Explore every episode of the podcast Relentless Health Value

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.

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.

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.

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."

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.

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.

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"?

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?

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."

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?

When a TPA gets acquired by a health plan, history suggests it stops being a TPA and starts acting like a full health plan — ancillary fees, opt-out-proof bells and whistles, and all, whether or not that's what the self-insured employer actually wants. Elizabeth Mitchell, president and CEO of the Purchaser Business Group on Health, joins Stacey Richter to widen the inertia conversation beyond employers and look at the TPAs, ASOs, and health plans that are supposed to be helping jumbo employers deploy their benefits — and often aren't. WHAT YOU'LL LEARN ✅ What a jumbo employer actually needs from a TPA or ASO, versus what many are getting instead: a de facto health plan charging health-plan-level fees ✅ Why the market genuinely lacks effective, independent TPAs that aren't owned by a health plan — and why that ownership structure tends to choke off both cost and quality data sharing ✅ What recent lawsuits against major carriers reveal about the scale of undisclosed fees flowing through TPA and ASO arrangements ✅ Why direct contracting between employers and providers is gaining traction as a way around TPA and health plan inertia ✅ Why some regional health plans are quietly doing this differently, and what that suggests is actually possible at scale WHY THIS MATTERS Employer inertia gets a lot of attention, but it's only part of the story: TPAs, ASOs, and health plans have their own structural reasons for maintaining the status quo, and those incentives don't always point toward serving the self-insured employers paying the bills. Lawsuits alleging hundreds of millions in undisclosed fees aren't outliers; they're a signal of just how much money is at stake when these entities operate with limited transparency and limited accountability. For jumbo employers trying to actually deploy their health benefits well, understanding where TPA and health plan incentives diverge from their own is a prerequisite to fixing it — whether that means direct contracting or simply demanding better data. MENTIONED IN THIS EPISODE Encore! EP337 with Olivia Webb: Apple Podcasts | Spotify | Other Apps EP427 with Rik Renard: 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 06:48 What is the overarching context for health plans in healthcare purchasing? 09:00 Encore! EP337 with Olivia Webb. 11:44 Why is it important to reestablish a connection between the people paying for care and people providing care? 14:07 What are the needs of a self-insured employer when managing employee benefits? 19:41 Is it doable for employers to set their own contracts? 22:11 Is transparency presumed? 23:25 Will the new transparency upon us actually expose wasted expense? 27:45 "This is not about individual bad actors. … The systems … that is not aligned." 29:32 Are there providers who want to work directly with employers? 32:46 Why is it important that incentives need to be aligned? 34:25 Why is the quality of care even more important than transparency? 36:29 EP427 with Rik Renard. 38:08 What's missing from the conversation on changing health plans?

It costs providers roughly 14% of a transaction's value just to get paid for it, and payers tack on another 5% to 15% just to pay it — putting 20% to 30% of every healthcare transaction into pure administrative waste before anyone talks about redundant care or unnecessary procedures. David Scheinker, PhD, executive director of systems design and collaborative research at Stanford Children's Health, joins Stacey Richter in this encore episode to explain why that waste persists even though everyone agrees it's a problem — and to lay out a genuinely actionable fix: standardizing healthcare contracts the way industries like derivative trading and credit card processing already have. WHAT YOU'LL LEARN ✅ How much administrative cost is actually baked into a typical healthcare transaction on both the provider side and the payer side, and how that adds up to 20% to 30% of total spend ✅ Why derivative traders cut their per-contract cost from $100,000 to $5,000 by standardizing how they transact — and why healthcare hasn't done the same, despite obvious parallels ✅ What it would mean to standardize healthcare contracts around shared "parameters" — similar to how Airbnb lets every listing negotiate price around a common set of defined variables like bedrooms and bathrooms ✅ Why some organizations actually profit from the current transactional waste, and why legacy technology, sunk costs, and CMS-driven regulatory complexity all work against collaboration ✅ Why Surescripts — created by a group of competing PBMs who needed a shared e-prescribing platform — is proof that healthcare competitors can and do collaborate around a genuinely common pain point WHY THIS MATTERS Administrative burden in healthcare isn't an unsolvable mystery; it's a coordination problem that other industries facing similar friction have already solved by standardizing how they transact. The obstacle isn't a lack of a workable solution — it's that some organizations profit from the current mess, legacy systems are expensive to unwind, and regulatory complexity makes collaboration harder than it needs to be. For anyone trying to reduce the real cost of getting paid and paying in healthcare, Dr. Scheinker's research points to a concrete, non-theoretical path forward: standardized contract parameters that leave plenty of room for competitive negotiation while making the underlying transactions dramatically cheaper to execute. === 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 10:39 What's the quantitative administrative cost in an average transaction? 11:05 What's the quantitative administrative cost in a healthcare transaction? 11:58 What does the healthcare billing and administration cost add to the US's overall healthcare spend? 12:53 Is it possible to cut billing and administrative costs in healthcare? 14:17 "In some ways, the problem for healthcare should be simpler." 15:30 What does the complexity of the current system look like in a doctor's office? 18:42 How did David go about studying healthcare administrative costs? 21:34 "It doesn't have to be simple; it should be standardized." 24:50 What would be the pushback on standardizing contracts in healthcare? 25:43 Why is it possible to gain more value by losing customization in contracts? 27:20 "Never let a good crisis go to waste." 27:41 "It's much easier in healthcare to build something new than to change something that exists." 30:47 What benefits does telemedicine have to cutting administrative costs? 32:17 What is another significant benefit of using standardized contracts? 33:26 Why haven't standardized contracts become a common thing in the current healthcare system?

Practicing medicine without considering pharmacy is like getting to the 90-yard line, putting down the ball, and walking off the field — and yet almost no mainstream contract holds a PBM accountable for the downstream medical costs caused by suboptimal pharmacy benefit design. Dan Mendelson, CEO of Morgan Health at JPMorgan Chase, joins Stacey Richter to dig into five vital considerations for optimizing pharmacy benefits within value-based care, building on a LinkedIn post he wrote that kicked off this whole conversation. WHAT YOU'LL LEARN ✅ Why pharmacy benefits have to be managed by a clinical team and integrated into the overall context of care — not purchased and siloed separately from medical benefits ✅ Why pharmaceutical companies need to be ready to contract on the basis of value, and what that actually requires from a manufacturer ✅ Why evidence requirements in pharmacy benefit design are good for everyone involved, including patients, plan sponsors, and manufacturers ✅ Why pooling risk matters for optimized pharmacy benefits, and how to do it without simply handing the problem to an insurance company ✅ Dan's specific advice for hospitals, primary care doctors, and entrepreneurs trying to operate in a value-based world where "buy and bill" no longer makes sense WHY THIS MATTERS Total cost of care, value-based medical care, and pharmacy benefits are not separate worlds, even though they're so often purchased and managed as if they were. A patient who gets an expensive organ transplant but can't afford the anti-rejection meds, or who's told to take insulin they can't afford, represents a system that optimized the medical side while leaving pharmacy as an afterthought — and the downstream costs of that gap land on patients, employers, and the system as a whole. Building pharmacy benefits with the same rigor, accountability, and clinical integration as medical benefits isn't optional if value-based care is the actual goal. MENTIONED IN THIS EPISODE Encore! EP206 with Ashok Subramanian: Apple Podcasts | Spotify | Other Apps EP426 with Nina Lathia, RPh, MSc, PhD: 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 04:50 How do we connect the dots between value-based care and pharmacy benefits? 07:43 Where do things need to go for employers in terms of drug spend integration? 08:42 How do we think about having a value-based component in the decision-making process? 09:44 How do we enable the necessary information to make proper decisions? 10:56 Encore! EP206 with Ashok Subramanian. 11:21 "Many payviders just haven't gotten to pharmacy yet; they need to." 14:14 Why do pharmaceutical companies need to be prepared to contract on the basis of value? 16:46 EP426 with Nina Lathia, RPh, MSc, PhD. 17:36 EP431 with Kenny Cole, MD. 18:07 Why is it important to "let the market work"? 21:04 Why do we have cost sharing, and when does it not make sense to have that as a co-pay? 23:59 Why are evidence requirements good for everyone? 28:45 Why is pooling of risk important? 29:49 How do you pool risk without going to an insurance company? 32:03 What is Dan's advice to hospitals? 33:30 "In a value-based world, buy and bill does not make sense." 33:36 What is Dan's advice to primary care doctors? 33:54 What is Dan's advice to entrepreneurs and innovators?

Why Twisted Ankles Cost Plan Sponsors Millions, With Jay Kimmel, MD. The MSK "White Space": How Triage-Before-the-Triage Could Cut Unnecessary Orthopedic Spend. Episode 499. Jay Kimmel, MD, an orthopedic surgeon with over 35 years in practice and co-founder of Upswing Health, joins Stacey Richter to unpack the "white space" of musculoskeletal (MSK) care—the moment a member twists an ankle or tweaks a back and has no one to call for guidance before deciding between the ER, urgent care, or just going home. MSK spend runs 20–30% of total plan spend and about $16 PMPM, and an estimated 80% of low-acuity injuries would heal on their own, yet lack of access to quick triage routinely sends members into unnecessary imaging, referrals, and even surgery. WHAT YOU'LL LEARN ✅ Why musculoskeletal (MSK) spend adds up to 20–30% of total plan spend and roughly $16 PMPM—making it one of the costliest categories for self-insured employers ✅ Why an estimated 80% of low-acuity MSK injuries, like a twisted ankle or minor back pain, would heal on their own without any medical intervention ✅ How the disappearance of doctor's lounges and informal curbside consults left patients to self-triage MSK injuries with no clinical guidance, a gap Dr. Kimmel calls the "white space" of MSK care ✅ Why roughly 50% of spine surgeries are considered unnecessary, and how an ER visit for a low-acuity injury can snowball into imaging, a surgical referral, and lost work time ✅ How Upswing Health's model—an athletic trainer within 15 minutes and an orthopedic specialist within 24 hours—gives members "triage before the triage" instead of defaulting to the ER WHY THIS MATTERS MSK injuries are exactly the kind of healthcare spend where more care doesn't mean better outcomes—it just means more cost without a corresponding health dividend. When patients are left to self-triage a twisted ankle or a sore back with no one to call, the default path is often the most expensive one: the ER, unnecessary imaging, and a surgical referral for something that would have healed on its own. Closing that white space with fast, low-friction access to real triage is one of the more straightforward inches available to plan sponsors. MENTIONED IN THIS EPISODE EP472 with Eric Bricker, MD: Apple Podcasts | Spotify | Other Apps Study : Lockton High-Cost Claimant 2025 Report EP464 with Al Lewis: Apple Podcasts | Spotify | Other Apps EP470 with Nikki King, DHA: Apple Podcasts | Spotify | Other Apps EP468 with Matt McQuide: Apple Podcasts | Spotify | Other Apps EP471 with Christine Hale, MD, MBA: 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 08:01 What is the "white space" in MSK spend? 13:30 How back pain also easily transitions from a low-acuity issue to a high-acuity problem. 15:11 How plan sponsors can detect their white space downstream spend. 18:15 Why where patients start their journey often dictates where they wind up and how costly that medical pathway is. 20:48 Where PCPs fit into this MSK spend issue. 25:39 Why access is key.

Most people who listen to this show know enough about bundled payments to be dangerous — which is exactly why Stacey Richter asked Ben Schwartz, MD, MBA, an orthopedic surgeon still in full-time clinical practice, what actually surprises people once they get past the basics. They walk through the four flavors of bundles currently in play — CMS bundles like BPCI and CJR, commercial carrier bundles, direct employer bundles, and condition- or diagnosis-specific bundles — and dig into why a program built to reward efficiency ends up penalizing the clinical teams who get too good at it. WHAT YOU'LL LEARN ✅ What distinguishes the four types of bundled payments — CMS bundles (BPCI, CJR), commercial carrier bundles, direct employer bundles, and condition- or diagnosis-specific bundles — and why most current bundles are built around a surgical intervention ✅ Why CMS's BPCI bundles are being sunsetted, and how a program designed to reward efficient clinical teams ends up penalizing them once the goalposts keep shifting ✅ What surprises even people who already know the bundled payments landscape reasonably well ✅ Why direct employer bundles for musculoskeletal care are drawing entrepreneurial orthopedic surgeons who want to contract straight with employers and cut out the middleman ✅ How bundled payments connect to Centers of Excellence strategy, and where the model is likely headed next WHY THIS MATTERS Bundled payments are one of the clearer on-ramps to value-based care, but the mechanics matter enormously: a CMS program that rewards efficiency in year one and penalizes that same efficiency in year three teaches clinical teams the wrong lesson, and a bundle built around a surgical intervention doesn't translate cleanly to condition-specific care. For plan sponsors, health systems, and clinicians alike, understanding which type of bundle is in play, who's setting the rules, and how those rules shift over time is the difference between a bundle that drives real value and one that just shuffles risk around. MENTIONED IN THIS EPISODE EP415 with Rob Andrews: Apple Podcasts | Spotify | Other Apps EP346 with Peter Hayes: Apple Podcasts | Spotify | Other Apps Encore! EP294 with Steve Schutzer, MD: Apple Podcasts | Spotify | Other Apps EP331 with Al Lewis: Apple Podcasts | Spotify | Other Apps Encore! EP372 with Cora Opsahl: Apple Podcasts | Spotify | Other Apps EP373 with 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 06:07 Where are we in the development of the bundled payments space? 08:09 What are the four types of bundled payments? 09:52 How can bundled payments create perverse incentives? 11:04 What are the positives in bundled payments, and how can they help push us toward value-based care? 13:02 What is surprising about bundled payments? 18:50 EP415 with Rob Andrews. 27:03 How do Centers of Excellence connect back to bundled payments? 29:00 EP346 with Peter Hayes. 30:29 Encore! EP294 with Steve Schutzer, MD. 33:38 EP331 with Al Lewis. 33:43 Encore! EP372 and EP373 with Cora Opsahl. 37:13 What does Dr. Schwartz think the future is for bundled payments?

Every week, self-funded employers get hit with a claims wire — a charge from their TPA or ASO vendor to cover plan expenses in weekly increments — and depending on how sophisticated the plan or its advisor is, that invoice might be a single lump total or a detailed breakdown. Justin Leader, president and CEO of BenefitsDNA, joins Stacey Richter to walk through five fees that frequently get buried inside that claims wire without ever showing up on an administrative invoice or in the ASO finance exhibit — plus a bonus mechanism, medical claims spread pricing, that moves money to vendors in ways plan sponsors often don't realize. WHAT YOU'LL LEARN ✅ What a shared savings fee is — including how it can quietly extend to overpayment recoupment fees, where a TPA charges the plan sponsor a percentage of money recovered after correcting its own mistake ✅ How prior auth fees, prepayment integrity fees, pay and chase fees, and TPA claims review fees each work, and why several of them charge extra for functions a TPA is arguably already being paid to perform ✅ Why so many of these fees are structured as a percentage of vendor-reported (and largely unvalidated) savings — and why that means the fees quietly grow every year right alongside medical trend ✅ What medical claims spread pricing is, and how a plan sponsor can end up paying a provider more than the actual check written for the service rendered ✅ Why identifying, reviewing, and documenting every fee in a vendor contract needs to become standard practice ahead of every renewal or RFP negotiation WHY THIS MATTERS If a fee has to be hidden to get paid, that alone is a signal worth taking seriously — even when the underlying service is legitimate. The core problem isn't that TPAs and ASO vendors charge for extra work; it's that plan sponsors are frequently paying for that work without ever agreeing to a known rate, without visibility into what's being charged, and without any way to validate the savings those fees are calculated against. For any employer or plan sponsor trying to control healthcare costs, understanding exactly what's buried in the weekly claims wire isn't a nice-to-have audit exercise — it's the baseline information needed to negotiate from a position of actual knowledge rather than trust. === 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 07:55 How is the claims wire typically explained to a plan sponsor? 11:18 What is the whole point of self-funding? 11:27 Why is it so vital to understand what you're paying for? 12:38 What are the five "buried" items that wind up in these claims wires? 13:03 What is a shared savings fee? 17:10 "Rates are important, but so are your rights." 21:01 What's going on with prior auth fees? 23:35 What is prepayment integrity? 28:16 What is pay and chase? 31:54 What is a TPA claim review? 35:47 Is there medical claim spread pricing?

Scott Conard, MD, grew a solo practice into a 510-clinician, value-based integrated delivery network that reduced the cost of care through prevention and proactive engagement — and then watched it get acquired by a hospital system whose incentives ran the opposite direction. In this encore episode, he tells Stacey Richter the story in detail, including how one North Texas health system managed to raise local healthcare spend by $100 million in a single year, partly by pulling back the population-health infrastructure that had been keeping patients out of hospital beds. It's a case study in what happens when margin quietly shoves mission off the bus — and Dr. Conard is careful to note that the people making these calls upstairs are rarely the doctors themselves. WHAT YOU'LL LEARN ✅ Why a PCP can produce genuinely high-value care inside a fee-for-service model — if they're willing to change practice patterns and think of themselves as a risk-management expert, not just someone who treats symptoms ✅ What a "Whole-Person Risk Score" is, and how it helped move Dr. Conard's practice from a transactional model to a relationship model ✅ Why total cost of care — not just primary care cost — is the number that actually matters when evaluating a risk-based contract ✅ How a local health system raised North Texas healthcare spend by $100 million year over year, partly by scaling back the very population-health efforts that kept patients out of hospital beds ✅ Why "fiduciary responsibility" so often functions as a euphemism for decisions with questionable community benefit — and why that's a systemic incentive problem, not evidence of bad people WHY THIS MATTERS Dr. Conard's story is a case study anyone trying to level up primary care should sit with: doing the right thing clinically doesn't protect a practice from getting acquired, financialized, and repurposed toward incentives that undo the very outcomes it was built to produce. As he puts it, this isn't about villainizing the people inside not-for-profit hospital systems — it's about recognizing that even well-intentioned organizations operate under incentives that can quietly increase spend, reduce prevention, and produce moral injury in the clinicians caught in the middle. Fixing that requires looking at the system's incentive structure, not just the intentions of the people working inside it. MENTIONED IN THIS EPISODE Encore! EP335 with Brian Klepper, PhD: Apple Podcasts | Spotify | Other Apps Encore! EP381 with Karen Root: Apple Podcasts | Spotify | Other Apps EP364 with David Muhlestein, PhD, JD: Apple Podcasts | Spotify | Other Apps EP384 with Wendell Potter: 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 06:54 What triggered Scott's career journey? 07:31 What caused Scott to rethink what is good primary care? 08:11 Why did Scott realize that he is actually a risk-management expert as a primary care doctor rather than someone who treats symptoms? 09:25 Encore! EP335 with Brian Klepper, PhD. 09:53 How did Scott's practice change after this realization? 10:04 What is a "Whole-Person Risk Score"? 13:05 "You start to move from a transactional model to a relationship model." 15:31 Did Scott have any risk-based contracts? 16:08 Why is it so important to look at total cost of care and not just primary care cost? 22:13 Encore! EP381 with Karen Root. 30:43 Why did Scott move over to help corporations? 33:10 EP364 with David Muhlestein, PhD, JD. 33:51 "Everybody thought they were honoring their fiduciary responsibility, and the incentives are completely misaligned." 34:31 EP384 with Wendell Potter. 34:43 "It's the system that's broken; it's not bad people."

The front desk is usually the most physically walled-off part of any healthcare practice — a half-wall at minimum, sometimes a full glass barrier — and that architecture sends a message: this team has nothing to do with the mission of anyone else in the building. Jerry Durham, a physical therapist turned practice consultant and founder of The Client Experience Company, joins Stacey Richter in this encore episode to make the case that the front desk is actually the most overlooked lever for patient outcomes, clinician burnout, and practice success — and that treating it as a separate fiefdom is costing practices on all three fronts. WHAT YOU'LL LEARN ✅ Why the front desk isn't just an administrative function but "phase two" of the patient life cycle — the moment a person first engages with a practice, with its own objectives and its own owner ✅ Why the front desk's three real objectives — building a relationship, being a problem solver, and setting the provider up for success — get replaced in most practices with a single, counterproductive goal: get everybody scheduled ✅ Why trust and expectations built before a patient ever reaches the exam room are what the research shows actually correlate with better outcomes ✅ Why an unoptimized front desk doesn't just hurt patient experience — it quietly drives clinician burnout by loading providers with the entire burden of patient success or failure ✅ Why culture change here can't happen from the middle of the org chart — it has to be driven by someone senior enough to sit where the front desk and clinical reporting lines actually meet WHY THIS MATTERS Provider organizations spend enormous energy on clinical protocols and data tools while treating the front desk as a separate, lower-stakes operation — even though it's the team setting expectations, building trust, and effectively pre-loading the outcome of every visit before the provider ever walks in the room. For any practice trying to succeed in value-based care, get into narrow or Centers of Excellence networks, or simply reduce clinician burnout, the front desk isn't a support function to optimize last; it's frequently the first and most consequential touchpoint a patient has with the entire system. MENTIONED IN THIS EPISODE EP236 with Liliana Petrova: Apple Podcasts | Spotify | Other Apps EP228 with Julie Rish, PhD: 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 05:49 What is the patient life cycle? 06:48 What are the milestones of the patient life cycle? When does it start? 10:05 "This isn't a business solution; this is a patient-driven solution." 10:21 "What is best for the patient is best for business." 13:25 "The takeaway there is that your team members are all driving toward the same goal." 14:34 How does the front desk impact health outcomes? 16:41 What is the objective of a front desk to reduce provider burden? 20:03 EP236 with Liliana Petrova. 21:18 "There's actually three roles at the front desk." 30:37 EP228 with Julie Rish, PhD.

Almost no digital health delivery solution providers measure outcomes of any kind — which raises an uncomfortable question: how do you know if the "waste" you're cutting to hit margin targets is actually waste at all? Kate Wolin, ScD, a behavioral epidemiologist who bootstrapped a digital health start-up to profitability before selling it to Anthem, joins Stacey Richter to talk about the knifepoint where margin and mission meet — and why the things that look most cuttable in the name of efficiency (slow conversations, relationship-building, trust) are often exactly what makes a clinical model work in the first place. WHAT YOU'LL LEARN ✅ Why efficiency without a clear outcome in mind is efficient toward nothing — and why so few healthcare delivery solutions actually measure whether they're achieving anything ✅ Why the things that read as "waste" on a spreadsheet — time spent building trust, engaging patients, assessing risk — are often the load-bearing parts of a clinical model that works ✅ Why founders and investors being genuinely aligned on the pace of growth is essential, and what happens to clinical quality when they aren't ✅ Why clinical leadership and a team dynamic that allows for innovation — without sacrificing clinical soundness — has to be built in deliberately, not left to chance ✅ Why measuring what actually matters, and communicating it in a way that inspires a mission-driven culture, is what lets a team scale without losing what made it work WHY THIS MATTERS Every healthcare business eventually hits the same tension: the pressure to scale, cut costs, and satisfy investors runs headlong into the slow, relational, hard-to-measure work that actually produces good outcomes. Cutting the wrong things in the name of efficiency doesn't just risk patient outcomes; it risks the business model itself, since a solution that stops working stops being worth paying for. Dr. Wolin's advice — align founders and investors, protect clinical leadership's ability to innovate soundly, and measure what actually matters — is a practical checklist for anyone trying to keep margin and mission from cutting each other's throats. MENTIONED IN THIS EPISODE Encore! EP361 with Carly Eckert, MD, PhD(c), MPH: Apple Podcasts | Spotify | Other Apps EP297 with Jerry Durham: Apple Podcasts | Spotify | Other Apps EP427 with Rik Renard: 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 06:24 Irrespective of money, what works in clinical care and population healthcare? 09:51 Encore! EP361 with Carly Eckert, MD, PhD(c), MPH. 10:26 Why is creating a gathering place and sense of community important in clinical care? 12:46 "Sometimes, we make this about the clinical provider. It always makes me think about the rest of the people in an ecosystem that create trust." 13:49 EP297 with Jerry Durham. 14:11 Where can things go wrong when we start to think about the margin in respect to the clinical care that works? 16:47 EP427 with Rik Renard. 19:35 "We're actually very unspecific in what we're trying to achieve a lot of times in these digital health programs." 24:00 "Are you aligned as a founder, as a business with your investors on the pace of growth and what is feasible … ?" 25:30 Why is Dr. Wolin optimistic about achieving growth and still providing value? 28:17 Why is it important to ask why something is being done? 30:39 EP421 with Jodilyn Owen. 34:35 How are people motivated, and how can you use that to reduce turnover? 35:21 Why measuring what matters and communicating that is important.

Dr. Kenny Cole splits his time between seeing patients one day a week as a primary care internist and serving as system vice president for Ochsner Health, where he designs and develops new care models. Stacey Richter talks with him about what it actually takes to make accountability for outcomes real in a clinical setting — measurable results, care flows that clinicians actually follow, and trust that patients can feel. WHAT YOU'LL LEARN ✅ Why clinical teams have to be accountable for outcomes that are actually measurable — not just asked to "deliver good care" in the abstract ✅ Why clinical teams need to see with their own two eyes and believe that a clinical goal is achievable before they'll genuinely commit to it ✅ What a care flow is, and why getting everyone aligned on what best-practice care looks like — and operationalizing how to achieve it — matters as much as the goal itself ✅ Why building trust and connecting with patients isn't a soft nice-to-have, but something a standardized care flow has to be built to support ✅ Why aligning clinical pathways with financial viability is the real challenge for any practice or health system trying to pull away from the status quo WHY THIS MATTERS Accountability for outcomes sounds simple until someone tries to operationalize it inside a clinic. Dr. Cole's four points — measurable and accountable outcomes, clinical teams who believe a goal is achievable, care flows that operationalize best practice, and patient trust — aren't independent checkboxes; they're sequential dependencies. A clinical team won't commit to a goal it doesn't believe is possible, and a care flow patients don't trust won't produce the outcomes it was built to standardize. For anyone building, selling to, or working inside a health system trying to reinvent its business model, this is a working blueprint for how clinical excellence and financial viability actually get reconciled in practice — not on a strategy whiteboard. MENTIONED IN THIS EPISODE EP412 with Robert Pearl, MD: Apple Podcasts | Spotify | Other Apps EP315 with Bob Matthews: Apple Podcasts | Spotify | Other Apps EP242 with Marty Makary, MD: Apple Podcasts | Spotify | Other Apps EP427 with Rik Renard: Apple Podcasts | Spotify | Other Apps EP415 with Rob Andrews: Apple Podcasts | Spotify | Other Apps EP391 with Scott Conard, 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 07:38 Is there an optimal care pathway where there might be a lot of treatment variability? 11:01 Why doesn't Dr. Cole like the terms "noncompliant" and "nonadherent"? 11:45 EP412 with Robert Pearl, MD. 13:50 Why is it important to start with the end in mind? 17:20 How do you scale clinical excellence? 20:21 EP315 with Bob Matthews. 21:15 EP242 with Marty Makary, MD. 23:49 Why is it important simply to demonstrate what's possible for better health outcomes? 24:58 EP427 with Rik Renard. 26:10 How do we reinvent the business model of healthcare? 27:50 EP415 with Rob Andrews. 30:06 EP391 with Scott Conard, MD. 38:37 Dr. Cole is published in various healthcare journals; check out his most recent article.

Why do so many digital health entrepreneurs set their sights on selling to employers? Per Barbara Wachsman, former director of strategy and engagement for enterprise benefits at Disney and now senior advisor at Frazier Healthcare Partners, the answer is the same one Willie Sutton gave when asked why he robbed banks: because that's where the money is. Stacey Richter and Barbara dig into what it actually takes for a digital health vendor or point solution to successfully sell to employers — and, in the process, give employers themselves a rare look at what's happening on the other side of the sales table. WHAT YOU'LL LEARN ✅ Why the market for a digital health solution only exists if the problem it solves is big enough that employers feel the fallout — and why plenty of smart entrepreneurs build something valuable for patients or clinicians that nobody will actually pay for ✅ Why Barbara Wachsman says HR purchasing decisions shouldn't really be driven by improving health and well-being for its own sake — the real driver is optimizing human capital to produce a productive employee and better business outcomes ✅ Why true differentiation matters as much as market need, and what Barbara considers the compelling "secret sauces" among today's standout digital health companies ✅ Why navigating an employer's internal politics and finding a genuine internal champion is essential Selling 101 — and why the sales cycle at jumbo employers can take far longer than most entrepreneurs expect ✅ Why vendors need to manage their investors' expectations on sale timelines just as carefully as they manage prospective clients, and what the Livongo story teaches about that balance WHY THIS MATTERS Selling to employers isn't just a go-to-market strategy; it's a bet that a vendor has correctly identified a problem employers feel acutely enough to pay to solve, packaged into something genuinely differentiated, sold through a real internal champion, on a timeline investors will tolerate. Get any one of those wrong, and the vendor joins the long list of entrepreneurs who built something valuable that nobody would fund. For employers, understanding this dynamic offers a useful gut check: a vendor's pitch reveals as much about what they think employers actually care about as it does about the product itself. MENTIONED IN THIS EPISODE EP331 with Al Lewis: Apple Podcasts | Spotify | Other Apps EP427 with Rik Renard: Apple Podcasts | Spotify | Other Apps Encore! EP372 with 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 06:55 Why have people cottoned on to selling to employers, and is it a good direction to focus? 07:28 What are the three ways healthcare gets paid for in America? 07:46 Where is the profit in the healthcare system? 08:32 What does an entrepreneur really need to understand in order to sell to employers? 13:05 "It really is about producing a productive employee." 17:49 Why it's not enough to understand the market but you must also differentiate. 21:01 What's the biggest misunderstanding entrepreneurs have about per member per month? 24:10 What companies are standing out right now as differentiators? 28:02 Why is it important to also show that you are improving quality? 28:51 EP331 with Al Lewis. 28:55 EP427 with Rik Renard. 29:33 EP372 with Cora Opsahl. 30:07 Why is it important to find a strong champion who will advocate for you as a partner? 35:05 Why is it important to manage your investors and set appropriate expectations around the timeline of a sale? 36:21 What's the lesson to be learned behind Livongo?

Most pharmacy pricing acronyms — AWP, WAC, and the rest — refer to a number with a dollar sign in front of it, and it's nearly impossible for a patient or plan sponsor to know how much that number actually reflects reality. Luke Slindee, PharmD, senior pharmacy consultant at Myers and Stauffer (the accounting firm that calculates the NADAC benchmark on behalf of CMS), joins Stacey Richter to follow a drug's dollar from the manufacturer's list price all the way through wholesalers, pharmacies, and PBMs to what a patient or plan sponsor actually pays — and to explain why the one benchmark in this whole chain that isn't a black box is the one CMS itself administers. WHAT YOU'LL LEARN ✅ What AWP (Average Wholesale Price) and WAC (Wholesale Acquisition Cost) actually mean, how manufacturers arrive at these list prices, and why the difference between them matters ✅ How the drug dollar moves from manufacturer to wholesaler to pharmacy, and why pharmacies so often end up buying a drug at one price from the wholesaler while getting reimbursed an entirely different price to dispense it ✅ How PBMs ended up doing three jobs at once — adjudicating patient claims, negotiating manufacturer rebates, and setting pharmacy reimbursement — and why that concentration of roles is what makes spread pricing possible ✅ Why spread pricing (charging the plan sponsor more than the PBM pays the pharmacy, then calling the difference a trade secret) can exist and persist when so much of the transaction happens under cover of darkness ✅ What NADAC (National Average Drug Acquisition Cost) is, how it's calculated from a retail price survey, and why it's one of the only benchmarks in the entire pharmacy pricing stack that reflects an actual, transparent average of what pharmacies pay WHY THIS MATTERS The opacity baked into pharmacy pricing isn't incidental — it's the mechanism that makes spread pricing and inflated PBM margins possible in the first place. When plan sponsors can't see what a PBM actually paid a pharmacy for a given drug, they have no way to know whether they're being charged a fair and reasonable price or quietly funding someone else's markup. Understanding acronyms like AWP, WAC, and NADAC isn't academic trivia; it's the literacy plan sponsors need to ask the right questions of their PBMs before they end up in a lawsuit like the ones discussed on this show recently. MENTIONED IN THIS EPISODE EP423 with Joey Dizenhouse: Apple Podcasts | Spotify | Other Apps EP344 with Steven Quimby, 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 09:52 Why is it important for plan sponsors to understand the going rate for every point in the supply chain? 10:21 How do manufacturers come up with a list price? 10:40 What does AWP stand for? 10:59 What does WAC stand for? 11:06 How are AWP and WAC numbers chosen by the manufacturer? 13:22 What is the difference between AWP and WAC? 14:54 How much are wholesalers paying to manufacturers? 16:43 How much is the pharmacy paying for branded drugs from a wholesaler? 17:34 Why might pharmacies be buying drugs for less than what wholesalers are paying? 19:22 EP423 with Joey Dizenhouse. 20:33 Why do things get weird when a PBM gets involved? 21:58 How does all of this work for generic manufacturers? 25:20 EP344 with Steven Quimby, MD. 26:15 How did Civica Rx come about? 32:21 What's the difference between the NADAC and the AWP value? 36:04 Luke discusses the downstream effects to pharmacies.

No prudent fiduciary would knowingly agree to pay 250 times more than the price available to anyone off the street — yet that's the core allegation in the J&J lawsuit, where the company is accused of paying upwards of $10,000 for a drug available for cash for about $50. Rather than rehash the gory details of the J&J and DOL v. BCBS lawsuits, Julie Selesnick, senior counsel at Berger Montague's Employee Benefits and ERISA group, joins Stacey Richter to answer the more urgent question: if you're a plan sponsor, broker, or employee benefit consultant, what should you actually be doing right now? WHAT YOU'LL LEARN ✅ Why getting your claims data is step one for every plan sponsor — and why that may require renegotiating administrative services agreements and scrutinizing CAA-mandated compensation disclosures from every covered service provider paid more than $1,000, not just brokers ✅ Why plan sponsors now need to verify not just that claims were paid correctly, but that the prices themselves — especially for generic specialty drugs — are fair and reasonable ✅ Why a payment integrity vendor should never be the same vendor (or share a parent company with the vendor) processing your claims — and why that setup is an obvious conflict of interest ✅ What cross-plan offsetting is, why the Department of Labor and multiple courts have found it violates ERISA, and why it's still happening at the majority of health plans anyway ✅ Julie Selesnick's practical advice for administering a plan well: form a health and welfare committee with an independent fiduciary expert, and make sure every committee member gets real fiduciary training on prudence, loyalty, self-dealing, and prohibited transactions WHY THIS MATTERS The J&J and DOL v. BCBS lawsuits aren't really about two isolated bad actors; they're a preview of what happens when plan sponsors have the data to spot a problem, don't act on it, and get named in a complaint alongside their brokers and consultants. Julie Selesnick's advice isn't about panicking over an impending wave of litigation — it's about closing the gap between what plan sponsors are now capable of knowing and what they're actually doing with that knowledge, before a lawsuit forces the issue. MENTIONED IN THIS EPISODE EP408 with Chris Deacon: Apple Podcasts | Spotify | Other Apps Encore! EP379 with AJ Loiacono: Apple Podcasts | Spotify | Other Apps Encore! EP337 with Olivia Webb: Apple Podcasts | Spotify | Other Apps EP285 with Dawn Cornelis: 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 05:48 What's happening with the J&J lawsuit? 07:38 What's going on with the DOL v BCBS case? 08:49 What do these cases mean for plan sponsors? 09:21 Why is engaging with claims data critical? 12:30 EP408 with Chris Deacon. 14:20 EP379 with AJ Loiacono. 16:58 What's one solution to avoiding a conflict of interest? 18:02 Why there's still not a total understanding about what to do with claims data once acquired. 20:58 NADAC (National Average Drug Acquisition Cost) to check pharmacy prices. 21:31 What advice do plan sponsors need to know that never gets recommended to them when dealing with conflicting interests? 27:02 EP337 with Olivia Webb. 28:41 EP285 with Dawn Cornelis. 30:24 "As a fiduciary, your money should only go to pay your plan's benefits, not to other plan benefits." 30:59 What's Julie's advice to advisors? 33:17 "Giving nonconflicted advice … is something you really can only do if you have no conflicts." 35:57 What's Julie's advice for administering whole plans?

Digital health vendors and virtual care point solutions only have a reason to exist if they perform better than traditional community providers — better outcomes, better affordability, better engagement. So how are they actually doing? Rik Renard from Awell, coauthor of a survey of 235 digital health professionals conducted with Health Tech Nerds, joins Stacey Richter with an answer that's more sobering than reassuring: 84% of digital health vendors say they use standardized care flows, but only 16% base those flows on scientific evidence, and a mere 7% actually measure whether their care flows are working across the metrics that matter. WHAT YOU'LL LEARN ✅ Why 84% of digital health vendors report using care flows, but only 16% of those flows are actually grounded in scientific evidence ✅ Why just 7% of digital health vendors measure all four things needed for a real picture of performance: engagement and compliance metrics, financial metrics like revenue per patient, clinician-reported outcomes, and patient-reported outcomes (PROMs) ✅ What Rik Renard calls "black box care" — the inevitable result when a vendor can't measure what its care flows are actually doing, meaning it can't manage or improve them either ✅ Why a digital health vendor's different payer and purchaser customers can demand conflicting care flows that ladder up to entirely different goals, complicating any single standard of care ✅ Why employers who lack the clinical expertise to evaluate quality tend to default to evaluating vendors on cost and service alone — creating a race to the bottom where being cheap and pleasant beats being effective WHY THIS MATTERS Standardized, evidence-based care flows are what let a digital health vendor deliver consistent, measurable outcomes at scale instead of results that depend entirely on which clinician a patient happens to get. Right now, the vast majority of vendors either aren't building on evidence or aren't measuring the results closely enough to know if their approach is actually working — which means most employers and purchasers evaluating these vendors have no reliable way to tell genuine performance from a well-produced pitch deck. Rik Renard's advice for any employer vetting a vendor is straightforward: ask to see the actual care flows, ask if they're evidence-based, and ask exactly what gets measured. MENTIONED IN THIS EPISODE EP315 with Bob Matthews: Apple Podcasts | Spotify | Other Apps Encore! EP392 with Emily Kagan Trenchard: Apple Podcasts | Spotify | Other Apps EP412 with Robert Pearl, 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 09:26 Why should clinicians care about care processes and care flows? 12:05 Why do care flows and care processes have a bad reputation? 12:31 What components does a good pathway include? 14:51 Why pathways need to be looked at as a process of continuous reconfiguration. 17:15 Who did Awell survey about care processes and flows? 18:42 How many clinicians were using care flows, and what did those care flows look like? 25:45 EP315 with Bob Matthews. 26:44 EP392 with Emily Kagan Trenchard. 28:21 EP412 with Robert Pearl, MD. 30:01 "Just document something." 30:14 What was a shocking find from this care process survey? 31:06 Is AI the answer? 34:13 Why is it important to get the foundation of data correct before introducing AI? 34:51 How should employers use this information to vet vendors?

Revenue cycle management is a $140 billion industry — already larger than the US auto industry and growing five times faster. RCM vendors use programmatic clearinghouses and increasingly sophisticated tools to maximize every cent of revenue from a claim. That is their job. On the other side sits the self-insured employer, often relying on less sophisticated processes and vendors who may be financially incented to look the other way. It is, as Mark Noel puts it, an arms race, a tug of war, and a zero sum game. In this episode, Stacey Richter speaks with Mark Noel, CEO of ClaimInsight, who has spent roughly 25 years in payment integrity on the health plan, TPA, and self-insured employer sides, about three revelations buried in plan sponsor claims spend. WHAT YOU'LL LEARN ✅ Revelation 1 — The small claim goldmine: 80% of claims volume by count is professional claims — doctor's office visits, lab draws, vaccines — not inpatient surgeries. Overpayments of $2, $5, or $10 on thousands of claims add up to millions in annual waste, but most prepayment integrity resources are focused on the 20% of large claims while the small-dollar volume flies through unchecked ✅ Revelation 2 — The conflict of interest trap: asking a TPA to report on its own errors is like asking the person who filed your tax return to also conduct the penalty audit — and large ASO TPAs edit claims on their fully insured book (where the dollars come out of their own pocket) at materially higher rates than on ASO client claims (where the dollars come out of the employer's pocket) ✅ Revelation 3 — Shared savings perverse incentives: many carrier and TPA contracts allow them to earn shared savings on the backend for fixing errors they did not catch on the frontend — creating a direct financial incentive to let errors through prepayment so they can be "recovered" for a fee later ✅ Why prepayment integrity must happen at the TPA level: to catch small errors before payment, a payment integrity vendor must be connected to the claims processor in real time — retrospective review can show where a plan has been overpaying and inform TPA contract negotiations, but the real savings require integration upstream ✅ The Goldilocks problem with turning on edits: turning on every available policy creates excessive provider friction and can inadvertently flag legitimate claims — including in sensitive areas like cancer treatment — so the right approach is a deliberate conversation with the plan about what edits to turn on, not "maximize everything and react when providers bark" ✅ Why this is a member protection issue, not just a financial one: 41% of Americans have medical debt; when claims are overpaid and members are on co-insurance, the member pays a portion of that error too — payment integrity is both a fiduciary obligation and a direct protection for the people the plan is supposed to serve WHY THIS MATTERS The RCM side will be up to date. Every January, coding rules update and RCM vendors adjust immediately. Payment integrity vendors that are not keeping policies equally current are falling behind in real time. For self-insured employers who are relying on a TPA's in-house payment integrity program, the question worth asking is: are those edits running at the same level of rigor on your ASO claims as on the carrier's fully insured book? The honest answer, in most cases, is no. === LINKS === 🔗 Show Notes with all mentioned links: Episode Page ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter ✉️ Visit ClaimInsight 🫙 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 06:03 How millions of dollars can be recovered per year from smaller claims under $500. 07:46 EP486 with Stan Schwartz, MD. 09:10 How to get to payment integrity prepayment. 11:20 How payment processing efficiency is necessary to payment integrity. 13:59 How TPAs fit into the claims payment process and how they can add to payment integrity. 15:59 LinkedIn post from Chris Deacon. 16:50 EP433 with Justin Leader. 17:04 LinkedIn post from Justin Leader. 17:10 How shared savings incentives can be perverse incentives. 23:05 How employers are doing retrospective reviews. 24:29 How employers should be negotiating their TPA contracts. 25:41 EP285 with Dawn Cornelis. 25:43 EP480 with Kimberly Carleson. 27:40 Why it's imperative that payment integrity vendors are up-to-date on all policies. 30:00 EP497 with Zack Kanter. 31:13 What should self-insured employers do to assess their payment integrity?

In this encore episode of 'Relentlessly Seeking Value,' Stacey Richter interviews A.J. Loiacono, CEO of CapitalRx. They delve into the hidden compensation practices of Employee Benefit Consultants (EBCs) and brokers engaging with plan sponsors. The discussion unveils the potential conflicts of interest and self-serving behaviors of these intermediaries, who sometimes prioritize their own financial gain over the best interests of employers and employees. With the enforcement of the Consolidated Appropriations Act (CAA), plan sponsors now have the power and responsibility to request full disclosure of all direct and indirect compensations being made. The conversation brings to light the murky and often unethical practices within the industry and emphasizes the importance of transparency and diligence for self-insured employers to avoid unreasonable and secretive fees that ultimately increase their total costs. === LINKS === 🔗 Show Notes with all mentioned links: https://cc-lnk.com/Encore379 ✉️ 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/ 07:09 Who can get in trouble for mismanaging employee funds? 07:48 "When you talk about conflicts of interest, they're everywhere." 13:13 "You're paying for access." 13:34 Why is it important to request that they disclose direct and indirect compensation? 14:04 What are the layers to these hidden fees and compensations? 18:13 What is a reasonable fee for a good plan admin? 19:27 "I think people need to take a step back and say, 'How many different ways are they getting compensated?'" 24:50 "The compensation is not just unreasonable, but if they were to move it, they would lose access to an entire column of revenue." 25:06 "For every good broker consultant, there's a horrible individual lurking out there and it's easy to figure out: Ask for them to disclose their fees." 28:08 "You can't win if you can't even pay the house fee to come in." 31:35 Why do you need to ask for disclosure, and what do you need to ask specifically? 32:21 What are some of the characteristics of a good plan consultant?

Poor pharmacy benefit strategy has documented, unintended consequences: rising costs of care, bankruptcies, and declining member satisfaction — and that's before considering the human cost when a plan denies access to a drug a patient genuinely needs. Nina Lathia, RPh, MSc, PhD, CEO of Healthcare Decision Making and a former senior technical advisor at the UK's National Institute for Health and Care Excellence (NICE), joins Stacey Richter to unpack why so many employers struggle to buy pharmaceuticals in a genuinely value-based way, and what a practical path toward one actually looks like. WHAT YOU'LL LEARN ✅ The four structural reasons value-based drug purchasing is hard for employers: no real pricing leverage with Pharma, pharmacy spend siloed away from medical spend, mismatched time horizons between plans and actual employee tenure, and FDA approvals based on thin evidence for expensive new drugs ✅ Why a PBM optimizing purely for pharmacy-spend reduction has no incentive to consider the ER visits or disease exacerbations that denying a drug might cause down the line ✅ Nina Lathia's five-step framework for a value-based formulary: set a stated goal, think holistically about total health spend, know the calculated value-based price of a drug, explore risk-based or installment payment deals with manufacturers, and build in shared decision-making with plan members ✅ How genetic testing can help determine whether an expensive drug will actually work for a specific patient before they take on its cost and side effects — turning a purely financial gatekeeping decision into a genuine clinical and patient benefit ✅ Why employers need to get more comfortable saying "no" to certain drugs, and what separates that kind of principled no from an opaque, value-blind prior authorization denial WHY THIS MATTERS Cost containment and value-based purchasing sound similar but aren't the same thing, and confusing them produces exactly the failure modes Nina Lathia describes: plans that either deny needed drugs to save money in a silo, or approve everything and drive premiums beyond what anyone can afford. Genuine value-based purchasing requires employers to look past pharmacy-only cost metrics, engage with the actual clinical evidence, and build real decision-making processes with the people who will be affected. None of this is easy, but the alternative — letting cost containment substitute for value — guarantees somebody loses, whether that's the plan's finances or a patient's access to care. MENTIONED IN THIS EPISODE EP352 with Pramod John, PhD: Apple Podcasts | Spotify | Other Apps EP353 with Pramod John, PhD: Apple Podcasts | Spotify | Other Apps Encore! EP337 with Olivia Webb: 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 06:34 What does cost containment mean? 07:43 Why is it important to consider health outcomes? 10:00 What does value-based purchasing mean in Pharma? 11:09 What are the principles of cost-effectiveness analysis? 12:50 Pharmacy plan time horizons versus employer time horizons. 14:42 Why is it increasingly important for payers to take a more global look at health and cost outcomes? 16:14 Why is the first step establishing a value-based price for drugs? 16:43 Why is the second step thinking about risk-sharing agreements with manufacturers? 19:20 What should an employer do if there's only one drug option and the price is too high? 21:20 What's a specialty carve-out solution? 21:26 EP352 and EP353 with Pramod John, PhD, of VIVIO. 22:10 Why should employers get more comfortable with saying "no" to certain drugs? 25:36 Why is patient engagement key? 28:23 What does "good" look like for employers implementing drug-spend changes? 29:51 EP337 with Olivia Webb.

About half the time, the cash price for a medical service is actually cheaper than the "negotiated" insurance rate — a fact that matters enormously given that roughly 90% of patients never meet their deductible in any given plan year. Marshall Allen, investigative journalist and founder of Allen Health Academy, joins Stacey Richter to explain, in concrete operational terms, how a "regular" clinical practice that still takes insurance can also accept cash from insured patients when it's the better deal — without abandoning insurance altogether, and without running afoul of contracts that sound like they forbid it. WHAT YOU'LL LEARN ✅ Why nearly half of insured commercial patients say they're delaying or forgoing care due to cost — and why those patients are invisible to clinicians who only see the people who show up ✅ How offering a clear, fixed cash price can reduce costly no-shows, which run practices as much as $7,500 a month, by giving patients pricing certainty for a next-day appointment instead of a six-months-out unknown ✅ The practical building blocks a practice needs to start taking cash from insured patients: a proper form, an actual set cash price, and a plan for how to market that option ✅ How Marshall Allen addresses the biggest objection practices raise — the belief that health plan contracts legally forbid accepting cash from an insured patient — including how HIPAA gives patients the right to request this ✅ Where to find fair-pricing benchmarks for setting a cash price, including tools like FAIR Health Consumer, BILLY, ColonoscopyAssist, Jason Health, and Green Imaging WHY THIS MATTERS This isn't a pitch for cash-only concierge medicine; it's about giving ordinary insurance-taking practices a legitimate, patient-friendly option for the very common situation where insurance makes care more expensive, not less. Practices that ignore this reality lose patients to care abandonment and revenue to no-shows, while patients who could have simply paid cash instead absorb costs they can't actually afford. Marshall Allen's framework turns a widely misunderstood pricing quirk into an accessible fix that benefits both sides of the exam table. MENTIONED IN THIS EPISODE EP363 with David Scheinker, PhD: Apple Podcasts | Spotify | Other Apps EP413 with Will Shrank, MD: Apple Podcasts | Spotify | Other Apps EP297 with Jerry Durham: 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 07:04 What Allen Health Academy is doing. 11:01 What's the problem with the system now? 14:19 EP363 with David Scheinker, PhD. 14:27 EP413 with Will Shrank, MD. 14:34 What's the hack Marshall Allen shares for insured patients paying cash? 15:06 How can patients cite HIPAA to pay cash instead of using their insurance? 19:00 What's the first recommendation Marshall Allen has when dealing with healthcare billing? 21:26 EP297 with Jerry Durham. 21:48 What are the other benefits of a clinic accepting cash payments? 25:36 Why do we need to have more direct pay happening? 26:36 How should a medical provider set a cash price? 27:12 Research tools for fair pricing: fairhealthconsumer.org, BILLY, colonoscopyassist.com, Jason Health, Green Imaging. 32:36 How do you find the win-win between a patient and a doctor? 32:51 What's the final tier of partners in creating more direct-pay opportunities? 34:30 What's Marshall Allen's opinion on having to pay credit card fees?

Vegans and vegetarians who can't stand each other. Fantasy football leagues with bitter internal schisms. Branches of the same religion at war with one another. Stacey Richter uses these examples to introduce "the narcissism of small differences" — the psychological tendency for people who are mostly aligned to fixate on their remaining disagreements rather than uniting around what they share. In this solo inbetweenisode, she applies the concept directly to healthcare reform: while massive, well-funded, well-organized profit-extracting entities consolidate market power unchecked, the people trying to fix the system for patients keep splintering into micro-camps and sniping at each other over whose cause matters most. WHAT YOU'LL LEARN ✅ What "the narcissism of small differences" means, and why it explains so much needless infighting among people who are actually 95% aligned on healthcare reform ✅ Why Jeff Hogan's framework for vetting conferences — is this a genuine platform for change, or an echo chamber for the same legacy incumbents who created the problem — is a useful gut check for evaluating any organization or event claiming to champion patients ✅ Why a corporate "transparency" talking point, repeated six times in five minutes by a PBM CEO, deserves scrutiny against what that entity's business model actually does ✅ Why working inside a profit-driven company doesn't automatically disqualify someone from being a genuine ally for patients — and why the people with the power to move the needle incrementally, at scale, are often still employed by the organizations we're skeptical of ✅ Why almost everything in healthcare sits on a matter of degrees — tip too far one way and costs exceed value delivered, tip too far the other way and the organization doing genuine good goes out of business WHY THIS MATTERS Achieving a real tipping point against consolidated, well-funded profit machines in healthcare requires mass — a village, not a handful of purists agreeing on every detail. When people who are mostly aligned spend their energy relitigating the 5% they disagree on instead of building on the 95% they share, the only winners are the entities with zero interest in patient outcomes at all. Stacey's point isn't that everyone working inside imperfect systems is beyond reproach — it's that reflexively excommunicating allies over minor differences, instead of judging people by whether their work actually moves outcomes for patients, guarantees the village stays too small to win. === 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 00:42 What "the narcissism of small differences" means. 02:18 How does this narcissism of small differences show up in the effort to fix the healthcare industry? 05:26 Quote from Jeff Hogan. 10:12 "What did the work we do add up to?" 16:31 Why we shouldn't judge someone for working within the "belly of the beast."

Not all hospital chains are the same, but today's conversation is about the big, rich, consolidated ones with the market and political power to shape entire regional economies. Peter Hayes, the recently retired president and CEO of the Healthcare Purchaser Alliance of Maine, joins Stacey Richter to lay out five things these behemoth health systems need to get real about in 2024 — even while they hold nearly unchecked leverage over the self-insured employers and communities that fund them. WHAT YOU'LL LEARN ✅ Why the Consolidated Appropriations Act obligates plan sponsors to pay only "fair and reasonable" prices for medical care — and why that legal obligation is becoming one of the real levers moving hospital pricing behavior ✅ Why health systems need to get ruthlessly aggressive about administrative and technology efficiency just to survive shrinking commercial reimbursement, especially as administrative costs have dwarfed growth in what hospitals pay their actual clinical staff ✅ Why the shift from fee-for-service to real downside-risk, outcomes-based reimbursement means moving from maximizing patient revenue to maximizing patient health ✅ Why hospitals need to be transparent and accountable about how they use their tax-exempt status and the estimated $55 billion in net margin they realize from the 340B drug program ✅ Why patient safety can't stay an afterthought: about 46% of US hospitals carry a Leapfrog grade of C or lower, and the chance of a fatal avoidable error is 90% higher at those hospitals than at an A- or B-rated one WHY THIS MATTERS None of Peter Hayes's five things individually will topple consolidated hospital systems' market power on its own — but per Peter, tipping points rarely come from one single force. They come from a confluence: new legal obligations under the CAA, employers running out of room to absorb rising costs, transparency tools exposing price variation, and states starting to demand accountability for tax-exempt and 340B dollars. Nearly half of Americans have already delayed or forgone care due to cost, and record insurer and hospital-executive profits sit uneasily next to nurses and hospital staff who themselves rank among the groups most burdened by medical debt. The pressure is mounting from multiple directions at once, which is usually how real change actually arrives. MENTIONED IN THIS EPISODE EP390 with Gloria Sachdev, PharmD, and Chris Skisak, PhD: Apple Podcasts | Spotify | Other Apps EP373 with Cora Opsahl: Apple Podcasts | Spotify | Other Apps EP415 with Rob Andrews: Apple Podcasts | Spotify | Other Apps EP394 with Vikas Saini, MD, and Judith Garber, MPP: 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 08:04 Why do hospitals need to get real about the implications of the Consolidated Appropriations Act? 10:09 What is considered fair pricing for hospitals? 13:00 EP390 with Gloria Sachdev, PharmD, and Chris Skisak, PhD. 15:59 The medical transparency tool, Billy. 16:34 How does lowering prices become more challenging with consolidated hospital systems? 18:07 What is one of the solutions available to combatting this now? 19:31 Why do hospital systems need to get real about administrative and technology efficiencies? 22:27 EP373 with Cora Opsahl. 26:51 Why do hospitals need to get real about pivoting from fee-for-service reimbursement to episode-based care? 30:16 EP415 with Rob Andrews. 30:53 Why do hospitals need to get real about the 340B program and their tax-exempt status? 35:38 EP394 with Vikas Saini, MD, and Judith Garber, MPP. 38:19 What are the ethical and moral issues that are coming to a head with healthcare costs? 39:03 Why do hospitals need to reexamine their care quality and patient safety? 40:05 "We just need to make sure that the health industry is as accountable as some of our other industries." 42:53 Why does Peter think it's going to take regulation to move the dial?

Copay maximizer programs started as pharma's workaround to PBM formulary leverage — cover the patient's out-of-pocket cost so a drug stays viable even when the PBM won't put it on formulary. But per Joey Dizenhouse, FSA, MAAA, CEO of SlateRx, that original chess move has since spawned an entire industry of maximizer and "the drug's not covered" schemes that plan sponsors are told will save money, and sometimes do the opposite. Stacey Richter walks through exactly how these programs work, who profits, and what a self-insured employer should actually be asking before signing on. WHAT YOU'LL LEARN ✅ Why copay maximizer and copay accumulator programs exist in the first place — as pharma's response to PBM formulary leverage over patient out-of-pocket costs ✅ The two scenarios that determine whether a maximizer program actually helps a plan: one where a drug has no cheaper alternative and patients are simply protected from a huge annual out-of-pocket cost, and one where a cheap, equally effective alternative exists but patients are steered toward the expensive option because their out-of-pocket cost is zeroed out ✅ The difference between the "spread model" and the "transparent model" of maximizer programs, and why Joey Dizenhouse says the question to ask any vendor is simply, "How do you make money? Prove it" ✅ How the "the drug's not covered" approach works, and why it's often pitched to plan sponsors as savings without disclosing the misaligned incentives underneath ✅ Joey's three pieces of advice for any self-insured employer evaluating these programs: do real purchasing due diligence, don't assume your PBM contract is above average just because everyone assumes theirs is, and actually talk to plan members using these drugs instead of trusting the vendor's own satisfaction claims WHY THIS MATTERS Maximizer programs aren't inherently good or bad — the same mechanism that protects a patient from an unavoidable $8,000 annual out-of-pocket cost can just as easily steer another patient toward an $8,000 drug when a $70 alternative would have worked just as well. The deciding factor isn't the program's marketing; it's whether the vendor running it makes more money when drug costs go up. Any self-insured employer that doesn't ask, and verify, how its maximizer vendor actually gets paid is trusting an entity with directly misaligned incentives to police its own pharmacy spend. MENTIONED IN THIS EPISODE EP419 with Andreas Mang: 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 06:21 How was the first iteration of maximizers conceived? 10:59 "I'd always encourage you to come back to the underlying incentives." 11:18 What does maximizer acceleration look like? 12:24 What are the two kinds of maximizers? 12:43 What is the spread model for a maximizer? 13:02 What is the transparent model for a maximizer? 15:26 "Ask the questions: How do you make money? Prove it!" 15:56 EP419 with Andreas Mang. 16:25 How might Pharma be making more money with maximizers? 26:14 What is the "it's not covered" approach? 32:29 "The right kind of program has been properly narrowed." 33:51 Is there a purpose that some of these programs can serve, issues aside? 35:57 How does a free drug program actually cost money?

What would you do if you owned an independent pharmacy and discovered that nearly all of your profit came from just 10% of the prescriptions you fill — and that you'd actually make more money by firing most of your staff and refusing to fill the other 90%? That's the math Benjamin Jolley, PharmD, a third-generation independent pharmacy operator and consultant, lays out for Stacey Richter in this episode, a natural companion to the recent conversations with Mark Cuban and Ferrin Williams (EP418) and Ge Bai (EP420). And here's the kicker: the 10% of drugs that actually make an indie pharmacy money are, unsurprisingly, the exact same drugs that PBM-owned mail-order pharmacies mandate get filled through them instead. WHAT YOU'LL LEARN ✅ Why roughly 10% of prescriptions generate nearly all of an independent pharmacy's profit — and why that 10% happens to be the same drugs PBM-owned mail-order pharmacies steer away from independents ✅ The two ways an indie pharmacy actually loses money on a prescription: when the PBM-mandated reimbursement is less than the drug's acquisition cost, and when the dispensing overhead (like the pill bottle itself) exceeds the profit on an ultra-cheap generic, even at a 100% margin ✅ Why what a patient pays at the counter has no real relationship to what the pharmacy is actually paid or to what the employer plan spends — because the PBM sitting in the middle controls all three independently ✅ Why, per Ge Bai's research (EP420), $41 of every $100 spent on generic drugs goes to the PBM — and why patients paying cash out of pocket often come out ahead of patients using their own insurance ✅ What Benjamin Jolley thinks independent pharmacies and employers can actually do to make the PBM less relevant to a transaction it has no legitimate role in WHY THIS MATTERS The core absurdity here is structural: a third party that never touches the drug, the patient, or the pharmacy's costs still controls what everyone pays and gets paid — and does so in a way that specifically starves independent pharmacies of the 10% of prescriptions that keep them financially viable. Benjamin Jolley's math isn't a complaint about margins; it's a demonstration that the PBM's role in routine generic drug transactions has become disconnected from any value it actually adds. For employers and patients alike, that disconnect is exactly where the money is quietly disappearing. MENTIONED IN THIS EPISODE EP379 with AJ Loiacono: 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 04:47 Benjamin Jolley's recent revelation. 06:14 What are the 10% of drugs that provide all the profit for pharmacies? 09:21 What's happening with the other 90% of drugs that pharmacies are filling? 11:05 What is the breakdown of costs when fulfilling prescriptions and running a pharmacy? 18:50 EP379 with AJ Loiacono. 21:42 What is the "cost savings" within the "insane system" of PBMs not sharing profit with independent pharmacies? 23:00 What is one of the things that PBMs and pharmacies don't often talk about? 26:39 What can employers do so that patients aren't getting overcharged by PBMs? 27:51 "How do I make the PBMs irrelevant?" 33:30 What's the difference between an independent pharmacy delivery service and a service like Express Scripts? 34:36 What's the other potential solution in solving the problems independent pharmacies face, and why does Benjamin Jolley feel that it's not the best solution to pursue?

Electronic health records were purpose-built for billing — some have called them glorified cash registers — which means the vast majority of a person's health-relevant life never gets captured anywhere. Stacey Richter re-airs this conversation after attending both the NODE (Network of Digital Evidence) conference and an employer-focused summit with the Pittsburgh Business Group on Health, because what Emily Kagan Trenchard describes isn't a nice-to-have for digital health entrepreneurs; it's a must-have for the self-insured employers quietly paying for every fragmented, unsupported patient journey through escalating commercial rates. Emily is SVP and chief of consumer digital solutions at Northwell Health, New York State's largest health system (21 hospitals, 850 outpatient clinics, 300,000 patients a year), and a former spoken-word poet who now works to put the human back into healthcare's digital infrastructure. WHAT YOU'LL LEARN ✅ Why EHRs, built around federal billing mandates, only capture the narrow slice of a person's life when they're actively a "patient" in a clinical encounter — and why everything that happens on someone's couch, with their COPD medication or their support network, falls outside that architecture entirely ✅ Emily Kagan Trenchard's four "tentpoles" health systems need to properly support patients and everyone around them: the EHR, a CRM (treated as a relationship-building philosophy, not just software), a cloud platform for data and analytics, and a data exchange ✅ The two facts driving Emily's thinking: providers and patients are increasingly intolerant of friction, and whatever is easiest is what people will actually do — the same logic Amazon and Google already build around ✅ Why treating population health seriously means understanding a patient's network of relationships — caregivers, family, community — not just the patient as an isolated data point, something EHRs are structurally unsuited to do ✅ Why non-purpose-built technology doesn't just frustrate patients; it drives clinician burnout and turnover, which is its own expensive, measurable cost to health systems WHY THIS MATTERS Every fragmented, friction-filled patient interaction that falls outside the EHR's billing-shaped architecture is a cost somebody eventually pays — usually the self-insured employer footing the bill through ever-escalating commercial rates. Emily Kagan Trenchard's framework reframes digital health investment not as a marketing or patient-experience nicety but as core infrastructure, on par with the clinical tech stack. Health systems that keep defaulting to the EHR as the center of the universe are optimizing for billing, not for the actual people — patients and everyone around them — the system is supposed to serve. === 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 07:08 How does customer digital solutions fit into the larger technology infrastructure in healthcare? 09:07 "Where else do you have centers of gravity that you should respect in the architecture?" 09:25 "There is a constellation of need here." 11:05 "We interact with way more than just patients." 13:42 "We have to be able to understand the network of relationships in a population." 14:25 How do EHRs and CRMs interact as two tentpoles in healthcare? 16:45 "The question is, where does a human being work?" 19:07 How are patients staying on a nonfragmented care journey in a proactive way? 23:00 "Anybody who's a consumer of our digital offerings has a relationship with us." 28:46 "The medicine is being practiced not only on our physical bodies but on our digital bodies."

"You cannot make smart … decisions and be a fiduciary of a fund without having data," as Cora Opsahl, director of the 32BJ Health Fund, puts it. Stacey Richter is re-airing this conversation because it's the missing prerequisite behind nearly everything discussed on this show lately — the recent episodes with Andreas Mang (EP419), Dan Mendelson (Encore EP385), and Mark Cuban and Ferrin Williams (EP418) all assume an employer actually has the data to act on. 32BJ Health Fund, a self-funded plan covering 200,000 union members (doormen, maintenance workers, security, cleaners, and more across 11 states), demanded its data from every vendor and used it to remove an overpriced hospital system from its network — saving $35 million and funding the union's biggest wage increase in years. WHAT YOU'LL LEARN ✅ How 32BJ Health Fund got 100% of its vendors to hand over data, and why Cora Opsahl treats a vendor's reluctance to share data as itself a red flag ✅ How 32BJ used its data to remove an overpriced hospital system from its network, saving $35 million — enough to fund the union's biggest wage increase in years plus a premium holiday for employers ✅ Why validating vendor cost estimates with your own data almost always tells a different story than what the vendor projected, and why that matters before adding any new benefit or program ✅ Why siloing pharmacy and medical data lets one side claim savings while quietly shifting costs to the other — the "squeezing the balloon" problem — and why only fund-level data can catch it ✅ The three things data ultimately buys a self-insured employer or union: cutting wasteful spending and catching fraud, making validated (not guessed-at) benefit decisions, and forecasting trends far enough ahead to protect financial solvency WHY THIS MATTERS Every strategy discussed on this show for improving employer and union health benefits — auditing vendors, redesigning benefits, holding hospitals accountable — depends on first having the data to know what's actually happening inside the plan. 32BJ's $35 million hospital-network decision wasn't a hunch; it was a direct result of demanding and using data most funds never bother to collect. Employers and unions that skip this step aren't just leaving savings on the table — per Cora Opsahl, they risk becoming imprudent fiduciaries, a fact class action attorneys are increasingly aware of. MENTIONED IN THIS EPISODE EP285 with Dawn Cornelis: Apple Podcasts | Spotify | Other Apps EP358 with Wayne Jenkins, 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 06:53 How much data does 32BJ Health Fund have, where do they get it, and how do they use it? 08:52 How did 32BJ Health Fund successfully demand their data from 100% of their vendors? 09:42 "We feel it's really important that we own this information ourselves." 10:05 "It always concerns me—if a vendor doesn't want to give you the information, what are they hiding?" 10:32 "It's not just getting the data; it's then using the data." 13:41 "Without data, you're really just taking a guess; and guesses are never gonna get you where you need to go." 15:19 EP285 with Dawn Cornelis. 15:40 Is the cost of creating a data analytics team worth the cost savings of those data discoveries? 19:03 "The use of data has really built our knowledge." 20:52 "It's really important to us that as we make benefit decisions, we're doing it smartly." 25:27 EP358 with Wayne Jenkins, MD. 25:38 How is 32BJ Health Fund making their data knowledge actionable? 28:11 "If we can figure out how to make telehealth accessible … there may be an opportunity for telehealth … to upset some of these … monopoly systems or low-choice options." 30:22 "It's really easy to think that we can solve this problem through benefit design … but in the end … it's the price."

"It's not a big mystery in the US economy that people do what you pay them to do," as Rob Andrews put it on this show a few weeks back (EP415). Stacey Richter opens this episode with his framing of maternal health's broken incentives — where a hospital system profits from a full NICU and carriers make the same money whether a baby is born healthy or in crisis — before turning to a clinic that proves the opposite is possible. Jodilyn Owen, clinical director of the Rainier Valley Birth & Health Center in one of the most linguistically diverse and medically underserved zip codes in Seattle, has built outcomes that beat the wealthy neighborhood down the road, where residents live 17 years longer. This episode is about how, and about the very unglamorous economics of getting anyone to actually pay for it. WHAT YOU'LL LEARN ✅ Why Rob Andrews' framing of misaligned incentives — where hospitals profit from a full NICU and carriers earn the same fee regardless of outcome — sets up exactly why a clinic like Jodilyn Owen's stays hard to fund ✅ How Rainier Valley Birth & Health Center, serving a zip code with 79 languages spoken and designated as a provider shortage area, achieves far lower cesarean rates, NICU admissions, and gestational diabetes rates than the wealthy hospital across town ✅ Why Jodilyn's birth bundle costs $5,000 to $7,000 total — a fraction of what a single NICU admission costs — and why most payers still won't contract with her clinic despite the math ✅ Why Jodilyn Owen says her clinic's real "secret sauce" is trust, relationships, listening to the patient, and being genuinely embedded in the local community — not a novel clinical protocol ✅ Why Dave Chase's line that "every big problem in healthcare has already been solved" applies directly here — the challenge isn't discovering what works, it's replicating it at scale WHY THIS MATTERS Maternal health is a case study, but the lesson generalizes to primary care, chronic disease management, and anywhere the person actually providing good care isn't the one who financially benefits from it. Jodilyn Owen's clinic didn't out-innovate the healthcare system with new technology; it out-performed a wealthier neighborhood by treating patients as whole people embedded in a community, and it's still fighting for the contracts that would let it exist sustainably. If the industry is serious about better outcomes, the obstacle isn't knowing what works — it's whether payers and self-insured employers are willing to pay for it. MENTIONED IN THIS EPISODE EP407 with Vivek Garg, MD, MBA: Apple Podcasts | Spotify | Other Apps Summer Shorts 3 with Vivek Garg, MD, MBA: Apple Podcasts | Spotify | Other Apps EP409 with Larry Bauer, MSW, MEd: 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 07:12 How much cost savings is there when you avoid a NICU admission? 09:43 How is "slow care" feasible among an ob-gyn shortage in many communities? 10:42 "Start people at the risk that they are appropriate for." 11:37 EP407 and Summer Shorts 3 with Vivek Garg, MD, MBA. 13:50 "To effect change, we have to unwind what has been wound so tightly and so carefully through medical … education." 14:13 "It's not a people problem; it's a system problem." 18:46 What does relationship-based care mean? 22:32 "Everything in pregnancy at least is a trend." 28:01 How does Jodilyn's practice work with payers? 31:08 EP409 with Larry Bauer, MSW, MEd. 32:24 Why is it important to address the root of this problem in the education space?

What FQHCs Can Teach Every Healthcare Leader About True Fiscal Discipline. There are two very different ways to end up with no profit. One is genuine struggle. The other is simply being very good at spending every dollar you are given. In healthcare, we have no functioning market to tell the difference — and the organizations that are crying poor may just be inefficient. Federally qualified health centers, which cannot cost-shift to commercial patients and cannot restrict access, are one of the few places in American healthcare where fiscal discipline is a real constraint rather than a slogan. In this Take Two episode, Stacey Richter revisits a conversation with Gary Campbell, CEO of Johnson Health Center, an FQHC in Lynchburg, Virginia, and president of Impact2Lead — along with a framing segment on Nikki King, CEO of Alliance Health Centers in Indiana, whose approach to meeting patients where they are produced results without a capital budget. WHAT YOU'LL LEARN ✅ Why FQHCs are one of the best case studies for operational efficiency in healthcare: they have a revenue cap, cannot cost-shift inefficiencies to commercial patients, cannot restrict access, and must find a way to serve a challenging patient population with what they have — or that patient population does not get care ✅ Nikki King's approach at Alliance Health Centers: instead of building infrastructure, she put clinics in a courthouse (next to addiction treatment referrals from judges), a daycare center, a homeless shelter, and beside a basketball court — meeting patients where they already are at near-zero real estate cost; compare this to "razor thin margins" and new construction appearing in the same sentence ✅ Why the first instinct in any workflow problem — throwing a body at it — is often the wrong one: as Gary Campbell puts it, you can overstaff yourself into margins so thin they disappear, and "throw two bodies at it" is not a Six Sigma approach to operational efficiency ✅ Why involving clinicians in process redesign is not optional: administrators who make workflow decisions without including the nurses, physicians, and APPs who do the work get non-compliance, workarounds, and resentment — the people closest to the work have to be part of building the standards ✅ How to create fiscal discipline without sacrificing care: Campbell deliberately pulls clinicians off the floor — foregoing short-term revenue — to work on care team reengineering projects, with deliverables, project plans, and accountability, because unimplemented committee recommendations are worse than no meeting at all ✅ The leadership imperative that underlies all of it: vision (if the team can't see where they are going, they cannot be motivated around purpose), cultural alignment (people who are misaligned with the values will undermine the effort), and the discipline to make sure every meeting produces a concrete outcome — not just a record that it occurred WHY THIS MATTERS Financial toxicity is clinical toxicity. A clinical partner that lacks fiscal discipline isn't struggling — it is inefficient. And the plan sponsor, the union, and ultimately the member pays for that inefficiency in premiums, in cost shifts, and in care that should cost less than it does. FQHCs that do this well — like Johnson Health Center and Alliance Health Centers — show what is actually possible when the option to pass the cost along simply does not exist. Those organizations make genuinely useful benchmarks for any plan sponsor evaluating a clinical partner. === 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 09:03 Why is there no opportunity to cost shift in an FQHC? 09:34 What happens when an FQHC is operating inefficiently? 10:00 "Have you workflowed it out? … You can overstaff yourself in a way that your cost per patient goes way up." 10:23 Why is taking a lean approach not an excuse to cut staff? 11:27 EP490 and EP492 with Shane Cerone and Sam Flanders, MD. 11:35 EP438 with John Lee, MD. 11:38 EP455 with Beau Raymond, MD. 11:40 EP402 with Amy Scanlan, MD. 11:42 EP405 with Eric Gallagher. 12:48 "The nurses are linchpins to everything." 13:44 LinkedIn post from Eve Cunningham, MD, MBA. 15:10 How does standardizing care lead to personalization of care? 16:34 "Our clinical teams see that we care." 16:53 "If you don't have a vision for where you want to be two and three years down the road, you're struggling." 17:09 "I want everybody to understand, What is their why?" 19:45 Lean & Meaningful by Roger E. Herman and Joyce L. Gioia. 24:44 "You have to project plan things out that you want." 25:51 "They don't teach leadership in most medical schools."—Dr. Robert Pearl 26:46 Outlive by Peter Attia, MD. 27:55 "Get to know these clinicians." 29:39 "From a core values perspective, you can make every single decision … on core values." 30:03 "We always start with those values. … They're embedded in everything we do." 30:20 How does an FQHC or private practices that are patient-oriented attract talent? 35:24 EP297 with Jerry Durham. 35:54 "First and foremost, be visible."

Cash-pay generic drugs sound like a fringe idea until you look at the numbers: for patients in their deductible phase, paying cash beats the price their PBM "negotiated" 79% of the time. Following on directly from last week's conversation about the financialization of health benefits (EP419), Stacey Richter talks with Ge Bai, PhD, CPA — a professor of accounting at Johns Hopkins Carey Business School who studies nothing but healthcare dollars — about two studies that reframe how cheap generic drugs actually get priced, and about who really profits when a patient runs a $3 prescription through insurance instead of just paying for it. WHAT YOU'LL LEARN ✅ Why generic drugs are already cheap thanks to manufacturing competition — and why that undercuts the whole rationale for a PBM's market power to "negotiate" a better price ✅ The study showing that for patients in their deductible phase, paying cash for a generic beats the PBM-negotiated price 79% of the time ✅ Why PBMs, not manufacturers, pharmacies, or wholesalers, capture the largest margin in a typical generic drug transaction — by about 10 percentage points ✅ Why insurance and PBMs exist to pool risk, and why the administrative cost of spreading a $3 drug expense across an entire risk pool can end up costing more than the drug itself ✅ Why Ge Bai is skeptical that HSAs solve the affordability problem, given how much financial literacy they demand from patients who already can't reliably explain what a deductible is WHY THIS MATTERS Insurance and PBMs are built to pool risk for expensive, unpredictable events — not to add an administrative toll booth in front of a $3 prescription that's already competitively priced. When the intermediary designed to lower costs ends up capturing the largest margin in the transaction, the system isn't protecting patients from unaffordable care; it's manufacturing unaffordability out of something that was already cheap. Ge Bai's research suggests the bar for doing better by patients on generics is lower than most people assume — it just requires asking who actually benefits from routing a cheap drug through an expensive process. MENTIONED IN THIS EPISODE EP344 with Steven Quimby, 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 06:13 What is the background on generic drugs that is need-to-know? 06:39 EP344 with Steven Quimby, MD. 07:04 Do we have affordability for generic drugs? 15:40 What's the policy failure around generic drugs? 18:34 Why is there a huge health equity issue? 20:13 How do PBMs have both a monopoly and a monopsony? 21:59 What should be the goal for cheap generics? 23:36 "Whenever we have no competition, we'll see high price." 26:00 What's the best approach to addressing operational challenges behind generic drug costs? 28:42 How do we solve generic drug costs on the back end? 31:15 "Healthcare insurance is not the same as health." 36:07 "It's time for us to reflect and think whether there is a better way to try."

Are you on the board of directors of a company? A shareholder of a publicly traded one? A CEO or CFO who reports to a board? This episode is for you. Following up on last week's conversation with Mark Cuban (EP418), Stacey Richter talks with Andreas Mang, senior managing director and CEO of Equity Healthcare at Blackstone, about how healthcare has become financialized at the exact moment health benefits became most companies' second-biggest line-item expense — and about the concrete, unglamorous purchasing discipline that can claw back 10% or more of that spend while improving employee health. WHAT YOU'LL LEARN ✅ Why Andreas Mang says it's an "unnatural act" for a non-healthcare company to dig into its own health benefits — and why that reluctance is exactly what lets financial actors take a bigger slice of the pie ✅ Andreas's six-item checklist for cutting health benefit spend by 10% or more: year-round CFO engagement, self-insuring once you hit a certain size, choosing brokers/consultants against five hard criteria, RFP'ing carriers and TPAs every three years, running dependent eligibility audits, and cautiously leveraging pharmacy coalitions and stop-loss collectives ✅ The five things Andreas says need to be true of any broker or benefits consultant: real experience doing the job, a flat-fee compensation model, no product pushing, 30%-or-more of fees genuinely at risk, and simple termination provisions ✅ Why self-insuring can save 5% to 9% automatically once a company reaches the right size, and why that funding decision is "a CFO thing," not a healthcare thing ✅ Why "where there's mystery, there's margin" — and why the C-suite's discomfort with healthcare complexity is itself a business strategy for the vendors profiting from that confusion WHY THIS MATTERS This isn't a story about paying more or less for better or worse employee health — it's a story about what happens when nobody in the C-suite is minding the shop. When that happens, financial intermediaries simply take a larger share of a company's second-biggest expense line, and both the employer and its employees lose while nobody notices. Andreas Mang's list isn't theoretical: it's the same purchasing discipline companies already apply to every other major expense, just finally pointed at health benefits. === 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 04:19 Why Andreas starts every conversation with the question, "How's your healthcare company?" 07:04 Why is it important, as a self-insured employer, to treat your business as a small healthcare company? 08:42 Why is it unnatural for companies to be providing health insurance? 10:13 What can be achieved when there is alignment between employers and insurers? 12:07 What things can a company do to reduce spend by 10%? 13:40 Why is it better to have CFO engagement in the benefits plan throughout the year? 15:51 Why does self-insurance save 5% to 9% for companies automatically? 17:41 "The funding isn't a healthcare thing; it's a CFO thing." 17:54 Why is it vital to have a reliable, trustworthy broker? 24:38 When is the last time your company has RFP'd their health plan? 27:06 Why does changing a health plan feel scary but is necessary? 27:58 What is an independent eligibility audit? 30:48 Why are employers better together? 34:02 How do employers truly get a flat-fee model with brokers?

"The Achilles' heel for most healthcare innovators is overlooking the role of change management," as a recent tweet from Rik Renard put it — the deal isn't sealed until the whole team is on board, and adoption never automatically follows a good idea. Stacey Richter is re-airing this conversation with Karen Root, director of experience strategy at Boehringer Ingelheim, because it fits squarely into an ongoing series for boards, CEOs, and CFOs of self-insured employers: last week's episode with Mark Cuban and Ferrin Williams (EP418) argued that dealing with healthcare's financialized layer requires customer centricity and change management at the employer level too. This conversation is about what it actually takes to drive transformation or innovation inside a very large organization, using pharma as the case study but applicable to just about any big, complicated institution. WHAT YOU'LL LEARN ✅ Karen Root's six essentials for making organizational transformation actually stick: a compelling, realistic vision; systems thinking about who and what will be affected; identifying the right entry point (a quick win or emotionally resonant "moment that matters"); measuring both the quick win and the broader effort; a clear before-and-after story arc; and never forgetting you're dealing with human beings, not rational economic actors ✅ What the "J curve" is, and why every transformation effort hits a "trough of disillusionment" that can kill the whole initiative if leadership's vision or will isn't strong enough to push through it ✅ Why so many pharma companies say they're patient-centric while remaining fundamentally brand-centric — and why that gap shows up in the halls, not on the walls, in things like reps who get kicked out of hospital systems for adding little value ✅ Why starting with a small, well-chosen quick win (like fixing a common complaint pulled straight from call center logs) makes it much harder for skeptics to defend the status quo ✅ Why measuring transformation qualitatively as well as quantitatively matters, and why leadership needs an actual story to tell, not just a vision statement WHY THIS MATTERS Most large organizations don't fail at innovation because they lack good ideas — they fail because they underestimate the change management required to get an entire team, department, or company to actually adopt something new. Karen Root's framework treats the human, emotional, and narrative dimensions of transformation as just as essential as the strategy itself, which matters because the organizations that quit during the J curve's trough of disillusionment don't just lose that initiative — they poison the well for every future attempt at change. === 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 08:51 What skills does leading a large company in customer centricity require? 10:36 What needs to be included in a vision for customer-centric change? 11:01 "In transformation, we have to adjust the approach to that vision. We have to break it down into a couple of key steps." 11:39 What is the J curve? 12:26 "Disruption is going to happen; it's just how do we minimize its impact." 14:00 Why is hope so important for success in change? 17:22 "Leverage your people; understand where they are in the change curve." 26:24 "We can't manage what we don't measure." 26:33 "We have to not only measure in quantitative ways but qualitative." 27:35 What's the downside to not being able to innovate? 28:55 Why does leadership need to have a story to tell? 31:19 "We have to remember that these are human beings and to look for those tells."

Healthcare benefits are usually a company's second-biggest line-item expense after payroll, yet most CEOs and CFOs never actually dig into where that money goes. In this episode, Stacey Richter talks with Mark Cuban and Ferrin Williams, PharmD, MBA, chief pharmacy officer at Scripta, about what happened when Cuban actually looked into his own company's benefits program — and about the financialized layer of consultants, PBMs, and administrators sitting between employers and their employees' health that's quietly extracting hundreds of thousands to millions of dollars a year. WHAT YOU'LL LEARN ✅ What Mark Cuban found when he actually dug into his own company's benefits program, and why it took him ten minutes to see the order of magnitude of what "trusted" consultants, PBMs, and ASOs were extracting from his business ✅ Why healthcare spend is disproportionately driven by a company's sickest employees — and why that means healthy employees' paychecks are effectively subsidizing a system CEOs and CFOs rarely examine ✅ Why rebates are going away without necessarily changing what PBMs actually earn, and what that reveals about how rebate-based pricing really worked ✅ How Mark Cuban Cost Plus Drug Company's direct-from-manufacturer, cost-plus-15%-plus-fees model routinely beats what plans pay their PBMs, and what Ferrin Williams and Scripta are building to help employees find the lowest-cost prescriptions ✅ Why CEOs and CFOs specifically hold the power to change healthcare economics for their companies — and why employers who skip that due diligence now risk ERISA-related legal exposure from their own employees WHY THIS MATTERS The healthcare benefits industry has been financialized to the point that opacity itself has become a business model, and per Mark Cuban, that opacity survives specifically because CEOs and CFOs treat healthcare benefits as someone else's problem. The fix isn't complicated in principle: roll up your sleeves, look at where the money actually goes, and push back the way Cuban did. But it does require the C-suite to treat health benefits with the same financial scrutiny they'd apply to any other multimillion-dollar line item — because right now, that scrutiny is exactly what's missing, and employees are the ones absorbing the cost of its absence. === 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 05:41 What was Mark Cuban's own journey as a self-insured employer with Cost Plus Drug Company? 06:56 What did Mark find when he decided to go through and look through his company's benefit program? 08:23 "When you think it through, you start to realize that money is being spent primarily by your sickest employees." —Mark 09:13 How do you get CEOs and CFOs of self-insured employers to realize that their sickest employees are the ones subsidizing their checks? 12:10 What is the role of insurance in healthcare? 13:42 "If you can't convince them, confuse them and hide it." —Mark 14:35 The reality behind getting a rebate check. 15:32 Why are rebates going away, and why isn't that changing PBM earnings? 18:17 How do you get CEOs and CFOs to dig into their benefits plan? 20:13 Does morally abhorrent move the needle? 20:47 "What we're trying to do is just simplify the [healthcare] industry." —Mark 23:33 What's been changing in consumer behavior? 24:18 "Transparency is a huge part of building that trust." —Ferrin 24:33 Why CEOs and CFOs really have the power to change healthcare. 31:42 What are Cost Plus Drugs' plans to expand? 38:36 Where is the future of the prescription drug market going? 41:25 What will happen to the prescription drug market in 10 to 20 years? 47:56 The wake-up call self-insured employers should be acknowledging now. 51:18 Where is the real change in the healthcare industry going to come from?

A physician practice can only truly transform from a fee-for-service volume machine into something built around health and value once it hits a tipping point: enough of its patients in value-based, risk-based arrangements to make accountability actually feasible. Self-insured employers, who cover roughly 150 million American lives, have an outsized opportunity to help local practices hit that tipping point — but most aren't offering any kind of accountable care arrangement at all. Stacey Richter is re-airing this conversation with Dan Mendelson, CEO of Morgan Health at JPMorgan Chase, as the first of an employer CEO/CFO trilogy on the podcast (Mark Cuban and Andreas Mang follow in the coming weeks), diving into the five concrete things Mendelson says self-insured employers should be doing right now to improve employee health. WHAT YOU'LL LEARN ✅ Why physician practices need a critical mass of patients in value-based, risk-based arrangements before transformation away from fee-for-service becomes financially feasible — and why the whole community benefits once a local practice hits that tipping point ✅ Why self-insured employers, who collectively cover about 150 million American lives, are mostly not offering accountable care arrangements — leaving huge swaths of provider patient panels stuck in the FFS status quo ✅ Dan Mendelson's five things employers should do right now: expand access to accountable care models, invest in the data needed to assess health outcomes, align employee benefits with population health outcomes, prioritize care models that meet employees where they are, and make care navigation central to the benefits experience ✅ What Morgan Health is actually building to help self-insured employers execute on these five things, not just understand them in theory ✅ Why alignment has to include the 150 million Americans getting insurance through their employer, not just providers and payers, for value-based care to actually work at scale WHY THIS MATTERS Self-insured employers sit on enormous latent leverage: enough collective patient volume to tip local provider practices into genuine value-based transformation, with benefits that spill over to the entire community once that happens. But per Dan Mendelson, most employers are stuck doing this year what they did last year, which means their communities stay stuck too. Mendelson's five things aren't abstract advice — they're a starting checklist for any self-insured employer ready to use its purchasing power to actually move outcomes, not just costs. MENTIONED IN THIS EPISODE Article: Dan Mendelson's "5 Things CEOs Can Do Today to Improve Employee Health" (Forbes) Encore! EP206 with Ashok Subramanian: Apple Podcasts | Spotify | Other Apps EP358 with Wayne Jenkins, MD: Apple Podcasts | Spotify | Other Apps EP308 with Mark Fendrick, MD: Apple Podcasts | Spotify | Other Apps EP334 with Sunita Desai, PhD: 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 06:03 What does an accountable care model mean to a self-insured employer? 07:58 "This alignment of value will never work … if the 150 million Americans … getting their health insurance through their employer are not also aligned in the same way." 11:28 "We're offering them a higher level of service." 11:40 "Everything that we do is intended to be scalable and not just for us." 12:09 "We have an obligation to do better for our employees." 14:52 "Employers need to understand, the only way to get outstanding care is locally." 18:18 Why is getting quantitative metric data important? 20:58 "This is a much broader vision of accountable care than … primary care." 22:48 "Until everything is aligned, the employer is just not going to be providing an optimal product." 23:39 "There are substantial issues with … health equity, and employers are paying for the care of 150 million Americans in this country." 25:23 Is digital health access important for creating meaningful relationships between patients and providers? 29:50 What is the myth that employers need to tackle? 30:18 Why is care navigation important for employees?

Most payer-provider relationships aren't collaborative — they're fairly adversarial, especially from the standpoint of provider organizations trying to find a payment model that lets them actually do right by patients. In this episode, Stacey Richter talks with Josh Berlin, JD, CEO of Rule of Three, about the real why, what, and how of payer-provider collaboration: what actually motivates a payer to collaborate (since payers other than in their fully insured book are just intermediaries, not the ones bearing the risk), the five distinct kinds of collaboration that exist, and the five must-haves that determine whether any of them actually work. WHAT YOU'LL LEARN ✅ Why "saving money" alone isn't actually a compelling reason for a payer to collaborate with providers — and what genuinely motivates payers instead: predictable spend, competitive differentiation, market resilience, margin, and Star Ratings/HEDIS-linked dollars ✅ The five kinds of payer-provider collaboration, ranked by depth of entanglement: sharing data, joint programmatic work like clinical pathways, joint ventures on narrow-network products, becoming capital partners, and full risk-bearing relationships where the provider gets a piece of the premium dollar ✅ The five must-haves Josh Berlin says any collaboration needs before it starts: complementary, scalable capabilities; shared goals and time horizon; flexibility on both sides; genuine skill at collaborating (not just stated intention); and compatible risk profiles ✅ Why "you have to be collaborative to collaborate" sounds obvious but is frequently an unexamined blind spot inside payer organizations — and what it actually looks like when a payer isn't ✅ Why Ochsner stands out as a real-world example of payer-provider collaboration working, and what a notable collaboration failure like Haven can teach about what goes wrong WHY THIS MATTERS Payer-provider relationships default to adversarial not because collaboration is impossible, but because most attempts skip the unglamorous prerequisites: shared goals, real flexibility, and the actual cultural capacity to collaborate rather than just the stated desire to. Josh Berlin's five-and-five framework gives both sides a concrete way to diagnose whether a proposed collaboration is set up to succeed before committing real time and capital to it — which matters, because plenty of providers and payers who've tried this confirm just how rare and hard-won a functioning collaboration actually is. MENTIONED IN THIS EPISODE EP359 with Dan O'Neill: 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 06:06 Why should payers want to collaborate with providers? 09:46 "Collaboration … is bilateral. … Both sides, plan and provider, should be equally as interactive with the individual populations they work with." 12:37 What are the must-haves for collaboration between providers and payers? 13:10 What are the five different types of collaboration? 16:03 What are the five characteristics you want to be focused on in partnership? 22:16 In order to collaborate, do you have to be collaborative? 26:11 Ochsner as a great example of collaboration. 27:46 Episodes with David Carmouche, MD, and Eric Gallagher. 28:51 A collaboration failure in Haven.

Ten years and $200,000 to $300,000 in real dollars — that's roughly what it costs to become a physician, and yet most medical schools teach almost nothing about how the business of medicine actually works. In this episode, Stacey Richter talks with Adam Brown, MD, MBA, a board-certified ER physician and founder of ABIG Health, about his MedPage Today article making the case that medical schools are doing their students a disservice by leaving business education out of the curriculum — and about what that gap costs physicians, patients, and the system once those students become practicing doctors. WHAT YOU'LL LEARN ✅ Adam Brown's five reasons medical schools should teach the business of medicine: the changed role of physicians, the expectation mismatch new doctors face, the need to advocate effectively, the reality that prescribing decisions drive costs patients and employers ultimately bear, and the alternative career paths physicians often don't know exist ✅ Why physicians who don't understand the business of medicine struggle to earn seats in boardrooms — and why so few doctors sit on the boards of major nonprofit hospitals as a result ✅ Why patients who fear they can't afford care skip doctors' orders, and why that's a business-of-medicine blind spot with direct clinical consequences, not just a billing issue ✅ Why moral injury and staff turnover are real organizational costs of leaving physicians out of business decisions — and why successful value-based care specifically depends on physicians understanding the business model underneath it ✅ What physician-administrators actually experience when they try to advocate with their "physician hat" on inside organizations built around administrator-determined goals WHY THIS MATTERS Too few mission-driven, business-savvy physicians in boardrooms means patients keep getting the kind of care — and the prices — the current system produces. Adam Brown's case isn't that doctors need an MBA; it's that basic business literacy is what lets physicians advocate for themselves, their colleagues, and their patients in terms decision-makers actually respond to. Without it, docs get squeezed out of the rooms where the rules get written, and value-based care efforts that depend on physician buy-in keep stalling for the same underlying reason. MENTIONED IN THIS EPISODE EP404 with Suhas Gondi, MD, MBA: Apple Podcasts | Spotify | Other Apps LinkedIn post: Denver Sallee, MD, MMM's predictive scheduling work === 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 08:49 What does it mean to teach the business of medicine? 11:04 The four Ps that are key within the business of medicine. 13:27 Why is it important for doctors to understand the business of medicine? 21:46 "Things don't happen without a physician's signature." 27:27 Why physicians who understand the business side of medicine can broaden the view of outcomes for the business decision-makers. 28:30 Why is it important to make sure physicians are in the boardroom? 30:52 "We are getting what we designed." 33:37 Dr. Brown's advice for clinicians in the boardroom.

"Morally abhorrent doesn't move the needle. What moves the needle is financial implications." That's the line from Rob Andrews that got Stacey Richter chasing this interview. In this episode, Stacey talks with Andrews, CEO of the Health Transformation Alliance (HTA) — an alliance of more than 60 jumbo self-insured employers covering over 8 million people and $30+ billion in annual healthcare spend — about the concrete financial case for buying better healthcare outcomes, using maternal health as the exemplar: readmissions down 29%, total cost of care 15% lower, and drug costs 25% less among HTA members who lean into paying for the right things. WHAT YOU'LL LEARN ✅ Why "morally abhorrent doesn't move the needle" — and why financial implications, not appeals to conscience, are what actually get self-insured employers and the healthcare system to change ✅ Why maternal health is such a stark case study for this: avoidable NICU and ICU admissions for moms and babies cost employers and communities hundreds of thousands of dollars per case, directly and indirectly ✅ Rob Andrews's three-step strategy for employers: get objective, risk-adjusted data on performance; negotiate contracts that hold intermediaries accountable for outcomes with real performance guarantees; and be transparent with employees about relative quality ✅ Why "buying things" — even at a steep discount — isn't a strategy, and why cost-shifting onto plan members isn't either; both dodge the root-cause work of paying for outcomes ✅ The concrete results HTA members have seen from leaning into this approach: 29% lower readmissions, 15% lower total cost of care, and 25% lower drug costs WHY THIS MATTERS Rob Andrews's pitch to self-insured employers isn't a moral argument, it's a financial one — and that's precisely why it's persuasive to organizations that have to answer to a board or a CFO. When employers get real data, negotiate for outcomes instead of discounts, and hold intermediaries accountable, the numbers move: fewer readmissions, lower total cost of care, cheaper drugs. That's a case study jumbo employers not yet doing this work can actually replicate, not just admire from a distance. === 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 07:29 How did Rob get to his current role? 09:11 The problem of maternal health and mortality rate, and how self-insured employers wind up directly and indirectly paying for this. 10:36 Why economic consequences move the needle, and why sometimes they don't. 12:36 Why the best way to address costs isn't to re-shift costs but to address them directly. 14:34 Why compensation that isn't dependent on outcomes is a problem. 18:09 "Strategy's not what people say; it's what they do." 21:40 How do you operationalize saving money with better outcomes? 29:46 How do employers turn conflict into collaboration? 31:41 What is the win-win-win structure among employers, payers, and providers in Rob's eyes? 34:13 To whom should the task of risk adjustment fall? 38:03 "Better contracts do improve outcomes."

Most conversations about value-based care happen at 50,000 feet. This one is much closer to the ground: a real, step-by-step how-to for how a specialist practice — an OB/GYN group, an orthopedic practice, whoever — can actually deliver coordinated, value-based care and get paid for doing it. In this episode, Stacey Richter talks with Justina Lehman, CNP, DNP, founder and president of Revolution Health, about why doing right by patients and growing the practice aren't actually in tension, and about the concrete process she uses to help physician groups make that case to payers. WHAT YOU'LL LEARN ✅ Justina Lehman's eight-step process for building a "value alliance": assembling a self-selected physician committee, defining the gap between care as usual and ideal care, designing the transition plan, aligning it to real financial models, measuring results, building the payer pitch, recruiting more physicians, and maintaining it over time ✅ Why patients drawn to nonfragmented, coordinated care and purpose-driven clinicians who want to deliver it can combine into a genuine growth strategy, not just a values-driven side project ✅ The four financial avenues available with an engaged payer: prospective bundle payments, retrospective shared-savings payments, quality incentives layered onto or withheld from fee-for-service, and PMPM specialty quality programs ✅ What to do when the payer isn't engaged: banding together with other practices into a value alliance to build leverage, or aligning your care pathway to whatever is actually payable within the existing fee-for-service model ✅ Why specialists who don't figure out how to work with capitated primary care physicians risk losing referrals altogether, and why demonstrating better outcomes is the only way to earn that trust WHY THIS MATTERS The idea that value-based care and short-term financial growth are at odds is, per Justina Lehman, a false choice — coordinated, high-value care creates real demand from patients and real appeal to purpose-driven clinicians, and that combination drives growth on its own. For specialists sitting on the sidelines waiting for the incentives to align before they act, the risk isn't just missed opportunity: it's losing referral relationships with primary care physicians who are increasingly expected to prove outcomes before sending patients anywhere. Having an actual process to follow, rather than waiting for a perfect payer environment, is what turns intention into results. MENTIONED IN THIS EPISODE EP412 with Robert Pearl, MD: Apple Podcasts | Spotify | Other Apps Summer Shorts 8 with Larry Bauer, MSW, MEd: Apple Podcasts | Spotify | Other Apps EP402 with Amy Scanlan, MD: Apple Podcasts | Spotify | Other Apps Summer Shorts 4 with Eric Gallagher: 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 07:35 What has Justina been up to, and why is it relevant to this conversation? 08:23 What is high-value care, and how do we figure out what it is in reality? 10:08 "What is the clinical design of … high-value care?" 10:21 Care as usual vs ideal care. 12:23 How does Justina figure out what the benchmark is for high-value care? 12:36 Meeting patients where they are at, not where we want them to be. 18:28 "What is the story as a group to the payer? What is the story as a group to the self-funded employer?" 19:19 How do you align business operations and the financials? 20:16 What are the four avenues for getting paid for high-value care? 21:58 What are highly engaged payers most intrigued by in high-value care? 24:11 What are the different ways a practice can get compensated? 28:52 Are there programs that have advanced without payers leading the way? 29:37 What's the "hook" for payers? 31:12 What's a winning message to payers and employers? 34:13 "Not everyone needs to participate." 38:24 Can a program be successful even if a physician is a passive participant in the program?

Estimates suggest the US healthcare system wastes upward of a trillion dollars a year, split across two broad categories: administrative failures (fraud/waste/abuse, administrative complexity, pricing failures) and clinical failures (care coordination, care delivery, and low-value care). In this episode, Stacey Richter talks with Will Shrank, MD, a venture partner at Andreessen Horowitz and former chief medical officer at Humana, CVS Health, and UPMC's health plan, about where that waste actually goes, why it's so hard to cut (someone's waste is someone else's profit), and why primary care physicians organizing and demanding better models might be an underrated lever for change. WHAT YOU'LL LEARN ✅ The six categories of healthcare waste, split between administrative failures (fraud/waste/abuse, administrative complexity, pricing failures) and clinical failures (care coordination, care delivery, and low-value care) ✅ Why cutting healthcare waste is so politically and economically difficult: nearly every dollar of waste is somebody else's revenue, which means constituencies exist to protect it ✅ Why aligning financial incentives with quality — paying for the longitudinal patient journey and for outcomes rather than volume — is Dr. Shrank's broad-stroke fix for the clinical-failures side of waste ✅ Why value-based care's slow pace of change is, per Dr. Shrank, more a reflection of how young the model still is than a sign it isn't working ✅ Why PCPs organizing and pushing back against being treated as RVU referral machines could become a meaningful source of leverage, especially if self-insured employers start demanding the same kind of value-based accountability WHY THIS MATTERS A trillion dollars of annual waste sounds like an obvious target, but as Will Shrank lays out, most of that waste is embedded in somebody's business model, which means fixing it requires realigning incentives, not just identifying the problem. Value-based care is the mechanism most likely to make that realignment happen, because it's the rare structure where reducing waste actually benefits the people positioned to reduce it. In the meantime, physicians and employers who are tired of waiting on that broader shift may have more collective leverage than they realize. MENTIONED IN THIS EPISODE EP363 with David Scheinker, PhD: Apple Podcasts | Spotify | Other Apps Books: Robert Pearl's Uncaring EP409 with Larry Bauer, MSW, MEd: Apple Podcasts | Spotify | Other Apps EP359 with Dan O'Neill: Apple Podcasts | Spotify | Other Apps Summer Shorts 2 with Scott Conard, 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 05:56 Can we cut healthcare waste while improving patient care? 06:35 What does "healthcare waste" consist of? 06:48 What are the six categories of "healthcare waste"? 09:39 How much money does Dr. Shrank estimate is wasted each year in healthcare? 12:11 Where is that healthcare waste going, and why does it happen? 20:20 "We've built a backbone of extraordinary waste on a fee-for-service chassis." 25:04 Dr. Shrank's warning to providers out there. 30:43 Why there might be a generational shift among younger providers looking to work with different models.

Healthcare Transactions Cost 1,000 Times More Than They Should — Here's Why Clearinghouses Are Part of the Problem Sending a claim through a healthcare clearinghouse costs 10 to 15 cents per transaction. Sending a thousand business emails at scale costs about 15 cents total. That is a thousand-to-one cost differential for something that healthcare has actually standardized more rigorously than most other industries — thanks to HIPAA's administrative simplification rules, which mandate X12 standard transaction formats, ICD-10 codes, CPT codes, and HCPCS codes. Logistics and retail would kill for that level of standardization. Healthcare has it and still pays 1,000 times more per transaction. In this episode, Stacey Richter speaks with Zack Kanter, CEO and founder of Stedi — the programmable healthcare clearinghouse — about the $5–$7 billion a year sitting in healthcare transaction processing costs that should be roughly 90% lower, the days of delay baked into batch-based legacy clearinghouse architecture, and why this is fundamentally an incentives problem more than a technology problem. WHAT YOU'LL LEARN ✅ What a clearinghouse actually does: it acts as a hub connecting all providers with all payers so that a practice doesn't have to set up separate authenticated data connections, BAAs, and field mappings with every payer — one connection routes claims, eligibility checks, claim status requests, and prior auth transactions to the right destination ✅ Why healthcare transactions cost 1,000 times more than other industries despite HIPAA standardization: the standards lower the technical complexity, but legacy batch-based systems, lack of competitive pressure, and payer incentives to maintain the float have kept the infrastructure expensive and slow ✅ Why the batch processing train-stop model adds days to every transaction: clearinghouses pick up files every 30 minutes to 12 hours, queue them for transmission, and payers receive and adjudicate on their own batch schedules — miss one train by a minute and you wait 24 hours for the next one, adding receivables days for providers and delays in clinical decisions for patients ✅ Why this is not really a technology problem: the technology to make these transactions instant and cheap already exists — what is missing is incentive to use it, because payers benefit from the float on billions of dollars held for additional days, and clearinghouses owned by payers have limited motivation to disintermediate themselves ✅ How opacity compounds the cost: when a claim goes wrong across the clearinghouse/EHR boundary, neither side can easily tell where the problem is sitting — providers call to find out whether their prior auth is approved while the request is held up somewhere in a batch queue between train stops ✅ What plan sponsors should understand about the arms race: RCM vendors on the provider side are already using programmatic clearinghouses to maximize revenue in real time; plan sponsors who do not have equally programmatic prepayment integrity programs connected to the same data streams are bringing an increasingly rusty knife to a gunfight WHY THIS MATTERS Every extra day in the transaction pipeline is a day a provider waits to get paid, a day a patient doesn't know whether their procedure is approved, and a day the patient may have moved or forgotten the context — reducing collection rates and potentially delaying care. Fixing the pipes does not require eliminating clinical review. It means replacing batch jobs with real-time processing for the tens of thousands of technical validation rules that should be instantaneous. The technology is not the obstacle. The incentives are. === LINKS === 🔗 Show Notes with all mentioned links: Episode Page 🔗 Visit Stedi ✉️ 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 09:47 What things are being paid for that we might not be aware we're paying for in healthcare? 12:09 Why HIPAA actually makes healthcare more standardized than other industries. 15:35 How healthcare is ahead in some ways and behind in others. 18:03 Where do the 4 to 5 days come from in healthcare transaction processing? 20:39 Why these transaction delays affect care delay. 23:14 EP482 with Preston Alexander. 23:18 EP472 with Eric Bricker, MD. 27:10 How should the process work from the time a provider clicks "validate"? 30:19 Why is the clearinghouse the right place to solve all these issues? 31:41 Why are we where we are in terms of these issues? 35:28 Why people should be looking at their clearinghouse costs. 36:59 What to know about Stedi.

If a hospital patient develops a central line infection that turns into sepsis, their odds of readmission within 30 days are nearly 99% — not a small cohort, and not a small problem. In this episode, Stacey Richter talks with Secretary David Shulkin, MD, former US Secretary of Veterans Affairs, and Erin Mistry, chief commercial officer at CorMedix, about a new innovation aimed at keeping dialysis patients from dying of bloodstream infections, and about a much bigger structural question: why hospitals often have a financial disincentive to adopt expensive new innovations at all, even when those innovations demonstrably improve outcomes. WHAT YOU'LL LEARN ✅ Why bloodstream infections in dialysis patients with central venous catheters (CVCs) are a major, underappreciated driver of hospital readmissions, and why preventing them is such a clear-cut economic case for preventive care ✅ How DRG (Diagnostic Related Group) payments work: Medicare pays hospitals a flat sum for roughly 13,000 diagnoses and 5,000 procedures, regardless of what's actually used to deliver the care — which means a hospital that adopts a more expensive but better innovation simply eats the cost difference ✅ Why that flat-payment structure can push purchasing decisions toward the cheapest available option, even when it's not what clinicians or patients actually need ✅ What an NTAP (new technology add-on payment) is, and how CMS created it specifically to give hospitals a financial reason to adopt certain new, qualifying technologies instead of avoiding them ✅ What a QIDP (Qualified Infectious Disease Product) designation is, and why infectious disease innovations currently get prioritized status in the NTAP process WHY THIS MATTERS When a hospital's payment for a procedure or diagnosis doesn't move regardless of what's used to deliver the care, the hospital's purchasing incentives and a patient's actual best interest can quietly diverge — and it's the hospital, not the innovator or the payer, left to eat the cost of doing better by the patient. Programs like NTAP exist because CMS recognized that gap and tried to close it with real money. Understanding how that mechanism works matters for anyone trying to get a genuinely better technology adopted inside a payment system built around flat, DRG-based reimbursement. === 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

A care gap is what happens when a transition of care goes wrong: a patient who doesn't understand discharge instructions, doesn't fill a prescription, or has uncontrolled hypertension or diabetes that no one ever adjusts the care plan for. Stacey Richter is re-airing this conversation with Carly Eckert, MD, PhD(c), MPH, a year later because she keeps finding herself quoting Dr. Eckert — even though the interview didn't go the way Stacey originally planned. She wanted to talk about closing care gaps; Eckert redirected the conversation toward something more fundamental: whether "closing care gaps" is even the right model of care to begin with, or just a reactive game of whack-a-mole. WHAT YOU'LL LEARN ✅ Why "closing care gaps" can function as reactive whack-a-mole — treating each missed preventative opportunity as it surfaces rather than building a genuinely nonfragmented system of care ✅ What a truly nonfragmented state of care would actually require, and why identifying and addressing care gaps is only one piece of a much bigger population health picture ✅ Why taking small, individualized steps with patients matters more than a one-size-fits-all approach, and why peer support carries real, underused power in closing gaps ✅ Why workforce diversity is a meaningful lever for closing care gaps, and where providers still have room to improve transparency with patients ✅ Why provider organizations so often default to reactive, appointment-based care gap closure instead of proactive whole-person population health programs — and why, per Stacey's own follow-up reflection, weak financial incentives are usually the real reason why WHY THIS MATTERS Care gaps are expensive and dangerous in ways that compound: uncontrolled hypertension and diabetes left unaddressed for too long lead to heart failure, and chronic kidney disease is often the very thing driving those heart failure readmissions back up. But per Carly Eckert, treating each individual care gap as it appears is a fundamentally reactive model, not a fix. Real progress requires the harder, more upstream work of building genuinely coordinated, nonfragmented care — and, as Stacey noted after a follow-up conversation with Dan O'Neill (EP359), providers won't make that shift until payment models actually reward it. MENTIONED IN THIS EPISODE EP322 with Monica Lypson, MD, MHPE: Apple Podcasts | Spotify | Other Apps EP347 with Ian Tong, 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 05:31 What is the true goal in making population health successful? 05:58 How does the clinical pathway need to manifest in population health? 06:29 How do we get a nonfragmented state of care? 06:54 What is the best model of care? 08:37 "Identifying and addressing care gaps is an important element of population health." 11:30 Closing care gaps vs creating a nonfragmented system of care. 15:38 "I think you have to take small steps with people." 16:45 "There's a lot of power in peer support." 17:18 Why should provider organizations connect with peer groups? 19:05 "The key is that it's not going to be the same for everybody." 23:09 Why is diversity of the workforce key to closing care gaps? 28:36 Where can providers improve transparency to help close care gaps?

In the old country-doctor days of medicine, there wasn't much science — mostly art: comfort and compassion, with little data to guide decisions. Today it's the opposite problem, or maybe the opposite opportunity: real data, real evidence-based standards of care, and a lot less room for going purely on personal recollection of what worked before. In this episode, Stacey Richter talks with Robert Pearl, MD, former 18-year CEO of The Permanente Medical Group, about what it takes to lead physicians through that shift, and why asking doctors to follow evidence-based guidelines instead of relying solely on their own experience can leave some feeling like they're just a cog practicing "cookie cutter" medicine. WHAT YOU'LL LEARN ✅ Why medicine used to be mostly art (comfort and compassion, little data) and why today's evidence-based standards of care represent a fundamentally different — and more complicated — way of practicing ✅ Why intrinsic physician motivation has declined as standards of care increasingly ask doctors to follow evidence-based guidelines rather than personal experience, and why that can feel like devaluing their expertise ✅ Robert Pearl's "A to G" model for healthcare leadership: aspirational vision, behaviors, context, data, engagement, faculty, and governance ✅ Why financial incentives so often fail to work the way they were designed to in medicine, and what actually drives lasting change instead ✅ What leaders in healthcare organizations consistently underestimate, and why Dr. Pearl says communication and engagement matter more than compensation structure WHY THIS MATTERS Medicine's shift from art to science isn't just a clinical evolution — it's a leadership challenge, because asking physicians to follow evidence over instinct can register as a loss of professional identity and autonomy if it's handled poorly. Robert Pearl's framework treats that tension as something leaders have to actively manage, not something that resolves itself once the data is good enough. Getting physician buy-in for evidence-based care, rather than just mandating it, is what determines whether standards of care actually improve outcomes or just breed resentment. MENTIONED IN THIS EPISODE EP407 with Vivek Garg, MD, MBA: Apple Podcasts | Spotify | Other Apps Books: Dr. Pearl's Mistreated and Uncaring === 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 04:50 What is the idea of the art of medicine? 09:32 Why has the intrinsic motivation of doctors plummeted? 09:48 Patient perspective versus doctor subjective response. 12:36 Why is there a fundamental change in what doctors and medical professionals can take pride in? 14:38 What did change management look like in the past? 15:24 "What does a patient really want? They'd like not to have a stroke, a heart attack … in the first place." 20:23 "How do leaders achieve evolution?" 23:57 "Incentives always work … the problem in medicine is, they rarely work the way you planned." 24:20 What's the way to make change happen, and why doesn't it involve financial incentives? 28:10 What do leaders in organizations today consistently underestimate? 29:11 What are the three parts of leadership? 29:25 What is the hardest part about leadership?