Relentless Health Value – Détails, épisodes et analyse

Maybe you've already caught Part 1 of my conversation with Shawn Gremminger, and if so, you're ahead of the game. But if not, no worries—here's the deal: I decided to split this deep dive into the 340B program with Shawn into two parts. So, feel free to jump into one or both—it's totally up to you.

These episodes don't have to be listened to in order, so you're good to start here with Part 2. Let's get into it!"

Right now, we are going to talk about how 340B impacts employers and commercial plans and other plan sponsors. So, if all you want to hear about is the why—as in, Why do employers care about what amounts to a program that is or was supposed to be for low-income Americans and Medicaid?—you are in the right place.

As just one example of the why should employers care if you are teetering on the edge of proceeding, did you know that if an employee or a member of a commercial plan gets a drug at a contract pharmacy participating in 340B, the employer does not get the rebate? The employer is gonna pay the list price for that med.

Wait, what? Yeah, details follow because Shawn Gremminger is gonna get into this and many other reasons why employers or anyone in the commercial market (or taxpayers, really) should care about this, as some may call it, Medicaid program. The fact is, 340B is currently so gargantuan that it creates market distortions that bleed into the prices and possibly the quality of healthcare for everybody, all Americans. And that could really matter to employer or Taft-Hartley plan sponsors.

After you listen to this show, if you want to drill in a little deeper on the "what the what" and the history of 340B, head back and take in Part 1 of this episode 448. Shawn Gremminger gives the skinny on how the program morphed over the years into a $53 billion juggernaut and is credited (or blamed) for all kinds of healthcare market consolidation and many other weird and unusual consequences that make me admire some of the folks who are truly gold medal winners in the sport of financial engineering.

=== LINKS ===
🔗  Show Notes with all mentioned links:  
https://cc-lnk.com/EP448-2

🔗  Healthcare Industry Acronyms and Terms
https://relentlesshealthvalue.com/healthcare-acronymns

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09:11 Why do employers care about 340B, which is a Medicaid program?

11:30 Why do I care as an employer, even if I'm not Pharma?

12:44 Why is 340B causing employers to pay significantly more for healthcare?

14:36 Study by Zack Cooper, PhD.

15:06 Why are there distorted pricing models at 340B hospitals?

21:22 Why do employers need to stop playing the blame game?

So, after some pondering, I decided to release this conversation with Shawn Gremminger about 340B in two parts. So, listen to one, listen to both, pick your poison. Shawn Gremminger came up with three really important takeaways relative to 340B, which is a feat unto itself, considering how sprawling this conversation can be. So, if you came here for some concise and actionable takeaways, you have come to the right place.

This first part you are listening to right now zeros in on Shawn's first takeaway: whether or not the original intent, or the presumed original intent, of the 340B program has actually been met.

Many do not realize that 340B began life as a caterpillar. It originally, actually, was conceived as a lowly bureaucratic fix. But over the past 15 years, it has gone into a chrysalis and emerged into a 500-pound gorilla that sits in the corner of a lot of rooms, actually—probably more than many people realize. All of that being said, when you're done listening to this first part of the convo, you should be able to competently assess whether or not 340B does, in fact, adequately help underserved communities get better healthcare—because 340B is supposed to help safety-net healthcare providers stretch scarce resources.

The second part of the show, which is a separate episode called Part 2, is how all of this impacts employers and commercial plans. And there's two more takeaways there.

So, if you already have the gist of how we got from the beginnings of 340B to where we are in 2024 already and all you want to hear about is why do employers care about what amounts to a low-income program or was purported to be a low-income program, feel free to zip over to the second show and cut to that chase.

=== LINKS ===
🔗  Show Notes with all mentioned links:  
https://cc-lnk.com/EP448-1

🔗  Healthcare Industry Acronyms and Terms
https://relentlesshealthvalue.com/healthcare-acronymns

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🎤  Listen on Spotify  https://open.spotify.com/show/6UjgzI7bScDrWvZEk2f46b

=== CONNECT WITH THE RHV TEAM ===
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05:25 Shawn's three takeaways from the 340B program.

06:04 What is the intent of the 340B program?

08:22 Read the full 32-page report of the Energy and Commerce Committee. 

09:17 Why does Medicaid have to get the best price?

13:26 Why was there a shift in how the 340B program looked starting in the mid-2000s?

15:11 Why do more than half of acute care hospitals now qualify for 340B?

18:18 How has hospital consolidation affected 340B?

20:37 What is the misalignment between how a hospital qualifies for 340B and how it benefits said hospitals?

24:11 How is a 340B designed for hospitals to make a profit?

28:45 Why isn't there a real patient definition in 340B?

31:46 Why is 340B still popular among policymakers?

33:05 Are 340B dollars being used in underserved communities?

33:57 EP394 with Vikas Saini, MD, and Judith Garber, MPP.

Episode 443 of Relentless Health Value pays tribute to the late Marshall Allen, an investigative journalist dedicated to exposing injustices within the American healthcare system. Hosted by Stacey Richter, the episode features Dave Chase, founder of Health Rosetta, who shares memories and insights into Marshall's tireless work in investigative reporting.

The episode highlights Marshall's impact on healthcare legislation, his significant contributions to ProPublica, and his book 'Never Pay the First Bill,' which empowers patients and employers to fight back against corrupt billing practices.

The episode also includes an earlier interview with Marshall, focusing on his perspective as an investigative reporter, the exploitation within the healthcare system, and the importance of patients and employers demanding transparency and fairness. The episode encourages listeners to continue Marshall's legacy by subscribing to the Marshall Health Academy and purchasing access for employees.

=== LINKS ===
🔗  Show Notes with all mentioned links:  
https://cc-lnk.com/EP443

🔗  Healthcare Industry Acronyms and Terms
https://relentlesshealthvalue.com/healthcare-acronymns

✉️  Enjoy this podcast? Subscribe to the free weekly newsletter:
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🎤  Listen on Spotify  https://open.spotify.com/show/6UjgzI7bScDrWvZEk2f46b

=== CONNECT WITH THE RHV TEAM ===
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09:28 What's the point of view that Marshall is coming from with his investigative reporting?

09:57 "How does this affect the people who are paying for it and the people who are undergoing the care?"

10:49 "There's a lot of good people working within this very messed up system."

11:03 Why are patients considered outsiders in the healthcare system?

11:45 "What's happened in healthcare is that the stakeholders treat each other more as the customer."

13:45 What is upcoding?

17:18 "These are schemes that have been created within the industry to increase revenue."

17:46 "This system is not set up for the benefit of the patient."

18:13 "On the financial side, the industry is actually oppressing the American people."

19:14 "We have been expected to pay whatever aggregate sum is thrown at us."

20:21 Why have patients been so passive toward this crooked healthcare system so far?

22:05 What's the difference between making a profit and profiteering?

29:45 What are the first-order and second-order consequences of what's happening in health care right now, and which of these consequences will actually drive change?

30:45 "When you tell the truth about what's going on … they become so ashamed … that they change their behavior."

32:00 "The patient … is not their most important customer."

32:50 "The sleeping giant is the employers."

In Episode 442 of 'Relentless Health Value,' host Stacey Richter shares an intriguing outtake from a previous episode featuring Andreas Mang, senior managing director at Blackstone, discussing the critical issue of cost management in oncology side effect treatment.

The conversation delves into the inefficiencies and patient harms caused by inadequate side effect management, particularly dehydration due to chemotherapy, and the resulting financial burdens on employers, taxpayers, and patients. 

Stacey explores the importance of a value-based mindset in drug purchasing, integrating oncology care, and the potential financial and health benefits of better side effect management. She highlights various expert opinions and studies supporting these points, encouraging listeners to reconsider their approach to healthcare cost structures and patient care protocols.

=== LINKS ===
🔗  Show Notes with all mentioned links:  
https://cc-lnk.com/EP442

🔗  Healthcare Industry Acronyms and Terms
https://relentlesshealthvalue.com/healthcare-acronymns

✉️  Enjoy this podcast? Subscribe to the free weekly newsletter:
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🎤  Listen on Spotify  https://open.spotify.com/show/6UjgzI7bScDrWvZEk2f46b

=== CONNECT WITH THE RHV TEAM ===
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01:12 Andreas Mang on oncology medication side effect management.

03:12 Mark Lewis, MD's Tweet.

03:39 Celena Latham's response.

04:22 How integrative oncology can save money and what it looks like.

04:47 EP157 with Ethan Basch, MD.

06:20 Why PBMs saving money doesn't necessarily mean savings for employers and payers.

07:36 EP435 with Dan Mendelson.

08:20 EP372 with Cora Opsahl.

08:40 EP331 with Al Lewis.

09:50 Stacey's second rumination.

10:19 Why having a value mindset when purchasing is a thing.

10:42 Stacey's third rumination.

12:03 EP370 with Erik Davis and Autumn Yongchu.

13:07 Why FFS does not pay or pay adequately for side effect management.

14:31 Stacey's final rumination.

17:08 Summarizing Stacey's four ruminations on this topic.

In this episode, Abby Burns from Radio Advisory interviews Stacey Richter, host of the Relentless Health Value podcast, during the Raising the Bar Value Summit. They discuss the complexities of defining and creating value in healthcare, focusing on the roles of various stakeholders including patients, providers, and payers.

Stacey shares insights on the challenges and tensions in the healthcare system, such as the fragmentation of care, financial toxicity, and the cultural norms that inhibit progress. The conversation also highlights practical examples and potential strategies to drive value and sustain positive changes within the industry.

=== LINKS ===
🔗  Show Notes with all mentioned links:  
https://cc-lnk.com/EP441

🔗  Healthcare Industry Acronyms and Terms
https://relentlesshealthvalue.com/healthcare-acronymns

✉️  Enjoy this podcast? Subscribe to the free weekly newsletter:
https://relentlesshealthvalue.com/join-the-relentless-tribe

🫙  Support the podcast with a small donation to the Tip Jar:
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📺  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/
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✭ Bluesky   https://bsky.app/profile/relentleshealth.bsky.social
✭ X   https://twitter.com/relentleshealth/

03:33 Stacey's journey and mission.

04:16 The story of Scott Conard, MD (EP391).

09:28 Why it's important not just to drive change but to sustain it.

12:23 Heart Failure: A Case Study in Value.

14:13 EP438 with John Lee, MD.

15:07 Why patient positive value often fails instead of succeeds.

18:07 How financial toxicity has become clinical toxicity in healthcare.

19:44 How cultural norms have evolved into healthcare challenges.

23:38 The story of Mike Tuggy, MD, in Washington.

25:13 Looking at the four tensions in measuring value as continuums.

25:37 Why timeline is important in creative value in healthcare.

27:52 Finding Allies by Michael Leavitt.

28:34 What are the four ways to measure value in healthcare?

29:27 How do payers and providers collaborate to align on value metrics?

31:26 Why will proven versus experimental treatments become more important in the next few years?

34:54 Stacey's manifesto (EP400) and values for personal integrity in healthcare.

38:55 Stacey's parting advice.

In Episode 440 of 'Relentless Health Value,' host Stacey Richter engages with David Muhlestein to explore the optimal size for a medical practice, concluding that 10 to 20 physicians supported by a capable team provide the best balance of economies of scale and community integration. The conversation transitions into the challenges large healthcare systems face, particularly the Diversification Discount.

This diversification often impedes patient care and operational efficiency by misaligning values with business practices. The episode delves into the paradox of optimizing primary care while still supporting specialty care, reflecting on how organizational values impact healthcare outcomes. Muhlestein suggests implementing business units or decentralized models to realign with patient care values and efficiencies.

=== LINKS ===
🔗  Show Notes with all mentioned links:  
https://cc-lnk.com/EP440

🔗  Healthcare Industry Acronyms and Terms
https://relentlesshealthvalue.com/healthcare-acronymns

✉️  Enjoy this podcast? Subscribe to the free weekly newsletter:
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📺  Subscribe to our YouTube channel   https://www.youtube.com/@RelentlessHealthValue

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🎤  Listen on Spotify  https://open.spotify.com/show/6UjgzI7bScDrWvZEk2f46b

=== CONNECT WITH THE RHV TEAM ===
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08:12 From a business and patient/better outcomes standpoint, what does an optimal provider practice look like?

11:48 EP412 with Robert Pearl, MD.

13:06 Why isn't the current landscape what David considers optimal?

14:53 What leads to the "crisis of autonomy"?

15:13 How do medical practices get to the phase of delegation?

17:39 EP438 with John Lee, MD.

18:55 EP437 with Brian Klepper, PhD.

20:53 EP432 with Kate Wolin, ScD.

20:55 EP421 with Jodilyn Owen.

23:48 Medicare Meet-Up podcast with Mai Pham, MD.

24:45 What metrics should boards of directors also be held accountable for?

28:48 Why is an efficiency-focused business not necessarily the best at managing population care?

31:13 What is the "diversification discount"?

32:49 Pivot podcast with Kara Swisher and Scott Galloway, MBA.

35:53 What can primary care doctors do to optimize their practices?

36:48 Why do we need to shift the mindset from "bigger" and "more"?

In Episode 439 of 'Relentlessly Seeking Value,' host Stacey Richter discusses the convoluted issues surrounding generic drug pricing with pharmacy consultant Luke Slindee.

They delve into the ways traditional Pharmacy Benefit Managers (PBMs) exploit the system to make immense profits, often leading patients to pay more even with insurance. The conversation explores various solutions, such as the removal of "Usual and Customary Prices" from PBM contracts, the advantages of bypassing insurance, and giving patients direct payment tools like health savings accounts.

Luke Slindee, with his extensive background in pharmacy and consulting, provides valuable insights into rebalancing the generic drug market to benefit patients, pharmacies, and plan sponsors alike. Additionally, the broader implications of these dysfunctional systems on pharmacy operations and staff conditions are discussed.

=== LINKS ===
🔗  Show Notes with all mentioned links:  
https://cc-lnk.com/EP439

🔗  Healthcare Industry Acronyms and Terms
https://relentlesshealthvalue.com/healthcare-acronymns

✉️  Enjoy this podcast? Subscribe to the free weekly newsletter:
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🫙  Support the podcast with a small donation to the Tip Jar:
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📺  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 ===
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08:12 Where do cash prices fall when pharmacies have contracts with PBMs?

08:39 What is a usual and customary price?

12:14 How is the usual and customary price affected by PBMs?

16:49 Should pharmacies be allowed to have two sets of cash prices?

17:14 Where does GoodRx fit into this because of the pharmacy/PBM dilemma?

19:06 What's happening with Amazon and the anticompetitive contract lawsuit, and how does it relate back to pharmacy contracts with PBMs?

20:38 EP395 with Brennan Bilberry.

21:05 EP420 with Ge Bai, PhD, CPA.

23:27 Why is there a new wave of cash-only pharmacies?

24:02 EP418 with Mark Cuban and Ferrin Williams, PharmD, MBA, from Scripta.

25:41 What would allow the generic market to return to normal competitive pricing?

26:39 How does this dysfunction create a negative downstream effect?

In this episode of Relentless Health Value we dive into the concept of Cognitive Dissonance in the healthcare industry with Dr. John Lee, an ER physician and chief medical information officer. We explore how healthcare professionals navigate the conflict between their beliefs and actions, especially in large healthcare organizations. Dr. Lee shares practical advice on celebrating small wins, incremental improvements, and fostering a supportive culture among colleagues.

This conversation sheds light on the challenges and solutions for those striving to deliver better patient care despite systemic obstacles. 

=== LINKS ===
🔗  Show Notes with all mentioned links:  
https://cc-lnk.com/EP438

🔗  Healthcare Industry Acronyms and Terms
https://relentlesshealthvalue.com/healthcare-acronymns

✉️  Enjoy this podcast? Subscribe to the free weekly newsletter:
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🫙  Support the podcast with a small donation to the Tip Jar:
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🎤  Listen on Spotify  https://open.spotify.com/show/6UjgzI7bScDrWvZEk2f46b

=== CONNECT WITH THE RHV TEAM ===
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The Unseen Influence of the RUC on Healthcare

This episode of 'Relentless Health Value' features a discussion with Brian Klepper, a healthcare analyst and former CEO of the National Business Coalition on Health, about the powerful yet obscure RUC (RBRVS Update Committee) and its significant impact on the economics of primary care and the broader healthcare system. The RUC, a committee within the American Medical Association, plays a critical role in determining the relative value of medical procedures, which directly influences Medicare payments.

The episode reveals how the RUC's composition—dominated by specialists over primary care physicians—skews the financial incentives in healthcare, affecting the viability of primary care practices and mental health services. The discussion also explores the flawed assumption that the financial value assigned to healthcare services by the RUC equals their true value to patients, highlighting the need for a better understanding of the inner workings of American healthcare to address its shortcomings.

=== LINKS ===
🔗  Show Notes with all mentioned links:  
https://cc-lnk.com/EP437

✉️  Enjoy this podcast? Subscribe to the free weekly newsletter:
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🎤  Listen on Apple Podcasts  https://podcasts.apple.com/us/podcast/feed/id892082003?ls=1

🎤  Listen on Spotify  https://open.spotify.com/show/6UjgzI7bScDrWvZEk2f46b

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00:00 Introduction

02:29 Unpacking the RUC: The Power Behind Healthcare Economics

04:26 The Financial Impact of the RUC on Primary Care

07:43 Exploring the Value of Healthcare Services

10:29 The Real-World Consequences of RUC Decisions

12:50 Debunking the Equivalence of Value and Money in Healthcare

15:09 Final Thoughts and How to Stay Informed

In this episode of Relentless Health Value we follow up on the topic of employer inertia discussed with Lauren Vela in episode 406, turning our focus to third-party administrators (TPAs), administrative services only (ASOs), and health plans.

Elizabeth Mitchell from the Purchaser Business Group on Health (PBGH) joins us to discuss the roles of TPAs and ASOs, highlighting the gap in the market for independent, efficient TPAs not owned by health plans. We also delve into the trend of direct contracting between employers and providers to enhance access, quality, and outcomes.

Bottom line, right now, there's a gap in the market. What is needed are indie TPAs who are effective and efficient and not owned by a health plan because, if history is any predictor of the future, the second the TPA gets owned by a health plan, the TPA sort of ceases to be a TPA and becomes a health plan.

The conversation today with Elizabeth Mitchell pretty quickly gets into the shift toward direct contracting between employers and providers to improve access quality and outcomes. If you can't beat them, get ruthlessly practical is my takeaway. I have to say, I truly admire some of these HR folks and their leadership willing to do what it takes on behalf of protecting the people that work for them.

There are certainly some health plans at least trying here, so I don't want to imply otherwise. There are some interesting initiatives that are afoot at, I'm gonna say, usually regional health plans. Elizabeth Mitchell has talked about some of these and made this clear also elsewhere.

Join us for a deep dive into these critical components of the healthcare system and their impact on self-insured employers.

=== LINKS ===
🔗  Show Notes with all mentioned links:  
https://cc-lnk.com/EP436

✉️  Enjoy this podcast? Subscribe to the free weekly newsletter:
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🎤  Listen on Apple Podcasts  https://podcasts.apple.com/us/podcast/feed/id892082003?ls=1

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