Welcome to Relentless Health Value, the podcast for those working in the belly of the beast to fix our fundamentally broken healthcare system. If you are a self-insured employer, plan sponsor, benefits consultant, clinician, a C-suite executive or anyone in the business of healthcare tired of the "transformational theater" and marketing fluff, you have found your tribe.
The U.S. healthcare system isn't a rational market; it's a game of Pachinko where perverse incentives reign, and as we always say, where there's mystery, there's margin.
Hosted by Stacey Richter, we relentlessly hunt down the administrative "inches" of waste and expose the hidden fees draining the $5.6 trillion healthcare sector. We transform wonky healthcare theory into ruthlessly practical, actionable insights.
Whether it's demanding radical transparency, navigating complex PBM contracts, or buying actual healthcare instead of illusory discounts, our mandate is simple: If it results in a net positive for patients, we do it. Join the Relentless Health Value Tribe to equip yourself with the fiduciary armor needed to outwit the status quo, demand accountability, and drive real change.
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Why Don't More Self-insured CEOs Take Bold Action in Health Benefits Strategy? With Lee Lewis. (EP508)
Épisode 508
jeudi 23 avril 2026 • Durée 44:02
The Three False Dogmas Keeping CEOs From Fixing Their Health Plan. In the show's first-ever Ask Me Anything episode, Stacey Richter puts a listener's question to Lee Lewis, chief strategy officer and GM medical solutions at the Health Transformation Alliance: why do so few self-insured CEOs take bold action on their health benefits strategy? Lee walks through three false dogmas, four external pressures, and the C-suite math behind a real acquisition where better-managed benefits alone created a quarter billion dollars of instant equity value nobody had priced in. WHAT YOU'LL LEARN ✅ The three false dogmas that keep CEOs stuck in the herd: health benefits are a fixed expense, saving money hurts people, and fixing healthcare is never worth the risk or disruption ✅ How one acquired company's better-managed health plan — $2,300 less per employee per year, with better benefits — created over a quarter billion dollars of unpriced equity value in an M&A deal ✅ The four external reasons C-suites avoid action: circles CEOs travel in with health system leaders, "balance of trade" threats and promises, personal incentives like trips and perks from status quo vendors, and a blind spot to how a $5,000 deductible lands very differently on a $25-an-hour employee ✅ Why perverse incentives baked into C-suite compensation at health systems make it structurally hard for consolidated systems to accept change ✅ Lee Lewis's concrete advice for benefits teams working under a risk-averse C-suite, and his direct advice to any CEO listening WHY THIS MATTERS Health benefits sit as one of the largest line items on a corporate balance sheet, and the false belief that fixing them is too risky or too disruptive keeps plan sponsors leaving real money and real employee health outcomes on the table. Understanding the dogmas and the external pressures behind CEO inertia is the first step to breaking it. MENTIONED IN THIS EPISODE EP500 with Stacey: Apple Podcasts | Spotify | Other Apps EP466 with Vivian Ho, PhD: Apple Podcasts | Spotify | Other Apps EP404 with Suhas Gondi, MD, MBA: Apple Podcasts | Spotify | Other Apps EP506 with Jerry DiMaso: Apple Podcasts | Spotify | Other Apps EP501 with Ivana Krajcinovic, PhD: Apple Podcasts | Spotify | Other Apps LinkedIn Post by Patrick Moore EP488 with Mark Cuban and Cora Opsahl: Apple Podcasts | Spotify | Other Apps === LINKS === 🔗 Show Notes with all mentioned links: Episode Page ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter 🫙 Support the podcast with a small donation to the Tip Jar 🎤 Listen on Apple Podcasts 🎤 Listen on Spotify 📺 Subscribe to our YouTube channel === CONNECT WITH THE RHV TEAM === ✭ LinkedIn ✭ Threads ✭ Bluesky ✭ X 00:00 Introduction to this episode. 00:43 Ask Me Anything Question 1: Why don't more self-insured executives take bold action toward their benefits strategy? 03:09 A summary of the three dogmas covered in the following conversation. 05:53 A look ahead at next week's episode. 06:36 An introduction to today's guest, Lee Lewis. 08:23 Why there is an aversion to digging into health benefits for some executives. 09:43 The first dogma: Healthcare costs are fixed expenses. 09:56 The second dogma: Saving money in healthcare hurts people. 12:01 The third dogma: Fixing healthcare is never worth the effort. 12:26 How these dogmas trickle down to HR teams. 13:47 Anecdote: One company that turned down saving $50 million and why. 16:28 A quick reminder about the context behind where CEOs' mindsets are. 17:10 The kinds of employers HTA seeks out. 20:03 The power of C-suites in health systems. 21:42 Why a CEO may pull the plug on health plan/health benefit improvements. 22:37 An anecdote about Lilly cancelling their health plan. 23:21 Items that CEOs need to be thinking about. 26:32 A summary of why CEOs should care about their health benefits costs now. 29:02 How do personal incentives play into CEOs' decisions about health benefits? 30:44 Another quick reminder about C-suites. 31:53 Why perverse incentives make it difficult for C-suites to accept change. 33:28 Why the salary gap plays into health benefit decisions in a perverse way. 36:13 Lee Lewis's advice to people in benefits who are aligned to the mission. 40:06 Lee Lewis's advice for CEOs.
4 Core Concepts to Buy or Deliver the Highest Value Healthcare — A Review With 14 Expert Voices (EP507)
Épisode 507
jeudi 16 avril 2026 • Durée 33:58
Buy Healthcare, Not Insurance: A Through-Line Review of the Four Concepts Behind High-Value Care. Episode 507. Stacey Richter pulls together clips from 15 past guests to lay out the four core concepts for buying or delivering the highest-value healthcare: buy healthcare (not just insurance), avoid the myth that less expensive automatically means lower quality, consider direct contracting between plan sponsors and clinicians, and make sure whatever you're buying or delivering is actually high value. WHAT YOU'LL LEARN ✅ Why health insurance is not healthcare, and why buying the two as if they were the same thing costs plan sponsors billions of dollars a year ✅ Why there is often no correlation between price and quality — sometimes less expensive care is higher quality, and low-quality care can be the most expensive care regardless of its price tag ✅ Why direct contracting between plan sponsors and clinicians helps eliminate low-value middlemen and opens the door to real collaboration on integration and shared goals ✅ Why "buy the highest-value healthcare" is a genuine north star rather than a slogan — and what plan sponsors should hold their direct-contracting partners accountable for delivering ✅ A sneak peek at the new Relentless Health Value Chatbot, trained on the show's 500-plus guests, that Stacey used with a light touch while building this episode WHY THIS MATTERS The Relentless Tribe moves fast, covering a lot of ground episode to episode — so this through-line review exists to make the big points stick: buy healthcare, not insurance; don't assume price and quality trade off against each other; use direct contracting to get plan sponsors and clinicians talking directly; and hold whatever you buy or deliver to a real standard of value. === LINKS === 🔗 Show Notes with all mentioned links: Episode Page ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter 🫙 Support the podcast with a small donation to the Tip Jar 🎤 Listen on Apple Podcasts 🎤 Listen on Spotify 📺 Subscribe to our YouTube channel === CONNECT WITH THE RHV TEAM === ✭ LinkedIn ✭ Threads ✭ Bluesky ✭ X 00:00 Introduction to this episode and guests. 01:38 The four core concepts to buy or deliver highest-value healthcare: a summary. 06:01 An exciting show announcement. 07:32 Core Concept 1: Why buy highest-value healthcare, not "best" coverage? 11:28 Core Concept 2: Will employers fall victim to the myth of inexpensive care? 13:00 Why better-quality care vs. more affordable care is a false choice. 17:09 Core Concept 3: Direct contracting. 17:58 Why demand curve matters in healthcare cost. 22:08 How Centers of Excellence play into all of this. 22:54 Core Concept 4: How do you conceive of and buy high-value healthcare? 23:48 The value equation in healthcare. 25:35 What is value? 28:20 What whole-person care looks like. 30:24 Relentless Health Value Chatbot sneak peek announcement. 32:14 Coming up: looking at the episodes ahead.
EP500: This Is Episode 500, and It's All About You, Tribe
Épisode 500
jeudi 12 février 2026 • Durée 38:21
Ten Years, 500 Episodes, and the Listener Stories Proving Healthcare Can Change. Episode 500. To mark 10 years and 500 episodes, Stacey Richter turns the mic over to the Relentless Health Value Tribe itself, playing voice messages and reading comments from listeners—benefits consultants, physicians, health system executives, and pharmacists—describing the specific decisions the show helped them make. Organized around three themes—moving from theory to practical transformation, the power of collective momentum, and unplugging from healthcare's opacity—the episode is less a highlight reel than a look at how information turns into action across an industry that badly needs it. WHAT YOU'LL LEARN ✅ Why "moving from theory to practical transformation" showed up again and again in listener stories, from EP373 (Cora Opsahl) reframing failures as design problems to a listener's direct-to-primary-care benefit rollout inspired by a later episode ✅ How the show's transcript-first, practical-over-theoretical format has led listeners to directly implement changes such as switching PBM models, offering new benefit designs, and renegotiating vendor contracts ✅ Why "the power of the tribe and collective momentum" became its own theme, with listeners describing the show as uniting different factions of healthcare change rather than dividing them ✅ How "unplugging from the matrix of healthcare opacity" ties together listener stories about generic drug pricing, EHRs functioning as revenue cycle tools, and shopping for care that isn't actually shoppable ✅ Why Stacey frames the tribe's collective decisions—not the show itself—as the actual mechanism for bending the healthcare cost and quality curve WHY THIS MATTERS A podcast doesn't fix healthcare—the decisions its listeners make afterward do. Ten years and 500 episodes in, the throughline across every listener story here is the same: information only matters once it changes a contract, a benefit design, or a conversation with a CEO. That's the actual mechanism by which an industry this opaque and this entrenched slowly bends toward doing right by patients and members. MENTIONED IN THIS EPISODE LinkedIn Post by Stacey Richter EP373 with Cora Opsahl: Apple Podcasts | Spotify | Other Apps EP391 with Scott Conard, MD: Apple Podcasts | Spotify | Other Apps EP462 with Scott Conard, MD: Apple Podcasts | Spotify | Other Apps === LINKS === 🔗 Show Notes with all mentioned links: Show Notes ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter 🫙 Support the podcast with a small donation to the Tip Jar 🎤 Follow us on Apple Podcasts 🎤 Follow us on Spotify 📺 Subscribe to our YouTube channel === CONNECT WITH THE RHV TEAM === ✭ LinkedIn ✭ Threads ✭ Bluesky ✭ X 00:00 Introduction and episode 500 announcement. 00:22 The origin of episode 500. 02:43 Celebrating the Relentless Health Tribe. 10:08 Theme 1: Moving From Theory to Practical Transformation. 10:38 Clip from Ken Wosczyna and the episodes that have led to consistently good decisions in his work. 11:27 The Tipping Point by Malcolm Gladwell. 12:55 Examples of tribe members changing and improving their corner of healthcare after being inspired by RHV episodes. 13:54 Clip from Mark Weber. 16:13 Clip from John Lee, MD, and how RHV helped him realize that "gaming the system" can also be used for good. 18:42 Theme 2: The Power of the Tribe and Collective Momentum. 19:28 Clip from Justin Leader. 21:45 Why being a "good villager" is so important to the overall outcome of healthcare. 23:22 Clip from Cristin Dickerson, MD, and how she draws inspiration from various RHV episodes. 25:21 Clip from Andrew Gordon. 27:39 Theme 3: Unplugging From the Matrix of Healthcare Opacity. 28:32 Clip from Andrew Tsang. 29:29 RHV episodes that cover better value out of health benefits. 32:15 Clip from Sergei Polevikov. 34:11 What tech needs to do in order for healthcare to succeed and improve. 35:06 Clip from Bryce Platt, PharmD. 36:01 More RHV episodes on unplugging from pricing opacity.
EP443: Let Us Never Pay the First Bill in Honor of Marshall Allen
Épisode 443
jeudi 4 juillet 2024 • Durée 36:17
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: https://relentlesshealthvalue.com/join-the-relentless-tribe 🫙 Support the podcast with a small donation to the Tip Jar: https://relentlesshealthvalue.com/join-the-relentless-tribe 📺 Subscribe to our YouTube channel https://www.youtube.com/@RelentlessHealthValue 🎤 Listen on Apple Podcasts https://podcasts.apple.com/us/podcast/feed/id892082003?ls=1 🎤 Listen on Spotify https://open.spotify.com/show/6UjgzI7bScDrWvZEk2f46b === CONNECT WITH THE RHV TEAM === ✭ LinkedIn https://www.linkedin.com/company/relentless-health-value/ ✭ Threads https://www.threads.net/@relentlesshealthvalue/ ✭ Bluesky https://bsky.app/profile/relentleshealth.bsky.social ✭ X https://twitter.com/relentleshealth/ 09:28 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."
EP442: A Short Rumination on Saving Money, Except Not Saving Money. Oncology Side Effect Management as a Case Study, With Andreas Mang
Épisode 442
jeudi 27 juin 2024 • Durée 18:51
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: 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/ 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.
EP441: Tables Get Turned. This Is Me Interviewed by Abby Burns From Radio Advisory About What Is Value
Épisode 441
jeudi 20 juin 2024 • Durée 40:18
The tables get turned this episode: it's Stacey Richter being interviewed, by Abby Burns of Advisory Board's Radio Advisory podcast, recorded live at the Raising the Value Bar Summit. Abby asks Stacey why she started the show, how she personally defines value, and why value is genuinely in the eye of the beholder — especially in an industry where, as Stacey puts it, one person eats the dinner, someone else orders it, and a third person pays for it. WHAT YOU'LL LEARN ✅ Why value in healthcare is so hard to pin down when the patient, the orderer, and the payer are often three different parties with three different definitions of a win ✅ The origin story behind Relentless Health Value: a primary care practice that cut total cost of care by 17% and got acquired and dissolved by a health system anyway, and the $100 million spend increase that followed ✅ Daniel Kuzmanovich's four tensions in measuring healthcare value: short-term versus long-term, individual patients versus populations, output versus outcome, and proven versus experimental approaches ✅ Why driving change in healthcare isn't the hard part — sustaining it is, and why so many value wins quietly unwind after the person who drove them moves on ✅ Why Stacey believes it's important to understand which of these tensions you personally sit on, and how misalignment across them is what actually drains value out of good ideas WHY THIS MATTERS Value in healthcare doesn't fail to materialize because good ideas are scarce; it fails because the person eating the dinner, the person ordering it, and the person paying for it are misaligned on what winning even looks like. Understanding Daniel Kuzmanovich's four tensions — timeline, whose value, what kind of value, and how proven it needs to be — gives stakeholders a shared vocabulary for diagnosing exactly where those misalignments are happening. And the case study underlying this whole show, a practice that objectively lowered cost of care and got shut down for it anyway, is a reminder that sustaining value requires more than just achieving it once. MENTIONED IN THIS EPISODE Encore! EP391 with Scott Conard, MD: Apple Podcasts | Spotify | Other Apps EP438 with John Lee, MD: Apple Podcasts | Spotify | Other Apps EP400 with Stacey Richter (solo, manifesto Part 2): Apple Podcasts | Spotify | Other Apps === LINKS === 🔗 Show Notes with all mentioned links: Episode Page ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter 🫙 Support the podcast with a small donation to the Tip Jar 🎤 Listen on Apple Podcasts 🎤 Listen on Spotify 📺 Subscribe to our YouTube channel === CONNECT WITH THE RHV TEAM === ✭ LinkedIn ✭ Threads ✭ Bluesky ✭ X 00:00 Introduction 03:33 Stacey's journey and mission. 04:16 The story of Scott Conard, MD (Encore! 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. 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.
EP440: What Is the Optimal Size for a Medical Practice? With David Muhlestein, PhD, JD
Épisode 440
jeudi 13 juin 2024 • Durée 38:15
David Muhlestein, PhD, JD, has a specific number in mind for the optimal size of a physician practice: 10 to 20 docs, plus supporting team. Big enough to afford the back-office functions and technology that come with scale, small enough that the practice stays collegial, local, and able to act on its own values rather than corporate policy. He joins Stacey Richter to dig into what happens once organizations grow well past that size — and into the "diversification discount" that quietly punishes big health systems trying to be fiduciarily responsible for both primary care and specialty care at once. WHAT YOU'LL LEARN ✅ Why 10 to 20 doctors is David's answer for the optimal practice size — large enough for economies of scale, small enough to preserve autonomy and shared values ✅ What the "crisis of autonomy" is, and how practices move through the phase David calls delegation as they grow ✅ What the Diversification Discount is on Wall Street, and why it applies with even more force to health systems that fund primary care by taking money away from specialty care ✅ Three concrete options for organizations wrestling with this tension: splitting into aligned business units, decentralizing to restore practice-level autonomy, or having the board directly confront what its actual values are ✅ Why boards — especially nonprofit boards often dominated by finance backgrounds rather than medicine or public health — need to ask whether their organization's value comes from market power or from improving community health WHY THIS MATTERS There's a paradox sitting at the center of most large, consolidated health systems: good primary care reduces the need for (and revenue from) specialty care, yet many systems fund primary care precisely by redirecting specialty care revenue. That's not a sustainable alignment of incentives, and pretending otherwise doesn't make the diversification discount go away. Whether the fix is organizational bifurcation, genuine delegation of autonomy back to practice-level teams, or a hard look from the board about what the organization is actually for, the underlying question is the same: is this organization's value coming from market and political power, or from an actual ability to improve patient and community health? MENTIONED IN THIS EPISODE EP412 with Robert Pearl, MD: Apple Podcasts | Spotify | Other Apps EP438 with John Lee, MD: Apple Podcasts | Spotify | Other Apps EP437 with Brian Klepper, PhD: Apple Podcasts | Spotify | Other Apps EP432 with Kate Wolin, ScD: Apple Podcasts | Spotify | Other Apps EP421 with Jodilyn Owen: Apple Podcasts | Spotify | Other Apps === LINKS === 🔗 Show Notes with all mentioned links: Episode Page ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter 🫙 Support the podcast with a small donation to the Tip Jar 🎤 Listen on Apple Podcasts 🎤 Listen on Spotify 📺 Subscribe to our YouTube channel === CONNECT WITH THE RHV TEAM === ✭ LinkedIn ✭ Threads ✭ Bluesky ✭ X 00:00 Introduction 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. 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"? 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"?
EP439: Fixing the Generic Drug Pricing Problem, Where Patients Pay More When They Use Their Insurance, With Luke Slindee, PharmD
Épisode 439
jeudi 6 juin 2024 • Durée 28:56
Traditional PBMs make billions of dollars on generic drugs simply by paying pharmacies less than what patients pay at the counter — buying low and selling high on the spread. Luke Slindee, PharmD, senior pharmacy consultant at Myers and Stauffer (the firm that calculates the NADAC benchmark for CMS), returns to offer a different fix than the one covered in the Ge Bai episode: adjusting the "usual and customary" price construct for generic medications that has gotten wildly inflated over time. WHAT YOU'LL LEARN ✅ What a "usual and customary" price is, and the logical, behavioral-economic reasons it has become so inflated for generic drugs ✅ How PBMs end up setting both what a pharmacy charges the patient and what the PBM pays the pharmacy for the same transaction — and why that dual role is what makes spread pricing possible ✅ Whether pharmacies should be allowed to maintain two separate cash prices, and how GoodRx fits into the pharmacy/PBM dynamic ✅ How the Amazon anticompetitive contract lawsuit connects back to pharmacy contracts with PBMs ✅ What it would actually take for the generic drug market to return to normal, competitive pricing WHY THIS MATTERS Generic drugs are supposed to be the cheap, boring part of pharmacy benefits, but spread pricing has turned them into a reliable profit center for PBMs at the direct expense of patients and pharmacies. The fact that 79% of the time a patient in their deductible phase pays less using GoodRx or a cash-pay option than using their own insurance is not a fluke of the market; it's the predictable result of a usual and customary pricing construct that PBMs have every incentive to keep inflated. Fixing this isn't just about saving patients money at the counter — it's about correcting a pricing mechanism that quietly undermines the entire premise of having insurance for generic drugs in the first place. MENTIONED IN THIS EPISODE EP395 with Brennan Bilberry: Apple Podcasts | Spotify | Other Apps EP420 with Ge Bai, PhD, CPA: Apple Podcasts | Spotify | Other Apps EP418 with Mark Cuban and Ferrin Williams, PharmD, MBA: Apple Podcasts | Spotify | Other Apps === LINKS === 🔗 Show Notes with all mentioned links: Episode Page ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter 🫙 Support the podcast with a small donation to the Tip Jar 🎤 Listen on Apple Podcasts 🎤 Listen on Spotify 📺 Subscribe to our YouTube channel === CONNECT WITH THE RHV TEAM === ✭ LinkedIn ✭ Threads ✭ Bluesky ✭ X 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? 00:00 Introduction 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?
EP438: Recognizing Cognitive Dissonance and Thinking About How to Overcome It When in the Belly of the Beast, With John Lee, MD
Épisode 438
jeudi 30 mai 2024 • Durée 38:58
Cognitive dissonance — acting in ways that conflict with your own stated beliefs, or holding two contradictory beliefs at once — is harder to sustain the closer you are to patients, which is probably why moral injury and burnout hit bedside clinicians hardest. John Lee, MD, a practicing emergency physician and clinical informaticist who has served as chief medical information officer at multiple organizations, joins Stacey Richter to talk about what to actually do when you're working inside a large healthcare organization — the "belly of the beast" — and recognize dissonance between what the system does and what you believe good care should look like. WHAT YOU'LL LEARN ✅ Why cognitive dissonance gets easier to sustain the further you are from the exam room, and harder to ignore the closer you get to patients ✅ Why celebrating small wins and acknowledging that you can't fix everything is not a consolation prize, but an actual strategy for surviving inside an imperfect system ✅ Why toxic culture and cognitive dissonance are connected — you can't credibly champion team-based care while tolerating cruelty toward the people on your own team ✅ Why a hierarchical healthcare structure works against the kind of incremental, collaborative improvement that reduces dissonance over time ✅ Why finding like-minded colleagues as a sounding board and support network is Dr. Lee's central piece of advice for anyone trying to do right by patients inside a large, imperfect organization WHY THIS MATTERS Almost everyone working in healthcare today is operating somewhere inside a system with real, uncomfortable contradictions between mission and margin — and waiting for a fully rebuilt system before acting on that discomfort isn't a realistic option. The alternative isn't denial or resignation; it's honestly naming the dissonance, focusing on the incremental improvements actually within your control, and building a support network of people who see the same problems you do. For clinicians and leaders alike, that combination is what makes it possible to keep doing meaningful work inside a system that will not be perfect anytime soon. MENTIONED IN THIS EPISODE Encore! EP391 with Scott Conard, MD: Apple Podcasts | Spotify | Other Apps EP421 with Jodilyn Owen: Apple Podcasts | Spotify | Other Apps EP415 with Rob Andrews: Apple Podcasts | Spotify | Other Apps Encore! EP326 with Rishi Wadhera, MD, MPP: Apple Podcasts | Spotify | Other Apps EP430 with Barbara Wachsman: Apple Podcasts | Spotify | Other Apps EP431 with Kenny Cole, MD: Apple Podcasts | Spotify | Other Apps === LINKS === 🔗 Show Notes with all mentioned links: Episode Page ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter 🫙 Support the podcast with a small donation to the Tip Jar 🎤 Listen on Apple Podcasts 🎤 Listen on Spotify 📺 Subscribe to our YouTube channel === CONNECT WITH THE RHV TEAM === ✭ LinkedIn ✭ Threads ✭ Bluesky ✭ X 00:00 Introduction 07:37 What is cognitive dissonance relative to the healthcare industry? 08:57 What are the systems that start to bear down on individuals within the healthcare system? 10:14 Encore! EP391 with Scott Conard, MD. 10:48 EP421 with Jodilyn Owen. 10:59 EP415 with Rob Andrews. 12:30 Encore! EP326 with Rishi Wadhera, MD, MPP. 13:10 "The system has almost gamed them." 17:49 EP430 with Barbara Wachsman. 19:07 How can alignment still be achieved in the face of cognitive dissonance? 20:34 EP431 with Kenny Cole, MD. 24:06 Why does it take more than one person to solve the dysfunction in the healthcare system? 26:26 What are some little changes that can help change the cognitive dissonance in healthcare? 28:22 Why is a hierarchal healthcare structure not necessarily beneficial? 30:38 The RaDonda Vaught story. 37:58 "Be happy in the small things."
EP437: The Most Powerful Committee No One Ever Heard of and Their Role in Primary Care and Mental Health Struggles, With Brian Klepper, PhD
Épisode 437
jeudi 23 mai 2024 • Durée 15:34
There's a 31-member AMA committee that, under a sole-source contract with CMS dating back to the late '80s, decides the relative value of every medical procedure — and 22 to 25 of those 31 seats go to specialists, leaving primary care with just five or six. Brian Klepper, PhD, a longtime healthcare analyst and former CEO of the National Business Coalition on Health, joins Stacey Richter to explain how the RUC (RVU Update Committee) works, why its math has almost nothing to do with patient or clinical value, and why it's a root cause of primary care's broken business model. WHAT YOU'LL LEARN ✅ What the RUC is, who sits on it, and why a committee dominated by specialists ends up horse-trading over whose procedures get the highest relative value ✅ Why primary care has developed an unearned reputation as the "easy" specialty, when in reality it requires enormous diagnostic complexity in a 10- to 15-minute visit ✅ Why the RUC's RVU allocations are based only on physician work, practice expense, and professional liability — with zero weight given to value delivered to the patient ✅ Why CMS accepting roughly 90% of the RUC's recommendations effectively hands pricing power for the entire physician fee schedule to a specialist-dominated committee ✅ Why chronic disease prevention, behavioral health integration, and care coordination all register as low relative value under the current system — even though they're exactly the services value-based care is supposed to reward WHY THIS MATTERS Almost every conversation about fixing primary care and mental health care in America skips over the RUC entirely, even though it's the mechanism quietly setting the prices that make primary care financially unsustainable in the first place. Health plans that pay fee-for-service rates are often just passing through Medicare rates, which are themselves built on RUC-determined RVUs — meaning the undervaluation of primary care and behavioral health isn't an accident of the market, it's baked into the pricing infrastructure underneath it. Understanding the RUC is a prerequisite for anyone who wants to actually fix primary care's business model rather than just talk about value-based care in the abstract. MENTIONED IN THIS EPISODE EP436 with Elizabeth Mitchell: Apple Podcasts | Spotify | Other Apps === LINKS === 🔗 Show Notes with all mentioned links: Episode Page ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter 🫙 Support the podcast with a small donation to the Tip Jar 🎤 Listen on Apple Podcasts 🎤 Listen on Spotify 📺 Subscribe to our YouTube channel === CONNECT WITH THE RHV TEAM === ✭ LinkedIn ✭ Threads ✭ Bluesky ✭ X 00:00 Introduction 02:29 What is the RUC? 06:26 Why is primary care not the "easy" specialty? 09:42 What are three low-value things per RUC? 10:33 EP436 with Elizabeth Mitchell. 10:38 What is a root cause of why primary care doesn't get paid more? 12:50 Why doesn't value equal money?
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