Relentless Health Value

American Healthcare Entrepreneurs and Execs you might want to know. Talking. Relentless Health Value is a weekly interview podcast hosted by Stacey Richter, a healthcare entrepreneur celebrating fifteen years in the business side of healthcare. This show is for leaders in pharma, devices, payers, providers, patient advocacy and healthcare business. It's for health industry innovators, entrepreneurs or wantrepreneurs or intrapreneurs. Relentless Healthcare Value is the show for you if you want to connect with others trying to manage the triple play: to provide healthcare value while being personally and professionally fulfilled.

EP473: Keeping Patients out of the ER: How Trusted Relationships in Primary Care Should Work. A Take 2 With Kenny Cole, MD 04/24/2025

EP473: Keeping Patients out of the ER: How Trusted Relationships in Primary Care Should Work. A Take 2 With Kenny Cole, MD This episode of Relentless Health Value features Dr. Kenny Cole from Ochsner Health System. The discussion emphasizes the critical role of trusted relationships and excellent primary care teams in keeping patients out of the emergency room, thus reducing healthcare costs. Stacey Richter revisits this conversation to highlight the importance of care teams building trust with patients and the concept of primary care as an investment in health and wellness. The episode outlines four key points for delivering great primary care, including accountability for outcomes, belief in clinical goals, standardized care flows, and building patient trust. Dr. Cole also discusses the real-world challenges and strategies for achieving clinical and financial success in primary care. The episode serves as a guide for plan sponsors, clinicians, and healthcare executives looking to improve primary care delivery and align it with financial viability. The discussion is further enriched with insights on digitizing care pathways and the importance of measuring and sharing best practices to achieve high standards of care.I Stacey revisits, in a take two, this episode with Dr. Kenny Cole because she's listening to it this time with a new focus. That focus is the theme that keeps coming up over and over and over again on Relentless Health Value these past few months. === LINKS === 🔗 Show Notes with all mentioned links: ✉️ 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 07:35 Is there an optimal care pathway where there might be a lot of treatment variability? 10:52 with Robert Pearl, MD. 12:32 Why is it important to start with the end in mind? 15:44 How do you scale clinical excellence? 18:18 with Bob Matthews. 19:12 with Marty Makary, MD. 21:29 Why is it important simply to demonstrate what’s possible for better health outcomes? 22:33 with Rik Renard. 23:18 How do we reinvent the business model of healthcare? 24:51 with Vivian Ho, PhD. 25:06 with Rob Andrews. 26:51 with Scott Conard, MD. 30:14 with Beau Raymond, MD. 34:22 Dr. Cole is published in various healthcare journals; check out his . /episode/index/show/healthvalue/id/36158985

EP472: The Well-Honed, Three-Prong Hospital Playbook to Maximize Revenue From High-Cost Claimants, With Eric Bricker, MD 04/17/2025

EP472: The Well-Honed, Three-Prong Hospital Playbook to Maximize Revenue From High-Cost Claimants, With Eric Bricker, MD In Episode 472, Stacey Richter speaks with Dr. Eric Bricker about the impactful strategies hospital systems use to maximize revenue from high-cost patients. They explore the financial complexities and contracting tactics that enable hospitals to profit significantly from a small percentage of high-cost claimants. Key points include the negotiation of provider stop-loss contract provisions, strategic adjustment of charge masters, and the intentional steerage of patients to high-revenue service lines. This episode highlights the intricacies of hospital finance and the hidden mechanisms that drive healthcare costs for self-insured employers and other plan sponsors. We could have 0.5% to 1% of total plan members costing upwards of 40% of total plan dollars. And I bring this up just to highlight the magnitude of the money here. In that show from last week, we take the issue of high-cost claimants from the standpoint of the plan sponsor. Today, however, we’re gonna be looking at this from the standpoint of the hospital system. If we were to come up with a motto for the show today with Dr. Eric Bricker, it’s that all costs are somebody else’s revenue. And when it’s revenue and profit of the magnitude that we’re talking about with many high-cost claimants, it starts to be less of an accidental “Oh, wow! How did that CABG patient wind up in our clinic? What are the odds?” and more of a “Whoever is not steering patients is letting someone else with a big profit incentive lock down that steerage in deeply embedded ways.” === LINKS === 🔗 Show Notes with all mentioned links: 📺 Dr. Bricker's AhealthcareZ Channel ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter: 🫙 Support the podcast with a small donation to the Tip Jar: 🎤 Listen on Apple Podcasts https://podcasts.apple.com/us/podcast/feed/id892082003?ls=1 🎤 Listen on Spotify 📺 Subscribe to our YouTube channel === CONNECT WITH THE RHV TEAM === ✭ LinkedIn https://www.linkedin.com/company/relentless-health-value/ ✭ Threads https://www.threads.net/@relentlesshealthvalue/ ✭ Bluesky https://bsky.app/profile/relentleshealth.bsky.social ✭ X https://twitter.com/relentleshealth/ 05:06 From a hospital revenue perspective, where do high-cost claimants fall? 08:45 How do hospitals structure their stop-loss provisions so that they ensure they’re always maximizing their revenue? 12:15 How hospitals acquire providers to steer as many patients as possible through specific service lines. 20:21 Why do carriers let hospitals get away with these rates and stop-loss negotiations? 21:06 How do Medicare Advantage and Medicare rates play into all of this? 22:00 What should a benefit consultant be doing here? 23:37 What are the keys to direct contracting? 27:21 Why is it important to get trusted relationships set up ahead of time? 28:04 by John Torinus Jr. 29:23 What needs to be the clinical consideration for specialists? 30:46 What is the advantage that employers have in all of this? 33:06 Dr. Bricker’s on 32 examples of healthcare deception. /episode/index/show/healthvalue/id/36065430

EP471: High-Cost Claimants in 2025 and Beyond—What Is Really Expensive Not to Know? With Christine Hale, MD, MBA 04/10/2025

EP471: High-Cost Claimants in 2025 and Beyond—What Is Really Expensive Not to Know? With Christine Hale, MD, MBA Recently on Relentless Health Value, we’ve been tinkering around with a few recurring themes—recurring through lines—that are just true about American healthcare these days. In this episode of Relentless Health Value, host Stacey Richter speaks with Dr. Christine Hale about high cost claimants and the implications for healthcare plans in 2025 and beyond. They discuss the importance of trust in patient care, the financial incentives behind patient steering, and the critical role of timely and comprehensive data analysis. Dr. Hale emphasizes the need for an integrated approach to medical and pharmacy claims data to avoid expensive consequences and improve patient outcomes. She also shares strategies for plan sponsors to effectively manage high cost claimants through evidence-based care, appropriate treatment settings, and creative problem-solving, while underlining the importance of patient engagement and satisfaction. Don't miss next week's episode with Dr. Eric Bricker for a deeper dive into these topics. === LINKS === 🔗 Show Notes with all mentioned links: https://relentlesshealthvalue.com/episodes ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter: https://relentlesshealthvalue.com/join-the-relentless-tribe 🫙 Support the podcast with a small donation to the Tip Jar: https://relentlesshealthvalue.com/join-the-relentless-tribe 🎤 Listen on Apple Podcasts https://podcasts.apple.com/us/podcast/feed/id892082003?ls=1 🎤 Listen on Spotify 📺 Subscribe to our YouTube channel https://www.youtube.com/@RelentlessHealthValue === CONNECT WITH THE RHV TEAM === ✭ LinkedIn ✭ Threads ✭ Bluesky ✭ X 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 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 with Matt McQuide. 25:37 What are the steps employers should take to improve their high-cost claimant spend? 31:02 with Erik Davis and Autumn Yongchu. 33:46 with Stacey. Recent past interviews: Click a guest’s name for their latest RHV episode! , , , , , , , , , , /episode/index/show/healthvalue/id/35962595

EP470: Continuing the ER and Primary Care Through Line Over to Rural Hospitals and Healthcare, With Nikki King, DHA 04/03/2025

EP470: Continuing the ER and Primary Care Through Line Over to Rural Hospitals and Healthcare, With Nikki King, DHA In this episode, host Stacey Richter revisits a conversation with Nikki King, CEO of Alliance Health Centers, discussing the critical issues facing rural hospitals and healthcare systems. They delve into the impacts of Medicaid cuts, the financial struggles of rural hospitals reliant on commercial insurance, and potential solutions like freestanding emergency rooms, telehealth, and the expanded roles of nurse practitioners. The conversation also covers the complexities of maternity care and mental health services in rural areas, emphasizing the urgent need for systemic reforms to ensure equitable access to healthcare. === LINKS === 🔗 Show Notes with all mentioned links: https://cc-lnk.com/EP470 ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter: https://relentlesshealthvalue.com/join-the-relentless-tribe 🫙 Support the podcast with a small donation to the Tip Jar: https://relentlesshealthvalue.com/join-the-relentless-tribe 📺 Subscribe to our YouTube channel https://www.youtube.com/@RelentlessHealthValue 🎤 Listen on Apple Podcasts https://podcasts.apple.com/us/podcast/feed/id892082003?ls=1 🎤 Listen on Spotify https://open.spotify.com/show/6UjgzI7bScDrWvZEk2f46b === CONNECT WITH THE RHV TEAM === ✭ LinkedIn https://www.linkedin.com/company/relentless-health-value/ ✭ Threads https://www.threads.net/@relentlesshealthvalue/ ✭ Bluesky https://bsky.app/profile/relentleshealth.bsky.social ✭ X https://twitter.com/relentleshealth/ 08:14 How dire is the rural hospital situation right now? 08:33 How could freestanding ERs be a potential solution for rural hospitals? 09:56 Advice from CHQPR: Rural hospitals should not be forced to eliminate inpatient care. 11:22 Why is broadband a roadblock to telehealth as a solution for rural health access? 14:52 What are other potential rural health access solutions? 15:37 The “hot potato” of nurse practitioners in the healthcare world. 16:34 “The number of residencies for physicians each year is not increasing, but the population … is increasing.” 20:28 with Douglas Eby, MD, MPH, CPE, of the Nuka System of Care. 22:00 What’s the issue with maternity care in rural America? 24:09 “As healthcare becomes more and more specialized, [the] ability to treat high-risk cases is better, but access gets worse.” 27:57 How is mental health care affected in rural communities? 28:29 “Rural communities are trying very hard to hang on to what they have.” 29:52 “When you look at the one market plan that’s available in a rural community, you probably can’t afford it.” 31:37 What’s the single biggest challenge to moving to a model that incentivizes keeping people healthy? 32:32 “The easiest low-hanging fruit … is having national Medicaid and have that put under the same hood as Medicare.” /episode/index/show/healthvalue/id/35874890

EP469 (Part 2): The Impact on Plan Sponsors of Medicare Site-Neutral Payments and HSA Reforms, With James Gelfand, JD 03/27/2025

EP469 (Part 2): The Impact on Plan Sponsors of Medicare Site-Neutral Payments and HSA Reforms, With James Gelfand, JD In part 2 of episode 469, host Stacey Richter discusses the implications of Medicare site neutral payments and Health Savings Account (HSA) reforms with James Gelfand, president and CEO of the ERISA Industry Committee (ERIC). The episode details how plan sponsors should adapt to Medicare's site neutral payment policies aimed at curbing hospital consolidation and inflated prices through facility fees and markups. Gelfand provides insights into how HSA reforms currently in Congress could expand the scope of preventive care covered before deductibles are met, benefitting both employers and employees. The conversation also touches on the challenges high deductible health plans pose and the potential benefits of codifying recent IRS guidance to allow greater flexibility in pre-deductible coverage. The discussion underscores the importance of plan sponsors staying ahead of Medicare policies to avoid higher costs. === LINKS === 🔗 Show Notes with all mentioned links: https://relentlesshealthvalue.com/episodes ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter: https://relentlesshealthvalue.com/join-the-relentless-tribe 🫙 Support the podcast with a small donation to the Tip Jar: https://relentlesshealthvalue.com/join-the-relentless-tribe 🎤 Listen on Apple Podcasts https://podcasts.apple.com/us/podcast/feed/id892082003?ls=1 🎤 Listen on Spotify https://open.spotify.com/show/6UjgzI7bScDrWvZEk2f46b 📺 Subscribe to our YouTube channel https://www.youtube.com/@RelentlessHealthValue === CONNECT WITH THE RHV TEAM === ✭ LinkedIn https://www.linkedin.com/company/relentless-health-value/ ✭ Threads https://www.threads.net/@relentlesshealthvalue/ ✭ Bluesky https://bsky.app/profile/relentleshealth.bsky.social ✭ X https://twitter.com/relentleshealth/ 05:42 What does Medicare site-neutral payments mean? 08:59 How do markups play into the dynamics here? 09:52 Upcoming episode with Christine Hale, MD, MBA. 10:36 What does the “narrow” start for these changes mean? 11:42 What action steps should plan sponsors be taking? 13:01 What options do plan sponsors have in highly consolidated markets? 14:27 with Erik Davis and Autumn Yongchu. 14:53 EP448 ( and ) with Shawn Gremminger. 15:46 Will this bill potentially make changes to HSA plans? 17:40 Why has the thinking behind healthcare usage changed since the inception of HSAs? 18:42 with Stacey. 23:24 How are preventive care and first-dollar coverage connected within the context of HSAs? 25:48 Why would it be difficult to completely get rid of a high-deductible health plan and offer HSAs without them? /episode/index/show/healthvalue/id/35733980

EP469 (Part 1): The Impact on Plan Sponsors of Medicaid Cuts, With James Gelfand, JD 03/27/2025

EP468: Very Common Assumptions That Aren’t Actually True About Member Engagement and the Healthcare Industry, With Matt McQuide 03/20/2025

EP468: Very Common Assumptions That Aren’t Actually True About Member Engagement and the Healthcare Industry, With Matt McQuide In Episode 468, host Stacey Richter engages in a conversation with Matt McQuide, CEO of Synergy Healthcare. This episode delves into the critical assumptions surrounding member engagement within the healthcare industry. Key points discussed include the role of employers in steering plan members, the importance of member engagement for navigating the healthcare marketplace, and Matt’s three major misconceptions about health plan membership. Matt also presents real-life examples of how engagement significantly impacts health outcomes, emphasizing that relationships and trust are paramount. The episode concludes with practical strategies for employers to enhance engagement and manage employee health effectively. === LINKS === 🔗 Show Notes with all mentioned links: https://cc-lnk.com/EP468 ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter: https://relentlesshealthvalue.com/join-the-relentless-tribe 🫙 Support the podcast with a small donation to the Tip Jar: https://relentlesshealthvalue.com/join-the-relentless-tribe 🎤 Listen on Apple Podcasts https://podcasts.apple.com/us/podcast/feed/id892082003?ls=1 🎤 Listen on Spotify https://open.spotify.com/show/6UjgzI7bScDrWvZEk2f46b 📺 Subscribe to our YouTube channel https://www.youtube.com/@RelentlessHealthValue === CONNECT WITH THE RHV TEAM === ✭ LinkedIn https://www.linkedin.com/company/relentless-health-value/ ✭ Threads https://www.threads.net/@relentlesshealthvalue/ ✭ Bluesky https://bsky.app/profile/relentleshealth.bsky.social ✭ X https://twitter.com/relentleshealth/ You can learn more at and by following Matt on . Matt McQuide is the founder and CEO of Synergy Healthcare, a role he has held since launching the company in 2012. Under his leadership, Synergy has made significant strides in improving member health, enhancing the health insurance experience and the financial integrity of health plans. 06:28 What are Matt’s three common assumptions that employers make about member engagement? 07:08 “Health is actually hard.” 08:19 Why is it important to meet people when their need for healthcare sparks their interest in their health? 11:29 “It didn’t take much … it just takes time.” 13:53 Why are relationships and trust more important today for employee health and member engagement? 16:04 Do people actually want optimal health? 17:44 Why is it important to meet people where they are today? 22:38 “Employers don’t want to fix healthcare.” 24:10 Why it’s important to remember that claims are real people. 24:38 from Steve Schutzer, MD, about with Betsy Seals. 26:44 How do you solve the “middle way”? /episode/index/show/healthvalue/id/35637995

EP467: Connecting Sky-High ER Spend to Primary Care Access—Following the Dollar Through Carriers and Hospitals, With Stacey Richter 03/13/2025

EP466: What Is Rising Faster, Insurance Premiums or Hospital Prices? With Vivian Ho, PhD 03/06/2025

EP466: What Is Rising Faster, Insurance Premiums or Hospital Prices? With Vivian Ho, PhD Healthcare costs keep rising, but what’s driving those increases? In this episode, Stacey Richter speaks with Dr. Vivian Ho, a health economist at Rice University and Baylor College of Medicine, to break down the real reasons behind skyrocketing commercial insurance premiums. Are insurance premiums rising faster than wages—and why does it matter? What’s the biggest driver of premium increases? (Spoiler: It’s hospital prices.) Are hospital price hikes justified by rising costs—or is something else at play? Dr. Ho shares data-backed insights on hospital consolidation, executive incentives, and how health system pricing impacts self-insured employers and plan sponsors. If you’re a healthcare executive or a jumbo employer managing benefits, this episode is a must-listen. === LINKS === 🔗 Show Notes with all mentioned links:https://relentlesshealthvalue.com/episodes ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter:https://relentlesshealthvalue.com/join-the-relentless-tribe 🫙 Support the podcast with a small donation to the Tip Jar:https://relentlesshealthvalue.com/join-the-relentless-tribe 🎤 Listen on Apple Podcastshttps://podcasts.apple.com/us/podcast/feed/id892082003?ls=1 🎤 Listen on Spotify https://open.spotify.com/show/6UjgzI7bScDrWvZEk2f46b 📺 Subscribe to our YouTube channel https://www.youtube.com/@RelentlessHealthValue === CONNECT WITH THE RHV TEAM === ✭ LinkedIn ✭ Bluesky ✭ Threads ✭ X 05:12 Are insurance premiums going up?05:59 What is the disparity between cost of insurance and wage increases?06:21 LinkedIn by Byron Hugley.06:25 by Michael Strain.06:46 How much have insurance premiums gone up for employers versus employees?09:06 showing the cost to insure populations of employees and families.10:17 What is causing hospital prices and insurance premiums to go up so exponentially?12:53 by (and tribute to) Uwe Reinhardt.13:49 with Marilyn Bartlett, CPA, CGMA, CMA, CFM.15:28 Are razor-thin operating margins for hospitals causing these rising hospital prices?16:56 Collaboration with Marilyn Bartlett and the .19:47 What is the explanation that hospitals give for justifying these profits?23:16 How do these hospital cost increases actually happen?27:06 by Zack Cooper, PhD.27:50 Who typically makes up a hospital board, and why do these motivations incentivize hospital price increases?30:12 with Mark Cuban and Ferrin Williams, PharmD, MBA.33:17 Why is it vital that change start at the board level? /episode/index/show/healthvalue/id/35427765

EP465: The Not Super Effective Contracting Industry Norm, Where Jumbo Plans and Others Wind Up Paying $10,000 for $50 Drugs, With Chris Crawford 02/27/2025

EP465: The Not Super Effective Contracting Industry Norm, Where Jumbo Plans and Others Wind Up Paying $10,000 for $50 Drugs, With Chris Crawford The Hidden Costs of PBMs: How Aggregate Discount Guarantees Inflate Drug Prices. In episode 465 of Relentlessly Seeking Value, host Stacey Richter interviews Chris Crawford, CEO of RxSaveCard, about the inflated costs within the pharmacy benefits industry. The discussion centers around a lawsuit involving J&J, highlighting how large PBMs can significantly overcharge for drugs that are available much cheaper through cash-pay options like Mark Cuban's Cost Plus Drugs. Crawford explains how Aggregate Discount Guarantees, a common contracting mechanism, often fail to control spread pricing effectively and instead may lead to higher costs for plan sponsors and employees. The episode also covers how RxSaveCard can help employers and employees access these lower cash prices, circumventing the inflated costs from traditional PBMs. === LINKS === 🔗 Show Notes with all mentioned links: https://cc-lnk.com/EP465 ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter: https://relentlesshealthvalue.com/join-the-relentless-tribe 🫙 Support the podcast with a small donation to the Tip Jar: https://relentlesshealthvalue.com/join-the-relentless-tribe 🎤 Listen on Apple Podcasts https://podcasts.apple.com/us/podcast/feed/id892082003?ls=1 🎤 Listen on Spotify 📺 Subscribe to our YouTube channel https://www.youtube.com/@RelentlessHealthValue === CONNECT WITH THE RHV TEAM === ✭ LinkedIn ✭ Bluesky ✭ Threads ✭ X 07:12 with Scott Haas. 07:17 with Paul Holmes. 07:19 with Luke Slindee, PharmD. 07:20 with AJ Loiacono. 07:44 What is the Aggregate Discount Guarantee? 13:49 Why do the divergent list prices and the perverse incentives prevent the Aggregate Discount Guarantee from really limiting cost spread? 17:55 Why is it important for plan sponsors to check these drug cost prices, and how can employers check them? 23:56 What drives cost lower, and why does it change everything? 25:09 How does RxSaveCard work? 25:44 with Chris Crawford. 30:01 Do you need a PBM’s permission to use RxSaveCard? 30:37 How does it look for employers/employees to use the RxSaveCard? 32:39 with Ge Bai, PhD, CPA. /episode/index/show/healthvalue/id/35335240

EP464: ER Visits Now 6% of Total Plan Spend. Is It Upcoding or What? With Al Lewis 02/20/2025

EP464: ER Visits Now 6% of Total Plan Spend. Is It Upcoding or What? With Al Lewis Emergency room costs now make up 6% of total healthcare plan spending—why? In this episode, host Stacey Richter welcomes Al Lewis to break down the data behind rising ER expenses, separating fact from fiction. They discuss whether increased patient acuity or widespread upcoding is driving costs, the impact of the No Surprises Act, and why plan sponsors struggle to negotiate fair ER rates. Plus, Al shares actionable strategies for employers to push back against inflated charges. If you want to understand the hidden forces behind escalating ER bills, this is a must-listen. You can find the charts and links mentioned in the show notes in the link below. === LINKS === 🔗 Show Notes with all mentioned links: https://cc-lnk.com/EP464 ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter: https://relentlesshealthvalue.com/join-the-relentless-tribe 🫙 Support the podcast with a small donation to the Tip Jar: https://relentlesshealthvalue.com/join-the-relentless-tribe 📺 Subscribe to our YouTube channel https://www.youtube.com/@RelentlessHealthValue 🎤 Listen on Apple Podcasts https://podcasts.apple.com/us/podcast/feed/id892082003?ls=1 🎤 Listen on Spotify https://open.spotify.com/show/6UjgzI7bScDrWvZEk2f46b === CONNECT WITH THE RHV TEAM === ✭ LinkedIn ✭ Bluesky ✭ Threads https://www.threads.net/@relentlesshealthvalue/ ✭ X 00:00 Introduction 08:32 What is going on in ER visits, and how big of a deal is the total spend? 10:16 Why is the price of ER visits going up when it should be going down? 11:59 What is the major source of unexpected medical debt? 13:27 What is code creep, and why is it happening? 16:26 Why are plan sponsors unable to negotiate emergency room services? 19:22 with Rob Andrews. 25:53 Why is it important not to agree to consent when you go in to visit the ER? 27:47 with Al Lewis. 31:28 What steps can plan sponsors take to be proactive about limiting ER spending for their employees? You can learn more at and by emailing . You can also follow Al on . Recent past interviews: Click a guest’s name for their latest RHV episode! , , , , , , , , , /episode/index/show/healthvalue/id/35228235

EP463: Medicare Advantage Policies—Which Will Stay and Which Will Go Now? With Betsy Seals 02/13/2025

EP463: Medicare Advantage Policies—Which Will Stay and Which Will Go Now? With Betsy Seals In this episode of Relentless Health Value, host Stacey Richter engages with Betsy Seals, CEO and co-founder of Rebellis Group, to analyze the future of key Medicare Advantage policies amidst a changing political landscape. They delve into four critical areas: 1. Medicare Advantage Stars Program: Examining potential changes due to recent lawsuits and the new administration’s stance on quality measures. 2. Risk Adjustment and Government Oversight: Discussing the focus on recouping improper payments and how oversight might evolve. 3. Use of Artificial Intelligence: Considering appropriate oversight for AI applications in prior authorization processes and ensuring they benefit patient care. 4. Agent and Broker Oversight: Exploring increased scrutiny over marketing practices and the dissemination of accurate information to beneficiaries. Betsy emphasizes the importance for Medicare Advantage plans to prioritize patient value, maintain compliance, and proactively utilize data to navigate these evolving policies. This discussion provides valuable insights for stakeholders aiming to understand the future of Medicare Advantage. === LINKS === 🔗 Show Notes with all mentioned links: https://cc-lnk.com/EP463 ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter: https://relentlesshealthvalue.com/join-the-relentless-tribe 🫙 Support the podcast with a small donation to the Tip Jar: https://relentlesshealthvalue.com/join-the-relentless-tribe 🎤 Listen on Apple Podcasts https://podcasts.apple.com/us/podcast/feed/id892082003?ls=1 🎤 Listen on Spotify 📺 Subscribe to our YouTube channel https://www.youtube.com/@RelentlessHealthValue === CONNECT WITH THE RHV TEAM === ✭ LinkedIn ✭ Bluesky ✭ Threads https://www.threads.net/@relentlesshealthvalue/ ✭ X https://twitter.com/relentleshealth/ 05:09 Will the Star Ratings program stay in this new administration? 08:08 How will the lawsuits against CMS policies play out with this new administration? 10:24 Why is it hard for Medicare Advantage plans to survive, let alone thrive? 16:22 How does AI directly impact beneficiary lives? 21:38 What’s going on now with the override payments? 27:08 How is non-collaboration going to impact Medicare beneficiaries moving forward? 31:45 Why is it important to become more technologically savvy in compliance? /episode/index/show/healthvalue/id/35136530

Encore! EP384: How Shareholders Impact Carrier Behavior, Exactly and Specifically, With Wendell Potter 02/06/2025

Encore! EP384: How Shareholders Impact Carrier Behavior, Exactly and Specifically, With Wendell Potter In this episode, Stacey Richter explores how the demands of shareholders influence the actions of publicly traded health insurance companies with guest Wendell Potter. Drawing from Milton Friedman’s assertion that a business’s primary responsibility is to its shareholders, we examine the implications of this philosophy in the healthcare sector. The discussion highlights concerns about fraud allegations among major insurers and the lack of open competition due to market consolidation. We delve into the concept of the “medical loss ratio,” a key metric for investors, and how it pressures insurers to prioritize profits, often at the expense of patient care. Our guest, Wendell Potter, a former health insurance executive turned advocate for healthcare reform, provides insider insights into these dynamics. He discusses the challenges insurers face in controlling costs, the impact of rising premiums, and the broader consequences for patients and the healthcare system. This episode offers a critical look at the intersection of corporate interests and patient care, shedding light on the systemic issues that arise when profit motives drive healthcare decisions. All mentioned links can be found in the show notes. === LINKS === 🔗 Show Notes with all mentioned links: https://cc-lnk.com/Encore384 ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter: https://relentlesshealthvalue.com/join-the-relentless-tribe 🫙 Support the podcast with a small donation to the Tip Jar: https://relentlesshealthvalue.com/join-the-relentless-tribe 🎤 Listen on Apple Podcasts https://podcasts.apple.com/us/podcast/feed/id892082003?ls=1 🎤 Listen on Spotify https://open.spotify.com/show/6UjgzI7bScDrWvZEk2f46b 📺 Subscribe to our YouTube channel https://www.youtube.com/@RelentlessHealthValue === CONNECT WITH THE RHV TEAM === ✭ LinkedIn ✭ Bluesky ✭ Threads https://www.threads.net/@relentlesshealthvalue/ ✭ X 08:31 What is the medical loss metric? 11:33 “The reality is, insurers have been jacking up premiums … for a long time.” 12:48 “It’s a short-term game.” 15:39 “You’re seeing that these companies are not doing a very good job … of controlling costs because they don’t have the incentive.” 20:19 with Kevin Schulman, MD. 22:45 How do payers ensure that they’re controlling utilization? 25:53 “It’s death by a thousand cuts.” 31:51 “Just like independent practice physicians are endangered, so are community pharmacists.” 33:17 Who runs our healthcare system? /episode/index/show/healthvalue/id/35053460

EP462: Managing Populations of Whole, Actual People Who Are Not the Sum of a Bunch of Different Body Parts, With Scott Conard, MD 01/30/2025

EP462: Managing Populations of Whole, Actual People Who Are Not the Sum of a Bunch of Different Body Parts, With Scott Conard, MD This podcast today is with Dr. Scott Conard, founder of Converging Health. You might remember him from the earlier episode (). First of all, I enjoyed how it came to be. Brian Uhlig, an employee benefit consultant of some acclaim, came to me and offered to sponsor a show for someone else. Not himself. I gotta say, it’s stuff like this that warms my heart. It’s this village that we have here, this tribe of Relentless folks trying so hard to stand up for and help patients. So, thanks again to Brian Uhlig. Right now, Dr. Conard is doing a bunch of work with Mike Adams from 7-Eleven, helping their plan members. A lot of this work is centered on and about a few pretty striking but very common insights that many plan sponsors will find in their own data. It turns out about 70%, give or take, of people who wind up costing the plan whatever the high-cost threshold is in any given plan year. These higher-cost claimants didn’t fall out of the sky unexpectedly, 70% of them. They were actually high risk but low cost in prior years. So, the trick is to find these individuals and help them not fall into the high-risk and high-cost part of the graph. If the goal is how to best manage a population of members, a lot of that is, again, identifying high-risk patients who are currently in the low-cost zone, who, any given plan year, are gonna go out of that zone and get into the high-cost area. So, if we’re thinking about best practices to avoid this, I’m gonna run through Dr. Conard’s list that we mostly run through in the show that follows. Lastly, we touch a little bit in the show today on community-run primary care. This is a community paying for primary care for community members, just like they pay the fire department and the police department. There’s a town in Rhode Island doing this that Dr. Conard talks about today. In fact, Michael Fine, MD, is part of this effort in Rhode Island. === LINKS === 🔗 Show Notes with all mentioned links and articles: https://cc-lnk.com/EP462 ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter: https://relentlesshealthvalue.com/join-the-relentless-tribe 🫙 Support the podcast with a small donation to the Tip Jar: https://relentlesshealthvalue.com/join-the-relentless-tribe 🎤 Listen on Apple Podcasts https://podcasts.apple.com/us/podcast/feed/id892082003?ls=1 🎤 Listen on Spotify 📺 Subscribe to our YouTube channel https://www.youtube.com/@RelentlessHealthValue === CONNECT WITH THE RHV TEAM === ✭ LinkedIn ✭ Bluesky ✭ Threads ✭ X 07:10 How do we think about data wrongly, and how does that affect our healthcare spend in regard to population health? 09:43 What needs to be done with population health data once it’s collected. 14:48 in Rhode Island doing effective proactive care. 16:09 with Marty Makary, MD, MPH. 16:44 A real, successful case study. 24:08 How do we define high-cost patients? 24:14 What do we know about high-cost patients in regard to population health spend? 29:02 Why avoiding prevention in primary care only harms yourself in the future. /episode/index/show/healthvalue/id/34943260

INBW42: A Philosophical Rabbit Hole of Considerations for Plan Sponsors and Others 01/23/2025

INBW42: A Philosophical Rabbit Hole of Considerations for Plan Sponsors and Others In this inbetweenisode Stacey Richter dives into the complexities of benefit design in American healthcare. Highlighting insights from recent episodes with Bill Sarraille () and upcoming episode with Scott Conard, MD, Richter explores the impact of cost containment measures and the moral hazard of insurance, emphasizing the importance of creating balanced and efficient benefit plans that align with plan values and avoid unintended consequences. She discusses the challenges and implications of high deductible health plans and copay maximizers/accumulators, urging plan sponsors to strive for pareto optimality and practical solutions. This episode is a call to carefully consider patient behavior, healthcare utilization, and the broader impacts of financial incentives in healthcare. Going black and white or over-indexing to prevent outlier kind of stuff is probably not gonna end well. Not seeking a middle way can easily result in a solution that is possibly worse than the problem. Moral hazard is actually a thing. There are lots of implications to patients not being able to distinguish high-value and low-value care. But if we know this, then, philosophically at least, how do we conceptualize a solve? What should we be doing? If we’re not doing black and white, what does the gray in the middle look like? === LINKS === 🔗 Show Notes with all mentioned links: https://cc-lnk.com/INBW42 ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter: https://relentlesshealthvalue.com/join-the-relentless-tribe 🫙 Support the podcast with a small donation to the Tip Jar: https://relentlesshealthvalue.com/join-the-relentless-tribe 🎤 Follow on Apple Podcasts https://podcasts.apple.com/us/podcast/feed/id892082003?ls=1 🎤 Follow on Spotify 📺 Subscribe to our YouTube channel https://www.youtube.com/@RelentlessHealthValue === CONNECT WITH THE RHV TEAM === ✭ LinkedIn https://www.linkedin.com/company/relentless-health-value/ ✭ Threads https://www.threads.net/@relentlesshealthvalue/ ✭ X https://twitter.com/relentleshealth/ ✭ Bluesky https://bsky.app/profile/relentleshealth.bsky.social 00:00 Introduction to the Rabbit Hole 04:05 Where did Stacey’s rabbit hole spiral start? 05:40 What is the moral hazard of insurance? 09:31 with Wayne Jenkins, MD. 12:49 Why isn’t moral hazard mitigated in insurance? 18:16 with Bill Sarraille. 20:51 “How do we conceptualize a solve?” 22:24 Why should we be striving for Pareto optimality? 25:20 What is the theory of second best? /episode/index/show/healthvalue/id/34840500

EP461: Pick Only One, Plan Sponsors: Do You Want to Control GLP-1 Volume or Control GLP-1 Unit Cost? With Chris Crawford 01/16/2025

EP461: Pick Only One, Plan Sponsors: Do You Want to Control GLP-1 Volume or Control GLP-1 Unit Cost? With Chris Crawford This episode with Chris Crawford, CEO of RxSaveCard, is not about the when, why, or how of GLP-1s for weight loss or best-practice prescribing. This episode very, very specifically is about the how and why of the pickle plan sponsors get themselves into often enough where if they impose formulary restrictions to limit the volume of meds that they are paying for, then unit prices go up, which is a thing for GLP-1s. And this is critical just given how the costs associated with GLP-1s for weight loss contribute to some pretty significant increases in pharmacy trend for plan sponsors who choose to cover the GLP-1s for weight loss. Chris Crawford and Stacey Richter discuss the challenges plan sponsors face with the rising costs of GLP-1 medications for weight loss. They explore how plan sponsors’ efforts to manage pharmacy trends often result in a tradeoff: lowering unit costs by increasing volume or vice versa. Chris also introduces a potential solution leveraging the growing cash marketplace, where employers can bypass traditional PBM contracts to achieve cost savings. Tune in for actionable insights into the perverse incentives in the pharmacy supply chain and innovative ways to navigate them. (Continued below the links) === LINKS === 🔗 Show Notes with all mentioned links: hhttps://cc-lnk.com/EP461 ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter: https://relentlesshealthvalue.com/join-the-relentless-tribe 🫙 Support the podcast with a small donation to the Tip Jar: https://relentlesshealthvalue.com/join-the-relentless-tribe 🎤 Listen on Apple Podcasts https://podcasts.apple.com/us/podcast/feed/id892082003?ls=1 🎤 Listen on Spotify 📺 Subscribe to our YouTube channel https://www.youtube.com/@RelentlessHealthValue === CONNECT WITH THE RHV TEAM === ✭ LinkedIn https://www.linkedin.com/company/relentless-health-value/ ✭ Threads https://www.threads.net/@relentlesshealthvalue/ ✭ X https://twitter.com/relentleshealth/ ✭ Bluesky https://bsky.app/profile/relentleshealth.bsky.social Bottom line, there are some really impactful and not frequently delved into perverse incentives at play here. And we’re gonna talk about these today. And these are really key for anybody on or about the pharmacy supply chain in the U.S. to know about. This is very actionable insight. So, again, there’s an unfortunate tradeoff, as it stands right now, for many plan sponsors. Lower your volume and raise the unit price or vice versa. This episode is sponsored by , and a big thanks for that. I really appreciate RxSaveCard for its financial support because this episode covers a really important topic that we probably would have covered anyway over here at Relentless Health Value. And so, RxSaveCard standing up and offering their financial support to cover it was a really nice thing to do. And I thank them for their generosity. 07:57 What are the two pieces going on with GLP-1 PBM prices and rebates for employers? 10:00 Is the cash price for these name brand drugs currently less than the rebated PBM price? 11:49 Why does the rebate for GLP-1s disappear if employers try to put restrictions on who can receive access to these drugs? 15:07 Where does RxSaveCard come in to play here? 19:55 “We exist to save people money.” 20:45 with Brian Reid. 21:16 with Ge Bai, PhD, CPA. 21:37 with Luke Slindee, PharmD. /episode/index/show/healthvalue/id/34759110

EP460: Rushika Fernandopulle, MD’s Theory of Change Starts With Status Quo Healthcare 01/09/2025

EP460: Rushika Fernandopulle, MD’s Theory of Change Starts With Status Quo Healthcare In this Relentless Health Value episode, Dr. Rushika Fernandopulle discusses with Stacey Richter his four-prong theory of change for transforming the American healthcare system. Key topics include the necessity of new payment models, process innovation, employing a relational technology infrastructure, shifting the cultural mindset towards team-based care, and emphasizing the importance of long-term partnerships. The conversation underscores the urgent need to move away from the current status quo to ensure better health outcomes and affordable care for all Americans. This is one of those episodes where we consider top-line strategic imperatives and key drivers. There was no better person to do this with than Rushika Fernandopulle, MD, who, in case you were unaware, was the founder of Iora Health, an advanced primary care group that was sold to One Medical and then to Amazon. They discusses his four-prong theory and as Stacey says, "I can’t leave well enough alone, so I plucked one more prong from our conversation and stuck it on the end." For a summary of this 5 prong approach, visit the show notes page where we also list all of the links mentioned in the episode. === LINKS === 🔗 Show Notes with all mentioned links: https://cc-lnk.com/EP460 ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter: https://relentlesshealthvalue.com/join-the-relentless-tribe 🫙 Support the podcast with a small donation to the Tip Jar: https://relentlesshealthvalue.com/join-the-relentless-tribe 🎤 Listen on Apple Podcasts https://podcasts.apple.com/us/podcast/feed/id892082003?ls=1 🎤 Listen on Spotify 📺 Subscribe to our YouTube channel === CONNECT WITH THE RHV TEAM === ✭ LinkedIn https://www.linkedin.com/company/relentless-health-value/ ✭ Threads https://www.threads.net/@relentlesshealthvalue/ ✭ X https://twitter.com/relentleshealth/ ✭ Bluesky 06:39 How Dr. Rushika Fernandopulle found himself where he is now. 08:06 Dr. Fernandopulle’s conversation with Kenny Cole, MD. 10:33 Why is it important to have new payment models? 12:21 with Claire Brockbank. 14:50 with Beau Raymond, MD. 16:19 Why it makes sense to change as quickly as possible. 19:55 How to be proactive and not be reactive and achieve value-based reimbursement for good care. 21:41 Why team-based care is so important for change. 23:37 Why is it important to have a different set of technology tools? 24:38 with Scott Conard, MD. 25:24 Why changing the culture is important. 27:01 “Getting doctors to do things they don’t like is a waste of time.” 33:22 “Healthcare is local.” 35:31 with David Muhlestein, PhD, JD. 35:43 by Zack Cooper, PhD. 36:53 with Suhas Gondi, MD, MBA. 39:04 Why long-term partnerships are the only way to make things better. /episode/index/show/healthvalue/id/34672655

EP459: Cost Containment by Co-Pay Maximizer or Co-Pay Accumulator: Points to Ponder, With Bill Sarraille 01/02/2025

EP459: Cost Containment by Co-Pay Maximizer or Co-Pay Accumulator: Points to Ponder, With Bill Sarraille In Episode 459, host Stacey Richter speaks with healthcare attorney Bill Sarraille about co-pay maximizers and accumulators, mechanisms designed to extract maximum co-pay support dollars from pharmaceutical companies. They discuss the financial implications for patients, plan sponsors, and pharmacy benefit managers (PBMs), emphasizing the legal and ethical issues and potential patient harm due to high out-of-pocket costs and surprise expenses. Sarraille provides five key pieces of advice for plan sponsors and highlights the importance of transparency and proper utilization management to minimize patient access problems and legal risks. Listen or read the on our site for the full list. (continued below the links) === LINKS === 🔗 Show Notes with all mentioned links: https://cc-lnk.com/EP459 ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter: 🫙 Support the podcast with a small donation to the Tip Jar: ===CONNECT WITH THE RHV TEAM === ✭ LinkedIn ✭ Threads ✭ X ✭ Bluesky Co-pay maximizers and accumulators are programs designed to capture maximum co-pay assistance from phara. Maximizers spread pharma co-pay support evenly throughout the year, ensuring plan sponsors benefit while, in theory, patients face minimal costs. More on how that can go wrong in the episode. Accumulators, however, design their plan to deplete pharma dollar support quickly, surprising patients with significant out-of-pocket expenses mid-year when they go visit the pharmacy. These programs usually exclude pharma assistance dollars from deductibles, potentially causing financial hardship because when pharma is paying your co-pay, those payments don't count against your deductible. 09:31 What should plan sponsors be aware of right now? 14:01 What is the justification for maximizers, and why is this at odds with the purpose of insurance? 18:05 Where does the issue of “fairness” land within cost containment? 20:00 Brian Reid’s LinkedIn on insurance company access challenges. 21:30 What are the real legal issues presented by some of these co-pay maximizers and co-pay accumulator programs? 27:06 How are these programs creating perverse incentives? 29:28 with Marilyn Bartlett, CPA, CGMA, CMA, CFM. 32:16 “If you’re covered by the ACA, I think this is unlawful.” 32:57 What advice does Bill have in regard to these programs? 33:49 What potential litigations does Bill see coming in the near future in regard to these co-pay maximizers and co-pay accumulator programs? /episode/index/show/healthvalue/id/34592660

INBW41: End-of-Year Wrap-Up and My Personal Charter Encore: Where the Rubber Hits the Road 12/26/2024

INBW41: End-of-Year Wrap-Up and My Personal Charter Encore: Where the Rubber Hits the Road In this Inbetweenisode titled 'End of Year Wrap Up and My Personal Charter Encore,' Stacey Richter extends heartfelt thanks to listeners and healthcare workers for their dedication. She reflects on the challenges of maintaining personal integrity in a profit-driven healthcare system and introduces her personal charter. This charter, focused on ensuring net positive outcomes for patients, acknowledges that achieving transformational change in healthcare requires a collective effort. Stacey discusses the complexities of balancing ethical decisions, financial constraints, and the broader impact on patient care, urging others to reflect on their own guiding principles. Here's her manifesto which she is now calling her Personal Charter below which she breaks down in this podcast episode: "If the thing results in a net positive for patients, then I will do it. The timeframe is short-term or medium-term. And the assumption is that it will take a village and I am not alone in my efforts to transform healthcare or do right by patients." === LINKS === 🔗 Show Notes with all mentioned links: https://cc-lnk.com/INBW41 ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter: https://relentlesshealthvalue.com/join-the-relentless-tribe 🫙 Support the podcast with a small donation to the Tip Jar: https://relentlesshealthvalue.com/join-the-relentless-tribe === CONNECT WITH THE RHV TEAM === ✭ LinkedIn https://www.linkedin.com/company/relentless-health-value/ ✭ Threads https://www.threads.net/@relentlesshealthvalue/ ✭ X https://twitter.com/relentleshealth/ ✭ Bluesky 06:52 “It’s a zero-sum game.” 07:02 Is the amount of profit fair? 07:13 What is an inescapable fact of the healthcare industry? 07:30 What does the financialization of healthcare mean? 07:55 Why does the self-interest in healthcare matter? 09:54 “It’s basically up to us as individuals to do the right thing.” 13:39 What is the first part of Stacey’s personal charter? 13:54 How does Stacey calculate the net positive of an impact? 14:17 What are two major upsides/downsides that Stacey contemplates? 17:08 Why are incremental change and disruptive change not mutually exclusive? 21:16 “I always try to keep in mind that it will take a village.” 22:55 Why finger pointing is killing innovation in healthcare. /episode/index/show/healthvalue/id/34489185

Encore! EP419: The Financialization of Health Benefits for Boards of Directors and C-Suites of Self-Insured Employers, With Andreas Mang 12/19/2024

Encore! EP419: The Financialization of Health Benefits for Boards of Directors and C-Suites of Self-Insured Employers, With Andreas Mang Are you on the board of directors of a company? Or are you a shareholder of a publicly traded company? Or are you a CEO or a CFO or in-house counsel who reports to a board of directors or these shareholders? Well, this show is for you. And it’s about how the healthcare industry has become financialized at the same time that providing health benefits has become the second-biggest line item after payroll for most companies. We talked about that in a recent encore with Mark Cuban () also, as well as the show with Cora Opsahl () and Claire Brockbank () from 32BJ. In this encore episode of 'Relentless Health Value,' Stacey Richter interviews Andreas Mang from Blackstone about the financialization of health benefits for boards of directors and C-suites of self-insured employers. They discuss the unseen financial layers in healthcare benefits and how companies can save significantly while improving employee satisfaction and health. === LINKS === 🔗 Show Notes with all mentioned links: ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter: 🫙 Support the podcast with a small donation to the Tip Jar: === CONNECT WITH THE RHV TEAM === ✭ LinkedIn https://www.linkedin.com/company/relentless-health-value/ ✭ Threads https://www.threads.net/@relentlesshealthvalue/ ✭ X https://twitter.com/relentleshealth/ ✭ Bluesky https://bsky.app/profile/relentleshealth.bsky.social 04:55 Why Andreas starts every conversation with the question, “How’s your healthcare company?” 07:38 Why is it important, as a self-insured employer, to treat your business as a small healthcare company? 09:16 Why is it unnatural for companies to be providing health insurance? 10:47 What can be achieved when there is alignment between employers and insurers? 12:41 What things can a company do to reduce spend by 10%? 14:14 Why is it better to have CFO engagement in the benefits plan throughout the year? 16:25 Why does self-insurance save 5% to 9% for companies automatically? 18:14 “The funding isn’t a healthcare thing; it’s a CFO thing.” 18:27 Why is it vital to have a reliable, trustworthy broker? 25:12 When is the last time your company has RFP’d their health plan? 27:39 Why does changing a health plan feel scary but is necessary? 28:31 What is a dependent eligibility audit? 31:20 Why are employers better together? 34:34 How do employers truly get a flat-fee model with brokers? /episode/index/show/healthvalue/id/34370155

EP458: A Really Unexpected Consideration for Solving Staffing Shortages That Impact Access and Care Quality That Is Based on a Ton of Evidence, With Komal Bajaj, MD 12/12/2024

EP458: A Really Unexpected Consideration for Solving Staffing Shortages That Impact Access and Care Quality That Is Based on a Ton of Evidence, With Komal Bajaj, MD In Episode 458 of Relentless Health Value, host Stacey Richter speaks with Dr. Komal Bajaj about innovative strategies for addressing staffing shortages in the healthcare sector. They explore the importance of cultural alignment within organizations, emphasizing trust and shared values to retain staff. Dr. Bajaj shares surprising findings from surveys indicating that healthcare workers are motivated by the goal of providing high-quality, planet-friendly care. The discussion highlights the interconnectedness of environmental sustainability and healthcare quality, presenting tangible ways to engage and empower healthcare workers while addressing both local community health and broader environmental concerns. The episode underscores the strategic importance of aligning organizational goals with the aspirations of the workforce to foster trust and mitigate staffing shortages. Stacey's guest today is Dr. Komal Bajaj. Dr. Bajaj is an ob-gyn who serves as the chief quality officer for a couple of hospitals in the Bronx, New York, that are part of the municipal health system of New York. She also now serves as medical director of sustainability for the municipal health system NYC Health + Hospitals. === LINKS === 🔗 Show Notes with all mentioned links: ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter: 🫙 Support the podcast with a small donation to the Tip Jar: === CONNECT WITH THE RHV TEAM === ✭ LinkedIn ✭ Threads ✭ X ✭ Bluesky 08:20 How do we quantify the issue of staffing shortages? 11:18 Why do we need to look at the root cause of the shortages? 11:51 Deloitte on staffing shortages. 11:54 Why is trust one of the core problems when it comes to staffing shortages? 13:59 “Healthcare workers have choice.” 15:34 What are the strongest correlations that influence healthcare workers’ desire to stay? 18:17 What things give healthcare workers the most pause? 19:36 The U.S. Department of Health and Human Services Health Sector . 20:20 The Commonwealth Fund on what health systems can do to address climate change. 22:29 What do we do about sustainable, climate-friendly healthcare being a driving factor in staffing? 27:28 How do you meet the desires of healthcare workers where they’re at? /episode/index/show/healthvalue/id/34254075

EP457: It’s a Big Thing: Medical Spread Pricing. So, Let’s Talk About Contract Transparency, With Cynthia Fisher 12/05/2024

EP457: It’s a Big Thing: Medical Spread Pricing. So, Let’s Talk About Contract Transparency, With Cynthia Fisher In this episode of 'Relentlessly Seeking Value,' host Stacey Richter is joined by healthcare entrepreneur Cynthia Fisher to discuss the crucial issue of medical spread pricing and the need for contract transparency. Fisher explains how hidden fees and spread pricing by middlemen are leading to substantial overcharges for employers and patients in the U.S. healthcare system. The conversation delves into recent lawsuits that highlight these practices, the legislative strides made to enforce price transparency, and how transparency can potentially transform the industry. Look, this is a thing now, medical spread. And similar to how PBM spreads adds up to millions, billions of dollars, medical spread is not change in the couch cushions. Did you see the lawsuit against Cigna? Cynthia Fisher mentions it in the conversation that follows. Spoiler alert, here’s the numbers: Self-insured employer paid $4 million for a claim. There’s a on this Cynthia Fisher gave me, by the way, if you want to see all this written out. So, the employer pays $4 million. The provider was paid—drumroll, please—$876,000. I’m pausing so that sinks in: $4 million paid by the employer; $876,000 of that makes it across the trench to the provider. To view the meme we created for how carriers are learning to do spread pricing from the PBMs, visit our show notes page below. (continued after the links below) === LINKS === 🔗 Show Notes with all mentioned links: https://cc-lnk.com/EP457 ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter: https://relentlesshealthvalue.com/join-the-relentless-tribe 🫙 Support the podcast with a small donation to the Tip Jar: https://relentlesshealthvalue.com/join-the-relentless-tribe === CONNECT WITH THE RHV TEAM === ✭ LinkedIn https://www.linkedin.com/company/relentless-health-value/ ✭ Threads https://www.threads.net/@relentlesshealthvalue/ ✭ X https://twitter.com/relentleshealth/ ✭ Bluesky https://bsky.app/profile/relentleshealth.bsky.social Fisher emphasizes the importance of employers and unions demanding accountability, using existing laws to unveil true pricing, and advocates for a revolution in healthcare to ensure fair, equitable, and transparent billing. Insights are also shared from industry experts who were previous guests including Chris Deacon, Justin Leader, and Andreas Mang. You can find the links in the show notes on our site. 09:03 What is the goal of PatientRightsAdvocate.org? 10:28 Is American competitiveness being affected by healthcare spend? 13:47 Why is transparency a root cause to healthcare costs? 15:11 What’s going on across the country to empower transparency in healthcare? 19:31 “I think people are fed up.” 21:22 The in California. 26:36 How do employers navigate contracts against anti-steering? 28:54 with Andreas Mang. 29:33 with Cora Opsahl and with Claire Brockbank. 29:45 with Justin Leader. You can learn more at . /episode/index/show/healthvalue/id/34145765

INBW40: Thank Yous and the Intersection of Product Value, Collaboration, and Being a “Giver” 11/27/2024

INBW40: Thank Yous and the Intersection of Product Value, Collaboration, and Being a “Giver” In this special Thanksgiving episode of Relentlessly Seeking Value, Stacey Richter discusses the significance of being 'givers' in healthcare, advocating for collaboration over transactional relationships to deliver real value to patients. She touches on the challenges and necessary shifts in healthcare market dynamics, emphasizing that true value is determined through bi-directional conversations between providers and end-users, like patients and plan sponsors. Stacey concludes with a call to action for listeners to reflect on their support networks and consider supporting valuable media and publications. To read the show notes with the mentioned links visit the . If you enjoy this podcast, be sure to subscribe to the free weekly to be a member of the Relentless Tribe. I want to drop a thank you right here to those who have left a tip in our and/or offer up a monthly contribution. From the bottom of my heart, thanks for the support. Thank you to , , , . Also, thank you to , , , , and . Plus everyone else who left a lesser amount. You guys are my village, and this matters because, as it’s been said by me and others a million times, it will take a village to transform healthcare. So, if you haven’t already done so, because … yeah, Thanksgiving, consider who is on your own list of villagers to thank right about now in your world. So, yeah, long story long, all the more thanks to everyone who has donated to our , who has written a nice review on or , or who interacts with our posts on . Thank you. This is how pods like this and any of the publications that you like are able to continue. It’s also, if you want to get really “why do givers succeed” about it, it’s through these interactions that like 99% of guests I’d estimate who get invited on a podcast, probably any podcasts, come from, or who likely get their name in any publication come from. As I said, this is true for this pod at least. But I would say that who are most hosts or most reporters going to reach out to when they need information or insight and are looking to quote somebody? It’s gonna be somebody that they know. It’s gonna be somebody that they like. So, giving, the healthcare industry. This is the actual point I wanted to make before I completely distracted myself. And I talked about this at length actually at a recent thINc360 panel about delivering better patient outcomes. So, collaborate, give. And thank you to all of you who do both of these things every day, despite the cognitive dissonance and corporate forces and the lack of time and resources that may plague your efforts. I appreciate you very, very much. And it is this gang—the Relentless Tribe, that listens to this show—it is you who will transform healthcare. It’s really you. And again, from the bottom of my heart, I thank you. 01:33 How do you calculate the number of people you’ve helped? 02:46 Why is giving so important within healthcare? 03:16 with Adam Grant. 05:47 How can you be a better giver? 07:50 Who is in charge of the bidirectional conversation of value? 11:35 Why is collaboration so important to value and being a giver? 12:58 Why is it important that plan sponsors are a part of all this giving and collaboration? 13:22 with Rob Andrews. 14:34 with Larry Bauer, MSW, MEd. 15:08 with Stacey on the narcissism of small differences. 15:12 and with Stacey. /episode/index/show/healthvalue/id/33985072

Encore! EP418: Mark Cuban With a PSA for CEOs and CFOs of Self-insured Employers, With Mark Cuban and Ferrin Williams, PharmD, MBA, From Scripta 11/21/2024

Encore! EP418: Mark Cuban With a PSA for CEOs and CFOs of Self-insured Employers, With Mark Cuban and Ferrin Williams, PharmD, MBA, From Scripta In this encore episode, Mark Cuban discusses his insights and experiences on disrupting the healthcare and pharmacy benefits landscape with Stacey Richter. This show from last year was one of the most popular episodes of the past year. And it’s also extremely relevant right now, given all of the PBM (pharmacy benefit manager) goings-on, as well as ongoing litigation like the , etc. Listen to the show with Julie Selesnick () for more on that one. You can find the show notes with all links mentioned and a transcript on our If you enjoy this podcast, be sure to subscribe to the free weekly to be a member of the Relentless Tribe. Joined by Ferrin Williams from Scripta, Cuban stresses the importance for CEOs and CFOs of self-insured companies to get actively involved in their healthcare plans to avoid overpaying. The conversation tackles the opaque practices of PBMs, the financialized nature of the healthcare industry, and introduces Mark Cuban's Cost Plus Drugs model which aims for transparency and cost reduction. Key topics also include the potential legal implications for employers, the importance of trust in healthcare transactions, and the real-world savings and benefits achievable with greater involvement and transparency in healthcare management. What do all of these numbers have in common: $140,000, $3 million, $35 million, and $3 billion? These are all actual examples of how much employers, unions, and some public entities saved on healthcare benefits for themselves and their employees. The roadmap to saving 25% on pharmacy spend and/or 15% on total cost of care in ways that improve employee health and satisfaction always begins when one thing happens. There’s one vital first step. That first step is CEOs and/or CFOs or their equivalents roll up their sleeves and get involved in healthcare benefits. Read the full article/show notes with all the mentioned links here: https://cc-lnk.com/Encore418 06:29 What was Mark Cuban’s own journey as a self-insured employer with Cost Plus Drug Company? 07:44 What did Mark find when he decided to go through and look through his company’s benefit program? 09:12 “When you think it through, you start to realize that money is being spent primarily by your sickest employees.” —Mark 10:02 How do you get CEOs and CFOs of self-insured employers to realize that their sickest employees are the ones subsidizing their checks? 13:00 What is the role of insurance in healthcare? 14:30 “If you can’t convince them, confuse them and hide it.” —Mark 15:24 The reality behind getting a rebate check. 16:21 Why are rebates going away, and why isn’t that changing PBM earnings? 19:05 How do you get CEOs and CFOs to dig into their benefits plan? 20:59 Does morally abhorrent move the needle? 21:33 “What we’re trying to do is just simplify the [healthcare] industry.” —Mark 24:19 What’s been changing in consumer behavior? 25:04 “Transparency is a huge part of building that trust.” —Ferrin 25:19 Why CEOs and CFOs really have the power to change healthcare. 32:29 What are Cost Plus Drugs’ plans to expand? 39:21 Where is the future of the prescription drug market going? 42:09 What will happen to the prescription drug market in 10 to 20 years? 48:40 The wake-up call self-insured employers should be acknowledging now. 52:02 Where is the real change in the healthcare industry going to come from? /episode/index/show/healthvalue/id/33896332

Encore! EP415: Some Jumbo Employers Buying Better Healthcare Outcomes While Saving 15% on Total Cost of Care, With Rob Andrews 11/14/2024

Encore! EP415: Some Jumbo Employers Buying Better Healthcare Outcomes While Saving 15% on Total Cost of Care, With Rob Andrews In this episode, Stacey Richter speaks with Rob Andrews, CEO of the Health Transformation Alliance (HTA) and former Congressman, about the strategic steps jumbo employers can take to achieve improved health outcomes while reducing cost. They delve into the importance of using data to discern effective practices, negotiate contracts, and hold intermediaries accountable. To Read The Show Notes With All Mentioned Links, Visit the . If you enjoy this podcast, be sure to subscribe to the free weekly to be a member of the Relentless Tribe. The discussion highlights maternal health as a critical area of focus, with successful interventions shown to reduce NICU admissions and overall healthcare costs. Andrews emphasizes the role of self-insured employers in driving systemic changes that align financial incentives with health outcomes. This encore is very relevant after the shows with Cora Opsahl (), Claire Brockbank (), and Marilyn Bartlett (). Getting better health for the 160 million Americans covered by commercial insurance is all about rates, rights, and power. 07:34 How did Rob get to his current role? 09:08 The problem of maternal health and mortality rate, and how self-insured employers wind up directly and indirectly paying for this. 10:27 Why economic consequences move the needle, and why sometimes they don’t. 12:26 Why the best way to address costs isn’t to re-shift costs but to address them directly. 13:22 Why compensation that isn’t dependent on outcomes is a problem. 16:23 “Strategy’s not what people say; it’s what they do.” 18:21 How do you operationalize saving money with better outcomes? 26:26 How do employers turn conflict into collaboration? 28:20 What is the win-win-win structure among employers, payers, and providers in Rob’s eyes? 30:53 To whom should the task of risk adjustment fall? 34:43 “Better contracts do improve outcomes.” /episode/index/show/healthvalue/id/33792957

EP456: Advice to Pharma at the Intersection of Product Value, Reputation, and Patient Affordability, With Brian Reid 11/07/2024

EP456: Advice to Pharma at the Intersection of Product Value, Reputation, and Patient Affordability, With Brian Reid In this comprehensive episode host Stacey Richter sits down with Brian Reid to discuss pivotal aspects for the pharmaceutical industry. Key topics include understanding product value from the perspectives of plan sponsors, patients, and society, and the significance of benefit design in improving patient affordability. For the show notes with all links mentinoed, visit the . If you enjoy this podcast, be sure to subscribe to the free weekly to be a member of the Relentless Tribe. The discussion delves into the complexities of drug pricing, the roles of Pharmacy Benefit Managers (PBMs) and brokers, and the impact of healthcare consolidation on costs. Reid emphasizes the importance of transparent communication among stakeholders, the detrimental effects of cost containment strategies, and the necessity of considering policy and reputational impacts. Throughout the conversation, examples such as the Hepatitis C drug illustrate the broader implications on drug access and affordability. Listeners are provided with critical insights into how pharmaceutical companies can better engage with ultimate purchasers to ensure patients receive necessary, cost-effective medications while navigating a changing healthcare landscape. For the show notes with all links mentinoed, visit the . 08:29 Why is it important to understand the term “value” in respect to medicine? 10:07 Why is it important to consider all the players affected by the idea of this “value”? 11:06 Who are the ultimate purchasers in Pharma? 12:23 Findings of the . 14:52 Why does it matter that we consider what value looks like to all players affected by Pharma? 16:46 with Bruce Rector, MD. 18:38 with Shawn Gremminger. 20:04 What does Pharma need to do to showcase their value when PBMs are often “locked in” at the moment? 23:11 Why Brian is celebrating companies that put their prices in their press releases. 32:31 Why does Pharma have an obligation to explain their value? 33:16 with Nina Lathia, RPh, MSc, PhD. 33:39 Why is it important for Pharma to keep an eye on hospital monopoly behavior? 35:55 with Erik Davis and Autumn Yongchu. 37:44 Why Pharma needs to capitalize on alignment. /episode/index/show/healthvalue/id/33668222

EP455: A Leadership Blueprint for Measurably Better Care, With Beau Raymond, MD 10/31/2024

EP455: A Leadership Blueprint for Measurably Better Care, With Beau Raymond, MD In this conversation, Stacey Richter engages with healthcare leader Dr. Beau Raymond from Ochsner Health Network to explore the blueprint for better patient care through enlightened leadership, data-driven strategies, and localized health initiatives. The discussion covers shifting from 'sick care' to preventative healthcare, integrating technology and data tools like glucometers for health coaching, and addressing health equity through accurate data and regional strategies. To Read the Show Notes with Mentioned Links and a Full Transcript, Visit the . If you enjoy this podcast, be sure to subscribe to the free weekly to be a member of the Relentless Tribe. The conversation explains the importance of stakeholder engagement, setting clear goals, financial incentives aligned with patient care, and continuous improvement through feedback loops. Practical steps such as weekly huddles for primary care teams and the role of digital health in managing chronic conditions like diabetes and hypertension are also highlighted to improve healthcare outcomes and operational excellence. A rate critical to attain better care for patients, I’m gonna say, is enlightened leadership—maybe dyad leadership—at a clinical organization. I am saying this because without enlightened leaders, it’d be harder to build from the blueprint that Beau Raymond, MD, talks about today on the show. 10:44 Why is it important to be flexible while keeping your goals in sight? 11:48 Dr. Eboni Price-Haywood’s on disparities in COVID. 12:29 How is equity a data point to achieving overall care improvement? 15:01 “If you can’t measure it … accurately, you’re not going to be able to do anything differently.” 20:52 What strategies have been successful in using data to improve healthcare outcomes? 23:17 Why did Ochsner Health avoid looking at the individual physician standpoint in regard to an equity standpoint? 30:40 Why engaging patients in their healthcare actually improved patient visits and did not necessarily reduce patient visits. 34:49 “It’s really about engaging with the patient.” /episode/index/show/healthvalue/id/33553827

EP454: How the Particle v Epic Lawsuit Impacts Plan Sponsors and Public Health Trying to Get Data, With Brendan Keeler 10/24/2024

EP453: Running a TPA (Third-Party Administrator) RFP Process That Is Less of a Wild West Fiduciary Shootout, With Claire Brockbank 10/17/2024

EP453: Running a TPA (Third-Party Administrator) RFP Process That Is Less of a Wild West Fiduciary Shootout, With Claire Brockbank In this episode, host Stacey Richter delves into the complexities of the Third Party Administrator (TPA) Request for Proposal (RFP) process with guest Claire Brockbank from 32BJUnion. The discussion highlights the critical role of contracts in managing health plans effectively and the potential pitfalls of accepting contracts crafted by TPAs without thorough review. Drawing from Claire's experience, they explore tactics like starting with your own contract paper in RFP processes to gain negotiation leverage, and the benefits of employer coalitions in navigating health care complexities. To Read the full article which includes mentioned links visit the . If you enjoy this podcast, be sure to subscribe to the free weekly to become a member of the Relentless Tribe. Real-world examples underscore the financial impacts of poorly negotiated contracts and highlight successful strategies for health plan sponsors to optimize costs and services. The episode aims to empower employers with tools and insights to negotiate effectively and ensure their health plan contracts align with their strategic goals, ultimately paving the way for better population health management and cost-effective care delivery. As but one example—and Cora Opshal spoke about this last week and Claire talked about this today—it’s about how allowing upside-down payments, for example, that are in a lot of ASO contracts, this allowing of upside-down payments. I mean, it turns out that 32BJ spent around $10 million paying more than the bill was for one year. If somebody signs that contract as handed to them by the carrier, then the plan is now contractually obligating themselves to pay more than the price the clinical practice was charging. So, doc sends bill for $100, and the carrier pays that practice $200 on behalf of the plan sponsor. So now the plan sponsor is paying $200 for a $100 bill. Is this conflict of interest? Is it imprudent? Is it not reasonable? Said another way, is that a bit of a fiduciary breach on the plan sponsor? So it's understandable why the team at 32BJ pushed back and pushed back hard. We all can see why the leading edge of plan sponsors and more and more C-suites are hotfooting it into conference rooms to plan their RFP process and doing it in the way that Claire Brockbank talks about today. For an and some other , please do head over to the . 05:36 How does the initial contract writing affect how events in your healthcare plan will go? 06:56 What happens if a plan sponsor or employer doesn’t do the contracting right? 10:42 How much could be saved by doing contracting right? 11:01 with Justin Leader. 12:22 How do you start an RFP process with your own contract? 14:06 What Claire Brockbank recommends doing to do a TPA RFP process in a way that’s best for you. 19:46 What factors do carriers need to get an ASO or TPA to respond to using your contract? 21:11 available from 32BJ. 21:57 Why it’s important to really probe brokers, despite loyalty to your broker/consultant. 24:30 Who are the reliable agents and experts when carriers are looking to start this process? 26:24 with Julie Selesnick. 27:56 What’s the silver lining to this effort? 29:17 Why is it important to make it clear why you’re doing what you’re doing for your lawyers and any other support team you need? 31:39 What does “good” look like in this process? 34:15 Why is it important to continue to hold your ASO accountable? /episode/index/show/healthvalue/id/33382782

EP452: Fiduciary Duty vs the Healthcare Status Quo, With Cora Opsahl 10/10/2024

EP452: Fiduciary Duty vs the Healthcare Status Quo, With Cora Opsahl In this episode I interview Cora Opsahl from the 32BJ Health Fund to examine the intricate dynamics between fiduciary duties and the entrenched status quo in healthcare. The discussion focuses on the challenges employers face when dealing with anti-competitive contracts and their responsibility to ensure plan expenses are reasonable. Cora Opsahl, my guest today, is the director of the 32BJ Health Fund, serving over 200,000 folks. Their ability to kick NewYork-Presbyterian, a big, consolidated, very expensive hospital, out of their network in 2018 enabled them to offer maternity benefits for $40 in total out-of-pocket for members. And also, employees got their biggest raise ever; employers got a premium holiday and a 3% rate increase for a bunch of years after that; and yeah … this is where we start the conversation today. Furthermore, you will find links to a template health savings calculator for plan sponsors and also a template contract (again for plan sponsors) that 32BJ has made available, in our . To Read the Full Show Notes with the Mentioned Links Visit the If you enjoy this podcast, be sure to subscribe to the free weekly to be a member of the Relentless Tribe. 06:16 Why is it imperative for employers to do something differently when it comes to being plan sponsors? 09:22 How analyzing claims data allowed 32BJ Health Fund to reshape their benefit design. 12:09 What anticompetitive rights did 32BJ run into that limited 32BJ Health Fund from managing their benefit design? 14:12 How do these anticompetitive rights have quality implications as well as cost implications? 18:43 How did 32BJ Health Fund remove NewYork-Presbyterian from their network, and how much did it save 32BJ Health Fund per year? 19:46 What did the healthcare savings allow the unions and employers to do? 20:46 by Zack Cooper, PhD. 21:26 Why rising healthcare costs has pushed 32BJ Health Fund to move beyond benefit design to manage healthcare spend. 24:15 Why 32BJ Health Fund wants to control the contracting process. 26:00 with Andreas Mang. 27:18 What are 32BJ Health Fund’s four non-negotiables? 33:17 on health insurance contract. 35:30 Upcoming episode with Claire Brockbank. 36:14 What is the challenge that exists in our current healthcare environment? 37:43 Cora’s advice on how to get high-quality healthcare at an affordable price. /episode/index/show/healthvalue/id/33298542

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