EP463: Medicare Advantage Policies—Which Will Stay and Which Will Go Now? With Betsy Seals
Release Date: 02/13/2025
EP473: Keeping Patients out of the ER: How Trusted Relationships in Primary Care Should Work. A Take 2 With Kenny Cole, MD
Relentless Health Value
This episode of Relentless Health Value features Dr. Kenny Cole from Ochsner Health System. The discussion emphasizes the critical role of trusted relationships and excellent primary care teams in keeping patients out of the emergency room, thus reducing healthcare costs. Stacey Richter revisits this conversation to highlight the importance of care teams building trust with patients and the concept of primary care as an investment in health and wellness. The episode outlines four key points for delivering great primary care, including accountability for outcomes, belief in clinical goals,...
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EP472: The Well-Honed, Three-Prong Hospital Playbook to Maximize Revenue From High-Cost Claimants, With Eric Bricker, MD
Relentless Health Value
In Episode 472, Stacey Richter speaks with Dr. Eric Bricker about the impactful strategies hospital systems use to maximize revenue from high-cost patients. They explore the financial complexities and contracting tactics that enable hospitals to profit significantly from a small percentage of high-cost claimants. Key points include the negotiation of provider stop-loss contract provisions, strategic adjustment of charge masters, and the intentional steerage of patients to high-revenue service lines. This episode highlights the intricacies of hospital finance and the hidden mechanisms that...
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EP471: High-Cost Claimants in 2025 and Beyond—What Is Really Expensive Not to Know? With Christine Hale, MD, MBA
Relentless Health Value
Recently on Relentless Health Value, we’ve been tinkering around with a few recurring themes—recurring through lines—that are just true about American healthcare these days. In this episode of Relentless Health Value, host Stacey Richter speaks with Dr. Christine Hale about high cost claimants and the implications for healthcare plans in 2025 and beyond. They discuss the importance of trust in patient care, the financial incentives behind patient steering, and the critical role of timely and comprehensive data analysis. Dr. Hale emphasizes the need for an integrated approach to medical...
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EP470: Continuing the ER and Primary Care Through Line Over to Rural Hospitals and Healthcare, With Nikki King, DHA
Relentless Health Value
In this episode, host Stacey Richter revisits a conversation with Nikki King, CEO of Alliance Health Centers, discussing the critical issues facing rural hospitals and healthcare systems. They delve into the impacts of Medicaid cuts, the financial struggles of rural hospitals reliant on commercial insurance, and potential solutions like freestanding emergency rooms, telehealth, and the expanded roles of nurse practitioners. The conversation also covers the complexities of maternity care and mental health services in rural areas, emphasizing the urgent need for systemic reforms to ensure...
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EP469 (Part 2): The Impact on Plan Sponsors of Medicare Site-Neutral Payments and HSA Reforms, With James Gelfand, JD
Relentless Health Value
In part 2 of episode 469, host Stacey Richter discusses the implications of Medicare site neutral payments and Health Savings Account (HSA) reforms with James Gelfand, president and CEO of the ERISA Industry Committee (ERIC). The episode details how plan sponsors should adapt to Medicare's site neutral payment policies aimed at curbing hospital consolidation and inflated prices through facility fees and markups. Gelfand provides insights into how HSA reforms currently in Congress could expand the scope of preventive care covered before deductibles are met, benefitting both employers and...
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EP469 (Part 1): The Impact on Plan Sponsors of Medicaid Cuts, With James Gelfand, JD
Relentless Health Value
In part 1 of this two part episode, Stacey Richter speaks with James Gelfand, President and CEO of the ERISA Industry Committee (ERIC), about the potential effects of proposed Medicaid cuts on plan sponsors and their members. They explore ways plan sponsors can prepare for the changes, including Medicaid's four major areas of possible cuts: reducing waste, fraud, and abuse; implementing work requirements; reeling in provider taxes; and addressing the 'Cornhusker Kickback' from the ACA. The conversation also delves into how state governments and hospitals might respond to these cuts...
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EP468: Very Common Assumptions That Aren’t Actually True About Member Engagement and the Healthcare Industry, With Matt McQuide
Relentless Health Value
In Episode 468, host Stacey Richter engages in a conversation with Matt McQuide, CEO of Synergy Healthcare. This episode delves into the critical assumptions surrounding member engagement within the healthcare industry. Key points discussed include the role of employers in steering plan members, the importance of member engagement for navigating the healthcare marketplace, and Matt’s three major misconceptions about health plan membership. Matt also presents real-life examples of how engagement significantly impacts health outcomes, emphasizing that relationships and trust are...
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EP467: Connecting Sky-High ER Spend to Primary Care Access—Following the Dollar Through Carriers and Hospitals, With Stacey Richter
Relentless Health Value
In this solo episode of 'Relentless Health Value,' host Stacey Richter dives into the intricate relationship between increased emergency room (ER) visits and the lack of access to effective primary care. Discussing insights from recent episodes featuring experts like Matt McQuide, Dr. Christine Hale, and others, Stacey explores how inadequate primary care leads to skyrocketing ER costs, which now account for 6% of total healthcare spending. Key points include the systemic issues driving this trend, the incentives misalignments within hospitals and insurance carriers, and the importance...
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EP466: What Is Rising Faster, Insurance Premiums or Hospital Prices? With Vivian Ho, PhD
Relentless Health Value
Healthcare costs keep rising, but what’s driving those increases? In this episode, Stacey Richter speaks with Dr. Vivian Ho, a health economist at Rice University and Baylor College of Medicine, to break down the real reasons behind skyrocketing commercial insurance premiums. Are insurance premiums rising faster than wages—and why does it matter? What’s the biggest driver of premium increases? (Spoiler: It’s hospital prices.) Are hospital price hikes justified by rising costs—or is something else at play? Dr. Ho shares data-backed insights on hospital consolidation, executive...
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EP465: The Not Super Effective Contracting Industry Norm, Where Jumbo Plans and Others Wind Up Paying $10,000 for $50 Drugs, With Chris Crawford
Relentless Health Value
The Hidden Costs of PBMs: How Aggregate Discount Guarantees Inflate Drug Prices. In episode 465 of Relentlessly Seeking Value, host Stacey Richter interviews Chris Crawford, CEO of RxSaveCard, about the inflated costs within the pharmacy benefits industry. The discussion centers around a lawsuit involving J&J, highlighting how large PBMs can significantly overcharge for drugs that are available much cheaper through cash-pay options like Mark Cuban's Cost Plus Drugs. Crawford explains how Aggregate Discount Guarantees, a common contracting mechanism, often fail to control spread pricing...
info_outlineIn this episode of Relentless Health Value, host Stacey Richter engages with Betsy Seals, CEO and co-founder of Rebellis Group, to analyze the future of key Medicare Advantage policies amidst a changing political landscape. They delve into four critical areas:
1. Medicare Advantage Stars Program: Examining potential changes due to recent lawsuits and the new administration’s stance on quality measures.
2. Risk Adjustment and Government Oversight: Discussing the focus on recouping improper payments and how oversight might evolve.
3. Use of Artificial Intelligence: Considering appropriate oversight for AI applications in prior authorization processes and ensuring they benefit patient care.
4. Agent and Broker Oversight: Exploring increased scrutiny over marketing practices and the dissemination of accurate information to beneficiaries.
Betsy emphasizes the importance for Medicare Advantage plans to prioritize patient value, maintain compliance, and proactively utilize data to navigate these evolving policies. This discussion provides valuable insights for stakeholders aiming to understand the future of Medicare Advantage.
=== LINKS ===
🔗 Show Notes with all mentioned links:
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05:09 Will the Star Ratings program stay in this new administration?
08:08 How will the lawsuits against CMS policies play out with this new administration?
10:24 Why is it hard for Medicare Advantage plans to survive, let alone thrive?
16:22 How does AI directly impact beneficiary lives?
21:38 What’s going on now with the override payments?
27:08 How is non-collaboration going to impact Medicare beneficiaries moving forward?
31:45 Why is it important to become more technologically savvy in compliance?