 28:51 How technology has also changed our expectations on timing and value.