EP471: High-Cost Claimants in 2025 and Beyond—What Is Really Expensive Not to Know? With Christine Hale, MD, MBA
Release Date: 04/10/2025
Take Two: EP445: What Does It Take for an Indie Primary Care Practice to Survive Right Now? With Tom X. Lee, MD
Relentless Health Value
In this second take on episode host Stacey Richter speaks with Dr. Tom Lee, founder of One Medical and Galileo. The discussion centers on the survival of independent primary care practices in the current healthcare economy, the associated challenges, and the paradox of primary care. Topics include reducing ER visits, managing downstream specialty spend, and the imbalance between CMS and commercial carrier payments to primary care practices. Dr. Lee highlights the importance of 'enlightened leadership' and a 'value-focused mindset' in balancing efficient service operations with...
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Bonus Clip: Dr. Tom Lee Talks About Why Retail Clinics Are Not Doing So Well, in His Opinion
Relentless Health Value
This short bonus episode is a side bar conversation with Dr. Tom Lee discussing why retail clinics are struggling with Dr. Tom Lee. They explore the shortcomings of retail clinics in providing longitudinal primary care, despite their convenience for minor urgent care and vaccinations. Dr. Lee emphasizes that true primary care requires consistent, long-term patient relationships and complex management which many retail clinics fail to deliver. They also discuss the economic challenges of running such clinics and the importance of defining primary care's value proposition correctly....
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EP481: Seriously, IRL, What Does “No Margin, No Mission” Even Mean? With Benjamin Schwartz, MD, MBA
Relentless Health Value
Balancing Mission and Margin in Healthcare: A Candid Conversation with Dr. Ben Schwartz In this episode, host Stacey Richter engages in a deep dive with Dr. Ben Schwartz to explore the phrase 'No Margin, No Mission' and its practical implications in the healthcare industry. They discuss the complex relationship between profitability and mission-driven care, the challenges of value-based care, and the role of dyad leadership. The episode emphasizes the importance of transparency, regulatory measures, and trust in fostering a balance between mission and margin. Along the way, Dr. Schwartz...
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Take Two: EP438: Is It Mission and/or Margin? With John Lee, MD
Relentless Health Value
In this Take Two episode of Relentless Health Value, host Stacey Richter reflects on her conversation with Dr. John Lee to explore the challenging intersection between mission and margin in healthcare. They discuss the nuances of cognitive dissonance faced by healthcare professionals, particularly when organizational priorities conflict with patient care. Dr. Lee shares insights on finding a sense of mission within the constraints of the current healthcare system, emphasizing the importance of incremental improvements, team-based care, and peer support. The conversation also...
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EP480: Payment Integrity Meets Health System Boasts, Such as Our Rates Are 2x Medicare, With Kimberly Carleson
Relentless Health Value
Enhancing Payment Integrity in Health Systems: An In-depth Discussion with Kimberly Carleson. In Episode 481 of Relentless Health Value, host Stacey Richter speaks with Kimberly Carleson, CEO of US Beacon, about payment integrity within health systems. They delve into strategies some hospitals use to maximize revenue without raising rates and discuss the importance of accurate billing. Key takeaways include the high prevalence of billing errors, which can lead to significant overcharges for plan sponsors, often due to documentation gaps and complex coding systems. Kimberly provides...
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Pharma Rebates: A Few Nuances You May Not Have Thought Of, With Ann Lewandowski—Summer Shorts
Relentless Health Value
Exploring the Complexities of Pharma Rebates with Ann Lewandowski In this Summer Short episode of Relentless Health Value, host Stacey Richter converses again with Ann Lewandowski about the intricate dynamics of pharmaceutical rebates, or as Lewandowski prefers, post-sale concessions. The discussion delves into the nuances of these rebates, the impact they have on drug costs, and the hidden consequences for patients and plan sponsors. They highlight articles and insights by Austin Chelko and Peter Hayes, touching on how rebates can disadvantage the pursuit of lower-cost generics...
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EP479: Part 2. What Could Go Wrong Covering High-Cost Claimants With Stop-Loss Reinsurance?
Relentless Health Value
In this second discussion with Andreas Mang and Jon Camire of Blackstone, Stacey Richter has an advanced discussion on the intricacies of stop-loss reinsurance for high-cost claimants. This show today, for sure, it’s for plan sponsors and anyone on or about plan sponsors; but also listen if you are serving high-cost claimants some other way. Because what you’ll learn here today is some insights relative to how plan sponsors go about making sure that they can pay you—like if you work for, for example, some clinical organization. There’s a, I don’t know, 101 starting point...
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Take Two: EP433: The Mystery of the Weekly Claims Wire, With Justin Leader
Relentless Health Value
Stacey Richter has a second take on the original episode 433 since it is so relevant right now. Stacey engages in a compelling conversation with Justin Leader, CEO of BenefitsDNA, about the opaque practices of third-party administrators (TPAs) and their impact on healthcare costs. They discuss the hidden fees tucked into weekly claims wires, including shared savings fees, prior authorization fees, prepayment integrity fees, pay and chase fees, and TPA adjudication fees. The episode emphasizes the need for transparency, understanding hidden costs, and ensuring fiduciary...
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EP478: Stop-Loss Coverage, Part 1: How It Goes Right, and How It Can Go Horribly Wrong, With Andreas Mang and Jon Camire
Relentless Health Value
Host Stacey Richter discusses the intricacies of stop-loss coverage with Andreas Mang and Jon Camire from Blackstone. The episode focuses on defining stop-loss insurance and exploring its critical role in protecting self-insured employers from catastrophic financial losses. The conversation delves into the nuances of individual and aggregate stop-loss policies, laser claims, and the importance of selecting an experienced consultant to navigate this complex landscape. The episode is essential listening for those managing high-cost claimants and exploring self-insurance options. This is a...
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EP477: Through Line Show: What the Tribe Thinks You Need to Know About Trust or It’s Gonna Be a Problem. Also, Why You Are Smart, With Stacey Richter
Relentless Health Value
In this episode, Stacey Richter explores the impact of trust on healthcare outcomes, drawing from listener contributions and prior episodes of Relentless Health Value. The discussion underscores how trust or the lack thereof affects patients, clinicians, and healthcare systems. Key points include the importance of building trusted relationships, the detrimental effects of antitrust behaviors, and the broader implications for healthcare delivery. Stacey also highlights a bonus show featuring Charles Green on earning and maintaining trust. The episode concludes with an uplifting message about...
info_outlineRecently on Relentless Health Value, we’ve been tinkering around with a few recurring themes—recurring through lines—that are just true about American healthcare these days.
In this episode of Relentless Health Value, host Stacey Richter speaks with Dr. Christine Hale about high cost claimants and the implications for healthcare plans in 2025 and beyond. They discuss the importance of trust in patient care, the financial incentives behind patient steering, and the critical role of timely and comprehensive data analysis.
Dr. Hale emphasizes the need for an integrated approach to medical and pharmacy claims data to avoid expensive consequences and improve patient outcomes. She also shares strategies for plan sponsors to effectively manage high cost claimants through evidence-based care, appropriate treatment settings, and creative problem-solving, while underlining the importance of patient engagement and satisfaction.
Don't miss next week's episode with Dr. Eric Bricker for a deeper dive into these topics.
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05:22 What is a high-cost claimant, and how is the definition changing?
07:42 Why buy-and-bill pharmaceuticals can be so costly for plan sponsors.
10:19 What are plan sponsors getting wrong about this situation?
11:28 What do you need as an employer to understand your plan data fully?
13:41 EP462 with Scott Conard, MD.
17:35 What are plan sponsors currently doing that they should not being doing?
19:54 Why starting small is important.
23:02 EP468 with Matt McQuide.
25:37 What are the steps employers should take to improve their high-cost claimant spend?
31:02 EP371 with Erik Davis and Autumn Yongchu.
33:46 EP467 with Stacey.
Recent past interviews:
Click a guest’s name for their latest RHV episode!
Nikki King, James Gelfand (Part 2), James Gelfand (Part 1), Matt McQuide, Stacey Richter (EP467), Vivian Ho, Chris Crawford (EP465), Al Lewis, Betsy Seals, Wendell Potter (Encore! EP384), Dr Scott Conard