Relentless Health Value

Cash-Pay Generic Drugs Are a Functioning Market in Healthcare, and Policymakers Could Break It. Episode 520. Cash-pay generic drugs are one of the few corners of US healthcare where a real, functioning market already exists — which is why Stacey Richter argues policymakers need to tread carefully when trying to "fix" drug affordability. In this solo episode, Stacey explains why cash generic prices can run as low as $1 a prescription, then plays clips from four past guests — Ge Bai, PhD, CPA; Bryce Platt, PharmD; Benjamin Jolley, PharmD; and Luke Slindee, PharmD — showing how inserting a PBM extracts $41 out of every $100 spent, leaving patients paying more for the "privilege" of using their insurance. WHAT YOU'LL LEARN ✅ Why cash-pay generic drugs are one of the few genuinely functioning markets left in US healthcare, with multisource manufacturer competition keeping prices as low as $1 to $18 per prescription ✅ Why using insurance/PBM coverage makes the 20 most prescribed generics more expensive 43% of the time overall, and up to 79% of the time in the deductible phase, per Ge Bai, PhD, CPA's research in Annals of Internal Medicine ✅ How PBMs extract $41 out of every $100 spent on generic drugs that cost roughly 47 cents to manufacture, largely through the administrative overhead of risk pooling ✅ How Most Favored Nation "lesser of" clauses in PBM-pharmacy contracts punish pharmacies for lowering their cash prices, and why Luke Slindee, PharmD, argues removing that single clause could unlock a more robust cash-pay market without pulling generics from insurance entirely ✅ Why generic drug adoption has slowed from about one month to six months to reach peak uptake, which Bryce Platt, PharmD, ties to PBM formulary control rather than reduced competition or prescriber resistance ✅ Four policy ideas Stacey floats for keeping generics affordable without wrecking the underlying market: eliminating MFN clauses, funded wallets or prepaid cards, pre-funded cash-pay pharmacy relationships, and removing generics from PBM adjudication entirely WHY THIS MATTERS Generic drugs are one of the only truly functioning markets left in US healthcare, and cash prices are already low because of it. But policymakers trying to make medications more affordable often reach for the same lever — routing everything through insurance/PBM adjudication — which the data shows frequently raises what patients pay while handing PBMs a 41-cent cut of every dollar spent. As Stacey puts it, "you have to be really careful what levers you push because you can't see what they're attached to," and the wrong fix could break the one part of healthcare that's actually working. MENTIONED IN THIS EPISODE EP444 with Ann Kempski: Apple Podcasts | Spotify | Other Apps LinkedIn Post by Bryce Platt, PharmD EP495 with Mick Connors, MD: Apple Podcasts | Spotify | Other Apps EP420 with Ge Bai, PhD, CPA: Apple Podcasts | Spotify | Other Apps EP422 with Benjamin Jolley, PharmD: Apple Podcasts | Spotify | Other Apps EP517 with Stacey: Apple Podcasts | Spotify | Other Apps LinkedIn Post by Bryce Platt, PharmD EP439 with Luke Slindee, PharmD: Apple Podcasts | Spotify | Other Apps LinkedIn Post by Patrick Moore EP465 with Chris Crawford: Apple Podcasts | Spotify | Other Apps === LINKS === 🔗 Show Notes with all mentioned links: Show Notes ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter 🫙 Support the podcast with a small donation to the Tip Jar 📺 Subscribe to our YouTube channel 🎤 Listen on Apple Podcasts 🎤 Listen on Spotify === CONNECT WITH THE RHV TEAM === ✭ LinkedIn ✭ Threads ✭ Bluesky ✭ X 00:00 Introduction to this episode. 03:48 Intermediaries versus functioning markets. 05:30 The use case for today's episode. 10:56 The reason why cash-pay generics are cheap right now. 11:42 The value proposition of PBMs versus cheap generics. 16:09 What risk pooling is and how it plays into all of this. 26:16 Solutions to keeping generics affordable.

Cognitive Atrophy, Referral Incentives, Fragmented Care: Is Primary Care Inevitable or Fixable? Episode 519. Primary care physicians are leaving traditional practice for concierge medicine in visible numbers—and the question is whether that exodus is an unavoidable consequence of how the system is built, or something we've simply chosen not to fix. Stacey Richter talks with Dr. Lisa Rosenbaum, a cardiologist at Beth Israel Deaconess Medical Center (BIDMC) and national correspondent for the New England Journal of Medicine, who recently devoted an entire season of her NEJM podcast, Not Otherwise Specified, to the state of primary care. Together they test three forces reshaping the field—cognitive atrophy, referral incentives, and care fragmentation—against a single question: inevitable, or fixable? WHAT YOU'LL LEARN ✅ Why Dr. Lisa Rosenbaum calls the risk of "cognitive atrophy" among primary care physicians a generational threat rather than an individual one—and why she believes it is not inevitable ✅ How financial incentives that pay far more for a specialist visit than a primary care visit (roughly 5% of healthcare dollars for close to 35% of outpatient visits) structurally push referrals earlier and more often than necessary ✅ Why "relational expertise"—the judgment a doctor builds by knowing a patient over time—is, in Dr. Rosenbaum's view, primary care's real and undervalued skill set ✅ How care fragmentation, illustrated by Miriam Paramore's LinkedIn essay about her father's end-of-life care, leaves patients bouncing among specialists with no one taking ownership of the whole picture ✅ Why Dr. Rosenbaum argues that blaming everything on structural constraints "strip[s] ourselves of our own agency," and what she thinks physicians and healthcare buyers should each do about it WHY THIS MATTERS Roughly 70% of physicians are employed today, and about 5% of every healthcare dollar goes to primary care despite it covering close to 35% of all outpatient visits—numbers that, per Dr. Rosenbaum, reflect choices the system has made, not laws of nature. When primary care doctors lose the time and incentive to build relationships with patients, the system loses its quarterback, and patients end up fragmented across specialists with no one accountable for the whole picture. Dr. Rosenbaum's core argument is that none of this is inevitable, but fixing it requires both structural change and individual physicians and healthcare buyers reclaiming their own agency. MENTIONED IN THIS EPISODE EP504 with Ryan Jacobs: Apple Podcasts | Spotify | Other Apps EP473 with Kenny Cole, MD: Apple Podcasts | Spotify Other Apps EP391 with Scott Conard, MD: Apple Podcasts | Spotify | Other Apps Article: "Ordinary Rural Death: My Father's End-of-Life Journey" by Miriam Paramore EP409 with Larry Bauer, MSW, MEd: Apple Podcasts | Spotify | Other Apps === LINKS === 🔗 Show Notes with all mentioned links: Show Notes ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter 🫙 Support the podcast with a small donation to the Tip Jar 📺 Subscribe to our YouTube channel 🎤 Listen on Apple Podcasts 🎤 Listen on Spotify === CONNECT WITH THE RHV TEAM === ✭ LinkedIn ✭ Threads ✭ Bluesky ✭ X 00:00 Introduction to this episode. 03:47 Cognitive atrophy: what is it in terms of primary care providers? 08:56 Why Lisa Rosenbaum, MD, did an entire series on primary care. 11:32 Why physicians need to practice at the top of their license. 13:54 Why a good internist is a "quarterback." 16:23 How family medicine and procedures play into skill atrophy. 20:21 The majority versus the minority in primary care. 21:00 Is cognitive atrophy inevitable for primary care providers? 23:34 Full-spectrum clinical scope versus referrals in primary care. 25:51 The fix for too many referrals in primary care. 27:36 Why the solution is not an either/or. 30:08 Longitudinal relationships versus fragmentation. 36:07 Is this inevitable, or is this fixable? 39:02 What every listener in a position of power needs to ask themselves.

The ASO vs. TPA Decision That Quietly Costs Self-Funded Employers More What's the real difference between an ASO and a TPA — and why does it matter that self-insured employers working with an ASO pay, by one referenced estimate, about 4.7% more than the insured book of business for the same care? In this Ask Me Anything, Stacey Richter puts a listener question from Dr. Alex Sommers, MD, ABEM, DipABLM, president of Astia Health, to Claire Brockbank, newly appointed director of the 32BJ Health Fund, who breaks down how ASO and TPA models diverge on ownership, networks, and incentives.  WHAT YOU'LL LEARN ✅ How an ASO (administrative services only) arrangement differs structurally from a TPA (third-party administrator) — in Claire Brockbank's words, an ASO is essentially "a TPA that's owned by one of the big insurance carriers" ✅ Why bringing your own network, doing carve-outs, or direct contracting is typically much easier with a TPA than with an ASO, since an ASO's network comes bundled in ✅ How ASO incentive structures can lead carriers to charge self-funded employers more to offset thinner margins on their insured book — and why a study referenced by Luke Prettol found self-insured ASO clients pay roughly 4.7% more on average ✅ Why many TPAs, as newer market entrants built around technology, can move faster on things like claims-audit integrations than legacy carrier systems that can take up to 18 months to implement changes ✅ A real-world example of how network rigidity under an ASO made it difficult for one employer to remove 40 identified unsafe physicians from its network ✅ Why reading a TPA contract carefully still matters, since aligned incentives are a structural possibility with a TPA, not a guarantee WHY THIS MATTERS ASO and TPA are routinely used interchangeably across the industry, but as Claire Brockbank lays out, the distinction isn't just terminology — it's what determines how much actual control a self-funded employer has over its own health plan. An ASO bundles in the carrier's network and legacy systems, often with built-in incentive misalignments that can show up as higher costs than the insured book of business pays. A TPA leaves more room to bring your own network, negotiate direct contracts, and move quickly when something needs to change. For any plan sponsor sorting out vendor options, knowing which model is actually on the table is foundational to getting the rights, rates, and flexibility they're after. MENTIONED IN THIS EPISODE Post by Luke Prettol EP453 with Claire Brockbank: Apple Podcasts | Spotify | Other Apps EP498 with Mark Noel: Apple Podcasts | Spotify | Other Apps === LINKS === 🔗 Show Notes with all mentioned links: [Episode Show Notes] ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter 🫙 Support the podcast with a small donation to the Tip Jar 🎤 Follow us on Apple Podcasts 🎤 Follow us on Spotify 📺 Subscribe to our YouTube channel === CONNECT WITH THE RHV TEAM === ✭ LinkedIn ✭ Threads ✭ Bluesky ✭ X 00:00 Introduction to this episode. 00:38 Dr. Alex Sommers' question. 04:05 Claire's answer to what differentiates a TPA and an ASO vendor. 04:25 What an ASO vendor is. 04:57 What a TPA is. 06:52 The pros and cons to choosing an ASO as a carrier. 09:05 The pros and cons to TPAs.

The PBM Rebate Math That Turns Prior Auths Into a Pharma Negotiating Tool What if a prior authorization has less to do with your medical need than with how big a rebate check a PBM is collecting on a competing drug? In this solo deep dive — a direct follow-up to last week's conversation with Ophelia Johnson on GLP-1s and cash pay (EP516 link below) — host Stacey Richter walks through a "Brand Darling" vs. "Brand 2" case study showing how PBM/GPO rebate contracting and the Inflation Reduction Act's pressure on list prices can turn prior auths and step therapy into negotiating leverage rather than clinical guardrails. She also breaks down the GoodRx reverse-auction mechanic and why a growing number of pharma manufacturers are responding to rebate-driven formulary exclusion by going cash-pay direct to patients. WHAT YOU'LL LEARN ✅ How PBM/GPO rebate contracts create a "rebate cliff" that locks new or lower-cost drugs out of formulary, regardless of price or clinical efficacy ✅ Why prior authorizations and step therapy are often used as a financial negotiating lever to extract bigger rebates from a dominant "Brand Darling," rather than as a clinical-necessity check ✅ How the Inflation Reduction Act's list-price pressure is collapsing the rebate spread that funds the current PBM contracting model ✅ Why cash-pay and direct-to-patient strategies are becoming a more attractive option for pharma brands excluded from preferred formulary tiers ✅ How GoodRx's reverse-auction model actually generates its advertised cash prices, and how GoodRx profits from sponsored placement, copay-card integration, and data sales ✅ Why copay accumulators and maximizers can erase the value of a manufacturer's copay card even when a patient does get coverage WHY THIS MATTERS For self-insured employers and plan sponsors footing the bill, this episode is a reminder that a prior authorization or a formulary tier placement may be a financial calculation between a PBM and a manufacturer first, and a clinical determination second. Because coinsurance is calculated off an inflated list price, the same rebate-cliff dynamics that lock a lower-cost drug out of formulary can also push more cost directly onto plan members. And as the Inflation Reduction Act squeezes the rebate spread that funds this model, cash-pay and direct-to-patient strategies are emerging as an alternative worth watching — even though, as Stacey notes, the usual PBM players are often still involved behind the scenes. MENTIONED IN THIS EPISODE EP516 with Ophelia Johnson: Apple Podcasts | Spotify | Other Apps Post by Robyn Tikia AEE13 with Ge Bai, PhD, CPA: Apple Podcasts | Spotify | Other Apps === LINKS === 🔗 Show Notes with all mentioned links: Show Notes ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter 🫙 Support the podcast with a small donation to the Tip Jar 🎤 Follow us on Apple Podcasts 🎤 Follow us on Spotify 📺 Subscribe to our YouTube channel === CONNECT WITH THE RHV TEAM === ✭ LinkedIn ✭ Threads ✭ Bluesky ✭ X 00:00 Introduction to this episode. 03:53 What needs to be true, no matter what your pharma brand is. 04:20 Why a PBM picks a brand "darling." 05:10 A message to PBM sales teams. 09:43 Clarifying a point about formulary decision making. 14:34 When might a cash-pay strategy start to look rational for a pharma brand? 16:25 Cash pay versus formulary from the patient perspective. 19:50 How PBMs feel about brands going cash pay. 20:56 Why GoodRx is allowed to sell non-formulary Rxs at cash prices on PBMs. 23:51 A clarification of points on GoodRx. 26:19 A point to ponder about discount coupons.

Only about half of new GLP-1 prescriptions got approved for coverage in 2023 — a gap Ophelia Johnson says is why pharma manufacturers started building cash-pay and direct-to-employer channels instead of waiting on PBMs. Johnson, who built new channels for the manufacturer behind the GLP-1 boom and now runs e-fi.works, walks Stacey Richter through how the money moves with GoodRx and telehealth, including the buydown math behind a $500 list-price drug becoming a $100 cash price. This is Episode 516 (EP516) of Relentless Health Value. WHAT YOU'LL LEARN ✅ Why IRA maximum fair price pressure, PBM reform lawsuits, and roughly 50% of new GLP-1 prescriptions going unapproved for coverage in 2023 pushed manufacturers to build cash-pay channels ✅ The buydown math behind cash pay: a manufacturer pays savings-coupon providers like GoodRx a flat fee instead of a PBM rebate to bring a $500 list-price drug down to a $100 cash price ✅ How telehealth and white-label or manufacturer-owned pharmacies add a second cash-pay channel, with new shipping and supply-chain costs once the PBM is cut out ✅ Why "direct-to-employer" GLP-1 deals are a misnomer — PBM exclusivity clauses bar manufacturers from selling straight to employers, routing them through third-party transparent administrators ✅ Ophelia Johnson's advice to plan sponsors: shift formulary conversations from rebate yields toward auditable medication abandonment rates and total cost of care WHY THIS MATTERS Stacey Richter's follow-the-dollar lens usually points at employers and patients as the ultimate purchasers — but the incentives driving pharma manufacturers matter just as much for collaboration to work. Legislative pressure on rebates, PBM reform litigation, and a GLP-1 boom that left half of new prescriptions unfilled in 2023 are pushing manufacturers toward cash-pay and direct-to-employer models that bypass PBM rebates entirely. That changes formulary math for plan sponsors and raises the stakes on gross-to-net accuracy for manufacturers. As Richter puts it, fair profit versus profiteering comes down to making more money when a patient does worse. MENTIONED IN THIS EPISODE Post by David Alderman Post by Ann Lewandowski Post by Madelaine Feldman, MD Post by Bryce Platt, PharmD AEE13 with Ge Bai, PhD, CPA: Apple Podcasts | Spotify | Other Apps EP439 with Luke Slindee, PharmD: Apple Podcasts | Spotify | Other Apps EP426 with Nina Lathia, RPh, MSc, PhD: Apple Podcasts | Spotify | Other Apps === LINKS === 🔗 Show Notes with all mentioned links ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter 🫙 Support the podcast with a small donation to the Tip Jar 🎤 Follow us on Apple Podcasts 🎤 Follow us on Spotify 📺 Subscribe to our YouTube channel === CONNECT WITH THE RHV TEAM === ✭ LinkedIn ✭ Threads ✭ Bluesky ✭ X 00:00 Introduction to this episode. 08:07 The conversation with Ophelia Johnson. 08:14 What is cash pay? 08:59 Why is this a thing and how did we get here? 12:28 The different ways that a patient could go about receiving and paying for their drug. 13:22 What's going on behind the scenes between GoodRx and the pharma manufacturer. 17:02 What dispense fees are and how they work. 17:41 A sidenote about next week's episode. 20:03 A sidenote about the pharma manufacturer POV. 21:44 The pharma supply chain in telehealth. 25:27 Why claims validation has never been more important. 28:19 Where do employers fit in all of this? 32:45 Where does it make sense to consider these alternative business models in lieu of the risks? 35:04 Why mapping the incentives is important. 38:42 Ophelia's advice to pharma manufacturers. 40:41 Ophelia's advice to plan sponsors. 42:46 More of Ophelia's advice to payers.

Is it fraud — or is it just a perverse incentive? That question sits at the center of Hunterbrook Media's latest investigation into skilled nursing facilities (SNFs), and the answer, as Stacey Richter puts it, matters to self-insured employers and anyone else paying for healthcare. In this episode, Stacey speaks with Michelle Cera, PhD, investigative reporter at Hunterbrook Media, whose investigation — triggered by a tip from an overwhelmed elder abuse attorney — uncovered a pattern of systematic understaffing, self-reported CMS STAR rating manipulation, executive bonuses tied to expense-cutting, and related-party financial engineering that funnels Medicare and Medicaid dollars straight back to corporate, while the most vulnerable patients pay with their health and their lives. WHAT YOU'LL LEARN ✅ How for-profit SNF chains systematically recruit the sickest patients to maximize Medicare and Medicaid reimbursement, then staff below what those patients actually need — keeping the difference as profit and, in some cases, doubling executive bonuses in a single year ✅ How Hunterbrook analyzed millions of publicly available CMS data points across roughly 14,000 skilled nursing facilities, applying a UCSF-developed expected-hours formula tied to patient acuity, to quantify the gap between staffing hours billed and care hours actually provided ✅ Why CMS STAR ratings — the primary tool consumers use to choose nursing homes for loved ones — are largely informed by self-reported, unaudited facility data, and how former employees described manipulation of those ratings as rampant ✅ How related-party transactions allow SNF chains to route Medicare and Medicaid dollars through owned subsidiaries for goods and services like pharmacy, equipment, and insurance — with CMS flagging the overcharges as disallowed costs but lacking any mechanism to recoup them ✅ How a 2024 CMS final rule establishing a federal minimum of 3.48 HPRD (hours per resident day) and a 24/7 on-site registered nurse requirement was ultimately rescinded after industry lobbying — and what that rescission reveals about regulatory capture in the SNF sector ✅ Four concrete policy fixes: codify federal minimum staffing hours adjusted for patient acuity, strengthen reporting standards and auditing so no quality metric is entirely self-reported, create a recoupment mechanism for flagged related-party overcharges, and reform STAR ratings so consumers can distinguish independently verified data from self-reported data WHY THIS MATTERS Right now, Stacey argues, we are endlessly trying to keep up with thousands of profit-extracting geniuses and creating mazes of complexity to regulate actors who have no societal construct keeping them in check. The SNF sector is a case study in what happens when there is no agreed-upon definition of harm — when perverse incentives are just incentives. These are taxpayer, employer, and patient co-insurance dollars potentially going into someone's pocket while a patient is simultaneously being hurt. The 65-plus population is growing, the market is expanding, and — as Hunterbrook's research shows — the model that works from a profit perspective is to take sicker patients, cut the highest-paid staff first, and grade your own homework so no one notices. That playbook, once proven, spreads fast. MENTIONED IN THIS EPISODE EP511 with Dr. Siva and Monica Lypson, MD, MHPE: Apple Podcasts | Spotify | Other Apps EP509 with Patrick Nelli: Apple Podcasts | Spotify | Other Apps Hunterbrook Media's full SNF investigation Study: University of Pennsylvania analysis on repealing the CMS minimum staffing rule EP482 with Preston Alexander: Apple Podcasts | Spotify | Other Apps === LINKS === 🔗 Show Notes with all mentioned links: Show Notes ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter 🫙 Support the podcast with a small donation to the Tip Jar 🎤 Follow us on Apple Podcasts 🎤 Follow us on Spotify 📺 Subscribe to our YouTube channel === CONNECT WITH THE RHV TEAM === ✭ LinkedIn ✭ Threads ✭ Bluesky ✭ X 00:00 Introduction to this episode. 00:40 Fixing the root cause problems with the American healthcare system. 01:50 Today's root problem topic. 05:12 Introducing today's guest and her latest investigation. 07:43 The conversation with Michelle Cera, PhD. 08:35 How Hunterbrook Media's latest investigation into skilled nursing facilities got started. 13:20 How inadequate staffing creates neglect in SNFs. 14:03 Connecting the dots between staffing and resident needs. 15:33 Why skilled nursing facility chains are extremely profitable to the detriment of patients. 17:15 How star ratings on CMS can be skewed in the favor of these SNF chains. 21:56 The perverse incentives playbook. 23:20 An example of how executive bonuses are tied to perverse incentives. 27:53 How lobbying walked back the CMS minimum staffing regulation for SNFs. 29:05 Another note in the perverse incentives playbook. 30:59 How much of these chain SNFs' funding is from taxpayer dollars. 33:16 Another perverse incentive: overpaying sister companies. 35:07 Why CMS can flag overcharging, but they don't have a cost recoup structure. 38:10 The case to be made about how current business dealings within SNFs is fraudulent. 39:30 How to fix the perverse incentives happening in skilled nursing facilities.

How the Sutter Health Antitrust Case Opened the Door for Employers and Members to Recover Hospital Overcharge Damages What happens when a self-insured employer or health plan member finally says enough is enough and takes a consolidated hospital system to court over anticompetitive contracting practices? That's exactly what antitrust attorney Matthew Cantor did — and after 13 years of litigation, three trips to the Ninth Circuit Court of Appeals, and a first trial, he and his team secured a landmark $228.5 million settlement in Sidibe v. Sutter Health. In this episode, Stacey Richter speaks with Matthew Cantor, JD, founding partner of Shinder Cantor Lerner LLP, about one of the most significant antitrust victories in healthcare history — and what it means for self-insured employers, plan sponsors, and everyday members who have been paying inflated premiums because of hospital market power. WHAT YOU'LL LEARN ✅ How all-or-nothing clauses and anti-steering/anti-tiering provisions allow dominant hospital systems to lock up local geographies and block members from accessing lower-cost, higher-quality care ✅ Why holding large, consolidated health systems legally accountable is so difficult — including the halo effect, the FTC's lack of jurisdiction over nonprofits, and the challenges of unsympathetic witnesses ✅ How Sidibe v. Sutter Health established a groundbreaking precedent allowing indirect purchasers — employers and plan members paying inflated premiums — to recover damages from hospital overcharges ✅ Why the DOJ is already pursuing similar anti-steering litigation against health systems like OhioHealth and NewYork-Presbyterian ✅ Four concrete options for employers ready to stop being passive price takers: federal legislation, state legislation, engaging the DOJ and state attorneys general, and direct litigation WHY THIS MATTERS Hospital charges make up roughly 50% of underlying medical costs, which in turn represent 80–85% of health insurance premiums. When consolidated systems operate in local markets with little competition, everyone — employers and members alike — pays more. Sidibe v. Sutter Health shows that accountability is possible. MENTIONED IN THIS EPISODE EP512 with Doug Aldeen: Apple Podcasts | Spotify | Other Apps EP452 with Cora Opsahl: Apple Podcasts | Spotify | Other Apps EP458 with Komal Bajaj, MD: Apple Podcasts | Spotify | Other Apps EP466 with Vivian Ho, PhD: Apple Podcasts | Spotify | Other Apps EP513 with Brennan Bilberry: Apple Podcasts | Spotify | Other Apps   LinkedIn Post by Kimberly Carleson LinkedIn Comment by Daron Pitts LinkedIn Comment by Thomas Frangione EP501 with Ivana Krajcinovic, PhD: Apple Podcasts | Spotify | Other Apps EP436 with Elizabeth Mitchell: Apple Podcasts | Spotify | Other Apps EP491 with Elizabeth Mitchell: Apple Podcasts | Spotify | Other Apps EP509 with Patrick Nelli: Apple Podcasts | Spotify | Other Apps === LINKS === 🔗 Show Notes with all mentioned links: Show Notes ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter 🫙 Support the podcast with a small donation to the Tip Jar 🎤 Follow us on Apple Podcasts 🎤 Follow us on Spotify 📺 Subscribe to our YouTube channel === CONNECT WITH THE RHV TEAM === ✭ LinkedIn ✭ Threads ✭ Bluesky ✭ X TIMESTAMPS 00:00 Introduction to this episode. 04:26 Why does the halo effect make it difficult to hold hospitals accountable? 06:16 Why the case around this episode matters. 09:31 The conversation with Matt Cantor. 09:36 The brief background of how we got here. 10:55 The Sutter litigation: an overview. 12:57 Local geography versus local market. 17:50 Why litigation? 23:50 Why are these cases so difficult? 27:36 What Matt Cantor thinks will be the future of litigation against these hospital systems. 28:11 Why Sutter? 31:21 What led to the ultimate victory in the Sutter case. 37:52 What is possible for employers now? 40:54 Antitrust enforcers that employers should consider. 41:49 The greatest challenge in fighting healthcare costs and medical spend.

The Hospital Contract Playbook: Four Clauses That Turn Market Power Into Higher Prices. Episode 513. Across the country, hospital systems have used their growing market power to write four specific contract terms into their deals with insurers — terms that all but guarantee higher prices for employers, unions, and patients, regardless of quality or competition nearby. In this episode, Stacey Richter speaks with Brennan Bilberry, founding partner of Fairmark Partners, an antitrust law firm that has sued multiple dominant hospital systems, about exactly how those four contract terms work, clause by clause, and why they set the stage for the litigation explored in next week's episode with Matt Cantor. WHAT YOU'LL LEARN ✅ How all-or-nothing contracting forces insurers and employers to accept every facility in a hospital system's network — including overpriced urban hospitals — just to get access to a single must-have rural facility, a tactic central to Sutter Health's $575 million antitrust settlement in one of two cases brought against it ✅ How anti-steering and anti-tiering clauses block health plans from directing members to lower-cost, equal-quality care — illustrated by a market where a C-section costs $44,000 at one hospital and $21,000 two miles away, and by the government's case against Atrium Health in North Carolina ✅ How price gag clauses prevent insurers and TPAs from telling self-funded employers what they're actually paying for care, even after recent transparency rules — including a case where North Carolina's state treasurer received hundreds of redacted pages when he requested UNC Healthcare's prices ✅ How dominant hospital systems squeeze nominally independent physician practices into charging hospital-level prices without ever buying them outright — in one North Texas market, this drove prices up $100 million in a single year ✅ Why these four contract terms reinforce each other — block steering and a plan can't build narrow networks; restrict independent providers and there's nowhere cheaper left to steer to — making each successive workaround harder for plan sponsors to use WHY THIS MATTERS From 1998 to 2015 there were 1,500 hospital mergers, and the pace has only accelerated since — today, most physicians no longer own the practices where they work. Anticompetitive contract terms are what let that consolidation translate directly into higher prices for employers and patients. Understanding the playbook clause by clause, as laid out here, is the first step toward fighting it. MENTIONED IN THIS EPISODE EP373 with Cora Opsahl: Apple Podcasts | Spotify | Other Apps EP452 with Cora Opsahl: Apple Podcasts | Spotify | Other Apps Post by Tricia Schildhouse EP249 with Dale Folwell: Apple Podcasts | Spotify | Other Apps EP391 with Scott Conard, MD: Apple Podcasts | Spotify | Other Apps EP389 with Mike Thompson: Apple Podcasts | Spotify | Other Apps EP390 with Gloria Sachdev, PharmD, and Chris Skisak, PhD: Apple Podcasts | Spotify | Other Apps === LINKS === 🔗 Show Notes with all mentioned links: Show Notes ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter 🫙 Support the podcast with a small donation to the Tip Jar 🎤 Follow us on Apple Podcasts 🎤 Follow us on Spotify 📺 Subscribe to our YouTube channel === CONNECT WITH THE RHV TEAM === ✭ LinkedIn ✭ Threads ✭ Bluesky ✭ X TIMESTAMPS 00:00 Introduction to this episode. 06:55 The conversation with Brennan Bilberry. 06:59 What happens after a hospital consolidates? 08:05 What an anticompetitive system looks like when a hospital consolidates. 11:12 Some anticompetitive "tricks" that hospitals employ. 13:13 Example: the Sutter case in northern California. 15:36 What to do if you're forced to engage in an all-or-nothing contract with a hospital system. 19:17 Example: the Atrium case in North Carolina. 22:12 Explaining price gag clauses. 23:48 How legacy gag clauses are designed to prevent scrutiny in litigation. 26:21 How hospital restrictions on other providers create an anticompetitive environment.

A Lawyer's Field Guide to Rent-Seeking Broker and EBC Payment Models. Epsiode 512. Brokers and employee benefit consultants often get compensated in ways health plans never fully see — and even when the dollars are technically disclosed, the math can hide an enormous overcharge. In this episode, Stacey Richter speaks with Doug Aldeen, JD, an ERISA healthcare attorney who has spent decades in the self-funded space, about the legal danger zones where broker and EBC payment models go wrong: rent-seeking solution recommendations, undisclosed vendor payments, and front-loaded voluntary-benefits commissions — and the practical roadmap any plan sponsor can use to catch them before they cost millions. WHAT YOU'LL LEARN ✅ How a level-funded plan's broker was paid more than $2 million in fees while the plan itself ended up roughly $600,000 in deficit — a cautionary tale Stacey and Doug call the Ohio Potato Company story ✅ How reference-based pricing vendors using a "cost of savings" fee model can be incentivized by rising hospital prices — illustrated by a $10,000 CT scan repriced to $1,000, netting the vendor $1,800 on a $9,000 "savings," on top of underlying facility markups that can run as high as 17,000% ✅ How a balance-billing vendor collected $2.2 million in fees over three plan years to protect against just $94,320 in disputed claims — even in a state where the hospital had no legal authority to balance bill in the first place ✅ Why voluntary benefits commissions, often front-loaded at 70% to 90% in the first year, can make a product more profitable for the broker than useful for members ✅ A practical roadmap for plan sponsors to catch rent-seeking arrangements before they cost millions: ask why repeatedly, demystify the commission structure, run an independent broker RFP, audit plan and stop-loss documents for gaps, and build a real contract "out" WHY THIS MATTERS Self-funded employers often assume their broker or EBC's incentives are aligned with the plan's. But when compensation is tied to cost-of-savings formulas, undisclosed vendor relationships, or front-loaded commissions, the incentive can quietly flip — rewarding higher healthcare prices and unnecessary point solutions instead of genuine savings. Knowing where to look, and which questions to ask, is what separates a fiduciary from a rent-seeking target. MENTIONED IN THIS EPISODE EP457 with Cynthia Fisher: Apple Podcasts | Spotify | Other Apps EP508 with Lee Lewis: Apple Podcasts | Spotify | Other Apps EP379 with AJ Loiacono: Apple Podcasts | Spotify | Other Apps EP484 with Dave Chase: Apple Podcasts | Spotify | Other Apps EP478 with Andreas Mang and Jon Camire (Part 1): Apple Podcasts | Spotify | Other Apps EP479 with Andreas Mang and Jon Camire (Part 2): Apple Podcasts | Spotify | Other Apps EP419 with Andreas Mang: Apple Podcasts | Spotify | Other Apps === LINKS === 🔗 Show Notes with all mentioned links: Show Notes ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter 🫙 Support the podcast with a small donation to the Tip Jar 🎤 Follow us on Apple Podcasts 🎤 Follow us on Spotify 📺 Subscribe to our YouTube channel === CONNECT WITH THE RHV TEAM === ✭ LinkedIn ✭ Threads ✭ Bluesky ✭ X TIMESTAMPS 00:00 Introduction to this episode. 00:59 A caveat for the record on this episode. 02:11 The first problematic payment model discussed in this week's episode. 03:27 The second problematic payment model discussed in this week's episode. 06:16 The conversation with Doug Aldeen. 06:27 Why is reviewing broker/EBC compensation so important? 08:05 The Ohio Potato Company anecdote. 10:28 The first way brokers/EBCs might get paid. 11:45 What "cost of savings" means. 14:07 A rent-seeking solution that requires a cost-benefit analysis. 19:16 Why the broker/EBC is sometimes in the dark about vendor kickbacks. 21:46 Where the CAA is unclear. 24:04 Actionable advice for plan sponsors. 24:57 The second piece of actionable advice for plan sponsors. 25:22 The third piece of actionable advice for plan sponsors. 26:08 Demystifying the commission structure. 27:35 Using a broker RFP from an open source. 28:31 Why you should be auditing data and claims. 31:29 The importance of having an "out." 33:11 Why the broker community may be at substantial risk.

When Risk-Based Payment Becomes Its Own Upcoding Arms Race. Episode 511 Medicare Advantage plans get paid more for sicker patients, which is why upcoding became a problem — and now health systems are upcoding visit complexity right back, with MA plans automatically downcoding in response. In this episode, Stacey Richter plays an unpublished clip from her conversation with Ahilan Sivaganesan, MD (Dr. Siva), a neurosurgeon and head of quality and value at Mishe Health, on why physicians must understand their own costs before taking on financial risk, then revisits an earlier conversation with Monica Lypson, MD, MHPE, vice dean for medical education at Columbia University Irving Medical Center, on whether handing health systems that same risk-based incentive could end up worsening the very disparities value-based care is meant to fix. WHAT YOU'LL LEARN ✅ Why Medicare Advantage plans' incentive to upcode patient complexity is now mirrored by health systems upcoding visit complexity — triggering automatic downcoding wars between MA plans and providers ✅ Why physicians can't responsibly go at risk for outcomes and costs without first understanding their own costs through time-driven activity-based costing — without it, Dr. Siva says, you're "jumping blind into an abyss," straight toward cherry-picking and lemon-dropping patients ✅ How sliding-scale bundled payments, calibrated to patient and procedure complexity rather than a flat lump sum, could let practices take on bundled risk without being punished for treating sicker patients ✅ Why handing health systems a sliding-scale risk adjustment framework risks recreating the same upcoding incentives that plagued Medicare Advantage, just one level up the chain ✅ How perverse incentives baked into value-based and risk-based contracting can worsen existing healthcare disparities when systems are structurally rewarded for avoiding complex or costly patients WHY THIS MATTERS Risk-based and value-based payment models are often framed as the fix for fee-for-service's worst incentives. But if the underlying cost data and risk-adjustment frameworks aren't built carefully, the same gaming that plagued Medicare Advantage — and fee-for-service before it — can simply move up the chain to health systems and physician practices, with disparities in care quietly bearing the cost. MENTIONED IN THIS EPISODE EP505 with Ahilan Sivaganesan, MD: Apple Podcasts | Spotify | Other Apps EP485 with Cristin Dickerson, MD: Apple Podcasts | Spotify | Other Apps EP436 with Elizabeth Mitchell: Apple Podcasts | Spotify | Other Apps EP491 with Elizabeth Mitchell: Apple Podcasts | Spotify | Other Apps SUMS9 with Elizabeth Mitchell: Apple Podcasts | Spotify | Other Apps EP462 with Scott Conard, MD: Apple Podcasts | Spotify | Other Apps EP319 with Grace Terrell, MD: Apple Podcasts | Spotify | Other Apps EP431 with Kenny Cole, MD: Apple Podcasts | Spotify | Other Apps EP409 with Larry Bauer, MSW, MEd: Apple Podcasts | Spotify | Other Apps EP495 with Mick Connors, MD: Apple Podcasts | Spotify | Other Apps LinkedIn Post by Mark Weber EP484 with Dave Chase: Apple Podcasts | Spotify | Other Apps === LINKS === 🔗 Show Notes with all mentioned links: Show Notes ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter 🫙 Support the podcast with a small donation to the Tip Jar 🎤 Follow us on Apple Podcasts 🎤 Follow us on Spotify 📺 Subscribe to our YouTube channel === CONNECT WITH THE RHV TEAM === ✭ LinkedIn ✭ Threads ✭ Bluesky ✭ X TIMESTAMPS 00:00 Introduction to this episode. 05:22 What is the minimum requirement for physicians to go at risk? 07:22 How sliding scale bundle payments can reduce risk for physicians. 10:43 The question covered in the upcoming episode. 13:19 Is value-based care good for underserved communities? 15:01 "If you create perverse incentives, you actually might make known healthcare disparities worse … to meet the demand's value." —Dr. Lypson 16:18 "There actually might be systematic and structural ways that the healthcare system might say … we're not interested in taking care of you." —Dr. Lypson 16:51 "The incentive to have a good outcome is not there; the incentive to have another visit is there." —Dr. Lypson 17:49 "The only indictment I have on the fee-for-service system is that it's gotten us to where we are right now." —Dr. Lypson 18:41 "If you don't have any connection in that system, even the provider trying to … provide a good outcome might be disconnected because the system is not in place to … connect the dots." —Dr. Lypson 19:28 What are the must-haves for a value-based system that create the patient outcomes we need? 19:51 What is a whole health model? 25:31 Why we need to fix the structural issues if we want to fix health. 26:00 Why a patient's bias is the one we want in the room. 27:36 Stacey's conclusion on this week's episode.

The Line Between Fair Profit and Profiteering in Medicare Advantage. Episode 510 There's a simple test for telling a fair profit from profiteering in Medicare Advantage: does the carrier make more money when the patients it serves are worse off? In this episode, Stacey Richter talks with Betsy Seals, co-founder of Rebellis Group and a Medicare Advantage consultant making her third appearance on the show, about how vertically integrated carriers shift costs onto self-insured employers' commercial rates, why MA plans can end up paying providers they own more than independent practices, and the back-to-basics strategy Seals recommends for any MA plan that wants to make money the right way. WHAT YOU'LL LEARN ✅ How vertically integrated carriers negotiate the lowest possible Medicare Advantage rates with consolidated health systems, then let those systems make up the difference by raising commercial ASO rates — a cost-shifting pattern research puts at 4.7% above what employers would otherwise pay ✅ Why Medicare Advantage carriers that own provider organizations have a financial incentive to pay those owned providers more than independent practices, since MA rate increases are pegged to fee-for-service benchmarks ✅ How Goodhart's Law shows up in STARS and other quality measures — once a measure becomes the target, it stops reliably reflecting genuine member health improvement ✅ The back-to-basics strategy Betsy Seals recommends for Medicare Advantage plans: don't get caught with your hand in the cookie jar, focus on the beneficiaries you actually serve well, and use STARS and clinical programs to genuinely improve health rather than to check boxes ✅ Why squeezing independent primary care practices on reimbursement can ultimately raise the total cost of care for everyone, even though it looks like savings in the short term WHY THIS MATTERS Medicare Advantage runs on taxpayer dollars, and it's the care seniors, family members, and friends depend on. When the financial incentive flips — when a plan makes more money the worse its members do — that's profiteering, not business. Seals's back-to-basics framework offers a way to tell the difference, and a roadmap for plans willing to make a fair profit instead. MENTIONED IN THIS EPISODE EP481 with Benjamin Schwartz, MD, MBA: Apple Podcasts | Spotify | Other Apps EP495 with Mick Connors, MD: Apple Podcasts | Spotify | Other Apps YouTube Video: Eric Bricker, MD, on the financial performance of the U.S. healthcare system EP463 with Betsy Seals: Apple Podcasts | Spotify | Other Apps EP482 with Preston Alexander: Apple Podcasts | Spotify | Other Apps EP462 with Scott Conard, MD: Apple Podcasts | Spotify | Other Apps Article: STAT, "Trump Goes Soft on Medicare Advantage Medical Underwriting," by Bob Herman === LINKS === 🔗 Show Notes with all mentioned links: Show Notes ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter 🫙 Support the podcast with a small donation to the Tip Jar 🎤 Follow us on Apple Podcasts 🎤 Follow us on Spotify 📺 Subscribe to our YouTube channel === CONNECT WITH THE RHV TEAM === ✭ LinkedIn ✭ Threads ✭ Bluesky ✭ X TIMESTAMPS 00:00 Introduction to this episode. 01:25 How Medicare Advantage is relevant to everyone. 06:15 A preview of today's conversation. 07:49 The "state of the state" of Medicare Advantage plans. 09:32 Does Medicare Advantage's losses matter to the patients? 10:29 A recap of Betsy's insights so far. 11:19 The underlying strategic through line that needs to be considered. 13:04 The impact of Goodhart's Law. 14:12 What the players that are succeeding right now are doing. 14:22 The first pillar of a back-to-basics strategy: Don't get caught with your hand in the cookie jar. 16:50 Why short-term strategies don't work. 18:26 Stats report on prior authorizations serving the beneficiary. 19:38 Why prior authorization needs change. 21:28 The better strategy to use. 23:17 The second pillar of a back-to-basics strategy: Focus on the beneficiaries you actually serve well. 24:37 What it looks like to implement this focus on the beneficiaries you serve well. 25:29 How special needs plans play into this. 27:43 The third pillar of a back-to-basics strategy: Think about how STARS in clinical programs improve health. 30:04 The ethical component to implementing a Medicare Advantage program. 31:04 Betsy's advice for independent practices dealing with prior authorizations. 34:08 Betsy's final notes for all players impacted by what's currently happening.

The Seven-Step Roadmap That Gets CFOs to Stop Being Passive Price Takers on Health Benefits. Episode 509. As a companion to last week's CEO-focused episode, Stacey Richter talks with Patrick Nelli — CEO of Aligned Marketplace and a former CFO himself — about how to bring finance teams into health benefits strategy using their own language. Patrick lays out a seven-step roadmap, starting with forecasting healthcare trend at an accurate 7.7%-or-higher rate rather than the CPI, to show finance teams exactly why the status quo is financially untenable. WHAT YOU'LL LEARN ✅ Why healthcare inflation structurally outpaces the Consumer Price Index, driven partly by Baumol's cost disease — healthcare's low productivity gains force price increases just to keep pace with salaries in higher-productivity sectors ✅ Patrick Nelli's seven-step roadmap: stop the renewal surprise, confront an accurate trend, offer a win-win alternative to the status quo, lean into proven strategies like advanced primary care, align incentives and safeguards, optimize contracting, and steer and tier ✅ Why setting next-year forecasts at a real 7.7%-or-higher trend (two to three points above CPI) is the fastest way to get a finance team to find its own "why" for changing the health plan ✅ How direct contracting with independent practices fits into a finance-team-aligned contracting strategy, and why risk-stratifying and steering members to high-value organizations matters most for rising-risk populations ✅ Why advanced primary care keeps surfacing as the proven strategy to bend the cost curve, and what a plan sponsor's next step looks like once it commits to that model WHY THIS MATTERS Finance teams often forecast health benefits using the Consumer Price Index, but healthcare costs have been running two to three points above CPI for years — meaning the status quo is already financially untenable even before considering the human cost. Speaking to CFOs in their own language, with real numbers and a concrete roadmap, is what turns finance from a passive price taker into an active partner in fixing the health plan. MENTIONED IN THIS EPISODE EP504 with Ryan Jacobs: Apple Podcasts | Spotify | Other Apps Take Two: EP341 with Gary Campbell: Apple Podcasts | Spotify | Other Apps EP492 with Sam Flanders, MD, and Shane Cerone: Apple Podcasts | Spotify | Other Apps INBW46 with Stacey: Apple Podcasts | Spotify | Other Apps EP391 with Scott Conard, MD: Apple Podcasts | Spotify | Other Apps Sumemr Short with Stan Schwartz, MD: Apple Podcasts | Spotify | Other Apps Study: Milbank Memorial Fund on the role of primary care EP466 with Vivian Ho, PhD: Apple Podcasts | Spotify | Other Apps EP464 with Al Lewis: Apple Podcasts | Spotify | Other Apps EP503 with Ryan Wells; Leo Spector, MD, MBA; and Adam Stavisky: Apple Podcasts | Spotify | Other Apps EP430 with Barbara Wachsman: Apple Podcasts | Spotify | Other Apps === LINKS === 🔗 Show Notes with all mentioned links: Episode Page ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter 🫙 Support the podcast with a small donation to the Tip Jar 🎤 Listen on Apple Podcasts 🎤 Listen on Spotify 📺 Subscribe to our YouTube channel === CONNECT WITH THE RHV TEAM === ✭ LinkedIn ✭ Threads ✭ Bluesky ✭ X 00:00 Introduction to this episode. 02:48 Roadmap Step 1-7 highlights. 06:28 Introduction to the conversation with Patrick Nelli. 06:36 Step 1 to Patrick's roadmap: Open the conversation. 07:57 What Patrick thinks is sometimes missing in health benefits. 09:07 What finance teams need in order to change their behaviors. 09:53 What Baumol's cost disease is. 12:18 The second item stacked against employers: Being price "takers." 13:49 The percent inflation employers should expect if they follow the status quo. 16:54 Proven strategies to bend the health benefits finance curve. 20:18 How employers and plan sponsors can bend the cost curve. 21:47 The two distinct business models that finance teams need to consider when setting up their health benefits model. 24:53 A quick reminder of high-cost spending within health plans. 25:59 What finance teams need to hear right now to understand why disrupting their health benefits plan is worth it. 27:45 The next step when an employer recognizes that they should seek out an advanced primary care option for their members. 30:27 Next steps after an employer enlists an advanced primary care system and aligns values and incentives in their benefits plan. 34:26 A last word to benefit teams working with finance teams. 35:08 How Aligned Marketplace fits into this entire conversation.

The Three False Dogmas Keeping CEOs From Fixing Their Health Plan. Episode 508. In the show's first-ever Ask Me Anything episode, Stacey Richter puts a listener's question to Lee Lewis, chief strategy officer and GM medical solutions at the Health Transformation Alliance: why do so few self-insured CEOs take bold action on their health benefits strategy? Lee walks through three false dogmas, four external pressures, and the C-suite math behind a real acquisition where better-managed benefits alone created a quarter billion dollars of instant equity value nobody had priced in. WHAT YOU'LL LEARN ✅ The three false dogmas that keep CEOs stuck in the herd: health benefits are a fixed expense, saving money hurts people, and fixing healthcare is never worth the risk or disruption  ✅ How one acquired company's better-managed health plan — $2,300 less per employee per year, with better benefits — created over a quarter billion dollars of unpriced equity value in an M&A deal  ✅ The four external reasons C-suites avoid action: circles CEOs travel in with health system leaders, "balance of trade" threats and promises, personal incentives like trips and perks from status quo vendors, and a blind spot to how a $5,000 deductible lands very differently on a $25-an-hour employee  ✅ Why perverse incentives baked into C-suite compensation at health systems make it structurally hard for consolidated systems to accept change  ✅ Lee Lewis's concrete advice for benefits teams working under a risk-averse C-suite, and his direct advice to any CEO listening WHY THIS MATTERS Health benefits sit as one of the largest line items on a corporate balance sheet, and the false belief that fixing them is too risky or too disruptive keeps plan sponsors leaving real money and real employee health outcomes on the table. Understanding the dogmas and the external pressures behind CEO inertia is the first step to breaking it. MENTIONED IN THIS EPISODE EP500 with Stacey: Apple Podcasts | Spotify | Other Apps EP466 with Vivian Ho, PhD: Apple Podcasts | Spotify | Other Apps EP404 with Suhas Gondi, MD, MBA: Apple Podcasts | Spotify | Other Apps EP506 with Jerry DiMaso: Apple Podcasts | Spotify | Other Apps EP501 with Ivana Krajcinovic, PhD: Apple Podcasts | Spotify | Other Apps LinkedIn Post by Patrick Moore EP488 with Mark Cuban and Cora Opsahl: Apple Podcasts | Spotify | Other Apps === LINKS === 🔗 Show Notes with all mentioned links: Episode Page ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter 🫙 Support the podcast with a small donation to the Tip Jar 🎤 Listen on Apple Podcasts 🎤 Listen on Spotify 📺 Subscribe to our YouTube channel === CONNECT WITH THE RHV TEAM === ✭ LinkedIn ✭ Threads ✭ Bluesky ✭ X   00:00 Introduction to this episode. 00:43 Ask Me Anything Question 1: Why don't more self-insured executives take bold action toward their benefits strategy? 03:09 A summary of the three dogmas covered in the following conversation. 05:53 A look ahead at next week's episode. 06:36 An introduction to today's guest, Lee Lewis. 08:23 Why there is an aversion to digging into health benefits for some executives. 09:43 The first dogma: Healthcare costs are fixed expenses. 09:56 The second dogma: Saving money in healthcare hurts people. 12:01 The third dogma: Fixing healthcare is never worth the effort. 12:26 How these dogmas trickle down to HR teams. 13:47 Anecdote: One company that turned down saving $50 million and why. 16:28 A quick reminder about the context behind where CEOs' mindsets are. 17:10 The kinds of employers HTA seeks out. 20:03 The power of C-suites in health systems. 21:42 Why a CEO may pull the plug on health plan/health benefit improvements. 22:37 An anecdote about Lilly cancelling their health plan. 23:21 Items that CEOs need to be thinking about. 26:32 A summary of why CEOs should care about their health benefits costs now. 29:02 How do personal incentives play into CEOs' decisions about health benefits? 30:44 Another quick reminder about C-suites. 31:53 Why perverse incentives make it difficult for C-suites to accept change. 33:28 Why the salary gap plays into health benefit decisions in a perverse way. 36:13 Lee Lewis's advice to people in benefits who are aligned to the mission. 40:06 Lee Lewis's advice for CEOs.

Buy Healthcare, Not Insurance: A Through-Line Review of the Four Concepts Behind High-Value Care. Episode 507. Stacey Richter pulls together clips from 14 past guests to lay out the four core concepts for buying or delivering the highest-value healthcare: buy healthcare (not just insurance), avoid the myth that less expensive automatically means lower quality, consider direct contracting between plan sponsors and clinicians, and make sure whatever you're buying or delivering is actually high value. To read the full list of Core Concepts, read the show notes (link below). WHAT YOU'LL LEARN ✅ Why health insurance is not healthcare, and why buying the two as if they were the same thing costs plan sponsors billions of dollars a year ✅ Why there is often no correlation between price and quality — sometimes less expensive care is higher quality, and low-quality care can be the most expensive care regardless of its price tag ✅ Why direct contracting between plan sponsors and clinicians helps eliminate low-value middlemen and opens the door to real collaboration on integration and shared goals ✅ Why "buy the highest-value healthcare" is a genuine north star rather than a slogan — and what plan sponsors should hold their direct-contracting partners accountable for delivering ✅ A sneak peek at the new Relentless Health Value Chatbot, trained on the show's 500-plus guests, that Stacey used with a light touch while building this episode WHY THIS MATTERS The Relentless Tribe moves fast, covering a lot of ground episode to episode — so this through-line review exists to make the big points stick: buy healthcare, not insurance; don't assume price and quality trade off against each other; use direct contracting to get plan sponsors and clinicians talking directly; and hold whatever you buy or deliver to a real standard of value. === LINKS === 🔗 Show Notes with all mentioned links: Episode Page ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter 🫙 Support the podcast with a small donation to the Tip Jar 🎤 Listen on Apple Podcasts 🎤 Listen on Spotify 📺 Subscribe to our YouTube channel === CONNECT WITH THE RHV TEAM === ✭ LinkedIn ✭ Threads ✭ Bluesky ✭ X 00:00 Introduction to this episode and guests. 01:38 The four core concepts to buy or deliver highest-value healthcare: a summary. 06:01 An exciting show announcement. 07:32 Core Concept 1: Why buy highest-value healthcare, not "best" coverage? 11:28 Core Concept 2: Will employers fall victim to the myth of inexpensive care? 13:00 Why better-quality care vs. more affordable care is a false choice. 17:09 Core Concept 3: Direct contracting. 17:58 Why demand curve matters in healthcare cost. 22:08 How Centers of Excellence play into all of this. 22:54 Core Concept 4: How do you conceive of and buy high-value healthcare? 23:48 The value equation in healthcare. 25:35 What is value? 28:20 What whole-person care looks like. 30:24 Relentless Health Value Chatbot sneak peek announcement. 32:14 Coming up: looking at the episodes ahead.

The Price Transparency Arms Race: What Self-Insured Employers and Clinics Can Both Do With the Data. Episode 506. Health price transparency data isn't just a compliance exercise anymore — it's becoming a competitive weapon for plan sponsors, shareholders, and clinics alike. Stacey Richter talks with Jerry DiMaso, co-founder and CEO of Payerset, about how self-insured employers can use hospital and carrier transparency files to benchmark against competitors, catch overpriced billing codes, and expose "discount shell games," while independent clinics use the same data to level an historically asymmetric market. WHAT YOU'LL LEARN ✅ How plan sponsors can use an EIN to look up their own or a competitor's negotiated rates and carve-outs, exposing which companies in their industry are quietly getting better pricing ✅ Why the "discount shell game" is exposed by transparency data — a TPA's claimed 90% discount can be checked against real negotiated rates instead of taken on faith ✅ How plan sponsors can direct their TPA to renegotiate rates, implement service carve-outs and direct contracts, and calculate objective savings instead of relying on vendors to grade their own homework ✅ How independent clinics use the same rate data to benchmark reimbursement, discover new payer contracts they didn't know existed, and defend their prices during negotiations using quality metrics ✅ Why identifying high-cost billing codes matters — including the kind of million-dollar infusion overpayment discussed in the recent episode with Ivana Krajcinovic, PhD WHY THIS MATTERS Health benefits are often the second-largest line item on a corporate balance sheet, yet most plan sponsors have never checked whether they're paying more than their competitors for the exact same care. Price transparency data turns that blind spot into an "arms race" — plan sponsors can benchmark and negotiate harder, while independent clinics can use the same data to keep from being squeezed out by consolidated health systems that would otherwise inherit all their volume, and all their pricing power. MENTIONED IN THIS EPISODE EP472 with Eric Bricker, MD: Apple Podcasts | Spotify | Other Apps EP503 with Ryan Wells; Leo Spector, MD, MBA; and Adam Stavisky: Apple Podcasts | Spotify | Other Apps LinkedIn Post by Chris Deacon LinkedIn Post by Andrew Tsang LinkedIn Post by Pearly Chen EP489 with Dan Greenleaf: Apple Podcasts | Spotify | Other Apps EP501 with Ivana Krajcinovic, PhD: Apple Podcasts | Spotify | Other Apps === LINKS === 🔗 Show Notes with all mentioned links: Episode Page ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter 🫙 Support the podcast with a small donation to the Tip Jar 🎤 Listen on Apple Podcasts 🎤 Listen on Spotify 📺 Subscribe to our YouTube channel === CONNECT WITH THE RHV TEAM === ✭ LinkedIn ✭ Threads ✭ Bluesky ✭ X 00:00 Introduction to this episode. 00:50 How does transparent pricing data fit into the "inches all around us"? 03:13 A quick overview of what plan sponsors do with these price transparency insights. 05:52 The specific ways that clinical organizations can leverage price transparency data. 08:13 How price transparency infrastructure started and how it's grown to where we are now. 09:21 What are the insights that can be gleaned from the price transparency data available? 10:01 How price transparency data is a treasure trove for self-insured employers. 11:21 How employers can utilize this transparency data. 14:48 How employers can help TPAs negotiate. 15:18 Why employers should be thinking about carving out services. 16:21 Why employers need to direct contract. 17:38 A quick summary of advice for plan sponsors. 19:32 How rates get set and how small providers can see this and benefit from it. 20:55 How small providers can use rate transparency to negotiate better rates. 25:46 Have prices increased due to price transparency? 29:25 Why price transparency makes it more important to eliminate lazy networks. 31:10 What is the transparency arms race, and what is happening because of it? 34:39 What Payerset does.

Time-Driven Costing and the Operative Value Index for Surgical Care, With Ahilan Sivaganesan, MD. Why "Value Equals Outcomes Over Cost" Doesn't Work Until You Can Actually Measure Both. Episode 505. What if the only way to know who's delivering high-value surgical care is to actually calculate it, instead of guessing? Stacey Richter talks with Ahilan Sivaganesan, MD—known as Dr. Siva—a practicing neurosurgeon with the Hospital for Special Surgery in Naples, Florida, and Head of Quality and Value at Mishe Health, about the Operative Value Index (OVI): a common mathematical framework, built on time-driven activity-based costing (TDABC) and condition-specific patient-reported outcomes, that finally lets self-funded employers and health systems quantify value instead of guessing at it. WHAT YOU'LL LEARN ✅ Why most hospitals and surgeons have no real idea what it actually costs to deliver a given episode of surgical care—a "complete guessing game" that becomes a serious business risk as procedural bundles expand ✅ How the Operative Value Index (OVI) combines time-driven activity-based costing (TDABC) with condition- and procedure-specific patient-reported outcomes into a single quantified value metric ✅ Why appropriateness, not just surgical skill, is the true foundation of quality—and how measuring conservative, non-surgical care can finally reward the right clinical decision instead of just surgical volume ✅ How Dr. Siva's "bubble chart" visualizations let self-funded employers compare surgeons, practices, and health systems on value at both the procedural and diagnosis level, risk-adjusted for confounders ✅ Why physicians can't reasonably be asked to take on risk-based payment models until they understand their own true costs of care ✅ Why Dr. Siva sees a "Google moment" coming for health systems still maximizing fee-for-service volume instead of competing on quantified value WHY THIS MATTERS Across the $5.6 trillion healthcare sector, both halves of the value equation—outcomes and cost—are effectively question marks: costs get rolled up into vague, triangulated numbers while outcomes get broken down to the level of a single blood test. Without quantified outcomes and unit-level costs, no one can actually identify where high-value care exists, let alone pay for it in a way that isn't a built-in perverse incentive. As Dr. Siva puts it, health systems that keep maximizing fee-for-service volume are Yahoo laughing at Google, right before the world changed underneath them. MENTIONED IN THIS EPISODE EP434 with Benjamin Schwartz, MD, MBA: Apple Podcasts | Spotify | Other Apps EP326 with Rishi Wadhera, MD, MPP: Apple Podcasts | Spotify | Other Apps EP295 with Rebecca Etz, PhD: Apple Podcasts | Spotify | Other Apps Article: by Dana Prommel Strauss EP449 with Marty Makary, MD, MPH: Apple Podcasts | Spotify | Other Apps EP503 with Ryan Wells; Leo Spector, MD, MBA; and Adam Stavisky: Apple Podcasts | Spotify | Other Apps EP501 with Ivana Krajcinovic, PhD: Apple Podcasts | Spotify | Other Apps EP398 with Jacob Asher, MD: Apple Podcasts | Spotify | Other Apps Substack post by John Lee, MD Essay by Dr. Siva === LINKS === 🔗 Show Notes with all mentioned links: Show Notes ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter 🫙 Support the podcast with a small donation to the Tip Jar 🎤 Follow us on Apple Podcasts 🎤 Follow us on Spotify 📺 Subscribe to our YouTube channel === CONNECT WITH THE RHV TEAM ===  ✭ LinkedIn ✭ Threads ✭ Bluesky ✭ X   00:00 Introduction to this episode. 00:38 The goal of this episode. 01:28 What the Operative Value Index (OVI) is. 02:04 A quick episode overview. 04:44 How this episode came about. 09:24 How Dr. Siva got involved in the research around outcomes and costs. 11:51 How the value equation doesn't add up to true quality. 14:12 What measuring quality across the entire care journey means. 16:07 Why appropriateness is the foundation of quality. 19:08 Why practicing clinicians need to be thinking about the true costs of delivering care. 21:20 Time-driven activity-based costing (TDABC). 23:44 The two things that must be known for value-based care to succeed. 27:09 A quick summary of the conversation thus far. 30:42 The power of transparency in Dr. Siva's bubble plots. 34:05 Why these bubble plots work not just at the procedural level but at the diagnosis level, too. 37:28 The "big blue ocean" opportunity for forward-looking providers. 40:37 The incredible opportunity for entities and groups that can help provide the infrastructure needed for this value index. 43:19 Last thoughts by Dr. Siva on TDABC and competition on value.

Why Evidence-Backed Primary Care Still Can't Scale, and a 3-Step Roadmap to Get Around It. Episode 504. Why isn't advanced primary care (APC) everywhere, if the evidence for it is this strong? Stacey Richter talks with Ryan Jacobs, SVP of Strategy and Partnerships at Marathon Health, about the two root causes blocking APC from scaling—conflicting fiduciary duties and what Jacobs calls "the black box of complacency"—and the three-step roadmap he uses to help plan sponsors and clinicians get around both. WHAT YOU'LL LEARN ✅ Why conflicting fiduciary duties push hospital boards and payers to keep driving volume, even when advanced primary care would improve outcomes and lower costs ✅ How the "black box of complacency" lets consolidated health systems and lazy networks do nothing and still keep their volume, since innovators usually lose to the status quo, not to a better competitor ✅ Ryan Jacobs' three-step roadmap: perform a reality-based assessment, anticipate the stakeholders' math, and build strategic conclusions such as direct contracting ✅ Why frustrated self-insured employers are increasingly going direct to APC organizations themselves instead of waiting on payers or health systems to change ✅ Why ER spend now tops out at roughly 6% of total plan costs for self-insured employers, and how limited primary care access feeds that number ✅ Why direct contracting for APC works by connecting the plan sponsor directly to the clinicians providing care, cutting out the conflicted middle WHY THIS MATTERS Advanced primary care has a robust evidence base—it improves outcomes and lowers costs—yet it still isn't everywhere, because the incentives of the largest players in a nonfunctioning healthcare market run the other way: health systems and payers get bigger by driving volume, not by keeping people out of the hospital. As Ryan Jacobs puts it, plan sponsors and clinicians who don't follow the dollar and anticipate that reality will keep losing to complacency rather than to a better competitor. MENTIONED IN THIS EPISODE SUMS5 with Jacob Asher, MD: Apple Podcasts | Spotify | Other Apps EP483 (Part 1 and Part 2) with Jonathan Baran: Part 1 Apple Podcasts | Spotify | Other Apps; Part 2 Apple Podcasts | Spotify | Other Apps EP465 with Chris Crawford: Apple Podcasts | Spotify | Other Apps EP391 with Scott Conard, MD: Apple Podcasts | Spotify | Other Apps EP436 with Elizabeth Mitchell: Apple Podcasts | Spotify | Other Apps EP398 with Jacob Asher, MD: Apple Podcasts | Spotify | Other Apps EP286 with John Rodis, MD, MBA: Apple Podcasts | Spotify | Other Apps EP438 with John Lee, MD: Apple Podcasts | Spotify | Other Apps === LINKS === 🔗 Show Notes with all mentioned links: Show Notes ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter 🫙 Support the podcast with a small donation to the Tip Jar 🎤 Follow us on Apple Podcasts 🎤 Follow us on Spotify 📺 Subscribe to our YouTube channel === CONNECT WITH THE RHV TEAM === ✭ LinkedIn ✭ Threads ✭ Bluesky ✭ X 00:00 A refresher on advanced primary care (APC). 02:36 Why APC isn't everywhere. 04:39 The problem of complacency in the healthcare system. 05:27 Ryan Jacobs' roadmap. 08:59 The pitfalls of advanced primary care. 09:58 What primary fiduciary responsibility means. 10:51 Growth on the payer side. 13:27 The reality of the healthcare system in the United States. 14:11 The flywheel created by the tension within the healthcare system. 15:51 The tension between APC's goals and fiduciary responsibility. 17:52 The black box of complacency. 20:05 What's driven most of the change in the advanced primary care space. 21:01 What would happen if there was a functioning market in healthcare. 21:52 Why complacency may be a rational move in healthcare. 23:22 A roadmap to success in advanced primary care. 23:55 Step 1: Follow the money. 24:50 Step 2: Someone's gonna do math. 25:17 What strategic thinking looks like as an employer. 28:34 Step 3: Proceed based on strategic conclusions. 30:20 How self-insured employers have created their own market. 31:07 The strategic decision for physicians wanting to create change. 32:25 A reiteration of the episode's discussion. 33:49 Better payment structures.

Listener Insights on Better Decisions, Price Transparency, and PBM Spread Pricing Tricks. Why "Insight Is Common, Execution Is Rare" Is the Whole Game in Fixing Healthcare. Episode INBW46. In this inbetweenisode, Stacey Richter spotlights two Relentless Tribe members whose LinkedIn posts crystallized something she'd been trying to say all season: that healthcare doesn't lack frameworks or commentary, it lacks better decisions. Along the way she walks through real examples of how spread pricing gets disguised as "profit" or a "discount," why avoiding disruption can itself become the most disruptive choice a health plan makes, and a listener-built interactive map of ten years of Relentless Health Value episodes and themes. WHAT YOU'LL LEARN ✅ Why Stacey believes "insight is common, execution is rare" — and how better, more informed decisions, not better frameworks, are what actually move healthcare outcomes ✅ How self-insured employers and their shareholders can use price transparency data to catch site-of-care overpayments before they show up on the balance sheet ✅ Real-world tricks used to reclassify spread pricing as "profit" or a "discount" — from PBM-owned pharmacies getting preferred volume to consultant fee arrangements ✅ Why avoiding the word "disruption" can itself create disruption, when a lazy network leaves members functionally uninsured or bankrupt ✅ A listener-built interactive map of ten years of Relentless Health Value episodes, guests, and themes — and what the most-repeated words since 2014 reveal about the industry's stuck patterns WHY THIS MATTERS Better decisions — not better frameworks or more commentary — are what actually change outcomes in a healthcare system that Stacey describes as so financialized, with so much regulatory capture and vertical integration, that surface-level transparency can still hide an arbitrage underneath. Making good decisions requires both transparent data and the knowledge to interpret it, since a "negotiated rate" or a "no spread" claim can look clean while still not adding up. As Stacey puts it, "Knowledge isn't just power. It's really fiduciary armor in a health system built on mystery and margin." MENTIONED IN THIS EPISODE LinkedIn Post by Ken Wosczyna SUMS8 with Larry Bauer, MSW, MEd: Apple Podcasts | Spotify | Other Apps SUMS7 with Keith Passwater and JR Clark: Apple Podcasts | Spotify | Other Apps EP501 with Ivana Krajcinovic, PhD: Apple Podcasts | Spotify | Other Apps EP472 with Eric Bricker, MD: Apple Podcasts | Spotify | Other Apps LinkedIn Comment by Craig Herndon LinkedIn Post by Michelle Bernabe, RN EP500 with Stacey Richter: Apple Podcasts | Spotify | Other Apps EP503 with Ryan Wells, Leo Spector, MD, MBA, and Adam Stavisky: Apple Podcasts | Spotify | Other Apps Website: RHV Universe interactive map, by Michelle Bernabe, RN EP480 with Kimberly Carleson: Apple Podcasts | Spotify | Other Apps === LINKS === 🔗 Show Notes with all mentioned links: Show Notes ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter 🫙 Support the podcast with a small donation to the Tip Jar 🎤 Follow us on Apple Podcasts 🎤 Follow us on Spotify 📺 Subscribe to our YouTube channel === CONNECT WITH THE RHV TEAM === ✭ LinkedIn ✭ Threads ✭ Bluesky ✭ X 00:00 Introduction: trying something new with this inbetweenisode. 03:08 The power of the C-suite versus the decision power of workers. 04:00 The power of actuaries to align with values. 04:50 Rate criticals for fixing the nonexistent healthcare market. 06:56 Why you can't fix what you don't understand. 10:44 Why avoiding disruption and problems with access can create disruption and problems with access. 15:56 Looking ahead: topics future episodes will be covering. 19:22 Check out this episode's sponsor.

Direct-to-Employer Specialty Care and Centers of Excellence 3.0, With Ryan Wells, Leo Spector, MD, and Adam Stavisky Why Self-Insured Employers and Specialists Need to Start Talking Directly Instead of Through a Lazy Middle. Episode 503. Self-insured employers and the specialists who actually deliver care sit on opposite ends of a long, crowded road—with carriers, ASOs, TPAs, and consolidated health systems clogging up the middle. Stacey Richter talks with Ryan Wells, founder and CEO of Health Here; Leo Spector, MD, MBA, CEO of OrthoCarolina; and Adam Stavisky, a board member at Omada Health and former SVP of U.S. Benefits at Walmart, about what it actually takes to bring those two ends together through direct contracting and smart collaboration. WHAT YOU'LL LEARN ✅ Why self-insured employers and specialists—the two ends of the healthcare "road"—rarely talk directly, with carriers, ASOs, TPAs, and consolidated health systems clogging the middle ✅ Why "disruption analyses" trap traditional carrier networks into keeping every doctor in-network, even when that means highly variable quality and safety sit side by side ✅ Why patient-reported outcomes are largely missing from most quality data, and how appropriateness—not just surgical skill—has to anchor any real comparison between clinicians ✅ How direct contracting has evolved from Centers of Excellence 1.0 (fly to a brand-name hospital) to 2.0 (scaled but still riding fee-for-service rails) to an emerging 3.0 model built on new infrastructure ✅ Why benefit design and value-based contracts are "peanut butter and jelly"—without aligned incentives like waived cost-sharing, a direct-contracting program gets built and nobody uses it WHY THIS MATTERS  Self-insured employers and the specialists actually delivering care are natural allies on cost and quality, but the rails of the healthcare system were built for fee-for-service, not for direct collaboration between the two. Left alone, that gap defaults to lazy networks, where price and quality are highly variable within the same plan and carriers compete only on discounts, not outcomes. Bridging it, as this conversation lays out, requires new infrastructure, better data on appropriateness and outcomes, and benefit design that actually rewards patients for using it. MENTIONED IN THIS EPISODE EP294 with Steve Schutzer, MD: Apple Podcasts | Spotify | Other Apps Take Two: EP398 with Jacob Asher, MD: Apple Podcasts | Spotify EP501 with Ivana Krajcinovic, PhD: Apple Podcasts | Spotify | Other Apps EP308 with Mark Fendrick, MD: Apple Podcasts | Spotify | Other Apps === LINKS === 🔗 Show Notes with all mentioned links: Show Notes ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter 🫙 Support the podcast with a small donation to the Tip Jar 🎤 Follow us on Apple Podcasts 🎤 Follow us on Spotify 📺 Subscribe to our YouTube channel === CONNECT WITH THE RHV TEAM ===  ✭ LinkedIn ✭ Threads ✭ Bluesky ✭ X   00:00 Introduction. 00:32 Collaboration as the next breakthrough innovation. 02:24 A summary of the upcoming conversation. 05:45 A summary of where we are and what the future looks like. 06:24 A relevant post from Jonathan Baran. 08:12 The conversation with Ryan Wells, Dr. Leo Spector, and Adam Stavisky: collaboration from the standpoint of a specialist. 12:22 The pitfalls of data accuracy and defining what quality means from the POV of a self-insured employer. 15:36 Defining quality and data accuracy from the POV of a physician. 15:57 How do you measure outcomes when assessing quality and looking at the available data? 22:06 Scale and operationalization: How do we do it? 27:00 Shout-out to OrthoForum. 30:30 How things could be better. 33:29 One last complication and how to structure benefit design to align incentives. 35:33 What an "anti-cricket" program looks like. 37:34 How do we operationalize benefit design and aligned incentives? 39:39 What we're seeing today in Centers of Excellence 2.0. 41:47 What Adam wants to make clear in all of this.

Why $3.5 Billion in Fake Catheters and an Even Bigger Skin Substitute Grift End Up Costing Self-Insured Employers Too. Episode 502. Hackers are using stolen medical data to bill CMS for catheters and other durable medical equipment that patients never actually received—and that's just one piece of a fraud scheme that adds up to 4% of the entire CMS budget. Stacey Richter talks with Brian Machut, a value-based actuary at Alliant Health, about how this fraud quietly sabotages ACO shared savings, squeezes independent physicians out of business, and cost-shifts downstream onto self-insured employers and other plan sponsors. WHAT YOU'LL LEARN ✅ How hackers use stolen medical data to bill CMS for catheters and other DME that was never sent to patients, adding up to 4% of the entire CMS budget in a single year ✅ Why ACOs in MSSP and REACH shared-savings programs get hit twice: once when a fraudulently billed patient's costs spike, and again through distorted trend pricing in future years ✅ How lost shared savings squeezes independent PCPs and other practices, often pushing them into consolidation with local health systems ✅ Why skin substitute fraud dwarfs the catheter scheme in dollar terms, and how CMS's SAHS classification decision affects whether that spending counts against an ACO's benchmark ✅ How this fraud ultimately cost-shifts onto self-insured employers, both through the loss of independent-practice competition and through health systems' higher commercial rates ✅ What a value-based actuary actually does all day, and how Brian Machut's team first uncovered this fraud pattern in DME billing data WHY THIS MATTERS Fraud, waste, and abuse in Medicare isn't just a government problem—it ripples straight into the commercial market. When hackers use stolen data to bill CMS for catheters and skin substitutes that patients never received, ACOs in MSSP and REACH programs can lose their shared savings simply because a fraudulently billed patient's costs spiked. That squeezes independent physicians and practices, often pushing them into consolidation with health systems that then have the leverage to raise commercial rates. As Brian Machut lays out, self-insured employers end up paying for this fraud twice: once as taxpayers, and again as plan sponsors absorbing the downstream cost-shift. MENTIONED IN THIS EPISODE Medicare Advantage Advance Notice for 2027: CMS fact sheet === LINKS === 🔗 Show Notes with all mentioned links: Show Notes ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter 🫙 Support the podcast with a small donation to the Tip Jar 🎤 Follow us on Apple Podcasts 🎤 Follow us on Spotify 📺 Subscribe to our YouTube channel === CONNECT WITH THE RHV TEAM ===  ✭ LinkedIn ✭ Threads ✭ Bluesky ✭ X   00:00 One way hackers are using medical data to commit Medicare fraud. 01:49 What today's conversation with Brian Machut entails. 02:16 The downstream impact that this Medicare fraud can have. 03:30 A brief outline of how plan sponsors can be affected by this Medicare fraud. 06:38 What does a value-based actuary do? 08:04 The conversation with Brian Machut: What caused his team to look into DME costs and uncover Medicare fraud? 08:46 How much did this fraud scheme cost organizations in 2023? 09:57 How this data was tracked down and uncovered. 11:13 How fee-for-service ACOs work, and why this Medicare fraud affected the ACOs' shared savings. 12:46 The two codes that were the target of this fraud. 15:13 Across the U.S., how much money in 2023 did this fraud, waste, and abuse cost, and what was done about it? 16:14 The framework that was created to combat this fraud spend. 17:49 Why the CMS decision to pull those expenditures negatively affected some ACOs. 20:17 Where things stand now with this catheter fraud. 21:33 Why this fraud is still able to happen. 22:19 Is this a use case for prior authorizations? 23:49 How this Medicare fraud affects self-insured employers and what they should keep in mind. 25:12 What is the correlation to employee affordability? 27:08 A cost that dwarfs the catheter Medicare fraud. 28:21 A brief summary of skin substitutes. 29:32 What SAHS means, and how CMS uses it to calculate an ACO's shared savings. 31:21 Why CMS chose not to classify skin substitutes as SAHS. 33:26 Why this fraud affects ACOs' prospective trend pricing risk. 36:40 Why these fraud cases make participating in ACO programs less appealing to provider organizations.

How a $135 Infusion Becomes a $13,560 Bill—and the Direct-Contracting Fix for It. Episode 501. Ivana Krajcinovic, PhD, recently retired vice president for healthcare delivery at UNITE HERE HEALTH, a Taft-Hartley fund that purchases healthcare for over 200,000 unionized hospitality workers and their families, joins Stacey Richter to unpack a jaw-dropping price variation: the same infusion that cost $135 at an independent practice ran $13,560 for the identical drug at the hospital down the street—a 10,000% markup off the billed price, or 40,000% off the Medicare rate. Ivana walks through why carrier networks face zero business consequences for such wild price variation, and lays out the roadmap her team used to fight back, built around data, site-of-care steerage, and direct contracting with independent practices. WHAT YOU'LL LEARN ✅ Why two members getting infusions at the same hospital instead of down the street cost their plan $1 million more combined—and why that kind of price variation is itself proof there's no real market ✅ How an independent practice charged $135 for a chemo infusion while a hospital charged $13,560 for the exact same drug and infusion—a 10,000% markup over the billed price, or 40,000% over Medicare ✅ Why carrier networks face no business consequences for letting a plan sponsor overspend by a million dollars, since the network itself doesn't lose business as a result ✅ The roadmap UNITE HERE HEALTH used to fight infusion cost variation, from drilling into claims data to carving out utilization management for site-of-care steerage ✅ Why direct contracts with independent practices play a starring role in bringing infusion costs down, and how that strategy ties fiduciary duty, transparency, and collective bargaining power together WHY THIS MATTERS When a health plan can pay $135 or $13,560 for the identical infusion depending only on which door the patient walks through, that is not a pricing problem—it's proof that no real market exists to rationalize the cost. As Stacey puts it, if you're waiting on a market to constrain these prices for you, that's magical thinking; every dollar wasted on wild price variation is a dollar that could have gone to wages for the hospitality workers UNITE HERE HEALTH exists to protect. MENTIONED IN THIS EPISODE EP373 with Cora Opsahl: Apple Podcasts | Spotify | Other Apps Take Two: EP398 with Jacob Asher, MD: Apple Podcasts | Spotify EP483 (Part 1) with Jonathan Baran: Apple Podcasts | Spotify | Other Apps EP475 with Peter Hayes: Apple Podcasts | Spotify | Other Apps EP370 with Erik Davis and Autumn Yongchu: Apple Podcasts | Spotify | Other Apps EP493 with John Quinn: Apple Podcasts | Spotify | Other Apps EP496 with Mark Newman: Apple Podcasts | Spotify | Other Apps EP482 with Preston Alexander: Apple Podcasts | Spotify | Other Apps EP486 with Stan Schwartz, MD: Apple Podcasts | Spotify | Other Apps EP492 with Sam Flanders, MD, and Shane Cerone: Apple Podcasts | Spotify | Other Apps EP490 with Shane Cerone and Sam Flanders, MD: Apple Podcasts | Spotify | Other Apps EP500 with Stacey: Apple Podcasts | Spotify | Other Apps === LINKS === 🔗 Show Notes with all mentioned links: Show Notes ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter 🫙 Support the podcast with a small donation to the Tip Jar 🎤 Follow us on Apple Podcasts 🎤 Follow us on Spotify 📺 Subscribe to our YouTube channel === CONNECT WITH THE RHV TEAM === ✭ LinkedIn ✭ Threads ✭ Bluesky ✭ X 00:00 $135 vs $13,560: How infusion drug prices play into the "Inches All Around Us" series. 02:02 How infusion drug pricing fits into the "No Market" series. 03:19 A roadmap and more episodes on this topic. 04:36 Introducing this week's expert, Ivana Krajcinovic, PhD. 05:10 A must-read Bloomberg News article on infusion pricing. 05:33 An overview of what to expect from this episode. 06:54 The first tell of the infusion nonmarket. 07:41 The price variations that Ivana has seen in the infusion nonmarket. 11:39 How hospital spend affects wage increases affects patients and employees twice over. 13:43 The second tell of the infusion nonmarket. 16:15 Why networks are apathetic to this pricing discrepancy. 17:55 The factors that play into the nonmarket issue of infusion drug pricing variations. 19:45 Are pricing discrepancies easy to spot? 22:38 Where we have power in a nonmarket situation. 23:22 A recap of the advice in the show so far. 25:51 How you place pricing pressure on an entity. 29:34 How an improved market creates time for better care coordination. 33:23 The fourth part of the roadmap. 36:49 Why serving the community and being fiscally responsible should go hand in hand.

Six Reasons California's Health Plan Market Share Never Changes, Year After Year. Take Two Episode 398. In this Take Two rebroadcast with a new commentary, Stacey Richter revisits a conversation with Jacob Asher, MD, who spent 14 years as a health plan chief medical officer in California—first at Anthem, then Blue Cross, then Cigna, then UnitedHealthcare—about why the relative market share of the state's biggest commercial carriers hasn't budged in over a decade. Dr. Asher and Stacey unpack why California's commercial health plan market functions less like a competitive marketplace and more like a stalemate. Stacey opens the episode with six reasons—drawn from conversations with Dr. Asher, Wendell Potter, and Lauren Vela—for why that stagnation persists nationwide, not just in California. WHAT YOU'LL LEARN ✅ Why California's largest health plans—Kaiser, the Blues, and others—have kept nearly the same relative market share for over 14 years despite an apparently competitive landscape ✅ How carriers use higher self-insured employer rates as leverage to negotiate lower Medicare Advantage rates, since it's the employer's money on the commercial side but the carrier's own money in Medicare Advantage ✅ Why Dr. Asher never once heard a sales rep say an employer chose a health plan because of quality rather than price ✅ How provider discount negotiations create a circular dynamic: the biggest plan gets the best price because of its member volume, which lets it offer the lowest premium, which keeps it the biggest plan ✅ Why Kaiser's closed, capitated network makes its cost and quality performance nearly impossible to benchmark against the "same hospitals, same doctors" non-Kaiser market ✅ Six systemic reasons—employer inertia, EBC incentives, ASO economics, provider network overlap, volume-based discounting, and the absence of quality-based buying—for why the commercial carrier market stays boring WHY THIS MATTERS If plan sponsors assume competition among carriers will naturally hold down costs or lift quality, this episode is a reality check: in California's commercial market, membership rankings have barely moved in 14 years, and the underlying incentives—volume-based discounts, Medicare Advantage trade-offs, and a total absence of quality-based buying—actively work against disruption. Real change, as Stacey puts it, has to be actively pursued rather than assumed; no one is going to hand plan sponsors a better deal. MENTIONED IN THIS EPISODE EP390 with Gloria Sachdev, PharmD, and Chris Skisak, PhD: Apple Podcasts | Spotify | Other Apps === LINKS === 🔗 Show Notes with all mentioned links: Show Notes ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter 🫙 Support the podcast with a small donation to the Tip Jar 🎤 Follow us on Apple Podcasts 🎤 Follow us on Spotify 📺 Subscribe to our YouTube channel === CONNECT WITH THE RHV TEAM === ✭ LinkedIn ✭ Threads ✭ Bluesky ✭ X 00:00 Introduction to the episode. 00:42 The "No Market" series. 01:51 Why is the carrier market boring? 04:26 A breakdown of what follows. 05:48 Six reasons why a marketplace doesn't actually exist. 10:04 Upcoming episodes in the "No Market" series. 10:41 The conversation with Dr. Jacob Asher. 11:01 What is the competitive picture of California's health plans? 11:03 Understanding the California health plan market. 12:28 What the competitive landscape looks like to get market share in California. 12:55 Challenges in market competition. 13:14 What are micro markets and market drivers? 15:14 How brokers and consultants shape the marketplace. 15:49 Why is it difficult to take market share? 16:56 Who was Dr. Asher pitching to and why? 18:56 How is Kaiser's position in the marketplace unique? 19:29 Did employers ever buy plans for quality? 23:23 What does this look like from the payer perspective? 27:42 What improvements have there been to engagement in health plans? 29:47 Have plans gotten better at communicating with employers? 31:19 Why is it hard to compare the Kaiser world to the non-Kaiser world? 31:19 Dr. Asher's final thoughts and reflections.

Ten Years, 500 Episodes, and the Listener Stories Proving Healthcare Can Change. Episode 500. To mark 10 years and 500 episodes, Stacey Richter turns the mic over to the Relentless Health Value Tribe itself, playing voice messages and reading comments from listeners—benefits consultants, physicians, health system executives, and pharmacists—describing the specific decisions the show helped them make. Organized around three themes—moving from theory to practical transformation, the power of collective momentum, and unplugging from healthcare's opacity—the episode is less a highlight reel than a look at how information turns into action across an industry that badly needs it. WHAT YOU'LL LEARN ✅ Why "moving from theory to practical transformation" showed up again and again in listener stories, from EP373 (Cora Opsahl) reframing failures as design problems to a listener's direct-to-primary-care benefit rollout inspired by a later episode ✅ How the show's transcript-first, practical-over-theoretical format has led listeners to directly implement changes such as switching PBM models, offering new benefit designs, and renegotiating vendor contracts ✅ Why "the power of the tribe and collective momentum" became its own theme, with listeners describing the show as uniting different factions of healthcare change rather than dividing them ✅ How "unplugging from the matrix of healthcare opacity" ties together listener stories about generic drug pricing, EHRs functioning as revenue cycle tools, and shopping for care that isn't actually shoppable ✅ Why Stacey frames the tribe's collective decisions—not the show itself—as the actual mechanism for bending the healthcare cost and quality curve WHY THIS MATTERS A podcast doesn't fix healthcare—the decisions its listeners make afterward do. Ten years and 500 episodes in, the throughline across every listener story here is the same: information only matters once it changes a contract, a benefit design, or a conversation with a CEO. That's the actual mechanism by which an industry this opaque and this entrenched slowly bends toward doing right by patients and members. MENTIONED IN THIS EPISODE LinkedIn Post by Stacey Richter EP373 with Cora Opsahl: Apple Podcasts | Spotify | Other Apps EP391 with Scott Conard, MD: Apple Podcasts | Spotify | Other Apps EP462 with Scott Conard, MD: Apple Podcasts | Spotify | Other Apps === LINKS === 🔗 Show Notes with all mentioned links: Show Notes ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter 🫙 Support the podcast with a small donation to the Tip Jar 🎤 Follow us on Apple Podcasts 🎤 Follow us on Spotify 📺 Subscribe to our YouTube channel === CONNECT WITH THE RHV TEAM === ✭ LinkedIn ✭ Threads ✭ Bluesky ✭ X 00:00 Introduction and episode 500 announcement. 00:22 The origin of episode 500. 01:49 The LinkedIn post and its impact. 02:43 Celebrating the Relentless Health Tribe. 07:55 Clip from Michelle Bernabe and how EP373 gave her a framework to model off of and understand that the failures in healthcare weren't personal failures. 10:08 Theme 1: Moving From Theory to Practical Transformation. 10:38 Clip from Ken Wosczyna and the episodes that have led to consistently good decisions in his work. 11:27 The Tipping Point by Malcolm Gladwell. 12:55 Examples of tribe members changing and improving their corner of healthcare after being inspired by RHV episodes. 13:54 Clip from Mark Weber. 14:54 Clip from Alex Sommers, MD, and how EP391 and EP462 changed his work 16:13 Clip from John Lee, MD, and how RHV helped him realize that "gaming the system" can also be used for good. 18:42 Theme 2: The Power of the Tribe and Collective Momentum. 19:28 Clip from Justin Leader. 21:45 Why being a "good villager" is so important to the overall outcome of healthcare. 23:22 Clip from Cristin Dickerson, MD, and how she draws inspiration from various RHV episodes. 25:21 Clip from Andrew Gordon. 27:39 Theme 3: Unplugging From the Matrix of Healthcare Opacity. 28:32 Clip from Andrew Tsang. 29:29 RHV episodes that cover better value out of health benefits. 32:15 Clip from Sergei Polevikov. 34:11 What tech needs to do in order for healthcare to succeed and improve. 35:06 Clip from Bryce Platt, PharmD. 36:01 More RHV episodes on unplugging from pricing opacity.

The MSK "White Space": How Triage-Before-the-Triage Could Cut Unnecessary Orthopedic Spend. Episode 499. Jay Kimmel, MD, an orthopedic surgeon with over 35 years in practice and co-founder of Upswing Health, joins Stacey Richter to unpack the "white space" of musculoskeletal (MSK) care—the moment a member twists an ankle or tweaks a back and has no one to call for guidance before deciding between the ER, urgent care, or just going home. MSK spend runs 20–30% of total plan spend and about $16 PMPM, and an estimated 80% of low-acuity injuries would heal on their own, yet lack of access to quick triage routinely sends members into unnecessary imaging, referrals, and even surgery. WHAT YOU'LL LEARN ✅ Why musculoskeletal (MSK) spend adds up to 20–30% of total plan spend and roughly $16 PMPM—making it one of the costliest categories for self-insured employers ✅ Why an estimated 80% of low-acuity MSK injuries, like a twisted ankle or minor back pain, would heal on their own without any medical intervention ✅ How the disappearance of doctor's lounges and informal curbside consults left patients to self-triage MSK injuries with no clinical guidance, a gap Dr. Kimmel calls the "white space" of MSK care ✅ Why roughly 50% of spine surgeries are considered unnecessary, and how an ER visit for a low-acuity injury can snowball into imaging, a surgical referral, and lost work time ✅ How Upswing Health's model—an athletic trainer within 15 minutes and an orthopedic specialist within 24 hours—gives members "triage before the triage" instead of defaulting to the ER WHY THIS MATTERS MSK injuries are exactly the kind of healthcare spend where more care doesn't mean better outcomes—it just means more cost without a corresponding health dividend. When patients are left to self-triage a twisted ankle or a sore back with no one to call, the default path is often the most expensive one: the ER, unnecessary imaging, and a surgical referral for something that would have healed on its own. Closing that white space with fast, low-friction access to real triage is one of the more straightforward inches available to plan sponsors. MENTIONED IN THIS EPISODE EP472 with Eric Bricker, MD: Apple Podcasts | Spotify | Other Apps Study: Lockton High-Cost Claimant 2025 Report EP464 with Al Lewis: Apple Podcasts | Spotify | Other Apps EP470 with Nikki King, DHA: Apple Podcasts | Spotify | Other Apps EP468 with Matt McQuide: Apple Podcasts | Spotify | Other Apps EP471 with Christine Hale, MD, MBA: Apple Podcasts | Spotify | Other Apps === LINKS === 🔗 Show Notes with all mentioned links: Show Notes ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter 🫙 Support the podcast with a small donation to the Tip Jar 🎤 Follow us on Apple Podcasts 🎤 Follow us on Spotify 📺 Subscribe to our YouTube channel === CONNECT WITH THE RHV TEAM === ✭ LinkedIn ✭ Threads ✭ Bluesky ✭ X 08:01 What is the "white space" in MSK spend? 13:30 How back pain also easily transitions from a low-acuity issue to a high-acuity problem. 15:11 How plan sponsors can detect their white space downstream spend. 18:15 Why where patients start their journey often dictates where they wind up and how costly that medical pathway is. 20:48 Where PCPs fit into this MSK spend issue. 25:39 Why access is key.

Revenue cycle management is a $140 billion industry — already larger than the US auto industry and growing five times faster. RCM vendors use programmatic clearinghouses and increasingly sophisticated tools to maximize every cent of revenue from a claim. That is their job. On the other side sits the self-insured employer, often relying on less sophisticated processes and vendors who may be financially incented to look the other way. It is, as Mark Noel puts it, an arms race, a tug of war, and a zero sum game. In this episode, Stacey Richter speaks with Mark Noel, CEO of ClaimInsight, who has spent roughly 25 years in payment integrity on the health plan, TPA, and self-insured employer sides, about three revelations buried in plan sponsor claims spend. WHAT YOU'LL LEARN ✅ Revelation 1 — The small claim goldmine: 80% of claims volume by count is professional claims — doctor's office visits, lab draws, vaccines — not inpatient surgeries. Overpayments of $2, $5, or $10 on thousands of claims add up to millions in annual waste, but most prepayment integrity resources are focused on the 20% of large claims while the small-dollar volume flies through unchecked ✅ Revelation 2 — The conflict of interest trap: asking a TPA to report on its own errors is like asking the person who filed your tax return to also conduct the penalty audit — and large ASO TPAs edit claims on their fully insured book (where the dollars come out of their own pocket) at materially higher rates than on ASO client claims (where the dollars come out of the employer's pocket) ✅ Revelation 3 — Shared savings perverse incentives: many carrier and TPA contracts allow them to earn shared savings on the backend for fixing errors they did not catch on the frontend — creating a direct financial incentive to let errors through prepayment so they can be "recovered" for a fee later ✅ Why prepayment integrity must happen at the TPA level: to catch small errors before payment, a payment integrity vendor must be connected to the claims processor in real time — retrospective review can show where a plan has been overpaying and inform TPA contract negotiations, but the real savings require integration upstream ✅ The Goldilocks problem with turning on edits: turning on every available policy creates excessive provider friction and can inadvertently flag legitimate claims — including in sensitive areas like cancer treatment — so the right approach is a deliberate conversation with the plan about what edits to turn on, not "maximize everything and react when providers bark" ✅ Why this is a member protection issue, not just a financial one: 41% of Americans have medical debt; when claims are overpaid and members are on co-insurance, the member pays a portion of that error too — payment integrity is both a fiduciary obligation and a direct protection for the people the plan is supposed to serve WHY THIS MATTERS The RCM side will be up to date. Every January, coding rules update and RCM vendors adjust immediately. Payment integrity vendors that are not keeping policies equally current are falling behind in real time. For self-insured employers who are relying on a TPA's in-house payment integrity program, the question worth asking is: are those edits running at the same level of rigor on your ASO claims as on the carrier's fully insured book? The honest answer, in most cases, is no. === LINKS === 🔗  Show Notes with all mentioned links:   https://cc-lnk.com/EP498 ✉️  Enjoy this podcast? Subscribe to the free weekly newsletter: https://relentlesshealthvalue.com/join-the-relentless-tribe ✉️  Visit ClaimInsight https://www.claiminsight.com/ 🫙  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/ 06:03 How millions of dollars can be recovered per year from smaller claims under $500. 07:46 EP486 with Stan Schwartz, MD. 09:10 How to get to payment integrity prepayment. 11:20 How payment processing efficiency is necessary to payment integrity. 13:59 How TPAs fit into the claims payment process and how they can add to payment integrity. 15:59 LinkedIn post from Chris Deacon. 16:50 EP433 with Justin Leader. 17:04 LinkedIn post from Justin Leader. 17:10 How shared savings incentives can be perverse incentives. 23:05 How employers are doing retrospective reviews. 24:29 How employers should be negotiating their TPA contracts. 25:41 EP285 with Dawn Cornelis. 25:43 EP480 with Kimberly Carleson. 27:40 Why it's imperative that payment integrity vendors are up-to-date on all policies. 30:00 EP497 with Zack Kanter. 31:13 What should self-insured employers do to assess their payment integrity?

What FQHCs Can Teach Every Healthcare Leader About True Fiscal Discipline. There are two very different ways to end up with no profit. One is genuine struggle. The other is simply being very good at spending every dollar you are given. In healthcare, we have no functioning market to tell the difference — and the organizations that are crying poor may just be inefficient. Federally qualified health centers, which cannot cost-shift to commercial patients and cannot restrict access, are one of the few places in American healthcare where fiscal discipline is a real constraint rather than a slogan. In this Take Two episode, Stacey Richter revisits a conversation with Gary Campbell, CEO of Johnson Health Center, an FQHC in Lynchburg, Virginia, and president of Impact2Lead — along with a framing segment on Nikki King, CEO of Alliance Health Centers in Indiana, whose approach to meeting patients where they are produced results without a capital budget. WHAT YOU'LL LEARN ✅ Why FQHCs are one of the best case studies for operational efficiency in healthcare: they have a revenue cap, cannot cost-shift inefficiencies to commercial patients, cannot restrict access, and must find a way to serve a challenging patient population with what they have — or that patient population does not get care ✅ Nikki King's approach at Alliance Health Centers: instead of building infrastructure, she put clinics in a courthouse (next to addiction treatment referrals from judges), a daycare center, a homeless shelter, and beside a basketball court — meeting patients where they already are at near-zero real estate cost; compare this to "razor thin margins" and new construction appearing in the same sentence ✅ Why the first instinct in any workflow problem — throwing a body at it — is often the wrong one: as Gary Campbell puts it, you can overstaff yourself into margins so thin they disappear, and "throw two bodies at it" is not a Six Sigma approach to operational efficiency ✅ Why involving clinicians in process redesign is not optional: administrators who make workflow decisions without including the nurses, physicians, and APPs who do the work get non-compliance, workarounds, and resentment — the people closest to the work have to be part of building the standards ✅ How to create fiscal discipline without sacrificing care: Campbell deliberately pulls clinicians off the floor — foregoing short-term revenue — to work on care team reengineering projects, with deliverables, project plans, and accountability, because unimplemented committee recommendations are worse than no meeting at all ✅ The leadership imperative that underlies all of it: vision (if the team can't see where they are going, they cannot be motivated around purpose), cultural alignment (people who are misaligned with the values will undermine the effort), and the discipline to make sure every meeting produces a concrete outcome — not just a record that it occurred WHY THIS MATTERS Financial toxicity is clinical toxicity. A clinical partner that lacks fiscal discipline isn't struggling — it is inefficient. And the plan sponsor, the union, and ultimately the member pays for that inefficiency in premiums, in cost shifts, and in care that should cost less than it does. FQHCs that do this well — like Johnson Health Center and Alliance Health Centers — show what is actually possible when the option to pass the cost along simply does not exist. Those organizations make genuinely useful benchmarks for any plan sponsor evaluating a clinical partner. === LINKS === 🔗  Show Notes with all mentioned links:   https://cc-lnk.com/TakeTwo-EP341 ✉️  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/ 09:03 Why is there no opportunity to cost shift in an FQHC? 09:34 What happens when an FQHC is operating inefficiently? 10:00 "Have you workflowed it out? … You can overstaff yourself in a way that your cost per patient goes way up." 10:23 Why is taking a lean approach not an excuse to cut staff? 11:27 EP490 and EP492 with Shane Cerone and Sam Flanders, MD. 11:35 EP438 with John Lee, MD. 11:38 EP455 with Beau Raymond, MD. 11:40 EP402 with Amy Scanlan, MD. 11:42 EP405 with Eric Gallagher. 12:48 "The nurses are linchpins to everything." 13:44 LinkedIn post from Eve Cunningham, MD, MBA. 15:10 How does standardizing care lead to personalization of care? 16:34 "Our clinical teams see that we care." 16:53 "If you don't have a vision for where you want to be two and three years down the road, you're struggling." 17:09 "I want everybody to understand, What is their why?" 19:45 Lean & Meaningful by Roger E. Herman and Joyce L. Gioia. 24:44 "You have to project plan things out that you want." 25:51 "They don't teach leadership in most medical schools."—Dr. Robert Pearl 26:46 Outlive by Peter Attia, MD. 27:55 "Get to know these clinicians." 29:39 "From a core values perspective, you can make every single decision … on core values." 30:03 "We always start with those values. … They're embedded in everything we do." 30:20 How does an FQHC or private practices that are patient-oriented attract talent? 35:24 EP297 with Jerry Durham. 35:54 "First and foremost, be visible."

Healthcare Transactions Cost 1,000 Times More Than They Should — Here's Why Clearinghouses Are Part of the Problem Sending a claim through a healthcare clearinghouse costs 10 to 15 cents per transaction. Sending a thousand business emails at scale costs about 15 cents total. That is a thousand-to-one cost differential for something that healthcare has actually standardized more rigorously than most other industries — thanks to HIPAA's administrative simplification rules, which mandate X12 standard transaction formats, ICD-10 codes, CPT codes, and HCPCS codes. Logistics and retail would kill for that level of standardization. Healthcare has it and still pays 1,000 times more per transaction. In this episode, Stacey Richter speaks with Zack Kanter, CEO and founder of Stedi — the programmable healthcare clearinghouse — about the $5–$7 billion a year sitting in healthcare transaction processing costs that should be roughly 90% lower, the days of delay baked into batch-based legacy clearinghouse architecture, and why this is fundamentally an incentives problem more than a technology problem. WHAT YOU'LL LEARN ✅ What a clearinghouse actually does: it acts as a hub connecting all providers with all payers so that a practice doesn't have to set up separate authenticated data connections, BAAs, and field mappings with every payer — one connection routes claims, eligibility checks, claim status requests, and prior auth transactions to the right destination ✅ Why healthcare transactions cost 1,000 times more than other industries despite HIPAA standardization: the standards lower the technical complexity, but legacy batch-based systems, lack of competitive pressure, and payer incentives to maintain the float have kept the infrastructure expensive and slow ✅ Why the batch processing train-stop model adds days to every transaction: clearinghouses pick up files every 30 minutes to 12 hours, queue them for transmission, and payers receive and adjudicate on their own batch schedules — miss one train by a minute and you wait 24 hours for the next one, adding receivables days for providers and delays in clinical decisions for patients ✅ Why this is not really a technology problem: the technology to make these transactions instant and cheap already exists — what is missing is incentive to use it, because payers benefit from the float on billions of dollars held for additional days, and clearinghouses owned by payers have limited motivation to disintermediate themselves ✅ How opacity compounds the cost: when a claim goes wrong across the clearinghouse/EHR boundary, neither side can easily tell where the problem is sitting — providers call to find out whether their prior auth is approved while the request is held up somewhere in a batch queue between train stops ✅ What plan sponsors should understand about the arms race: RCM vendors on the provider side are already using programmatic clearinghouses to maximize revenue in real time; plan sponsors who do not have equally programmatic prepayment integrity programs connected to the same data streams are bringing an increasingly rusty knife to a gunfight WHY THIS MATTERS Every extra day in the transaction pipeline is a day a provider waits to get paid, a day a patient doesn't know whether their procedure is approved, and a day the patient may have moved or forgotten the context — reducing collection rates and potentially delaying care. Fixing the pipes does not require eliminating clinical review. It means replacing batch jobs with real-time processing for the tens of thousands of technical validation rules that should be instantaneous. The technology is not the obstacle. The incentives are. === LINKS === 🔗  Show Notes with all mentioned links:   https://cc-lnk.com/EP497 🔗  Visit Stedi: https://www.stedi.com   ✉️  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/ 09:47 What things are being paid for that we might not be aware we're paying for in healthcare? 12:09 Why HIPAA actually makes healthcare more standardized than other industries. 15:35 How healthcare is ahead in some ways and behind in others. 18:03 Where do the 4 to 5 days come from in healthcare transaction processing? 20:39 Why these transaction delays affect care delay. 23:14 EP482 with Preston Alexander. 23:18 EP472 with Eric Bricker, MD. 27:10 How should the process work from the time a provider clicks "validate"? 30:19 Why is the clearinghouse the right place to solve all these issues? 31:41 Why are we where we are in terms of these issues? 35:28 Why people should be looking at their clearinghouse costs. 36:59 What to know about Stedi.

Plan Sponsors Pay $1.20 to Buy $1 of Healthcare — and Providers Collect 80 Cents of That A self-insured employer pays $1.20–$1.30 to access a dollar of negotiated healthcare. Providers budget their business around collecting 70 to 80 cents of what they are contractually owed — because denial rates, unpaid patient balances, and collection timelines of 2 to 9 months are the operating reality. The gap — roughly $1.5 trillion a year by Mark Newman's accounting — is not one boogeyman. It is just the cost of the friction. In this episode, Stacey Richter speaks with Mark Newman, CEO and founder of Nomi Health, about why the life of a claim produces administrative waste accounting for 28–30% of total US healthcare spending — and the two structural reasons behind it. WHAT YOU'LL LEARN ✅ Revelation 1 — Data isn't data: as a claim moves through the system, each stakeholder — provider clinical team, provider billing, TPA operations, TPA payments, TPA treasury, plan sponsor HR, plan sponsor finance — works from a different data set with different fields, accounting periods, and definitions of what the transaction was ✅ How the fragmentation creates a barrier to negotiation: a plan sponsor says "we spent $10 million with you last year"; the hospital says "we received $5 million" — and both could be correct, once you account for member balances never collected, accounting method differences, and what the plan funded vs. what it accrued ✅ Revelation 2 — A dollar isn't a dollar: the employer pays $1.20–$1.30 to access a dollar of care (admin fees, consulting fees, PEPMs, transactional fees, broker costs, stop-loss); the provider collects 70–80 cents of what they are owed; and 12–15% of any health system or practice budget now goes to RCM staff — the cost of just figuring out how to get paid ✅ Why payment delays are not accidental: payers make 10–20% of profit margin on float — on billions held while providers wait 2 to 9 months to get paid — and providers, unable to run their business on the hope of a dollar, budget for 80 cents and absorb the rest as RCM overhead ✅ Why finance and HR within the same employer will have fundamentally different numbers: HR tracks cash claims outflows against a budget burn-down; finance accrues a flat monthly amount and hopes not to overrun Q4; neither may have line-item visibility into what the TPA is actually doing with the funds ✅ Why the gap is an opportunity: self-insured employers know how to negotiate, buy things, and manage cost of goods sold — the infrastructure to do that directly in healthcare is finally starting to exist WHY THIS MATTERS School districts cannot hire teachers because per-family healthcare costs have hit $40,000 a year and rising. Every dollar in friction is a dollar not available for wages, not available for better care, not reducing premiums — Figure out the comp model, as Charlie Munger said, and you know the outcome. The comp model for large payers rewards earnings per share and swagger — not lower costs. The only way forward is to bypass the 27 layers, and self-insured employers are the parties with purchasing leverage to do it. === LINKS === 🔗  Show Notes with all mentioned links:   https://cc-lnk.com/EP496 🔗  Visit our sponsor Nomi Health:   https://www.nomihealth.com/ ✉️  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/ 06:48 What is actionable to know about the life of a claim? 08:14 How data can change as it moves through the claims process. 11:45 Why a dollar isn't a dollar in healthcare. 18:50 Why employers are actually paying more than a dollar to access a dollar of healthcare (the medical loss ratio). 21:54 Why cutting out the "friction" is actually better for employees and members. 22:48  EP482 with Preston Alexander. 22:50 EP472 with Eric Bricker, MD. 23:36  EP490 and EP492 with Sam Flanders, MD, and Shane Cerone. 23:53 Infographic by Andrew Tsang showing 27 streams of income. 26:53 How do we fix these issues? 28:05 LinkedIn comment from Sandra Raup. 28:59 How Nomi Health is experimenting with a no co-payment, no deductible model. 31:29 INBW42 with Stacey on moral hazard. 32:26 EP486 with Stan Schwartz, MD. 32:31  EP485 with Cristin Dickerson, MD. 32:56 The Innovator's Dilemma by Clayton M. Christensen. 34:55 How does Nomi Health work with and help employers?

This is Part 2 of Stacey's year-end synthesis of the most actionable themes from 2025. Last week covered Themes 1–3. This week covers 4 and 5 — which are, if you squint, really two sides of the same problem: plan sponsors can't buy value when they can't see what they're buying, and they can't see what they're buying because the vendors who benefit from opacity are the ones controlling the data. WHAT YOU'LL LEARN ✅ Theme 4 — Lack of transparency and data access allows wild overspending and undermines fiduciary duty: status quo TPAs, PBMs, and brokers routinely withhold essential claims data, creating "data hostage" situations that expose self-insured employers to both financial and legal risk — Elizabeth Mitchell from PBGH puts it directly: jumbo employers are spending over $350 billion a year on healthcare services and people's health is not improving, yet carriers are "remarkably resistant" to even sharing data their clients are legally entitled to under the CAA ✅ How the transparency gap plays out for members: patients with so-called good insurance now fear unexpected bills enough to delay or abandon necessary care — suspicious moles, chest pain, asthma inhalers — worsening long-term health outcomes in ways that compound costs downstream ✅ The hospital price and ownership transparency angle: up to 80% of hospital bills may contain errors; carrier spread pricing adds an estimated 30% on top of what hospitals actually charge; and without itemized bill access, plan sponsors have no way to know which part of their spend is going to clinicians vs. getting absorbed by intermediaries or health system administrative expansion ✅ Theme 5 — Shifting purchasing from discounts and volume to value: the healthcare cost flywheel is driven by buying discounts off inflated list prices — and as Mark Cuban describes it, the fix is direct contracting where providers get cash upfront, zero member deductible, zero collection risk, and zero prior auth denial risk; in return, the plan gets pricing at or near cash/Medicare rates ✅ What Sarah Emond explains about rebates vs. value: the rebate model rewards market dominance and discount size, not clinical outcomes — if payers paid value-based prices, prior auth requirements and cost sharing could largely disappear, and physicians could prescribe the drug that's actually best for the patient rather than the one that generated the best rebate negotiation ✅ Why self-insured employers are the demand curve — or there isn't one: 160 million Americans get coverage through self-insured employers; if those employers don't act as an elastic demand curve — meaning they stop buying from high-cost, low-value providers — there is no market incentive for anyone on the supply side to lower prices or improve quality; the market that everyone assumes is constraining healthcare costs does not exist without a demand curve WHY THIS MATTERS The one-star Spotify review Stacey received this year said this was an echo chamber for out-of-touch CEOs. Stacey's response: when employers shift purchasing to value and pay upfront at fair prices, clinicians get paid more, faster, with less administrative overhead. The interests are more aligned than they appear. The opacity is what keeps them from finding each other. Theme 4 and Theme 5 are not abstract policy goals — they are the infrastructure on which better outcomes, lower member costs, and sustainable clinical practice all depend. === LINKS === 🔗  Show Notes with all mentioned links:   https://cc-lnk.com/INBW45 ✉️  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/ 00:00 Introduction 03:30 Theme 4: lack of transparency and data access. 04:46 Clip of Elizabeth Mitchell from EP436. 07:07 Is there a tipping point finally coming regarding transparency? 08:58 Why and how siloed data is also part of this transparency issue. 11:37 How opaque pricing leads to more opaque pricing. 13:21 The need for transparency around ownership and what that looks like in healthcare. 14:06 Theme 5: the need to shift purchasing from discounts/volume to value. 14:52 Clip of Mark Cuban from EP488. 16:35 Clip of Sarah Emond from EP494. 17:02 How pricing transparency can eliminate the need for rebates and prior authorizations. 18:30 Why healthcare needs a demand curve. 22:09 Shows covered in 2025 that touched on other timely ideas.

As Stacey Richter reflects on a year of Relentless Health Value episodes, three themes kept surfacing in nearly every conversation: the foundational role of trusted relationships, the cost of underinvesting in primary care, and the dominance of perverse financial incentives and profiteering. This is Part 1 of a two-part year-end Inbetweenisode hosted by Stacey Richter, drawing on episodes featuring Dr. Kenny Cole, Ann Lewandowski, Jonathan Baran, Nikki King, Yashaswini Singh, Dr. Ben Schwartz, Dr. Mick Connors, Mark Cuban, and more. WHAT YOU'LL LEARN ✅ Why trust is the foundational element required for both clinical and financial outcomes — and how a pervasive lack of trust is showing up across the system, from the patient-clinician relationship to the employer-TPA-PBM relationship ✅ How "trust and verify" or defensive plan sponsorship protects self-insured employers whose partners may not be as transparent as assumed — and why simplicity in benefit design is directly linked to trust ✅ Why ER spend reaching approximately 6% of average total plan costs is evidence of broken primary care — and how investing in unconflicted, independent advanced primary care reverses the cost flywheel ✅ How hospital systems can undermine primary care by acquiring practices and using them as referral funnels for expensive downstream services, gutting their ability to deliver real primary care ✅ Where the line is between fair profit and profiteering — and how private equity, carrier float, intercompany eliminations, upcoding, and consolidated market power all function to extract value from the system rather than create it ✅ Why Kevin Lyons' observation that "profit defends profit" matters: healthcare entities use growing revenues to fund lobbying and political contributions to the very legislators negotiating contracts with them WHY THIS MATTERS Healthcare costs keep rising in part because the incentives at nearly every layer of the system reward spending more, not less. Stacey's 2025 recap makes the case that trust, primary care investment, and confronting financial misalignment aren't separate problems — they're the same problem showing up in different settings. As she put it, 2025 surfaced some of the most egregious behavior she's seen in 25-plus years, which is exactly why understanding these dynamics — and demanding accountability — matters more than ever. === LINKS === 🔗  Show Notes with all mentioned links:   https://cc-lnk.com/INBW44 ✉️  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/ 02:06 Theme 1: the critical need for trusted relationships and simplicity. 02:28 The two categories of trust that are needed. 02:43 Clip of Kenny Cole, MD, from EP473. 03:43 Clip of Ann Lewandowski from EP476. 06:07 Why simplicity and trust have to go together. 08:30 Theme 2: primary care as an investment, not a cost. 08:41 Clip of Jonathan Baran from EP483 (Part 1). 09:01 Clip of Nikki King, DHA, from EP470. 09:34 How broken primary care affects self-insured employers. 10:12 Why there are perverse financial incentives to gut primary care. 15:19 Theme 3: the dominance of perverse financial incentives and profiteering. 15:46 Clip of Benjamin Schwartz, MD, MBA, from EP481. 16:18 The actual definition of margin. 16:55 Clip of Mick Connors, MD, from EP495. 18:25 Clip of Yashaswini Singh, PhD, from EP474.

From $9 Million in the Hole to $112 Million in the Black: How Marilyn Bartlett Turned Around Montana's State Employee Health Plan. What happens when a self-funded health plan is headed for bankruptcy and a CPA with a spreadsheet and her eye on the target gets to work? In roughly three years, Marilyn Bartlett, CPA, CMA, CFM, CGMA took the State of Montana's employee health plan from a $9 million deficit to a $112 million surplus — while enhancing member benefits and holding premiums flat since 2015. In this encore episode, Stacey Richter revisits her conversation with Marilyn Bartlett, who served as plan administrator for Montana's state employee health plan starting in 2015 and is now the driving force behind the NASHP Hospital Cost Tool, which version five launches in January 2026 as a resource for plan sponsors negotiating directly with hospitals. WHAT YOU'LL LEARN ✅ How Marilyn followed the dollar on day one — identifying out-of-control medical trend, non-transparent PBM rebates, and redundant point solutions — and turned those findings into immediate action, including terminating four of five wellness vendors and saving $5.5 million right off the top ✅ Why Montana hospitals represented 43% of total plan spend, how Marilyn used Medicare cost reports, 990s, and audited financial statements to build cost-plus reference-based pricing contracts, and how signing two cooperative hospitals first created the momentum to bring the rest along ✅ How pharmacy spend, which was approximately 20% of total plan costs, was brought down 23% by switching to a transparent pass-through PBM and removing CVS from the network when they would not match required pricing ✅ Why assembling the right internal and external team — including the governor's office, budget director, union leadership, a retired primary care physician, a pharmacist consultant, and a communications specialist — was the single most important factor in surviving the lobbying and political pressure that came from every direction ✅ What happened after Marilyn left in 2018: successors reversed the reference-based pricing strategy and added point solutions back, adding costs — a cautionary tale about the institutional will required to sustain these gains ✅ How the NASHP Hospital Cost Tool, now in its fifth version, can serve as a starting point for any plan sponsor approaching hospital contract negotiations WHY THIS MATTERS This is what is actually possible. Marilyn Bartlett didn't find a magic solution — she followed the dollar, eliminated waste, built a coalition with enough power to negotiate, and refused to get sidetracked by what Stacey calls transformational theater. The fact that hundreds of millions of dollars were sloshing out of a state health plan and into vendor pockets is not unique to Montana. It is the norm. What is rare is a plan administrator with the fiscal discipline and political backing to stop it. === LINKS === 🔗  Show Notes with all mentioned links:   https://cc-lnk.com/EncoreEP450 ✉️  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/ 07:09 What gave Marilyn the confidence to fix Montana's state health plan? 08:35 Why Marilyn knew she would have enough power to make the changes needed in Montana's state health plan. 09:35 What Marilyn achieved in her time as the administrator of the Montana State Employee Health Plan. 11:03 What were the "quick wins" Marilyn was able to achieve when she first took over as administrator? 17:55 EP453 with Claire Brockbank, which covers RFP in detail. 18:12 How Marilyn structured her plan for the Montana State Employee Health Plan. 21:42 What's the key to setting yourself up for success when doing what Marilyn was able to achieve? 25:23 Why putting together your own team is so important. 28:20 EP397 with Paul Homes. 28:24 EP418 with Mark Cuban and Ferrin Williams, PharmD, MBA. 29:28 What happened when Marilyn left the Montana State Employee Health Plan? 31:28 Have the costs of the plan gone up since Marilyn's time working on it?

The value equation in healthcare is outcomes divided by cost — but here's the revelation Stacey Richter had in this conversation: we've been measuring it exactly backwards. In American healthcare, costs are tracked at the macro aggregate level while outcomes are measured at the narrow individual service level. Flip that — measure costs at the unit level and outcomes at the whole person and whole community level — and a very different picture of the system emerges. In this episode, Stacey Richter speaks with Dr. Mick Connors, MD, an emergency room pediatrician and healthcare entrepreneur who has worked across for-profit institutions, hospital administration, and pediatric telemedicine, about why the margin-over-mission drift is making everyone miserable — clinicians, patients, and plan sponsors alike. WHAT YOU'LL LEARN ✅ Why the absence of unit-level cost accounting is a foundational flaw in healthcare: when no one knows what it costs to deliver any individual service, and purchasers are buying discounts rather than prices, the only financial lever left is raising aggregate revenue ✅ How "no margin, no mission" is routinely misapplied — conflating revenue with margin — and why Dr. Connors illustrates this with a real case where spinal surgery rods cost more than the reimbursement, producing negative margin despite high downstream revenue ✅ How an investor mindset in pediatric primary care — whether driven by private equity or fee-for-service incentives — produces the same result: cherry-picking healthy patients, routing sick and complex kids to the ER, and gaming HEDIS metrics rather than improving total cost of care for the attributed population ✅ Why Dr. Connors argues outcomes should be measured at the population level, not the process level — and what it would actually look like to say: here are 1,500 attributed patients, here is what they spent this year, now reduce that spend by improving outcomes for the 20% driving costs ✅ Why dyad leadership — a clinical co-leader paired with a finance or business co-leader, both with actual decision-making authority — is necessary to keep mission from getting steamrolled by margin, and what happens to trust and care quality when that balance is lost ✅ How CEO salaries have grown 100% over 10 years while physician compensation has declined — and why Dr. Connors argues the pendulum needs to swing back before the system loses what remains of patient and clinician trust WHY THIS MATTERS When the incentive structure rewards volume, revenue, and efficiency over outcomes, clinicians who do the non-billable work — the follow-up call, the 20-minute visit with a complex family, the relationship that keeps a kid with asthma out of the ICU — are effectively penalized for practicing good medicine. Stacey's framing here cuts to the core: we are incentivizing A and expecting B. Until cost accounting happens at the unit level and outcomes are measured at the whole-patient level, the value equation that everyone claims to be pursuing remains structurally impossible to actually achieve. === LINKS === 🔗  Show Notes with all mentioned links:   https://cc-lnk.com/EP495 🔗  Visit this week's sponsor Payerset:   https://payerset.com ✉️  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= 🎤  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 How Dr. Mick Connors defines margin. 08:18 EP294 with Steve Schutzer, MD. 08:54 Why nobody wants to do cost accounting in healthcare. 09:20 EP490 with Shane Cerone and Sam Flanders, MD. 11:05 Infographic by Andrew Tsang showing streams of income. 12:27 What is the value equation? 15:55 EP404 with Suhas Gondi, MD, MBA. 15:59 EP466 with Vivian Ho, PhD. 16:01 EP482 with Preston Alexander. 16:25 EP474 with Yashaswini Singh, PhD. 17:44 How business decisions can really undermine the value proposition. 18:58 Classic article on incentivizing. 23:07 EP295 with Rebecca Etz, PhD. 24:21 Why it comes down to the 80/20 rule. 26:31 EP445 with Tom X. Lee, MD. 26:35 EP460 with Rushika Fernandopulle, MD. 26:40 Why mission return requires dyad leadership. 27:13 What does dyad leadership mean? 27:33 EP492 with Sam Flanders, MD, and Shane Cerone.  

If a drug keeps a patient out of the hospital — and hospital spend is 50% of most plan sponsors' total costs — why do we design benefits that make patients less able to afford that drug? That's the martini-fueled question Stacey Richter started with, and it threads through this entire conversation about why pharmaceutical pricing in America is so persistently broken. In this episode, Stacey Richter speaks with Sarah Emond, CEO of ICER (the Institute for Clinical and Economic Review), the only financially independent nonprofit in the US conducting rigorous health technology assessment, about the six core tensions that prevent drug prices from reflecting drug value — and what it would actually take to fix that. WHAT YOU'LL LEARN ✅ Why list prices are, in Sarah Emond's words, a lie — and how the rebate system creates a dynamic where formulary placement is driven by discount size rather than clinical value, leaving patients on the wrong drug for the wrong reason ✅ How coinsurance based on list price rather than net price means a patient can face unaffordable cost sharing even after their payer negotiated a steep discount — and why that directly undermines adherence to high-value medications ✅ Why GLP-1s like Wegovy and Zepbound are wildly cost effective by ICER's analysis — meaning society is paying a reasonable amount per unit of health gain over a patient lifetime — but still threaten to bankrupt plans due to the sheer size of the eligible population ✅ How 70 to 75% of ICER drug reviews find that pharma has overreached on price, and why a decade of tolerating that overreach has left purchasers with sticker shock that causes them to block access even to fairly priced cell and gene therapies ✅ Why value-based pricing would eliminate the logic for most prior authorization and most cost sharing — and what Dupixent's launch for atopic dermatitis and Eisai's Leqembi for Alzheimer's Disease show about what it looks like when manufacturers actually price within the ICER range ✅ Why siloed pharmacy and medical data make it nearly impossible for self-insured employers to see whether a drug reduced hospitalizations — and how that analytic gap makes draconian cost containment look rational even when it isn't WHY THIS MATTERS The mother of all tensions here, as Stacey frames it, is that without value-based pricing there is almost no mechanism connecting net drug price to patient affordability and access. ICER's framework — measuring how much better patients feel and how much longer they live, then comparing that to what the drug costs including net downstream savings — exists to fill that gap. But without more unconflicted entities doing this work, and without pharma and PBMs willing to use it, plan sponsors are left managing drug spend with blunt instruments that shift costs onto the sickest patients. === LINKS === 🔗  Show Notes with all mentioned links:   https://cc-lnk.com/EP494 ✉️  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/ 08:18 Why list prices are a lie. 10:59 How does the rebate model sometimes get in the way of paying for value? 12:50 Bonus clip with Sarah Emond. 13:14 EP491 with Elizabeth Mitchell. 13:20 EP490 and EP492 with Shane Cerone and Sam Flanders, MD. 14:37 The tension that is created between affordability and adherence. 15:03 When cost sharing makes sense in pharmaceutical drug pricing. 17:26 INBW42 with Stacey on moral hazard. 18:53 How GLP-1s are "wildly cost effective." 21:32 Why the sticker shock on cost-effective drugs is a failure in the system for paying for value. 22:38 ICER's report on GLP-1s. 26:59 EP385 with Dan Mendelson. 28:57 How employers and payers can have a value assessment approach and a health insurance system that allows access to cost-effective drugs. 29:48 How cost-effective prices are calculated. 31:55 One of the core value underpinnings for value assessment of drugs. 34:54 Why manufacturers and pharmacy benefit managers should work together more by referencing something like an ICER report. 36:55 EP426 with Nina Lathia, RPh, MSc, PhD. 38:21 "We can make different choices."

Pharma raises list prices to maximize rebates. Higher list prices blow up patient coinsurance. Pharma responds with copay cards. PBMs fight back with maximizers and accumulators. Prior auths ramp up. Premiums rise. Deductibles climb. And at no point in this cycle does anyone stop to ask: is this drug actually worth its price? That is the pharmaceutical pricing arms race Stacey Richter lays out in this bonus episode — and it is the entire reason ICER exists. This short companion episode to EP494 features Sarah Emond, CEO of ICER (the Institute for Clinical and Economic Review), the only financially independent nonprofit in the US conducting rigorous, public, multistakeholder value assessment of prescription drugs. If you have not heard of ICER before, start here. WHAT YOU'LL LEARN ✅ What ICER is and how it works: comparative clinical effectiveness analysis combined with cost-effectiveness modeling to determine a fair, evidence-based price for new therapies — conducted publicly, with all stakeholders invited, free from financial conflicts of interest ✅ How the pharmaceutical arms race was built: list prices inflated to generate rebates, coinsurance tied to list rather than net price, copay cards disrupting PBM formulary strategy, maximizers and accumulators responding, and the whole system spiraling without anyone anchoring price to value ✅ Why Sarah Emond believes the arms race can be deescalated — because higher prices, more access restrictions, and more cost sharing are the result of choices the system has made, and different choices are possible ✅ Who actually pays for all of it: only three ultimate purchasers exist in US healthcare — taxpayers, self-insured employers, and patients themselves — and every dollar extracted by any intermediary comes from one of those three WHY THIS MATTERS The pharmaceutical pricing debate generates a lot of heat and very little light because most of the actors in the system have a financial stake in the status quo. ICER's value — as Sarah Emond describes it — is not just the math but the process: a public, multistakeholder forum where the evidence gets scrutinized and a fair price gets defined, independent of who stands to gain. Without that anchor, plan sponsors and patients are left absorbing costs that have nothing to do with how good the drug actually is. === LINKS === 🔗  Show Notes with all mentioned links:   https://cc-lnk.com/EP494-BonusClip ✉️  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/ 06:51 EP293 ("Game Theory Gone Wild") with Dea Belazi, PharmD, MPH. 02:38 What is ICER? 02:54 What does the Institute for Clinical and Economic Review do? 05:14 The importance of still showing up, even when others don't understand or disagree. 09:12 Why it's important to think about population health and how our choices impact affordability for everyone.

It will take a village to transform healthcare. Stacey Richter says this so often it is taped to her wall on a Post-It. This Thanksgiving Inbetweenisode is her chance to say thank you to the people actually building that village — and to make the case, with a detour through a drunk blacksmith charity auction, that the demand curve is the most underappreciated concept in healthcare reform. This is a solo episode hosted by Stacey Richter, with short audio clips from community members including Cora Opsahl of 32BJ Health Fund, Shane Cerone of Kada Health, Chris Skisak of the Houston Business Coalition on Health, Rob Marty, Chris Deacon of VerSan Consulting, and Vivian Ho, PhD. WHAT YOU'LL LEARN ✅ Why Stacey calls 2025 the lowest point for basic civility and integrity she has seen in 25-plus years in healthcare — and why community, not individual heroics, is the antidote ✅ What the narcissism of small differences costs the healthcare reform movement, and why Winston Churchill's line about fighting with allies versus without them applies directly to this tribe ✅ Why effective collaboration will be the next breakthrough innovation — and why members of the RHV tribe do not need Stacey as an intermediary to connect with each other ✅ Why there is no healthcare market without a demand curve — and who actually has to be that demand curve for 160 million Americans covered by employer-sponsored insurance ✅ Why independent clinicians, indie practices, and others who offer real alternatives matter to market function: competition is a prerequisite for a market to rationalize prices and quality WHY THIS MATTERS The secret to a fulfilled life, Stacey quotes, is relationships, purpose, and service. This community exists at the intersection of all three. The demand curve argument is not abstract: without purchasers — self-insured employers and unions — actively using their buying power to reward value over volume, there is no market mechanism to rationalize hospital prices, drug prices, or anything else. The tribe is not just a podcast audience. It is the demand curve. === LINKS === 🔗  Show Notes with all mentioned links:   https://cc-lnk.com/INBW43 ✉️  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/ 01:25 First thank you: to those who do not succumb to healthcare narcissism. 01:36 INBW39 with Stacey. 02:51 INBW37 with Stacey. 03:00 EP399 and EP400 with Stacey. 05:40 Second thank you: to those willing to pay it forward. 05:53 EP489 with Dan Greenleaf. 08:12 EP452 with Cora Opsahl. 08:38 Third thank you: to those who aid the demand curve in healthcare. 09:14 EP490 with Shane Cerone and Sam Flanders, MD. 09:16 EP491 with Elizabeth Mitchell. 09:17 EP492 with Sam Flanders, MD, and Shane Cerone. 09:49 Why healthcare needs a demand curve. 13:34 Fourth thank you: to those who have contributed financial support to the Relentless Health Value podcast. 15:47 The final thank you: to the listeners.

Direct contracts between employers and clinical organizations perform way better than what most third parties negotiate — and the Employers Centers of Excellence Network (ECEN), built by the Purchaser Business Group on Health (PBGH), proved exactly that. This Take Two episode revisits that work in light of a key finding from a recent PBGH data demonstration project: plan sponsors can now use publicly available transparency and claims data to build their own high-value networks, all by themselves. In this episode, Stacey Richter speaks with Olivia Ross, who led the ECEN program at PBGH, about how the network selected Centers of Excellence down to the individual surgeon level, structured prospective bundles to create price predictability, and avoided unnecessary surgeries — which turned out to be the single largest source of cost savings. WHAT YOU'LL LEARN ✅ Why over 50% of spine surgery patients referred to ECEN Centers of Excellence were counseled against surgery after multidisciplinary review — and why that number reflects the scale of inappropriate surgical care happening in local markets ✅ How ECEN used prospective bundled payments covering facility fees, all physician fees, and initial post-discharge outpatient care at a single negotiated price — and why competitive pricing alone was not enough to drive employer adoption ✅ Why the ECEN center selection process went down to the individual surgeon level, measuring procedure-specific outcomes like surgical site infection rates and return-to-OR rates — and why that granularity matters when hospital-level quality scores mask wide variation between surgeons ✅ How direct contracting creates market pressure even in consolidated geographies where hospital monopolies have eliminated local competition — giving self-insured employers a way to route members to higher-value care elsewhere ✅ Why self-insured employers pay on average approximately 30% more in their claims wire than what the actual provider received — and what transparent, direct contracting without confiscatory middlemen changes about that math ✅ How continuous quality improvement within ECEN allowed best practices — like a nurse follow-up call 24 hours post-discharge — to spread beyond ECEN patients to the broader patient population at participating centers WHY THIS MATTERS The ECEN model got dismantled when the TPA administering it was acquired by a larger firm — a cautionary tale about institutional will. But the underlying lesson is more durable than any one program: employers who are willing to act as the demand curve, and who pair that with genuinely rigorous quality assessment, can create competition where none exists, eliminate unnecessary care, and drive costs down without shifting them onto patients. With current price transparency data now making it possible for any plan sponsor to do this themselves, the old is new again. === LINKS === 🔗  Show Notes with all mentioned links:   https://cc-lnk.com/Take2-EP240 ✉️  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/ 07:40 Prospective bundles and the cost of care. 08:22 How the largest cost savings come from the improvements in quality. 09:51 What Olivia looks for in choosing centers of excellence. 10:36 Creating market pressure and avoiding consolidation. 11:17 Creating positive disruption in the healthcare system. 12:17 How Olivia chooses the centers and providers she works with in the Purchaser Business Group on Health. 13:12 The quality metrics Purchaser Business Group on Health looks at when assessing providers and centers. 14:04 What a team assessment is, and why it's important. 15:07 How local PCPs have to factor into this health care model. 17:57 How Purchaser Business Group on Health intervenes in the patient journey to ensure that the patient and the employer are getting the best quality care for the best price. 19:39 Olivia's suggestions on how to have an intervening conversation with a patient who has already been told he or she needs surgery. 20:18 EP468 with Matt McQuide. 20:20 EP471 with Christine Hale, MD, MBA. 20:22 EP472 with Eric Bricker, MD. 25:27 "Even at a more competitive price point, there's still an upside to them getting this new business." 25:52 How choosing specific physicians is part of the COE designation process. 27:35 How COEs and their physicians are also involved in continuous quality improvement. 30:56 Employers Centers of Excellence Network collaboration with The Leapfrog Group. 32:24 How the Employers Centers of Excellence Network program is open to any employer, no matter the size. 32:54 What it takes to join the Employers Centers of Excellence Network.  

Employer C-suites have been largely absent from healthcare purchasing decisions for decades — dipping in once a year at renewal, then handing the whole thing back to HR. That era is ending. Boards are noticing missed earnings numbers. CEOs are confronted with 10 to 12% trend forecasts on top of already strained budgets. And cost-shifting to employees — the go-to move for 20 years — has finally hit the wall. In this episode, Stacey Richter speaks with John Quinn, CEO of Wellnecity, a health plan management firm that helps self-insured employers manage healthcare as the spend category it actually is, about what is driving this C-suite awakening and what employers who are ready to act should do next. WHAT YOU'LL LEARN ✅ Why employer C-suites are finally paying attention: boards are now regularly discussing healthcare trend as a direct earnings variable — one large client faced a $70 million swing when medical and pharmacy trend both came in above 10% ✅ Why cost-shifting to employees is no longer a viable strategy — high deductibles have already pushed household healthcare costs to the breaking point, and further shifting creates a workforce productivity and retention problem that offsets any premium savings ✅ Why healthcare benefit management has to move at the speed of business: waiting for annual renewal to make decisions means acting on data that is already a year old, while cancer diagnoses, new prescriptions, and high-cost claimant trajectories emerge daily ✅ How vendor performance guarantees are routinely gamed — and why employers who let vendors calculate their own savings are discovering those savings often aren't real once the employer runs the math independently ✅ Why 80% of plan members need wide-access commodity care while the 20% driving costs need specialized care pods with managed, direct-contracted pricing — and how blurring that distinction is where most of the waste lives ✅ Three concrete steps for employers ready to act: integrate a finance function into health benefits, hold vendors to genuinely auditable performance guarantees, and buy service bundles you can evaluate independently rather than black-box solutions WHY THIS MATTERS Self-insured employers cover roughly 160 million Americans and are the demand curve for any functioning healthcare market. When they don't act like purchasers — when they accept discounts off inflated prices, let vendors audit themselves, and treat benefits as a once-a-year administrative task — prices rise unchecked. John Quinn's argument is that fixing this doesn't require taking away necessary care. It requires finding people when they need care and routing them to higher quality, more efficiently priced options. The waste in the system is large enough that winning is possible without cutting benefits. === LINKS === 🔗  Show Notes with all mentioned links:   https://cc-lnk.com/EP493 🔗  Visit our Sponsor Wellnicity https://wellnecity.com/:   ✉️  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/ 07:06 Why CEOs are looking more closely at healthcare spend. 08:06 EP397 with Paul Holmes. 08:21 How savings and health benefits are directly connected. 10:45 EP436 with Elizabeth Mitchell. 11:46 What missed earnings look like in relation to healthcare. 14:27 How costs have been shifting to employees for years, and why this doesn't work anymore. 17:36 EP475 with Peter Hayes. 18:23 What employers need to do instead of cost shift. 19:12 EP406 with Lauren Vela. 21:30 Why it's important to make health benefit changes at the speed of business, not at the speed of the benefits year. 26:17 Why is it important to put a finance function into your benefits? 27:10 EP488 with Mark Cuban and Cora Opsahl. 27:33 EP478 (Part 1) with Andreas Mang and Jon Camire. 27:35 Why daily data matters. 31:10 EP487 (Part 1) with Kevin Lyons. 31:21 Why it's important to hold vendors accountable. 31:47 Why it's important to move on from vendors who can't hold up to your scrutiny and needs. 33:46 EP472 with Eric Bricker, MD. 34:46 EP471 with Christine Hale, MD, MBA.

Beaumont Hospital Royal Oak was nationally recognized in nine medical specialties, received top hospital awards for seven consecutive years, and charged 143% of Medicare. That combination — genuinely high quality and genuinely low price — is supposed to be impossible. Shane Cerone and Dr. Sam Flanders built the management model that made it happen, and in this solutions-focused episode they explain exactly how. Stacey Richter speaks with Shane Cerone, former president of Beaumont Hospital Royal Oak, and Dr. Sam Flanders, MD, former chief quality and safety officer for the Beaumont health system, now both at Kada Health, about the management operating system that got them there and what employers can do to create the market conditions that reward health systems for doing the same. WHAT YOU'LL LEARN ✅ Why the Toyota continuous improvement model — not Lean, which is a different thing — is the management framework that allows a hospital to improve quality and reduce costs simultaneously: Toyota's principle is that no one loses their job from improvements, and the people doing the work are the ones finding and fixing the problems ✅ How Kaizen at the frontline works in practice: a small team watching CAT scan flow identified empty gaps between patients, dedicated a transporter to the area, nearly doubled throughput, and avoided a $1 million equipment purchase — without making technicians work harder ✅ Why decentralized, frontline-empowered improvement outperforms centralized quality teams and conference-room spaghetti diagrams — and why consolidation and centralized decision-making actively undermine the two things that matter most: making it easier for clinicians to deliver care and easier for patients to receive it ✅ Why hospitals spend every dollar they are given — not because hospital CEOs are bad people, but because there is no market pricing pressure constraining them, and their fiduciary duty is to maximize resources for their organization ✅ How employers can create competition where none exists: issue RFPs to providers asking for quality data and prices as a percent of Medicare, set tiered networks based on value, and use TPAs to administer the contracts employers negotiate themselves — not to negotiate on their behalf ✅ Why Shane Cerone believes employers working together within a single metropolitan market could achieve 15 to 25% price reductions in a first-year pass, with much larger long-term gains once market structure changes WHY THIS MATTERS The problem and solutions shows with Shane Cerone and Dr. Sam Flanders are a pair — listen to EP490 first if you haven't. This episode is the actionable half. The management model is proven. The question is whether enough hospitals have leaders willing to adopt it, and whether enough employers are willing to stop asking their TPAs to negotiate prices and start negotiating themselves. As Shane puts it: don't let Visa negotiate the price of the milk. Negotiate the prices, then let the card process the transaction. === LINKS === 🔗  Show Notes with all mentioned links:   https://cc-lnk.com/EP492 ✉️  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/ 07:08 What are the many problems that health systems deal with? 08:44 EP483 (Part 1 and Part 2) with Jonathan Baran. 09:43 What was the real achievement in building this hospital system? 10:25 EP489 (Part 1 and Part 2) with Dan Greenleaf. 10:42 Why productivity and patient access are the top two things to focus on. 11:36 EP488 with Mark Cuban and Cora Opsahl. 12:32 EP455 with Beau Raymond, MD. 12:58 The lean model versus the Toyota model. 16:06 EP438 with John Lee, MD. 16:40 EP481 with Benjamin Schwartz, MD, MBA. 17:44 Why small changes accumulated create greater change than big changes. 21:01 How an efficiency mindset can increase improvement faster. 27:42 Why administrators should not be negotiators. 28:11 EP491 with Elizabeth Mitchell. 29:06 What are the steps to this multifaceted process? 30:17 EP286 with John Rodis, MD, MBA. 30:48 Study by Suhas Gondi, MD, MBA, on hospital boards. 33:03 Why it's important to focus on the pricing issue first. 33:49 What Kada Health is all about.

There is zero correlation between price and quality in hospital care. That is not speculation — it is in the data. The PBGH Transparency Demonstration Project, conducted by the Purchaser Business Group on Health with Milliman and Embold and funded by the Peterson Center on Healthcare, combined price transparency data, claims data, and quality and safety scores from Leapfrog down to the individual NPI level. The result is the first tool that lets jumbo self-insured employers see what they are actually paying, what they should be paying, and how quality and safety compare — all at once. In this episode, Stacey Richter speaks with Elizabeth Mitchell, CEO of PBGH, whose member employers collectively spend over $350 billion a year on healthcare, about what this project found, what it means for TPAs and consultants, and what employers should be doing with it right now. WHAT YOU'LL LEARN ✅ Why the Consolidated Appropriations Act (CAA) of 2021 changed the fiduciary accountability calculus for self-insured employers: you cannot outsource this risk to a consultant or TPA, individual C-suite executives and CHROs are personally accountable, and not using available transparency data now actively increases liability ✅ What the PBGH Transparency Demonstration Project actually did: combined hospital price transparency MRF files and health plan negotiated rate files with employer claims data, Embold quality scores, and Leapfrog safety data to give employers a true cost-quality-safety comparison across providers — a tool that did not previously exist anywhere on the market ✅ Why discounts are irrelevant without actual prices: one employer participating in the project discovered she was paying 30% more than her peers for the same services, despite being assured by her consultants and carriers that she was getting competitive rates ✅ Why directly contracted arrangements outperformed TPA-negotiated rates in the PBGH data — confirming a decade of anecdotal evidence that when employers negotiate directly, they get better prices than when TPAs do it for them ✅ How site-of-service cost variation is dramatic enough to matter: the same high-quality service from the same type of provider can cost half as much at a different location — without any compromise in care quality or access ✅ Why some incumbent consultants and TPAs are now being called into client boardrooms to answer hard questions — and why unconflicted advisors who can actually use this data have a competitive advantage for the first time in the history of employer-sponsored health benefits WHY THIS MATTERS As Elizabeth Mitchell puts it, if you are a self-funded employer and you do not use this data, it is irresponsible. The tool exists. The compliance obligation is clear. And for the first time, employers have enough information to distinguish high-value providers from expensive-but-not-better ones, to build their own high-value networks and Centers of Excellence, and to hold their advisors accountable. The market for high-value providers is finally becoming visible — but only for the employers willing to look. === LINKS === 🔗  Show Notes with all mentioned links:   https://cc-lnk.com/EP491 ✉️  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 did PBGH's transparency project start? 07:35 EP428 with Julie Selesnick. 07:37 EP408 with Chris Deacon. 07:39 Why the changes to the CAA and ERISA meant heightened risk for employers and individuals within companies. 09:09 "You can't outsource the risk." 11:10 How PBGH's transparency project demonstrated some clients being noncompliant. 12:52 Why is it irresponsible not to use the data presented if you're a self-insured employer? 15:06 How did PBGH use the transparency data and apply it effectively to improve their offerings and business? 18:37 Why TPAs should not negotiate contracts. 19:17 EP485 with Cristin Dickerson, MD. 19:22 EP486 with Stan Schwartz, MD. 19:24 EP488 with Mark Cuban and Cora Opsahl. 20:58 "There is no good price for unsafe care." 21:36 How PBGH found using the transparency data to be totally feasible. 25:03 EP483 (Part 1) with Jonathan Baran. 25:32 Why the market will evolve with this data. 28:04 EP369 with Keith Hartman, RPh. 28:06 EP370 with Erik Davis and Autumn Yongchu. 28:34 What PBGH discovered about high-value centers and centers of excellence. 28:59 EP240 with Olivia Ross. 32:26 Why incentives are another challenge. 33:49 Why this is good news for unconflicted benefits consultants. 36:04 EP487 (Part 1) with Kevin Lyons. 39:48 Why transparency is going to become the new normal. 40:22 The Innovator's Dilemma by Clayton M. Christensen. 42:14 EP436 with Elizabeth Mitchell. 44:07 EP286 with John Rodis, MD, MBA. 45:22 Why there is a great incentive to be a great clinician right now. 46:18 How this information can motivate competition in the right place. 46:52 EP490 (Part 1) with Shane Cerone and Sam Flanders, MD.

The myth is that we have a functioning marketplace. We don't. We don't have a broken market — it's closer to a nonexistent market. That's Shane Cerone speaking, a former CEO of multiple hospital systems, and it is the central argument of this episode: the pricing crisis in American healthcare isn't being solved because the foundational premise — that market forces are constraining hospital prices — is false. Stacey Richter speaks with Shane Cerone and Dr. Sam Flanders, MD, both now at Kada Health, who together ran Beaumont Hospital Royal Oak at approximately 150% of Medicare while achieving national quality and safety rankings, about the three myths that keep health systems and employers from confronting what is actually driving costs. WHAT YOU'LL LEARN ✅ Why the healthcare market is not broken but nonexistent: hospitals do not compete on price or quality for patients, carriers cannot create competition that does not exist, and the absence of real transactions means supply and demand curves have nothing to equilibrate — welcome to 37% renewals ✅ Why Dr. John Rodis's experience is the proof: as CEO he drove his hospital's Leapfrog safety rating from a D to an A and received zero volume reward — no additional patients steered to him, no better carrier rates — because there is no mechanism in the current system to reward quality or efficiency ✅ Why razor-thin hospital operating margins are not automatically evidence of financial hardship: without competitive pricing pressure, organizations that spend every dollar they are given will always show thin margins, and the two explanations — genuine cost pressure versus spending without constraint — are impossible to separate ✅ Why the data already refutes the "hospitals can't survive below 200% of Medicare" claim: Kada Health has published a list of over 20 nationally ranked hospitals operating at or below 200% of Medicare, and Beaumont Hospital Royal Oak ran at roughly 150% with top-decile quality ratings for seven consecutive years ✅ Why lowering prices and raising quality are not a tradeoff — they move together: a finding backed by the work of W. Edwards Deming and the Toyota model, where process discipline that reduces waste also reduces defects, and the frontline improvements that lower cost simultaneously improve safety and reliability ✅ Why pricing as a percent of Medicare reference-based model is the only path to simplicity legible enough for physicians, patients, and employers to actually make decisions — and why the current mess of negotiated rates is by design, not by accident WHY THIS MATTERS This is the problem show. The solutions show is EP492. Listen to both. As Shane Cerone puts it, we have been focused for decades on controlling volume and utilization while doing nothing about price. Until price is addressed in a functioning market structure — where employers negotiate directly, where quality and cost are visible, and where high-value providers are actually rewarded — the flywheel keeps spinning in the wrong direction. === LINKS === 🔗  Show Notes with all mentioned links:   https://cc-lnk.com/EP490-Part1 ✉️  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/ 09:28 EP466 with Vivian Ho, PhD. 09:31 EP486 with Stan Schwartz, MD. 09:42 EP488 with Mark Cuban and Cora Opsahl. 10:08 Why we need to focus on prices in healthcare. 11:50 The first myth that holds change back: the healthcare "market." 15:04 EP286 with John Rodis, MD, MBA. 15:51 The reality behind why there is no functional market in healthcare. 17:11 Why price simplicity is so important. 19:15 EP472 with Eric Bricker, MD. 19:31 How there is pricing failure while hospitals are still facing razor-thin margins. 22:11 The second myth: Can a hospital survive on Medicare rates alone? 25:21 What is the best hospitals can achieve? 26:01 List of hospitals recognized as national leaders for care quality and affordability. 29:23 The third myth: When you lower prices, do you get lower quality? 33:11 Why a decentralized approach at improvement is the way to lower cost and raise quality.

One third of adults in this country are delaying or forgoing care due to cost. Financial toxicity is clinical toxicity. And yet the standard assumption in healthcare is that affordable prices and financial sustainability are in fundamental tension with each other. Dan Greenleaf's argument — backed by the operating results of Duly, a 1,800-clinician multispecialty group in Chicago — is that they are not. In this Part 2, Stacey Richter speaks with Dan Greenleaf, CEO of Duly Health and Care, a six-time CEO with three public companies and three PE-backed organizations under his belt, about how Duly generates margin by achieving its mission rather than despite it — and why physician compensation adjusted for inflation is down 36% over 25 years while the competitors he names are sitting on tax-exempt balance sheets of $6 to $24 billion. WHAT YOU'LL LEARN ✅ How Duly's operational model generates margin: 65% of primary care referrals stay in-network, 76% of specialist-to-ambulatory-surgery-center referrals are captured, and the group's 30 lab sites, 6 ASCs, 16 imaging centers, 11 immediate care centers, and 100 infusion chairs allow it to deliver care at roughly 30% less than institutional competitors — every patient kept in network is a mission win and a margin win simultaneously ✅ Why 600 of Duly's 1,800 physicians are shareholders and 40% of the company is physician-owned — and how aligned financial incentives change the organizational psychology in ways that matter for both culture and operational performance ✅ How five of eleven Duly board seats are held by physicians — and why that governance structure is what actually operationalizes the "dyad leadership" concept that most organizations talk about but few sustain at the board level ✅ How ambient AI scribing reduced physician administrative burden by four and a half hours per week per physician while improving patient experience scores by five percentage points — and what that means for clinician retention and the margin case for mission-aligned technology ✅ Why Dan Greenleaf's framing for capital partners is performance-based rather than mission-based: he competes against organizations with $10 to $24 billion on their balance sheets and his credibility with Ares, his capital partner, comes from a track record of operational performance, not from making the moral case for value-based care ✅ Why the fee-for-service versus value-based care debate misses the point — the real problem is institutional pricing, and every patient Duly keeps out of a hospital system charging 9 to 12 times more is a concrete affordability and quality win regardless of payment model WHY THIS MATTERS The mission show is EP489 Part 1. This is Part 2. Dan Greenleaf's central argument is that the successful care models are those that create value inherently — and that reducing friction for patients and reducing friction for clinicians, pursued relentlessly, produces both better outcomes and sustainable margin. The organizational structures that make this possible — physician ownership, physician board seats, aligned incentives, transparent mission metrics — are not incidental to the financial model. They are the financial model. === LINKS === 🔗  Show Notes with all mentioned links:   https://cc-lnk.com/EP489-Part2 ✉️  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/. 09:56 How does Dan achieve his mission given the realities of margin? 14:49 How Duly Health's approach and incentives differ from other health systems. 16:04 EP466 with Vivian Ho, PhD. 16:28 EP462 with Scott Conard, MD. 16:31 Summer Shorts episode with Stan Schwartz, MD. 17:27 EP460 with Rushika Fernandopulle, MD. 17:29 EP445 with Tom X. Lee, MD. 17:30 EP407 with Vivek Garg, MD, MBA. 18:50 How having physicians on the hospital board greatly improves margin and mission. 20:04 How Dan explains his approach to his capital partners. 22:23 Fee for service vs. institutional care.

Hospitals have increased their prices 256% over the last 20 years while physician compensation adjusted for inflation is down 36%. The average American family of four now spends $24,000 a year on healthcare — up from $6,000 in 2000 — while wages have risen far more slowly. Dan Greenleaf's argument is that in this environment, focusing on mission is not a financial sacrifice. It is a competitive advantage. In this episode, Stacey Richter speaks with Dan Greenleaf, CEO of Duly Health and Care, a large multispecialty group in Chicago, about how Duly defines and measures mission across four concrete quadrants — affordability, access, consumer experience, and quality — and why achieving those quadrants reduces friction for patients and clinicians in ways that also produce financial sustainability. The margin show is EP489 Part 2. WHAT YOU'LL LEARN ✅ Why affordability is the foundational mission quadrant: Duly's MRI costs $500 versus $4,500 at a Chicago hospital system, colonoscopies are $10,000 less, and the group estimates it saves employers, unions, and taxpayers in excess of $1 billion — likely closer to $2 billion — in the Chicago market alone ✅ How co-insurance math makes affordability a direct patient health issue: a $4,500 MRI at 20% co-insurance is $900 out of pocket versus $100 at Duly — and that $800 difference is the difference between patients seeking or delaying necessary care ✅ Why access at two days average wait time versus eight to sixty days at Chicago hospital systems is both a mission priority and a cost issue: an Avalere study found Duly Medicare fee-for-service patients had 15% fewer hospital admissions and 13% fewer ER admissions than comparable populations ✅ How Duly measures consumer experience with 50,000 Press Ganey survey responses per quarter and a net promoter score of 74 — above the 70 threshold for world-class, and compared to a 46 national hospital average — with price transparency explicitly built into the consumer experience definition ✅ Why Duly's prostate biopsy positive rate of 77% versus a national average of 25% is a proxy for diagnostic discipline — every unnecessary biopsy is both a quality failure and a financial harm to the patient ✅ How outbound activation campaigns for lung screening, colonoscopies, mammograms, and diabetic screening — work Duly does without getting paid for it — have detected hundreds of early-stage lung cancers and led to outcomes like a 25-day diagnosis-to-therapy timeline that Dan Greenleaf says nobody else achieves WHY THIS MATTERS Dan Greenleaf's framing is direct: there are only three ultimate payers in healthcare — taxpayers, employers and unions, and patients themselves — and everyone else is a middleman. The communities where Duly serves 40 to 50% of patients rank among the healthiest in the country. That is not incidental. When a clinical organization actually defines what mission means, measures it the way it measures any strategic priority, and builds operations around reducing friction for patients and clinicians, the mission and the margin move in the same direction. === LINKS === 🔗  Show Notes with all mentioned links:   https://cc-lnk.com/EP489-Part1 ✉️  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/ 08:32 What should mission be in multispecialty? 08:54 Are mission and margin mutually exclusive? 10:47 What are the four "vectors" of Dan's mission? 11:32 Why does affordability matter? 12:11 EP466 with Vivian Ho, PhD. 12:40 EP488 with Mark Cuban and Cora Opsahl. 13:32 Who are the three payers in the marketplace? 17:31 EP388 with Merrill Goozner. 19:19 How does access play into mission? 20:28 EP464 with Al Lewis. 21:07 EP467 with Stacey. 22:56 Why price transparency is important to consumer experience. 24:16 LinkedIn post from Patrick Moore. 29:06 EP481 with Benjamin Schwartz, MD, MBA.

High deductible health plans were supposed to give patients skin in the game. What they actually did was create a class of functionally uninsured Americans — because if your deductible is more than you have in your bank account, your insurance is worthless. And then there's the second layer: self-insured employers hired armies of consultants and middlemen to navigate the complexity, which made the complexity worse. In this episode, Stacey Richter speaks with Mark Cuban, founder and CEO of Mark Cuban Cost Plus Drugs, and Cora Opsahl, Health Fund Director of the 32BJ Health Fund, about the two well-intentioned solutions that have arguably made American healthcare worse — and what direct contracting, transparent pricing, and a healthcare CFO can actually do instead. WHAT YOU'LL LEARN ✅ Why high deductibles function as a payroll deduction for employees and a cash addition for insurance companies — with 40% of Americans holding $400 or less in savings, a $1,500 deductible is functionally equivalent to a $10 million deductible for a large portion of the workforce ✅ Why high deductibles shifted cost onto providers: hospitals now take on deductible financing risk, CFOs report 50% nonpayment rates on patient balances, and the fastest-growing private equity healthcare investment area is revenue cycle management — which Mark Cuban calls proof of system failure ✅ What 32BJ Health Fund did when it removed a hospital from its network that was generating millions in excess charges: members got the biggest raise they had ever received and the fund got a premium holiday — with almost no member complaints because access to high-quality care was preserved ✅ How Mark Cuban's direct contracting model works: cash up front, no employee deductible, no pre-authorization risk, no underpayment risk, no collection risk — and providers are willing to offer their cash price or Medicare reference-based pricing in exchange for all of that ✅ Why Mark Cuban believes every company with 500 or more employees can afford to hire a dedicated healthcare CFO or CEO at around $150,000 and see an immediate return — because most C-suites have no idea how much money they are leaving on the table ✅ Why power in the current system sits with hospital C-suites and large insurance companies, not with patients, employers, or independent providers — and why Cora Opsahl frames the goal as making healthcare prices transparent and simple enough to pay with a chicken WHY THIS MATTERS The conversation lands on a point that is both obvious and radical: healthcare on the business side has only three questions — how much does it cost, how do you pay for it, and who takes the risk for nonpayment? The current system has buried all three under layers of administrators, opaque contracts, and misaligned incentives. Direct contracting, transparent pricing, and a serious commitment to managing health benefits as the large spend category they are can answer all three. The rest is theater. === LINKS === 🔗  Show Notes with all mentioned links:   https://cc-lnk.com/EP488 🔗  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 🎤  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/ 06:25 What was the original rationale behind high deductibles? 07:38 How high deductibles are creating a class of functionally uninsured people. 09:29 EP482 with Preston Alexander. 10:20 "We're using health insurance as a proxy for healthcare." —Mark 12:30 How providers are now in the debt collecting business rather than the healthcare business. 12:55 EP486 with Stan Schwartz, MD. 15:16 "We have a fundamental reasonability problem." —Cora 16:07 EP425 with Marshall Allen. 18:25 Direct contracting versus self-funded employers. 19:27 EP436 with Elizabeth Mitchell. 19:30 EP480 with Kimberly Carleson. 19:33 EP372 with Cora Opsahl. 23:53 Why the current system doesn't allow the accountability that is needed. 24:39 EP452 with Cora Opsahl. 26:34 How direct contracting gives strength back to independent practices that high deductible plans take away. 27:46 Who pays, what's the price, and where does the power lie? 31:24 EP419 with Andreas Mang. 34:45 How it comes down to power and leverage when controlling healthcare costs. 38:13 EP483 (Part 1 and Part 2) with Jonathan Baran. 38:35 Why putting together a network and just buying healthcare—not discounts—is not as difficult as it seems. 40:10 Why we need to stop talking about disruption and start talking about change. 40:56 EP453 with Claire Brockbank. 41:02 EP484 with Dave Chase. 43:07 EP485 with Cristin Dickerson, MD. 44:32 EP487 (Part 1) with Kevin Lyons. 46:34 EP466 with Vivian Ho, PhD. 47:40 Why it's the incentives that are different between American hospitals and hospitals in a single-payer program. 50:25 The main takeaways from the conversation. 51:08 Why you can't fix the problems in healthcare without transparency.  

The New Jersey state employee health plan is projected to cost $3.5 billion in 2026 — with no medical director employed by the state and no unconflicted experts at the negotiating table. Kevin Lyons, a former police detective and executive director of labor employee benefits at the New Jersey State Policemen's Benevolent Association, which represents 33,000 members, is trying to change that. In Part 2 of this two-part episode, he explains how he uses detective training to follow the healthcare dollar. Part 1 covers the three structural barriers driving up public sector healthcare costs: profit defends profit, lack of unconflicted expert representation, and industry influence over the media. This episode is the practical advice half. WHAT YOU'LL LEARN ✅ Why statement analysis is Kevin Lyons's most useful detective tool in healthcare vendor meetings: bad actors leave holes in their answers, sidestep questions, and retreat to "it's proprietary" — and that retreat is the X marking the spot ✅ How to treat a vendor's refusal to answer as equivalent to pleading the Fifth: if they don't give you the answer, your job is to go find it — the omission tells you where to look ✅ Why preparation is the prerequisite: if you walk into a TPA or vendor presentation without doing your homework, you will follow their path instead of yours, and they are counting on that ✅ Why "disruption" is a shutdown word — Kevin Lyons's counterpart at 32BJ, Claire Brockbank, confirms it is the status quo's go-to move to stop anyone pushing for change — and why learning to recognize it and push through it matters ✅ What the actual scale of the NJ public sector problem looks like: the KFF average family plan cost is $25,000 in member contribution alone, with towns and the state picking up the remaining share — for a total family plan cost Kevin Lyons estimates at $67,000 WHY THIS MATTERS Kevin Lyons's advice is deceptively simple: be fearless, speak truth to power, follow the money, and never let a good crisis go to waste. The people on the other side of the table have every incentive to keep plan sponsors in the dark and every tool to do it. The only counter is preparation, persistent questioning, and the willingness to treat a non-answer as a confession. === LINKS === 🔗  Show Notes with all mentioned links:   https://cc-lnk.com/EP487Part2 ✉️  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/ 00:00 Introduction and Episode Overview 00:25 Recap of Part One: Barriers to Reducing Healthcare Costs 03:01 Introducing Kevin Lyons: Detective Skills in Healthcare 03:52 Detective Techniques Applied to Healthcare 06:41 Challenges and Solutions in Healthcare Transparency 12:15 Final Thoughts and Acknowledgements 13:10 Closing Remarks and Podcast Information

The New Jersey PPO family plan cost $67,000 in 2026 — having almost doubled in five years, with a 37% rate increase proposal for that year alone, cumulating to 115% over five years. State workers including teachers, police officers, and public employees are paying roughly $25,000 of that themselves. And the state has no medical director, no unconflicted experts at the table, and a legislature whose campaign contributions run heavily toward the very carriers and hospital systems driving the increases. In this episode, Stacey Richter speaks with Kevin Lyons, a former police detective and executive director of law enforcement labor employee benefits at the New Jersey State Policemen's Benevolent Association (NJ State PBA), which represents 33,000 members, about three structural barriers that keep the public sector from getting better, more affordable healthcare — and why they are so hard to dismantle. WHAT YOU'LL LEARN ✅ Why profit defends profit in the public sector: healthcare industry campaign contributions to legislators are second only to real estate, those legislators oversee the contracts with those same companies, and the more money those companies make from the status quo, the more they can spend protecting it ✅ Why the NJ state health plan covering roughly 800,000 lives has no medical director and employs no pharmacists — and how this vacuum gets filled by the contracted partners, who then effectively audit themselves and negotiate on behalf of the entity that pays them ✅ How a real-world prior authorization fight over proton vs. photon therapy for a member with brain cancer — where the state sent a pediatrician to argue the commission's position — illustrates what happens when no unconflicted clinical expertise sits on the purchaser's side ✅ Why the lack of willingness to pay for unconflicted talent at the state level is a self-defeating strategy: the right person at $250,000 annually could save ten times their salary — but the system defaults to career bureaucrats supervised by politicians who are not incentivized to know what they don't know ✅ Why media sponsorship by incumbent TPAs and carriers completes the circle: the same entities being investigated sponsor the coverage, and union publications advertising those same TPAs make member education nearly impossible ✅ What Kevin Lyons brings to the negotiating table from detective training — and why Part 2 covers how he uses those skills to follow the healthcare dollar once he identifies where the answers are being hidden WHY THIS MATTERS As Kevin Lyons puts it: unions can't tax their members to fund a PAC at the scale carriers and hospitals fund lobbying. The financial asymmetry is foundational to the problem. When the people whose job is to advocate for the plan's members are outgunned financially, politically, and informationally, the flywheel keeps spinning. The barriers are real. The question is whether enough people who understand them will push loud enough and long enough to change it. === 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/   00:00 Introduction to Episode 487 00:33 Viral Video and Metaphor for Healthcare 04:48 Healthcare Costs and Union Challenges 07:32   Interview with Kevin Lyons Begins 08:17 Why is it important to "dig in" right now on health benefit cost increases? 08:39 Barriers to Affordable Healthcare 10:16 The first barrier to better health benefits: profit defending profit. 10:54 Profit Defense and Political Influence 16:38 Why "throw money at the problem" isn't a real solution. 18:31 The second barrier: why a lack of employed experts costs more money. 18:59 Government Inefficiencies and Conflicts of Interest 25:58 The third barrier: media sponsorship from incumbents prevents change. 26:19 Media Influence and Public Perception 28:55 EP483 (Part 1 and Part 2) with Jonathan Baran. 30:23 Conclusion and Teaser for Part Two  

A 23-year-old roofing laborer paid $125 for a comprehensive metabolic panel — a test available directly for $6.52. That is not a healthcare problem. That is a pricing failure. And it is the origin story of ZERO.health, a direct contracting platform that gets plan members access to high-quality providers for $0 out of pocket using bundled payments. In this episode, Stacey Richter speaks with Dr. Stan Schwartz, MD, co-founder of ZERO.health, who has been building and operationalizing direct contracting arrangements since 2014, about how bundled payments actually work in practice — what providers get, what employers get, what members get, and specifically how to solve the logistics problems that have sunk other direct contracting attempts. WHAT YOU'LL LEARN ✅ How ZERO's bundled payment model works: a five-star Medicare hospital in Tulsa performs outpatient gallbladder surgery for $5,641 all-in — covering anesthesia, surgeon, hospital, and recovery room — compared to roughly $8,000–$10,000 through a typical claims process, with the employer covering 100% so the member pays zero ✅ Why Dr. Schwartz's mantra is "if you can schedule it, you can put a price on it" — and how this applies not just to major surgeries but to lab tests, imaging, and routine services where spread pricing adds unnecessary cost on top of already inflated prices ✅ Why the utilization concern is asking the wrong question: good evidence shows that prior authorization impedes necessary care more often than unnecessary care — and the greater financial risk for most plans is members not getting care they need, not members overconsumption ✅ How ZERO solves the double-billing and administrative chaos problem: everything is pre-arranged through personal health assistants, providers send a simple invoice or claim directly to ZERO, the member pays nothing at point of service, and double billing is easy to catch because members know they should owe zero ✅ Why Surgery Center of Oklahoma, one of ZERO's earliest providers, runs at a 10-to-1 clinical-to-administrative staff ratio versus the industry average of 2-to-1 — because bundled, direct-paid care eliminates collections, accounts receivable, and coding complexity ✅ How ZERO tracks utilization and improves it over time: in year one, roughly 30% of ZERO-eligible services actually go through the ZERO program; by years two and three, the best-performing companies reach 70% — and the gap is monitored through ongoing claims review and targeted member outreach WHY THIS MATTERS So much of what we call healthcare expense is pricing failure — something that should cost $7 is billed at $100, spread through an insurance mechanism, and processed with administrative overhead that can reach 30% of total plan spend. Direct contracting with bundled payments is not a new idea, but operationalizing it — training providers, educating members off open enrollment cycle, tracking missed opportunities in real time — is where most attempts fall apart. Dr. Schwartz has been doing this for over a decade. This episode is the how. === 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/ 07:59 How did ZERO.health start? 10:38 EP480 with Kimberly Carleson. 11:04 Why does the emotional energy behind understanding how the problem of healthcare affects individuals matter in changing healthcare? 12:45 "If you can schedule it, you can put a price on it." 15:32 EP420 with Ge Bai, PhD, CPA. 16:38 EP436 with Elizabeth Mitchell. 18:21 How do employers ensure that patients and clinicians are coordinated and on board with direct contracting within their health plans? 20:26 EP475 with Peter Hayes. 22:52 Why is it important that this direct contracting system isn't mandatory for health plan members? 24:50 How does direct contracting affect excessive utilization? 26:41 EP477 (Through Line Show) with Stacey. 27:29 Why is it important that your plan benefits benefit health? 29:39 Why is it important to educate not only members but also providers who agree to participate in the program? 31:06 "It's all about simplicity." 33:11 How do you ensure plan members use the service after it is installed?

Imaging costs 6 to 11% of total plan sponsor spend — and that figure requires aggregating CPT codes, contrast charges, professional services, and facility fees, many of which are split across different code categories in ways that make the true total hard to see. The same MRI that costs $5,000 at a hospital system might cost $300 to $500 at a freestanding imaging center of equivalent quality. And prior authorization for imaging, per a study by the American College of Radiology, does not reduce the number of scans performed — it only delays care. In this episode, Stacey Richter speaks with Dr. Cristin Dickerson, MD, founding partner of Green Imaging, an $18 million physician-led radiology network, about why direct contracting for imaging is one of the highest-leverage moves a plan sponsor can make — and how to actually do it, including when to go around the TPA entirely. WHAT YOU'LL LEARN ✅ How hospital revenue codes allow imaging claims to bypass standard CPT-based claims adjudication — the Osceola County school district case found one CT scan billed at over $50,000 using hospital revenue codes rather than CPT codes, escaping standard review entirely ✅ Why 62% of Texans are delaying or forgoing care because they can't afford it — and how direct contracting with zero member cost-sharing can solve an access problem while the employer still saves money, as the City of Plano health plan discovered ✅ Why prior authorization for imaging delays care without reducing utilization, per the American College of Radiology — and how radiologist-specific protocols (such as clarifying whether contrast is truly needed, which eliminates unnecessary contrast in roughly 30% of chest CT orders) do more to control appropriate use than prior auth ✅ Why TPAs often cannot or will not facilitate direct imaging contracts — because of carrier contract clauses, competing internal vendors, or referral fee arrangements — and how approximately 80% of Green Imaging's larger employer clients simply go around the TPA and contract directly ✅ How employers can execute a direct imaging contract without TPA involvement: under HIPAA's omnibus rule, employers can withhold PHI from carrier network partners and pay cash, Green Imaging sends a single invoice with all data needed for stop-loss compliance, and there is no repricing or prior auth complexity ✅ Why the "down the hall" referral habit is weakening as patient bills get larger — doctors often cannot estimate what imaging costs at their affiliated hospital, and patients are increasingly aware of the risk of an unexpectedly large bill WHY THIS MATTERS When a plan sponsor pays for imaging through a traditional claims process, they are paying whatever the system decides — which can include misapplied codes, facility fees, contrast charges in separate buckets, and RBP fees that sometimes exceed what the provider actually received. Direct contracting strips all of that away. The price is set in advance, the member pays nothing, the provider gets paid quickly without collections overhead, and the employer saves money. The model works. The barriers are real but navigable. === LINKS === 🔗  Show Notes with all mentioned links:   https://cc-lnk.com/EP486 ✉️  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/ 00:00 Introduction and Episode Overview 00:31 The Case for Direct Contracting in Imaging 01:43 Real-World Examples and Challenges 04:47 The Importance of Data and Transparency 08:49 Interview with Dr. Kristen Dickerson 12:39 Barriers to Direct Contracting 24:05 Overcoming Barriers and Final Thoughts 33:22 Conclusion and Contact Information

PBGH member employers collectively spend over $350 billion a year on healthcare. And per Elizabeth Mitchell, 30% of that spend disappears in the middle — not reaching providers, not improving health — just gone into administrative spread, misaligned fee structures, and the cost of a system that was never designed to pass money through efficiently. That number is not speculation. It is what she observes across her member organizations. In this Take Two episode, Stacey Richter revisits a conversation with Elizabeth Mitchell, President and CEO of the Purchaser Business Group on Health (PBGH), about why health plan and TPA inertia is arguably a bigger problem than employer inertia — and what employers who are done waiting are actually doing about it. WHAT YOU'LL LEARN ✅ Why a TPA's job should be exactly three things — pay claims, provide transparent data, negotiate contracts — and how the moment health plans start layering in care management services and carve-outs, they retain more of the money and make it harder for employers to work directly with the providers they want ✅ How one employer discovered they were paying five times the hospital's published price for a service, sought a refund directly from the hospital, and had their own health plan try to block the transaction — because the health plan's network rate was higher than the direct price ✅ What happens when employers direct contract without a TPA in the middle: in every case PBGH has tracked, employers see a 10 to 30% reduction in total cost of care, better access, better patient experience, and better outcomes ✅ How the Consolidated Appropriations Act (CAA) changed employer accountability: employers can no longer say "my consultant recommended it" — they are held to an expert standard, they are entitled to their data, and the liability is personal and organizational ✅ Why a 4.7% price markup appears when hospitals are in a TPA's Medicare Advantage network — TPAs negotiate commercial clients to pay higher rates so their MA members pay lower rates, which is not in the interest of commercial plan participants ✅ What PBGH did when three jumbo employers issued a direct RFP for high-quality whole-person primary care: providers literally asked "what do you mean, there's no health plan?" — and then the RFP was wildly successful, because providers and employers want the same things WHY THIS MATTERS As Elizabeth Mitchell puts it, having a health plan in the middle between an employer and a provider is like being at the UN with a bad translator. The plot gets lost. The money gets lost. And for decades, employers had no way to verify what was actually happening because they couldn't get the data. That is now changing. The employers who are using it are seeing results. The question is whether enough of them move fast enough to create a market that makes inertia an unviable strategy. === LINKS === 🔗  Show Notes with all mentioned links:   https://cc-lnk.com/EP436-Take2 ✉️  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/ 08:06 What is the overarching context for health plans in healthcare purchasing? 11:31 Why is it important to reestablish a connection between the people paying for care and people providing care? 13:47 What are the needs of a self-insured employer when managing employee benefits? 19:00 Is it doable for employers to set their own contracts? 21:24 Is transparency presumed? 22:39 Will the new transparency upon us actually expose wasted expense? 24:23 EP408 with Chris Deacon. 25:58 "This is not about individual bad actors. … The systems … that is not aligned." 27:39 Are there providers who want to work directly with employers? 30:53 Why is it important that incentives need to be aligned? 32:42 EP427 with Rik Renard. 33:51 What's missing from the conversation on changing health plans?  

Across the country, self-insured employer teams are waking up to the fact that "I trusted my consultant" is not a legal defense. Not under ERISA. Not under the Consolidated Appropriations Act. And the lawsuits — J&J, Wells Fargo, Tiara Yachts versus Blue Cross Blue Shield of Michigan, Osceola County — are making it impossible to ignore. In this episode, Stacey Richter asks Dave Chase, co-founder and CEO of Health Rosetta, to answer the three most burning questions plan sponsors are asking right now: how to verify a benefits advisor actually works for you, how to avoid personal liability when TPA contracts have hidden conflicts, and how to tell if pharmacy costs are being systematically inflated despite PBM guarantees. WHAT YOU'LL LEARN ✅ The four canaries in the coal mine of trust for any benefits advisor: comprehensive compensation disclosure with no excuses, full data and reporting access, real experience with high-performance health plan components, and a meaningful share of their book of business with independent plan administrators ✅ Why unfettered access to claims data is the single most predictive factor of a high-performance health plan — confirmed by a Tufts University study of 2,000 to 3,000 Health Rosetta plan grade reports — and why being blocked from that data is a near-certain sign you are being overcharged ✅ How spread pricing works on the medical side: the Tiara Yachts lawsuit documents Blue Card claims being repriced out-of-network to inflate so-called savings, with the carrier collecting fees larger than what was actually paid to the provider ✅ Why pharmacy guarantees can hide systematic overcharges: PBMs have created approximately 50 different revenue streams, rebate guarantees often retain manufacturer revenue, and without net cost disclosure after all fees, the numbers that appear favorable on paper conceal the actual extraction happening in the background ✅ What the Ann Lewandowski whistleblower case revealed: one EBC's TPA arm took $20 million in client pharmacy rebates and funneled them into their executive bonus pool — not a single client discovered this without the whistleblower ✅ What Health Rosetta and Nautilus Health Institute have open-sourced for free: an advisor RFP template, a TPA contract template, a data platform, and a PBM Field Guide — tools that represent approximately $4 million in direct investment, available at nautilushealth.org WHY THIS MATTERS The retirement industry went through this same reckoning 15 to 20 years ago. The status quo players disappeared and a completely different set of market leaders emerged. Dave Chase argues the same thing is happening now in employer-sponsored health benefits — and the employers who act on these three questions before the lawsuits find them are the ones who will come out ahead, with better health outcomes for their members and meaningfully lower 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/ 06:36 What questions does a plan sponsor need to ask their consultant, EBC, or broker to ensure they are protecting the interest of the plan sponsor? 07:59 EP478 with Andreas Mang and Jon Camire. 08:49 EP453 with Claire Brockbank. 09:51 EP433 with Justin Leader. 09:53 EP436 with Elizabeth Mitchell. 11:03 How can plan sponsors avoid personal liability when their TPA has hidden conflicts of interest? 11:40 Tiara Yachts v. Blue Cross Blue Shield of Michigan lawsuit. 13:48 EP483 (Part 1) with Jonathan Baran. 14:18 EP457 with Cynthia Fisher. 16:18 The Marshall-Hickenlooper bill called the Price Tags Act. 16:50 Summer Short with Elizabeth Mitchell. 17:36 How do plan sponsors figure out if they are being overcharged for pharmacy benefits? 18:09 EP365 with Scott Haas. 20:18 EP397 with Paul Holmes. 20:22 EP465 with Chris Crawford. 20:37 EP429 with Luke Slindee, PharmD. 22:56 EP476 with Ann Lewandowski. 28:38 Where to find open-source resources to help guide plan sponsors with making better health plan decisions. 29:47 How the open-source trend is growing for health transparency. 30:48 What to look forward to at RosettaFest.  

The negative healthcare flywheel spins on one axle: employers buying discounts. Discounts create no incentive for health systems to control prices, no incentive to invest in primary care, and no way to know what anything actually costs. The flywheel just keeps spinning. In Part 2 of this conversation, Jonathan Baran turns it around — and the fix starts with employers refusing to buy discounts at all. In this Part 2 episode, Stacey Richter speaks with Jonathan Baran, co-founder and CEO of Self Fund Health, a Wisconsin-based health plan designed around the premise that employers should be buying healthcare, not insurance products built around discount arithmetic. WHAT YOU'LL LEARN ✅ Why stopping the purchase of discounts is Step 1 — and not a theoretical idea: if employers demanded unit cost transparency instead of discount reports, the entire incentive structure downstream would begin to shift ✅ Why the most expensive thing in healthcare is the pen of the primary care doctor — and why independent, unconflicted direct primary care is the essential first move in any flywheel reversal, because trying to redirect a patient after they've already scheduled expensive care is too late ✅ How benefit design has to be realigned with actual unit costs — not in-network status — so that members have a financial reason to choose a $500 MRI over a $5,000 one, and why without this realignment, navigation alone cannot close the gap ✅ Why the broker's role needs to fundamentally shift from presenting health plan options to driving health outcomes — sitting with high-cost members, running education meetings on DPC and imaging access, and owning the results of the plan design choices they recommend ✅ How self-funded employers paying at time of service can eliminate prior authorization backlogs, denial follow-up, and 30-to-90-day accounts receivable from hospitals' cost structures — and what that kind of administrative simplification does to the unit cost of care ✅ Why EHR interoperability is not a technical problem — it is an incentive problem, and flipping the incentives would allow technology that already exists to start doing what patients, employers, and providers actually need it to do WHY THIS MATTERS Jonathan Baran's conclusion is worth sitting with: if the status quo guarantees higher costs and less control, it is not the safer option. Every employer that continues to buy discounts is spinning the flywheel one more turn. The reverse flywheel — better member health at the center, direct primary care, aligned benefit design, honest brokers, direct-contracting hospitals — is not theoretical. Purdue University and others in the Midwest are doing it. The question is whether enough employers decide to act before the next renewal shock. === 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/ 05:23 Where to start in reversing the flywheel. 06:57 Why investing in primary care is pivotal to containing healthcare costs. 10:02 EP453 with Claire Brockbank. 10:04 EP452 with Cora Opsahl. 10:07 EP457 with Cynthia Fisher. 10:12 EP365 with Scott Haas. 10:13 EP465 with Chris Crawford. 10:14 EP475 with Peter Hayes. 11:11 EP468 with Matt McQuide. 11:13 EP472 with Eric Bricker, MD. 12:14 "The most expensive thing in healthcare is the pen of the primary care doctor." 13:04 How the role of the broker has to fundamentally change. 16:16 What will the single most challenging aspect of this restructuring become? 20:20 How self-funded employers can be amazing customers in containing the rising cost flywheel in healthcare. 22:56 How do EHRs and other medical record systems play into reversing the flywheel of rising healthcare costs? 23:57 Ramy Khalil, MD's post on interoperability. 24:59 Why is it important for employers to drive volume differently? 25:38 How Self Fund Health is helping in this regard.