Relentless Health Value

Host Stacey Richter discusses the intricacies of stop-loss coverage with Andreas Mang and Jon Camire from Blackstone. The episode focuses on defining stop-loss insurance and exploring its critical role in protecting self-insured employers from catastrophic financial losses.  The conversation delves into the nuances of individual and aggregate stop-loss policies, laser claims, and the importance of selecting an experienced consultant to navigate this complex landscape. The episode is essential listening for those managing high-cost claimants and exploring self-insurance options. This is a two part show. The second show will cover major fails, mistakes that happen with stop-loss when somebody doesn't understand or do everything that we talk about. So, tune back in for the next part of this conversation, in two weeks. Thank you to Havarti Risk for sponsoring this weeks episode.  Havarti Risk empowers healthcare leaders like you to make smarter decisions that increase quality and lower cost of care. https://havarti-risk.com/ === LINKS ===

In this episode, Stacey Richter explores the impact of trust on healthcare outcomes, drawing from listener contributions and prior episodes of Relentless Health Value. The discussion underscores how trust or the lack thereof affects patients, clinicians, and healthcare systems. Key points include the importance of building trusted relationships, the detrimental effects of antitrust behaviors, and the broader implications for healthcare delivery. Stacey also highlights a bonus show featuring Charles Green on earning and maintaining trust. The episode concludes with an uplifting message about the collaborative and giving nature of the Relentless Health Value community. === LINKS ===

In this bonus add-on to episode 477 of Relentless Health Value, host Stacey Richter revisits a decade-old conversation with trust expert Charles Green, founder of Trusted Advisor Associates. Green discusses the intricacies of building and maintaining trust in healthcare, emphasizing four key trust principles: client focus, collaboration, long-term relationships, and transparency. The discussion highlights the challenges within the healthcare industry, compounded by conflicts of interest and transactional dynamics. Green underscores the importance of individual actions and leadership in fostering trust, advocating for empathetic listening and genuine curiosity about others as foundational behaviors. === LINKS ===

In this episode, host Stacey Richter speaks with Ann Lewandowski about whistleblowing in the healthcare industry, focusing on a significant case involving a whistleblower at an employee benefit consultant (EBC) firm. This EBC allegedly pocketed their clients' pharma rebates, violating the Consolidated Appropriations Act of 2021.  The discussion highlights the nuances of being a whistleblower, the ethical dilemmas faced, compliance challenges, and the significant financial implications for companies and individuals involved in illegal activities.  Ann Lewandowski provides insights into documenting and protecting oneself legally and discusses the broader context of trust and transparency in the healthcare sector. Click through to the show notes below to access all of the mentioned links and prior episodes mentioned. === LINKS ===

In this episode of Relentless Health Value, host Stacey Richter sits down with Peter Hayes to discuss the major forces driving change in the healthcare industry. Hayes outlines three critical factors: changing public opinion, heightened transparency, and new regulations such as the Consolidated Appropriations Act.  He emphasizes the unprecedented convergence of these elements, creating a pivotal moment for healthcare transformation. The discussion delves into the erosion of trust within the healthcare system and the growing public unrest over high costs and inefficiencies.  Hayes also highlights the role of state-level initiatives as experimental laboratories for potential national solutions. The episode concludes with a call to focus on root causes and collaborative approaches to restore trust and improve healthcare affordability and quality. === LINKS ===

In Episode 474 of 'Relentless Health Value', host Stacey Richter interviews Dr. Yashaswini Singh, an economist and assistant professor at Brown University, about the growing influence of private equity (PE) in healthcare.  The conversation delves into the corporate transformation of medicine, highlighting the potential misalignment between business interests and patient care. Dr. Singh discusses the diverse strategies PE firms use to drive profitability, such as increasing negotiated prices, consolidating market share, employing real estate leasebacks, and emphasizing performance metrics that may not align with patient benefits.  The episode also examines the significant impacts these strategies have on physicians, including increased turnover and changes in practice patterns, as well as the broader implications for patients and communities. Dr. Singh stresses the importance of informed leadership, education, policy enforcement, and transparency to ensure that private investments ultimately benefit healthcare systems without compromising patient care. === LINKS ===

This episode of Relentless Health Value features Dr. Kenny Cole from Ochsner Health System. The discussion emphasizes the critical role of trusted relationships and excellent primary care teams in keeping patients out of the emergency room, thus reducing healthcare costs. Stacey Richter revisits this conversation to highlight the importance of care teams building trust with patients and the concept of primary care as an investment in health and wellness. The episode outlines four key points for delivering great primary care, including accountability for outcomes, belief in clinical goals, standardized care flows, and building patient trust. Dr. Cole also discusses the real-world challenges and strategies for achieving clinical and financial success in primary care. The episode serves as a guide for plan sponsors, clinicians, and healthcare executives looking to improve primary care delivery and align it with financial viability. The discussion is further enriched with insights on digitizing care pathways and the importance of measuring and sharing best practices to achieve high standards of care.I Stacey revisits, in a take two, this episode with Dr. Kenny Cole because she's listening to it this time with a new focus. That focus is the theme that keeps coming up over and over and over again on Relentless Health Value these past few months. === LINKS ===

In Episode 472, Stacey Richter speaks with Dr. Eric Bricker about the impactful strategies hospital systems use to maximize revenue from high-cost patients. They explore the financial complexities and contracting tactics that enable hospitals to profit significantly from a small percentage of high-cost claimants. Key points include the negotiation of provider stop-loss contract provisions, strategic adjustment of charge masters, and the intentional steerage of patients to high-revenue service lines. This episode highlights the intricacies of hospital finance and the hidden mechanisms that drive healthcare costs for self-insured employers and other plan sponsors. We could have 0.5% to 1% of total plan members costing upwards of 40% of total plan dollars. And I bring this up just to highlight the magnitude of the money here. In that show from last week, we take the issue of high-cost claimants from the standpoint of the plan sponsor. Today, however, we're gonna be looking at this from the standpoint of the hospital system. If we were to come up with a motto for the show today with Dr. Eric Bricker, it's that all costs are somebody else's revenue. And when it's revenue and profit of the magnitude that we're talking about with many high-cost claimants, it starts to be less of an accidental “Oh, wow! How did that CABG patient wind up in our clinic? What are the odds?” and more of a “Whoever is not steering patients is letting someone else with a big profit incentive lock down that steerage in deeply embedded ways.”  === LINKS ===

Recently on Relentless Health Value, we've been tinkering around with a few recurring themes—recurring through lines—that are just true about American healthcare these days. In this episode of Relentless Health Value, host Stacey Richter speaks with Dr. Christine Hale about high cost claimants and the implications for healthcare plans in 2025 and beyond. They discuss the importance of trust in patient care, the financial incentives behind patient steering, and the critical role of timely and comprehensive data analysis. Dr. Hale emphasizes the need for an integrated approach to medical and pharmacy claims data to avoid expensive consequences and improve patient outcomes. She also shares strategies for plan sponsors to effectively manage high cost claimants through evidence-based care, appropriate treatment settings, and creative problem-solving, while underlining the importance of patient engagement and satisfaction. Don't miss next week's episode with Dr. Eric Bricker for a deeper dive into these topics. === LINKS ===

So, the show today, it's sort of an encore but not really an encore because I recorded this whole new introduction that you are currently listening to. And I also did a few inserts that we popped into the show itself. Inserts from the future, you might say. For a full transcript of this episode, click here. If you enjoy this podcast, be sure to subscribe to the free weekly newsletter to be a member of the Relentless Tribe. But why did I pull this episode from 2021, you might be wondering, as an immediate follow-on to the show from last week (EP469) about possible Medicaid cuts? Well, for one thing, the show last week about Medicaid cuts was about how the cuts might impact plan sponsors. And it left me feeling a little bit like part of the story was going unsaid. So much of what happens in healthcare, we see numbers on a spreadsheet but can easily lose track of human beings. I was reading something the other day. It reminded me of the people behind these numbers. I don't know if this happened in rural America, but it easily could have. Here's the link. Someone could not get a needed surgery. This surgery had all of the medical necessity boxes checked, except the hospital would not perform the needed surgery without cash up front in prepayment. This patient, he did not have enough money to cover the prepayment. So, somebody in the hospital finance department gave him a solution: Just wait until the situation becomes life-threatening, and then I guess you can go to the ER with your newly life-threatening condition, and they will have to perform the surgery without the money up front. And here we have the theme of people not being able to afford or not being able to access primary care or, in this case, I guess something more than that—a surgery—and they wind up in the emergency room. As John Lee, MD, put it, the healthcare system in this country is like a balloon. And the way we are currently squeezing it, everybody is getting squeezed into the emergency room—which is the very most expensive place to obtain care, of course, especially when that care is non-emergent. In rural America, this is particularly true. Now, by no means am I suggesting any kind of magic bullet to this Medicaid situation. As we all know, health and healthcare are not the same thing as health insurance; and we all know enough about the issues with Medicaid. That is not what the show is about. The episode that follows with Nikki King, who is my guest today, offers some great advice when there's just such a scarcity of clinicians available; and she does a great job of it. So, I am going to spend my time with you in this intro talking about rural hospitals in rural areas—the place where many patients wind up when they cannot get primary care in their community, just exacerbating all of the issues we have with Medicaid and affording Medicaid. But yeah, even if there is adequate or even great primary care, you still kind of need a hospital. The thing is, if an economic situation emerges where, say, for example—and this is the case in a lot of rural places—let's just say a factory or two or a mine or whatever closes down. It might mean the local hospital also closes down if that local hospital was dependent on commercial lives and cost shifting to those commercial lives. Like, this is not higher math or anything. It's easy to see how a doom loop immediately gets triggered. Recall that one big reason—and Cynthia Fisher (EP457) talked about this in an episode from a few months ago—one reason why employers in rural areas are choosing to move facilities somewhere else or overseas is that hospital costs are too high in the USA in these rural areas. So, they are closing their factory down because the hospital is charging too much. The lower the volume of commercial lives, the higher the hospital winds up raising their prices for the other employers in the area. Now, there's a point that comes up a lot in 2025 in conversations about rural hospital financials or just hospital financials in general, I guess. I had a conversation with Brad Brockbank about this a while back, and I've been mulling over it ever since. There are many who strongly suggest the reason why rural and other hospitals are in trouble is squarely because they don't have enough patients with commercial insurance in their payer mix. As Nathan Kaufman wrote on LinkedIn the other day, he wrote, “The ‘tipping point' is the percent of commercial gross revenues. When most hospitals hit 25%, if they don't have commercial rates in the high 300% [over Medicare] range, things begin to unravel.” And look, I'm not gonna argue any of the points here. How would I know? For any given hospital, it could be a financial imperative to try to get 300% over Medicare out of the local employers. I don't doubt it. The question I would ask, if someone knows that hospital finances are currently dependent on cost shifting, especially in a rural area with unstable industry, what are the choices that are made by hospital boards or leadership? Is this current dependency used as a justification to level up the cost shifting to local employers just as volume diminishes keep charging more, which is ultimately going to cause even more employers to leave the area? Which seems to be kind of a default. It's like the safety valve is, charge the local employers more. The point I'm making here is not all that profound, actually. It's just to point out that safety valve, taking advantage of it, comes with downstream impact that actually worsens a situation. So, what do we do now? And similar to the Medicaid, what I just said about Medicaid, I'm not showing up with any silver bullet here. And running a hospital is ridiculously hard. So, I do not wanna minimize that. And I certainly do not wanna minimize Medicare advantage paying less than Medicare going on and the mental health crisis and the just crippling issues that a lot of rural hospitals face. Here's a link to a really interesting report by the Center for Healthcare Quality & Payment Reform (CHQPR) about the ways hospitals can restructure and rethink how they deliver services, but I will take a moment to point out some case studies of success for what happens when people crossed off go get more money from the local employers off the list. Then there's also FQHCs (Federally Qualified Health Centers) doing some amazing things even in rural areas. Listen to the episode a while back with Doug Eby, MD, MPH, CPE (EP312) about the Nuka System of Care in Alaska, serving areas so rural, you need to take a prop plane to get to them. Their patients, their members have some of the best outcomes in the entire country. Their secret: yeah … great primary care teams that include behavioral health, the doctor, the nurse, a whole crew. And look at us. We've come full circle. Primary care (good primary care, I mean) is an investment. Everything else is a cost. Lastly, let me just offer a very large update: Today, you cannot just say rural hospital anymore and automatically mean a hospital in dire financial straits struggling to, like, make the rent. Large consolidated hospital systems have bought up so many rural hospitals for all kinds of reasons that may (or maybe not) have less to do with mission and more to do with all the things I discussed with Brennan Bilberry (EP395) in the episode entitled “Consolidated Hospital Systems and Cunning Anticompetitive Contracts.” Here is the original episode with Nikki King. Nikki, let me just mention, has gotten a new job since she was on the pod. She is now the CEO of Alliance Health Centers in Indiana. Also mentioned in this episode are Alliance Health Centers; John Lee, MD; Cynthia Fisher; Patient Rights Advocate; Brad Brockbank; Nathan Kaufman; Doug Eby, MD, MPH, CPE; Nuka System of Care; and Brennan Bilberry.   You can learn more at Alliance Health Centers and by following Nikki on LinkedIn.   Nikki King, MHSA, DHA, is the chief executive officer for Alliance Health Centers, Inc. Her work serves both urban and rural populations and is focused on substance abuse, communities underserved in healthcare, affordable housing, and economic development. Before working in the healthcare industry, she worked for the Center of Business and Economic Research studying models of sustainability in rural communities. Growing up as a first-generation college student in Appalachia, she brings lived experience of rural communities and approaches her work in healthcare as pivotal in breaking the cycle of poverty. Nikki completed her DHA at the Medical University of South Carolina and her MHSA from Xavier University.   08:14 How dire is the rural hospital situation right now? 08:33 How could freestanding ERs be a potential solution for rural hospitals? 09:56 Advice from CHQPR: Rural hospitals should not be forced to eliminate inpatient care. 11:22 Why is broadband a roadblock to telehealth as a solution for rural health access? 14:52 What are other potential rural health access solutions? 15:37 The “hot potato” of nurse practitioners in the healthcare world. 16:34 “The number of residencies for physicians each year is not increasing, but the population … is increasing.” 20:28 EP312 with Douglas Eby, MD, MPH, CPE, of the Nuka System of Care. 22:00 What's the issue with maternity care in rural America? 24:09 “As healthcare becomes more and more specialized, [the] ability to treat high-risk cases is better, but access gets worse.” 27:57 How is mental health care affected in rural communities? 28:29 “Rural communities are trying very hard to hang on to what they have.” 29:52 “When you look at the one market plan that's available in a rural community, you probably can't afford it.” 31:37 What's the single biggest challenge to moving to a model that incentivizes keeping people healthy? 32:32 “The easiest low-hanging fruit … is having national Medicaid and have that put under the same hood as Medicare.”   You can learn more at Alliance Health Centers and by following Nikki on LinkedIn.   Nikki King, MHSA, DHA, discusses #ruralhospitals and #ruralprimarycare. #healthcare #podcast #changemanagement #healthcareleadership #healthcaretransformation #healthcareinnovation   Recent past interviews: Click a guest's name for their latest RHV episode! James Gelfand (Part 2), James Gelfand (Part 1), Matt McQuide, Stacey Richter (EP467), Vivian Ho, Chris Crawford (EP465), Al Lewis, Betsy Seals, Wendell Potter (Encore! EP384), Dr Scott Conard, Stacey Richter (INBW42)

In part 2 of episode 469, host Stacey Richter discusses the implications of Medicare site neutral payments and Health Savings Account (HSA) reforms with James Gelfand, president and CEO of the ERISA Industry Committee (ERIC).  The episode details how plan sponsors should adapt to Medicare's site neutral payment policies aimed at curbing hospital consolidation and inflated prices through facility fees and markups. Gelfand provides insights into how HSA reforms currently in Congress could expand the scope of preventive care covered before deductibles are met, benefitting both employers and employees.  The conversation also touches on the challenges high deductible health plans pose and the potential benefits of codifying recent IRS guidance to allow greater flexibility in pre-deductible coverage. The discussion underscores the importance of plan sponsors staying ahead of Medicare policies to avoid higher costs. === LINKS ===

In part 1 of this two part episode, Stacey Richter speaks with James Gelfand, President and CEO of the ERISA Industry Committee (ERIC), about the potential effects of proposed Medicaid cuts on plan sponsors and their members.  They explore ways plan sponsors can prepare for the changes, including Medicaid's four major areas of possible cuts: reducing waste, fraud, and abuse; implementing work requirements; reeling in provider taxes; and addressing the 'Cornhusker Kickback' from the ACA.  The conversation also delves into how state governments and hospitals might respond to these cuts and suggests actions for plan sponsors to mitigate potential impacts. The episode is part one of a two-part series, with the second episode covering Medicare site neutral payments and HSA reforms. === LINKS ===

In Episode 468, host Stacey Richter engages in a conversation with Matt McQuide, CEO of Synergy Healthcare. This episode delves into the critical assumptions surrounding member engagement within the healthcare industry.  Key points discussed include the role of employers in steering plan members, the importance of member engagement for navigating the healthcare marketplace, and Matt's three major misconceptions about health plan membership.  Matt also presents real-life examples of how engagement significantly impacts health outcomes, emphasizing that relationships and trust are paramount. The episode concludes with practical strategies for employers to enhance engagement and manage employee health effectively.  === LINKS ===

Here's my new idea for an episode. Welcome to it. I want to talk about a major theme running through the last few episodes of Relentless Health Value. And this theme is, heads up, going to continue through a few upcoming shows as well. For a full transcript of this episode, click here. If you enjoy this podcast, be sure to subscribe to the free weekly newsletter to be a member of the Relentless Tribe. We have Matt McQuide coming up, talking about patient engagement, and Christine Hale, MD, MBA, talking about high-cost claimants. And we also have an encore coming up with Kenny Cole, MD, talking about a lot of things; but patient trust is one of them. But before I get to the main theme to ponder here, let me talk about what gets selected to talk about on Relentless Health Value. I will freely admit, how topics for shows get picked, it's not exactly a linear sort of affair. And furthermore, even if it were, I can't always get the stars to align to get a specific cluster of guests to all come on like one after the other. So, for sure, it might be less than obvious at times where my head is at—and sometimes, admittedly, I don't even know. This may sound incredibly scattershot (and it probably is), but in my defense, this whole healthcare thing, in case you didn't know, it's really complicated. Every time I get a chance to chat with an expert, I learn something new. I feel like it's almost impossible to sit in a vacuum and mastermind some kind of grand insight. Very, very fortunately, I don't need to sit in a cave and do all this heavy thinking all by myself. We got ourselves a tribe here of like-minded, really smart folks between the guests and you lot, all of you in the tribe of listeners who are here every week. Yeah, you rock! And I can always count on you to start teasing out the themes and the through lines and the really key actionable points. You email me. You write great posts and comments on LinkedIn and elsewhere. Even if I am a little bit behind the eight ball translating my instinct into an actual trend line, it doesn't slow this bus down. It's you who keeps it moving, which is why I can confidently say it's you all who are to blame for this new idea I came up with the other day after the podcast with Al Lewis (EP464) triggered so much amazing and really deep insight and dot connecting back and forth that hooked together the past six, I'm gonna say, or so shows. Let's just start at the beginning. Let's start with the topics that have been discussed in the past several episodes of the pod. Here I go. Emergency room visits are now costing about 6% of total plan sponsor spend on average. That was the holy crap moment from the episode with Al Lewis (EP464). Emergency room volume is up, and also prices are up. In that show with Al Lewis, I did quote John Lee, MD, who is an emergency room doctor, by the way. I quoted him because he told a story about a patient who came into the ER, winds up getting a big workup in his ER. Dr. Lee says he sees this situation a lot where the patient comes in, they've had something going on for a while, they've tried to make an appointment with their PCP or even urgent care, they could not get in. It's also really hard to coordinate and get all the blood work or the scans and have that all looked at that's needed for the workup to even happen. I've spoken with multiple ER doctors at this point, and they all say pretty much the same thing. They see the same scenario happen often enough, maybe even multiple times a day. Patient comes in with something that may or may not be emergent, and they are now in the ER because they've been worried about it for weeks or months. And the ER is like the only place where they can get to the bottom of what is going on with their body. And then the patient, you know, they spend the whole day in the ER getting what amounts to weeks' worth of outpatient workup accomplished and scans and imaging and labs. And there's no prior authing anything down. It's also incredibly expensive. Moving on from the Al Lewis show, earlier than that I had had on Rushika Fernandopulle, MD (EP460) and then also Scott Conard, MD (EP462). Both are PCPs, both talking about primary care and what makes good primary care and what makes bad primary care and how our current “healthcare marketplace,” as Dr. Conard puts it, incentivizes either no primary care and/or primary care where volume driven throughput is the name of the game—you know, like seeing 25 patients a day. These visits or episodes of care are often pretty transactional. If relationships are formed, it's because the doctor and/or the patient are rising above the system, not the other way around. And none of that is good for primary care doctors, nurses, or other clinicians. It's also not good for patients, and it's not good for plan sponsors or any of the ultimate purchasers here (taxpayers, patients themselves) because while all of this is going on, those patients getting no or not good primary care are somebody's next high-cost claimant. Okay, so those were the shows with Rushika Fernandopulle and Scott Conard. Then this past week was the show with Vivian Ho, PhD (EP466), who discusses the incentives that hospital leadership often has. And these incentives may actually sound great on paper, but IRL, they wind up actually jacking up prices and set up some weird incentives to increase the number of beds and the heads in them. There was also two shows, one of them with Betsy Seals (EP463) and then another one with Wendell Potter (EP384), about Medicare Advantage and what payers are up to. Alright, so let's dig in. What's the big theme? What's the big through line here? Let's take it from the top. Theme 1 is largely this (and Scott Conard actually said this flat out in his show): Primary care—good primary care, I mean—is an investment. Everything else is a cost. And those skyrocketing ER costs are pure evidence of this. Again, listen to that show with Al Lewis earlier (EP464) for a lot of details about this. But total plan costs … 6% are ER visits. Tim Denman from Premise Health wrote, “That is an insane number! Anything over 2% warrants concern.” But yeah, these days we have, on average across the country, 200 plan members out of 1000 every single year dipping into their local ER. That number, by the way, will rise and fall depending on the access and availability of primary care and/or good urgent cares. Here's from a Web site entitled ER Visit Statistics, Facts & Trends: “In the United States, emergency room visits often highlight gaps in healthcare accessibility. Many individuals turn to ERs for conditions that could have been managed through preventative or primary care. … This indicates that inadequate access to healthcare often leads to increased reliance on emergency departments. … “ED visits can entail significant costs, particularly when a considerable portion of these visits is classified as non-urgent. … [Non-urgent] visits—not requiring immediate medical intervention—often lead to unnecessary expenditures that could be better allocated in primary care settings.” And by the way, if you look at the total cost across the country of ER visits, it's billions and billions and billions of dollars. In 2017, ED visits (I don't have a stat right in front of me), but in 2017, ED visits were $76.3 billion in the United States. Alright, so, the Al Lewis show comes out, I see that, and then, like a bolt of lightning, François de Brantes, MBA, enters the chat. François de Brantes was on Relentless Health Value several years ago (EP220). I should have him come back on. But François de Brantes cemented with mortar the connectivity between runaway ER costs and the lack of primary care. He started out talking actually about a new study from the Milbank Memorial Fund. Only like 5% of our spend going to primary care is way lower than any other developed country in the world—all of whom, of course, have far higher life expectancies than us. So, yeah … they might be onto something. François de Brantes wrote (with some light editing), “Setting aside the impotence of policies, the real question we should ask ourselves is whether we're looking at the right numbers. The short answer is no, with all due respect to the researchers that crunched the numbers. That's probably because the lens they're using is incredibly narrow and misses everything else.” And he's talking now about, is that 5% primary care number actually accurate? François de Brantes continues, “Consider, for example, that in commercially insured plans, the total spend on … EDs is 6% or more.” And then he says, “Check out Stacey Richter's podcast on the subject, but 6% is essentially what researchers say is spent on, you know, ‘primary care.' Except … they don't count those costs, the ER costs. They don't count many other costs that are for primary care, meaning for the treatment of routine preventative and sick care, all the things that family practices used to manage but don't anymore. They don't count them because those services are rendered by clinicians other than those in primary care practice.” François concludes (and he wrote a great article) that if you add up all the dollars that are spent on things that amount to primary care but just didn't happen in a primary care office, it's conservatively around 17% of total dollars. So, yeah … it's not like anyone is saving money by not making sure that every plan member or patient across the country has a relationship with an actual primary care team—you know, a doctor or a nurse who they can get on the phone with who knows them. Listen to the show coming up with Matt McQuide. This theme will continue. But any plan not making sure that primary care happens in primary care offices is shelling out for the most expensive primary care money can buy, you know, because it's gonna happen either in the ER or elsewhere. Jeff Charles Goldsmith, PhD, put this really well. He wrote, “As others have said, [this surge in ER dollars is a] direct consequence of [a] worsening primary care shortage.” Then Dr. John Lee turned up. He, I had quoted on the Al Lewis show, but he wrote a great post on LinkedIn; and part of it was this: “Toward a systemic solution, [we gotta do some unsqueezing of the balloon]. Stacey and Al likened our system to a squeezed balloon, with pressure forcing patients into the [emergency room]. The true solution is to ‘unsqueeze' the system by improving access to care outside the [emergency room]. Addressing these upstream issues could prevent patients from ending up in the [emergency room]. … While the necessary changes are staring us in the face, unsqueezing the balloon is far more challenging than it sounds.” And speaking of ER docs weighing in, then we had Mick Connors, MD, who left a banger of a comment with a bunch of suggestions to untangle some of these challenges that are more challenging than they may sound at first glance that Dr. Lee mentions. And as I said, he's a 30-year pediatric emergency physician, so I'm inclined to take his suggestions seriously. You can find them on LinkedIn. But yeah, I can see why some communities are paying 40 bucks a month or something for patients without access to primary care to get it just like they pay fire departments or police departments. Here's a link to Primary Care for All Americans, who are trying to help local communities get their citizens primary care. And Dr. Conard talked about this a little bit in that episode (EP462). I can also see why plan sponsors have every incentive to change the incentives such that primary care teams can be all in on doing what they do. Dr. Fernandopulle (EP460) hits on this. This is truly vital, making sure that the incentives are right, because we can't forget, as Rob Andrews has said repeatedly, organizations do what you pay them to do. And unless a plan sponsor gets into the mix, it is super rare to encounter anybody paying anybody for amazing primary care in an actual primary care setting. At that point, Alex Sommers, MD, ABEM, DipABLM, arrived on the scene; and he wrote (again with light editing—sorry, I can't read), “This one is in my wheelhouse. There is a ton that could be done here. There just has to be strategy in any given market. It's a function of access, resources, and like-minded employers willing to invest in a direct relationship with providers. But not just any providers. Providers who are willing to solve a big X in this case. You certainly don't need a trauma team on standby to remove a splinter or take off a wart. A great advanced primary care relationship is one way, but another thing is just access to care off-hours with the resources to make a difference in a cost-plus model. You can't help everybody at once. But you can help a lot of people if there is a collaborative opportunity.” And then Dr. Alex Sommers continues. He says, “We already have EKG, most procedures and supplies, X-ray, ultrasounds, and MRI in our clinics. All that's missing is a CT scanner. It just takes a feasible critical mass to invest in a given geography for that type of alternative care model to alter the course here. Six percent of plan spend going to the ER. My goodness.” So, then we have Ann Lewandowski, who just gets to the heart of the matter and the rate critical for primary care to become the investment that it could be: trust. Ann Lewandowski says, “I 100% agree with all of this, basically. I think strong primary care that promotes trust before things get so bad people think they need to go to the emergency room is the way to go.” This whole human concept of trust is a gigantic requirement for clinical and probably financial success. We need primary care to be an investment, but for it to be an investment, there's got to be relationships and there has to be trust between patients and their care teams. Now, neither relationships nor trust are super measurable constructs, so it's really easy for some finance pro to do things in the name of efficiency or optimization that undermine the entire spirit of the endeavor without even realizing it. Then we have a lot of primary care that doesn't happen in primary care offices. It happens in care settings like the ER. So, let's tug this theme along to the shows that concern carriers, meaning the shows with Wendell Potter (EP384) on how shareholders influence carrier behavior and with Betsy Seals (EP463) on Medicare Advantage plans and what they're up to. Here's where the primary care/ER through line starts to connect to carriers. Here's a LinkedIn post by the indomitable Steve Schutzer, MD. Dr. Schutzer wrote about the Betsy Seals conversation, and he said, “Stacey, you made a comment during this fabulous episode with Betsy that I really believe should be amplified from North to South, coast to coast—something that unfortunately is not top of mind for many in this industry. And that was ‘focus on the value that accrues to the patient'—period, end of story. That is the north star of the [value-based care] movement, lest we forget. Financial outcome measures are important in the value equation, but the numerator must be about the patient. As always, grateful for your insights and ongoing leadership.” Oh, thank you so much. And same to you. Grateful for yours. Betsy Seals in that podcast, though, she reminded carrier listeners about this “think about the value accruing to the patient” in that episode. And in the Wendell Potter encore that came out right before the show with Betsy, yeah, what Wendell said kind of made me realize why Betsy felt it important to remind carriers to think about the value accruing to patients. Wall Street rewards profit maximization in the short term. It does not reward value accruing to the patient. However—and here's me agreeing with Dr. Steve Schutzer, because I think this is what underlies his comment—if what we're doing gets so far removed from what is of value to the patient, then yeah, we're getting so removed from the human beings we're allegedly serving, that smart people can make smart decisions in theoretical model world. But what's being done lacks a fundamental grounding in actual reality. And that's dangerous for plan members, but it's also pretty treacherous from a business and legal perspective, as I think we're seeing here. Okay, so back to our theme of broken primary care and accelerating ER costs. Are carriers getting in there and putting a stop to it? I mean, as aforementioned about 8 to 10 times, if you have a broken primary care system, you're gonna pay for primary care, alright. It's just gonna be in really expensive care settings. You gotta figure carriers are wise to this and they're the ones that are supposed to be keeping healthcare costs under control for all America. Well, relative to keeping ER costs under control, here's a link to a study Vivian Ho, PhD, sent from Health Affairs showing how much ER prices have gone up. ER prices are way higher than they used to be. So, you'd think that carriers would have a huge incentive to get members primary care and do lots and lots of things to ensure that not only would members have access to primary care, but it'd be amazing primary care with doctors and nurses that were trusted and relationships that would be built. It'd be salad days for value. Except … they're not doing a whole lot at any scale that I could find. We have Iora and ChenMed and a few others aside. These are advanced primary care groups that are deployed by carriers, and these organizations can do great things. But I also think they serve—and this came up in the Dr. Fernandopulle show (EP460)—they serve like 1% of overall patient populations. Dr. Fernandopulle talked about this in the context of why these advanced primary care disruptors may have great impact on individual patients but they have very little overall impact at a national scale. They're just not scaled, and they're not nationwide. But why not? I mean, why aren't carriers all over this stuff? Well, first of all—and again, kind of like back to the Wendell show (EP384) now—if we're thinking short term, as a carrier, like Wall Street encourages, you know, quarter by quarter, and if only the outlier, mission-driven folks (the knights) in any given carrier organization are checking what's going on actually with plans, members, and patients like Betsy advised, keep in mind it's a whole lot cheaper and it's easier to just deny care. And you can do that at scale if you get yourself an AI engine and press Go. Or you can come up with, I don't know, exciting new ways to maximize your risk adjustment and upcoding. There's an article that was written by Sergei Polevikov, ABD, MBA, MS, MA

This episode has three chapters. Each one answers a key question, and, bottom line, it all adds up to action steps directly and indirectly for many, including plan sponsors probably, community leaders, and also hospital boards of directors. Here's the three chapters in sum. For a full transcript of this episode, click here. If you enjoy this podcast, be sure to subscribe to the free weekly newsletter to be a member of the Relentless Tribe. Chapter 1: Are commercial insurance premiums rising faster than the inflation rate? And if so, is the employee portion of those premiums also rising, meaning a double whammy for employees' paychecks (ie, premium costs are getting bigger and bigger in an absolute sense, and also employees' relative share of those bigger costs is also bigger)? Spoiler alert: yes and yes. Chapter 2: What is the biggest reason for these premium increases? Like, if you look at the drivers of cost that underpin those rising premiums, what costs a lot that is making these premiums cost a lot? Spoiler alert: It's hospitals and the price increases at hospitals. And just in case anyone is wondering, this isn't, “Oh, chargemasters went up” or some kind of other tangential factor. We're talking about the revenue that hospitals are taking on services delivered has gone up and gone up way higher than the inflation rate. In fact, hospital costs have gone up over double the amount that premiums have gone up. Wait, what? That's a fact that Dr. Vivian Ho said today that threw my brain for a loop: Hospital costs have gone up over double the amount that premiums have gone up. Chapter 3: Is the reason that hospital prices have rocketed up as they have because the underlying costs these hospitals face are also going up way higher than the inflation rate? Like, for example, are nurses' salaries skyrocketing and doctors are getting paid a lot more than the inflation rate? Stuff like this. Too many eggs in the cafeteria. Way more charity care. Bottom line, is an increase in underlying costs the reason for rising hospital prices? Spoiler alert: no. No to all of the above. And I get into this deeply with Dr. Vivian Ho today. But before I do, I do just want to state with three underlines not all hospitals are the same. But yeah, you have many major consolidated hospitals crying about their, you know, “razor-thin margins” who are, it turns out, incentivizing their C-suites to do things that ultimately wind up raising prices. I saw a PowerPoint flying around—you may have seen it, too—that was apparently presented by a nonprofit hospital at JP Morgan, and it showed this nonprofit hospital with a 15.1% EBITDA (earnings before interest, taxes, depreciation, and amortization) in 2024. Not razor thin in my book. It's a, the boards of directors are structuring C-suite incentives in ways that ultimately will raise prices. If you want to dig in a little deeper on hospital boards and what they may be up to, listen to the show with Suhas Gondi, MD, MBA (EP404). Vivian Ho, PhD, my guest today, is a professor and faculty member at Rice University and Baylor College of Medicine. Her most major role these days is working on health policy at Baker Institute at Rice University. Her work there is at the national, state, and local levels conducting objective research that informs policymakers on how to improve healthcare. Today on the show, Professor Vivian Ho mentions research with Salpy Kanimian and Derek Jenkins, PhD. Alright, so just one quick sidebar before we get into the show. There is a lot going on with hospitals right now. So, before we kick in, let me just make one really important point. A hospital's contribution to medical research, like doing cancer clinical trials, is not the same as how a hospital serves or overcharges their community or makes decisions that increase or reduce their ability to improve the health and well-being of patients and members who wind up in or about the hospital. Huge, consolidated hospital networks can be doing great things that have great value and also, at the exact same time, kind of harmful things clinically and financially that negatively impact lots of Americans and doing all of that simultaneously. This is inarguable. Also mentioned in this episode are Rice University's Baker Institute for Public Policy; Baker Institute Center for Health Policy; Suhas Gondi, MD, MBA; Salpy Kanimian; Derek Jenkins, PhD; Byron Hugley; Michael Strain; Dave Chase; Zack Cooper, PhD; Houston Business Coalition on Health (HBCH); Marilyn Bartlett, CPA, CGMA, CMA, CFM; Cora Opsahl; Claire Brockbank; Shawn Gremminger; Autumn Yongchu; Erik Davis; Ge Bai, PhD, CPA; Community Health Choice; Mark Cuban; and Ferrin Williams, PharmD, MBA. For further reading, check out this LinkedIn post.   You can learn more at Rice University's Center for Health Policy (LinkedIn) and Department of Economics and by following Vivian on LinkedIn.   Vivian Ho, PhD, is the James A. Baker III Institute Chair in Health Economics, a professor in the Department of Economics at Rice University, a professor in the Department of Medicine at Baylor College of Medicine, and a nonresident senior scholar in the USC Schaeffer Center for Health Policy and Economics. Ho's research examines the effects of economic incentives and regulations on the quality and costs of health care. Her research is widely published in economics, medical, and health services research journals. Ho's research has been funded by the National Institutes of Health (NIH), the Agency for Healthcare Research and Quality, the American Cancer Society, and Arnold Ventures. Ho has served on the Board of Scientific Counselors for the National Center for Health Statistics, as well as on the NIH Health Services, Outcomes, and Delivery study section. She was elected as a member of the National Academy of Medicine in 2020. Ho is also a founding board member of the American Society for Health Economists and a member of the Community Advisory Board at Blue Cross Blue Shield of Texas. Ho received her AB in economics from Harvard University, a graduate diploma in economics from The Australian National University, and a PhD in economics from Stanford University.   05:12 Are insurance premiums going up? 05:59 What is the disparity between cost of insurance and wage increases? 06:21 LinkedIn post by Byron Hugley. 06:25 Article by Michael Strain. 06:46 How much have insurance premiums gone up for employers versus employees? 09:06 Chart showing the cost to insure populations of employees and families. 10:17 What is causing hospital prices and insurance premiums to go up so exponentially? 12:53 Article by (and tribute to) Uwe Reinhardt. 13:49 EP450 with Marilyn Bartlett, CPA, CGMA, CMA, CFM. 14:01 EP452 with Cora Opsahl. 14:03 EP453 with Claire Brockbank. 14:37 EP371 with Erik Davis and Autumn Yongchu. 15:28 Are razor-thin operating margins for hospitals causing these rising hospital prices? 16:56 Collaboration with Marilyn Bartlett and the NASHP Hospital Cost Tool. 19:47 What is the explanation that hospitals give for justifying these profits? 23:16 How do these hospital cost increases actually happen? 27:06 Study by Zack Cooper, PhD. 27:35 EP404 with Suhas Gondi, MD, MBA. 27:50 Who typically makes up a hospital board, and why do these motivations incentivize hospital price increases? 30:12 EP418 with Mark Cuban and Ferrin Williams, PharmD, MBA. 33:17 Why is it vital that change start at the board level?   You can learn more at Rice University's Center for Health Policy (LinkedIn) and Department of Economics and by following Vivian on LinkedIn.   Vivian Ho discusses #healthinsurance #premiums and #hospitalpricing on our #healthcarepodcast. #healthcare #podcast #changemanagement #healthcareleadership #healthcaretransformation #healthcareinnovation   Recent past interviews: Click a guest's name for their latest RHV episode! Chris Crawford (EP465), Al Lewis, Betsy Seals, Wendell Potter (Encore! EP384), Dr Scott Conard, Stacey Richter (INBW42), Chris Crawford (EP461), Dr Rushika Fernandopulle, Bill Sarraille, Stacey Richter (INBW41)  

The Hidden Costs of PBMs: How Aggregate Discount Guarantees Inflate Drug Prices. In episode 465 of Relentlessly Seeking Value, host Stacey Richter interviews Chris Crawford, CEO of RxSaveCard, about the inflated costs within the pharmacy benefits industry. The discussion centers around a lawsuit involving J&J, highlighting how large PBMs can significantly overcharge for drugs that are available much cheaper through cash-pay options like Mark Cuban's Cost Plus Drugs. Crawford explains how Aggregate Discount Guarantees, a common contracting mechanism, often fail to control spread pricing effectively and instead may lead to higher costs for plan sponsors and employees. The episode also covers how RxSaveCard can help employers and employees access these lower cash prices, circumventing the inflated costs from traditional PBMs. === LINKS ===

Emergency room costs now make up 6% of total healthcare plan spending—why? In this episode, host Stacey Richter welcomes Al Lewis to break down the data behind rising ER expenses, separating fact from fiction. They discuss whether increased patient acuity or widespread upcoding is driving costs, the impact of the No Surprises Act, and why plan sponsors struggle to negotiate fair ER rates. Plus, Al shares actionable strategies for employers to push back against inflated charges. If you want to understand the hidden forces behind escalating ER bills, this is a must-listen. You can find the charts and links mentioned in the show notes in the link below. === LINKS ===

Every Gen X'er listening to this is gonna be singing that Clash song in your head for the rest of the day. So, let's turn our attention to Medicare Advantage policy. And on the show today, I grill the one and only Betsy Seals to find out which policies she thinks are going to stay and which are going to go. For a full transcript of this episode, click here. If you enjoy this podcast, be sure to subscribe to the free weekly newsletter to be a member of the Relentless Tribe. Obviously, this is very much in the context of a new administration and also just other things that are going on. But today we talk about the following four “stay or go” policy areas. Here's the first policy area we talk about: changes and activities within the Stars program. How will the Medicare Advantage Stars program change or not? Not only with this new administration, but also there are lawsuits and how they will impact the goings-on moving forward. Second policy, will it stay or will it go, that we talk about is risk adjustment and all of the activity in government oversight and focus on recoupment of improper payments as kind of the overarching bucket and what will be the incoming administration's method around risk adjustment. This is certainly on many people's minds. The third “will it stay or will it go” policy that we discuss is the use of AI (artificial intelligence) by Medicare Advantage plans. What does the appropriate oversight of the use in AI look like? Lots of talk about those prior auth AI algorithms and the high levels of denied care. A big topic of everybody's collective mind is looking at how to ensure that oversight is appropriate and that we're using AI for good and that it's not having any adverse impact. So that's the third will it stay or will it go. Fourth, and lastly, the whole agent broker realm—additional CMS and government oversight over misleading or inaccurate information coming from the marketing or the agent broker marketing world. How will that look in 2025 and moving forward? This last one, I'm kind of all over the nuance there after reading posts and comments by Samantha George, and I would recommend following her on LinkedIn would be my suggestion. I am reflecting back on the Ann Kempski episode (EP444), where we talk about the whole, really consider the downstream impact when making any policy changes, because there can be unintended consequences. Now, in a show about carriers—in this case, Medicare Advantage carriers—I'd be pretty tone deaf not to mention the nation's ire at carriers at this exact moment in time, some of it extremely well earned and some of it reflective of an extremely dysfunctional healthcare system. I'd also be tone deaf not to mention the MedPAC (Medicare Payment Advisory Commission) report, which states that Medicare Advantage plans receive payments from CMS that are 122% of spending for similar beneficiaries in traditional Medicare. This translates to an estimated $83 billion in higher spending in 2024. And I would lastly be remiss not to mention how Medicare Advantage plans are most carriers' most profitable service lines, with average earnings of around $1800 per enrollee. All of what I said is not some kind of grand revelation, of course, to most listeners of this show. And it's also not the topic of the conversation today, although some of this did get asked and answered in the earlier shows (EP387, EP375, EP291) with Betsy Seals. One thing I will remind everyone about is that there are regional carriers that are not the big five who may or may not be doing big five types of things. And also, it is actually really difficult to run a Medicare Advantage plan successfully. They call it risk for a reason. One thing I really appreciated about the conversation with Betsy Seals that follows is her advice to contemplate value to the patient and make sure that anybody working on the carrier side, you have enough of a bead on what's actually happening to be able to identify when things are going off the rails, which does not seem to be the case in some instances. This also, by the way, having a bead on what's actually happening on the ground, helps to ensure compliance and that's piece of advice two. Last piece of advice is to learn how to be proactive and not reactive. And this is eminently more possible vis-à-vis data that's available and learning how to use it well. Betsy Seals, my guest today, has had a very busy last couple of years since she was on Relentless Health Value the last time. Betsy is CEO and co-founder of Rebellis Group, a managed care consulting firm focused specifically in Medicare Advantage. Rebellis was actually acquired in February of 2024 and joined as a family of a couple of other consulting firms that now Betsy heads up. So, in short, she's really busy. Also mentioned in this episode are Samantha George; Ann Kempski; Rebellis Group; and Vivian Ho, PhD.   You can learn more at rebellisgroup.com and alerionadvisors.com and by following Betsy on LinkedIn.   Betsy Seals is the CEO of Alerion Advisors, a family of companies dedicated to delivering unparalleled consulting services across the healthcare spectrum. As a parent organization, Alerion Advisors unites three specialized firms—Rebellis Group, Advent Advisory, and Toney Healthcare—to provide health plans and their partners with comprehensive, innovative, and results-driven solutions. With over 25 years of experience in the managed care industry, Betsy is a nationally recognized leader known for her regulatory expertise and strategic insights. Betsy brings to the table a solid mix of leadership and business acumen, as well as regulatory and strategic knowledge within the managed care landscape. Betsy's expertise is focused in the areas of mergers and acquisitions, compliance, sales and marketing, strategy, supplemental benefit landscape, innovative benefit design that address social determinants of health (SDoH), and health plan operations.   05:09 Will the Star Ratings program stay in this new administration? 08:08 How will the lawsuits against CMS policies play out with this new administration? 10:24 Why is it hard for Medicare Advantage plans to survive, let alone thrive? 16:22 How does AI directly impact beneficiary lives? 21:38 What's going on now with the override payments? 27:08 How is non-collaboration going to impact Medicare beneficiaries moving forward? 31:45 Why is it important to become more technologically savvy in compliance?   You can learn more at rebellisgroup.com and alerionadvisors.com and by following Betsy on LinkedIn.   @betsyseals discusses #medicareadvantage policies on our #healthcarepodcast. #healthcare #podcast #changemanagement #healthcareleadership #healthcaretransformation #healthcareinnovation   Recent past interviews: Click a guest's name for their latest RHV episode! Wendell Potter (Encore! EP384), Dr Scott Conard, Stacey Richter (INBW42), Chris Crawford, Dr Rushika Fernandopulle, Bill Sarraille, Stacey Richter (INBW41), Andreas Mang (Encore! EP419), Dr Komal Bajaj, Cynthia Fisher    

In this episode, Stacey Richter explores how the demands of shareholders influence the actions of publicly traded health insurance companies with guest Wendell Potter. Drawing from Milton Friedman's assertion that a business's primary responsibility is to its shareholders, we examine the implications of this philosophy in the healthcare sector. The discussion highlights concerns about fraud allegations among major insurers and the lack of open competition due to market consolidation.  We delve into the concept of the “medical loss ratio,” a key metric for investors, and how it pressures insurers to prioritize profits, often at the expense of patient care. Our guest, Wendell Potter, a former health insurance executive turned advocate for healthcare reform, provides insider insights into these dynamics. He discusses the challenges insurers face in controlling costs, the impact of rising premiums, and the broader consequences for patients and the healthcare system. This episode offers a critical look at the intersection of corporate interests and patient care, shedding light on the systemic issues that arise when profit motives drive healthcare decisions.   All mentioned links can be found in the show notes.  === LINKS ===

This podcast today is with Dr. Scott Conard, founder of Converging Health. You might remember him from the earlier episode (EP391). First of all, I enjoyed how it came to be. Brian Uhlig, an employee benefit consultant of some acclaim, came to me and offered to sponsor a show for someone else. Not himself. I gotta say, it's stuff like this that warms my heart. It's this village that we have here, this tribe of Relentless folks trying so hard to stand up for and help patients. So, thanks again to Brian Uhlig. Right now, Dr. Conard is doing a bunch of work with Mike Adams from 7-Eleven, helping their plan members. A lot of this work is centered on and about a few pretty striking but very common insights that many plan sponsors will find in their own data. It turns out about 70%, give or take, of people who wind up costing the plan whatever the high-cost threshold is in any given plan year. These higher-cost claimants didn't fall out of the sky unexpectedly, 70% of them. They were actually high risk but low cost in prior years. So, the trick is to find these individuals and help them not fall into the high-risk and high-cost part of the graph. If the goal is how to best manage a population of members, a lot of that is, again, identifying high-risk patients who are currently in the low-cost zone, who, any given plan year, are gonna go out of that zone and get into the high-cost area. So, if we're thinking about best practices to avoid this, I'm gonna run through Dr. Conard's list that we mostly run through in the show that follows. Lastly, we touch a little bit in the show today on community-run primary care. This is a community paying for primary care for community members, just like they pay the fire department and the police department. There's a town in Rhode Island doing this that Dr. Conard talks about today. In fact, Michael Fine, MD, is part of this effort in Rhode Island.  === LINKS ===

There have been two episodes lately that have sent me down a rabbit hole that I wanted to bring to your attention. Now, disclaimer: I know you people; you're busy. You listen on average to, like, 26 minutes of any given episode. So, yeah … look at me being self-aware. I say all this to say welcome to this inbetweenisode, otherwise known as The Rabbit Hole. But it's like a 20-something-minute rabbit hole, not a day-and-a-half retreat; so just be kind if you email me and tell me I forgot something or failed to dredge into a nuance or a background point. It might be that I just could not manage to pack it in. For a full transcript of this episode, click here. If you enjoy this podcast, be sure to subscribe to the free weekly newsletter to be a member of the Relentless Tribe. This rabbit hole really, really matters for anybody creating benefit design. It really matters for anybody trying to optimize the health that can be derived from said benefit design. It also probably matters for a whole lot of operational decisions involving patients or members, nothing for nothing. But it really matters for anybody trying not to, by accident, as an unintended consequence, hammer plan members or patients with some really blunt-force cost containment measures that do a lot of harm in the process of containing costs or, flip side, accidentally cost a whole lot but don't actually improve member health. Nina Lathia, RPh, MSc, PhD, kind of summed up this whole point or gave an adjacent thought really eloquently in episode 426. She said there's better or worse ways to do things and doing the worst kinds of cost containment may not actually contain costs. You squeeze a balloon, and that works great for some, like pharmacy vendors who don't really have any skin in the game. (See me using the “skin in the game” term for other people besides plan members? That's some really good foreshadowing right there, by the way.) So, squeezing the balloon works for some when they don't have skin in the game, in the place where the air goes when you squeeze the balloon—like a pharmacy vendor who makes it super unaffordable for patients to get meds so the patient doesn't take their meds and winds up in the ICU, or the patient's formerly controlled with meds condition that is now newly uncontrolled and requires all kinds of medical interventions to get said condition back under control. Like, these are the reasons and the why behind why some cost containment efforts don't actually contain costs at the plan level. But not at the vendor level. You see what I mean? Most pharmacy vendors don't get penalized if medical costs wind up going up. And I'm picking on pharmacy vendors a little bit here, but it's true for a lot of siloed entities. But, you know, balloon squeezing can also work, actually, at the plan level if where the air goes, it's to a place where the member or the patient has to pay themselves. Like, if there's a huge, I don't know, max out of pocket or deductible, does it really matter to a very mercenary plan that's running on a very short time horizon? Do they really care, that plan, if the patient's formerly controlled condition gets uncontrolled? Maybe not, I guess, as long as it doesn't cost more than the max out of pocket that the patient is on the hook for, for any given plan year. So, yeah … again, there are better or worse ways to do things; and a lot of questions kind of add up to, What kind of plan do we want to be? What are our values, and does the plan align with them? But that's not the rabbit hole I wanted to go down today—the aligning with our values rabbit hole—so let us move on. The Relentless Health Value episode that kicked off the rabbit hole for me on multiple levels was the show with Bill Sarraille (EP459) about co-pay maximizers and accumulators. And don't get me wrong, that is a complicated topic with lots of pros, lots of cons; and I am not weighing in on the inherent lawfulness or value of any of this. I am also not weighing in on the fact that there are forthright and well-run maximizers and really not good ones, which cause patients financial, for sure, and possibly clinical harm. But not talking about that right now at all. Go back and listen to the show with Bill Sarraille if you are interested. Where my “down the rabbit hole” spiral started was when I started noticing the very, very common main plan pushback that was given right out of the gate so often when talking about the problems that any given plan sponsor has with these pharma co-pay programs—that if these pharmacopeia card dollars count toward the plan deductibles, then the patient's deductible gets met and the plan member will then often overuse healthcare and cost the plan excessive dollars from that point forward. So again, if you ask any given plan sponsor what I was gonna say their main issue but a main issue that they have with these pharma co-pay programs, that's gonna be it—that if these pharma dollars count toward the plan deductible, then the patient's deductible is met and from that point henceforth, the patient goes nuts and overuses healthcare services and it costs the plan a lot of money. The second episode causing this rabbit hole to open up is the one coming up actually with Scott Conard, MD. So, check back in a couple of weeks for that one. But in the show with Dr. Conard, we get into the impact of high-deductible health plans or just big out of pockets, however they transpire in the benefit design. Both of these scenarios, by the way, the maximizer meets the deductible scenario and the very, very high-deductible plan scenario are to blame, in other words, for this rabbit hole of an inbetweenisode. So, let's do this thing. Let's talk about the moral hazard of insurance to start us off. In the context of health insurance, if you haven't heard that term moral hazard before, it's an economics term; and it is used to capture the idea that insurance coverage, by lowering the cost of care to the individual, because their plan is paying for part of said care, by lowering the cost of care to the individual, it increases healthcare use. So, you could see why this may be related to having a deductible fully paid or not. Pre-deductible, the plan is not paying for a part of said care or paying a much smaller part. And after the deductible is paid for, then the plan is paying for a much larger percentage of care. So, moral hazard kicks in bigger after the deductible is fully paid, when the plan is paying for a bigger percentage or a bigger part of the care. So, before I proceed, let me just offer again a disclaimer to the many economists who listen to this show that this is a short inbetweenisode; so I am 100% glossing over some of the points that, for sure, have a lot of nuance. For anyone who wants a thick pack of pages for background reading, I have included some links below. Because you see, a few weeks ago, my Sunday did not go as planned. And instead of running errands, I wound up reading eight papers on moral hazard. So, my lack of groceries is your gain. You're welcome. I am happy to send you these links if you really want to dig in hard on this. Okay … so, moral hazard is the concept that individuals have incentives to offer their behavior when their risk or cost is borne by others. That's the why with deductibles, actually. We gotta give patients skin in the game because once a member has their deductible paid, it's like member gone wild and they will get all manner of excessive care. Again, I hear that a lot from plan sponsors—a lot, in all kinds of contexts but almost always, again, whenever the conversation has anything to do with manufacturer co-pay card programs and a lot when it has to do with just, you know, high-deductible plans and what happens when the patient meets their deductible. Once a patient or family has a fully paid deductible, their medical trend is like a spike, I hear over and over again. And again, this is the reason why many insist—and again, no judgment here, maybe they're right, I'm just rehashing the conversation—but this is why many insist the moral hazard of letting people have their deductible paid for them by Pharma or whatever is the reason why some believe it is imperative to have maximizers or accumulators where pharma dollars can absolutely not apply to patient deductibles. Because then we have sick patients who now have their deductibles reached, who have very few financial disincentives to go seek whatever care they want. Right. Moral hazard has entered the building. I've beaten this point to death, so let's move on. One time, I asked a plan sponsor, What exactly is it that these plan members are going wild spending plan money on once their deductible gets paid off? And he said, well, you know, they go get their suspicious-looking moles checked. Did you hear that silence just now? Yeah, that was my reaction. I don't know. I would consider getting suspicious moles checked kind of high-value care. There are posters all over the place saying if you have a suspicious-looking mole, it might be melanoma. Cancer. So, you should get ahead of that before you have a metastasized cancer. I'm no doctor, but yeah, this feels like high-value care. So, let's just, in arguendo, say it is high-value care and follow this thread for a sec. Once members reach their deductible, let's say they run around and get high-value care, care they actually need but haven't gotten before because they couldn't afford it earlier or were putting it off until they saved up enough, right? Like, this is the other side of the moral hazard coin. If patients delay or abandon care—and, by the way, there was a survey (it's in the Wayne Jenkins, MD, show from a while ago [EP358])—but 46% of patients with commercial insurance these days have delayed or abandoned care due to cost. But if they delay or abandon care that is high value and medically actually necessary and they put it off or abandon that high-value care because they cannot afford said care, then yeah, we have, again, the opposite of the moral hazard problem. We have members paying a whole lot for insurance that they cannot afford to use, they're functionally uninsured, and it's not gonna end healthfully if they need high-value care and they're not getting it. It's not. Functionally uninsured patients who have chronic conditions that really should be managed will, as per evidence, wind up with health problems if those chronic conditions are not managed. I read another study about this just recently. This is why members with chronic diseases on high-deductible health plans tend to have worse health, by the way. Now, I need to say, same rules do not always apply for healthy patients who, at least at this point, don't need regular healthcare. But do keep in mind, as it comes up in the Dr. Scott Conard show, 30% of patients who think they're healthy, they feel fine—actually they are not fine and will become sick and costly in the coming years. So, yeah … tune back in for that discussion if you are interested, but you get the gist of this whole thing, right? So, that's scenario 1 as to what patients may choose to buy once they're in the moral hazard zone and have met their deductible. They go get high-value care. So, let's move on from the high-value care case study where patients reach their deductible and get high-value care or they haven't met their deductible and fail to get care they actually need. I want to circle over to the other moral hazard potential situation: patients who meet their deductible. And in this scenario, they again embark on a health system jamboree; but they don't get a whole lot of high-value care in this scenario. They run around getting all manner of all kinds of stuff that is well outside of any evidence-based pathway. Like, weird example, I went to a doctor recently asking a question about something that everyone ultimately agreed was nothing. At which point, the doctor asked if I wanted an MRI. I was like, “What?” We and everyone else just agreed this was a big nothing burger. Why would I want an MRI? Is there something else that we didn't discuss to indicate that I need imaging? Like, why are we going there? And the doc said, “Oh, well, everyone in New York City has an anxiety problem. So, I thought you might just want to get an MRI.” Yeah, low-value stuff like that is now not financially prohibitive. So, someone who had met their deductible, in a similar situation to my example, might have shrugged and said, “Sure, I do have some anxiety. Let's go get that MRI.” Or if they hadn't met their deductible, then the whole skin-in-the-game, market-driven approach may work, I guess, to prevent them from getting low-value care that was clearly excessive and pretty wasteful. So, summing up these two scenarios, the implications of the moral hazard issue are, if it's expensive, people don't do it. If it's free or cheap, they will overutilize. And the issue with both of these patient choices is, patients are not good at discerning low-value care from high-value care. And because patients are not good at discerning high-value from low-value care, moral hazard is not mitigated with any sort of binary kind of vote for moral hazard or against moral hazard types of brute-force, broad-stroke tactics. Like, say I'm a moral hazard full-on believer. I assume all or most of the care a patient will go for is low value, right? Because if I try to prevent moral hazard from happening, then by default, what I'm effectively saying is, whatever they choose to buy on the basis of moral hazard is low value. So, I make basically everything I can pretty unaffordable so as not to invoke any moral hazard. But right, the problem with that is that some of the care is actually high value. And it's also expensive for the patient, so they don't get it. And patients are harmed, and balloons might get squeezed. Or the opposite, against moral hazard, right? Like, I'm against the concept of moral hazard. I don't believe in it, so I don't set up absolutely anything to combat it. Maybe because I assume all care that a patient might want to get is actually high value and totally worth it. That's gonna be a problem for the opposite reason. Plans can waste a lot of money this way. Random example, in 2014, the Commonwealth of Virginia reported spending $586 million on unnecessary costs from low-value care. I mean, they say something like a third of all care is waste and unnecessary, so … yeah. Plan sponsors can waste a lot of money on low-value care, and a bunch of that may happen when patients have less skin in the game because they reach their deductible, as one example, and the care is not financially prohibitive and moral hazard is realized. So, yeah … as I said, a couple of weeks ago, I did not spend my Sunday as planned. I spent my Sunday reading papers about moral hazard in insurance and how financial incentives impact patient decision making. And I'm gonna repeat the grand takeaway because this is a podcast and you might be multitasking. So, once again, here's the sum of it all: If it's expensive, people tend not to do it. If it's free or cheap, they will overutilize. And the issue with both of these patient choices is, patients are simply quite bad at distinguishing high-value care from low-value care. Once their deductibles are met, most patients will—due to moral hazard—they will, in fact, go on a spending spree; and part of what they will get done will be really, really important and necessary stuff, like getting their unusual moles looked at or their heart pain checked out or going for that follow-up visit or lab work that their doctor told them they need to come in for. And the other part of what they will do will be things that are outside the best-practice, evidence-based pathway guidelines by the length of the Appalachian Trail—you know, doing what appears to be a tour of specialty medicine physicians for unclear reasons but which lead to a cascade of testing and who knows what else. Why do they do this, these members? Do they do this on purpose? No. There is study after study that shows, again, members/patients do not, most of the time, have the chops to figure out if some medical service is high-value or low-value care. And no kidding. Most members and patients have no clinical training. They're not doctors. They're not nurses. They're not physician assistants. They're humans whose uncle died of cancer, and now they have a pain in their foot and they're convinced it's a tumor. Right? Like, do we blame them when they finally go see a doctor because they crushed their budget that particular year paying thousands and thousands of dollars out of pocket for whatever earlier in the year, and now they've made it to their deductible—do we blame them for taking the very rational step of getting the most out of those thousands of dollars of sunk costs? At that point, it's a “let me get my money's worth” situation because they can't afford to do this again next year. I mean, we hire employees because they're smart and rational, and this is really actually a pretty smart and rational thing to do. It's not somebody trying to commit fraud. Okay, sure … some people are. There's always bad apples. But the vast majority are just trying to live their life and not spend all of their vacation money next year on medical services like they did this year. I'm saying all this because it's actionable, by the way. And I'm getting to that, but indulge me for like 60 more seconds because I want to acknowledge you, listeners of this show, are probably nodding along to this whole thing this whole time and thinking all of this is pretty obvious. Well, yeah … maybe. Except here's the reason I decided to do an inbetweenisode about this rabbit hole instead of doing my normal thing, which is just ranting about it over dinner for three days straight—and God bless my husband for sitting through it—is the bottom line. But the reason we are here together today is the number of emails and posts and et cetera that cross my desk where it doesn't seem like these dots have been connected on all of this or at least connected in magic marker. Like fat, indelible magic marker, which is what I think is necessary for these dots to be connected with the ones between moral hazard and patients not being able to discern high- and low-value care. There are so many ways and places these dots will show up. Like, here's another moral hazard issue with those maximizers or accumulators, which apparently are on my mind right now—the not good ones I'm talking about now, where patients find themselves on the hook for hundreds or thousands of dollars midyear if they want to pick up the meds that they've been prescribed. If you need more details on how that might happen to understand what I'm saying fully, listen to the show again a couple of weeks ago with Bill Sarraille (EP459). But even if you're a little confused, it doesn't matter because the question is this: Do we justify having programs that make drugs really expensive for patients? Do we put in place one of these pretty darn punitive types of accumulators or maximizers, right? Like, there's different kinds, and I'm talking about the punitive ones of accumulators or maximizers. Do we justify putting one of those into place and figure that if a patient really wants the med, they'll pay a whole lot of money for it? Because if they're willing to pay a whole lot of money for it, then, right? It must be high-value care, so they'll figure out how to pay for it. Keep in mind, as I said earlier, if it's expensive, people don't do it. If it's free or cheap, they will overutilize. And the issue with both of these patient choices is, patients are not good at discerning low-value care or meds from high-value care or meds. So, look, Pharma can be up to all kinds of crap, and list prices are really expensive. No arguments here. That isn't the point. The point is, What is the actual problem that we're trying to solve for, for our plan and our patients and our members? And if that problem is making sure that the right patients get the right high-value meds or care, then not letting members get co-pay assistance such that all drugs—the good ones and the too-expensive ones and the ones that we don't really want our members to take for whatever reason—if we make all of them way too expensive with a maximizer or accumulator designed to make all the drugs really expensive … dots connected. We wind up with the all-in to prevent moral hazard issue we just talked about, where patients could easily be harmed and the plan can easily get into a balloon squeezing situation. All I'm saying is that there's a big-picture view of moral hazard here that we need to be looking at and over-indexing into binary, moral hazard black and white, where we attribute malice to members, some of whom, some of the time, may actually be trying to get high-value care, or the flip side, the plan's paying too much for low-value care and causing financial difficulties and not understanding the root cause. Going black and white or over-indexing to prevent outlier kind of stuff is probably not gonna end well. Not seeking a middle way can easily result in a solution that is possibly worse than the problem. So, look, moral hazard is actually a thing. There are lots of implications to patients not being able to distinguish high-value and low-value care. But if we know this, then, philosophically at least, how do we conceptualize a solve? What should we be doing? If we're not doing black and white, what does the gray in the middle look like? Alright, we don't want to be a solution looking around for a problem. So, let's think about the problems that we want to solve for. I would start with, What's the goal? The goal of plan sponsors providing insurance most of the time is attract and retain talent. Also, I was at the HBCH (Houston Business Coalition on Health) Conference at the beginning of December 2024. And there was a poll question. There was a bunch of employers in the audience, and the poll question asked the audience, “What's your biggest plan goal this year?” Main answer by a mile: Cut costs. Okay … so, we want to attract and retain, and we want to control costs. Obviously, you can go about achieving these three things a bunch of different ways, and they will all be tradeoffs. As Luke Prettol reminded me of the other day, there are no solutions, only tradeoffs. And so, with that, right now, I want to introduce the second concept that I have been ruminating over in my rabbit hole lately, that I've kind of been hinting at for this whole time. But here's a word we've been waiting for to solve all of our problems in a good kind of way, not the bad black-and-white ways that are so often either financially a problem or deploying brute force and harming patients in the name of solving something else: Pareto optimality. Pareto optimality is the state where resources are allocated as efficiently as possible so that improving one criterion will not worsen other criteria. It's essential to consider this, that Pareto optimality is the ideal we should at least be striving for when attempting to overcome any challenge but, in particular, the moral hazard issue, when we know that patients do not know what care is high value and what care is low value. Because if we don't try to at least Pareto optimize (if that's a word), if we try to fix the moral hazard problem and wind up with a new problem or new problems that might be worse than the old problem, that's not optimal. We have improved one criterion and worsened another. So, fixing the members going wild after they meet their deductible by slamming the lid on the fingers of members trying to get high-value care as well as low-value care, well … not sure about this, but I'd assume if not the attract but at least the retain criterion might be compromised by member dissatisfaction. But also, as I've said nine times, we might not actually cut costs. We might be doing a squeeze of the balloon. Especially that could be true when, as we all probably know or suspect, what's driving costs at the plan level is rising hospital prices. There's a show coming up on rising hospital prices as a primary driver of rising plan costs, and it's pretty hard to argue with. So, it's financially pretty advantageous to keep patients from needing to go to the hospital. So, yeah … I'd strongly suggest not squeezing balloons when hospitalizations are where the air goes. I'm not gonna belabor this. My only suggestion is, do the Pareto optimality math. A lot of you already are, I'm sure, and do a great job. But just for any given policy plan change, or decision, keep in mind moral hazard and then really go through the whole cascade of likely impact on other factors based on likely member/patient behavior. It's so easy to get sucked into kind of these philosophical, “those are my enemies” kinds of conversations that are actually philosophically sort of interesting, but they aren't the goal. I mean, there's always unintended consequences; but not all unintended consequences should come as some kind of, like, wild-ass surprise. They were pretty predictable, actually. Let me also mention that when considering Pareto optimal solutions, advanced primary care starts to get really compelling. It's because having a PCP team with data and a relationship to the patient helps patients stay on the high-value care bus. And that can minimize the bad that comes from lowering the barrier to care and inviting in a little bit of moral hazard. Just saying. Okay, so this has been going on a little bit longer than I had originally intended, but I do want to remind you of the so-called theory of second best. It's probably really appropriate here, and one of the reasons why I'm mentioning this and not finishing the show right now is that, in a very synchronistic moment, I was writing up my outline for this inbetweenisode and—how random is this?—Steve Schutzer, MD, wrote an email that included something about the theory of second best. Great minds and all of that. Anyway, the theory of second best is really aligned with Pareto optimality. It's just that sometimes you gotta be really practical. You gotta be a little scrappy. If you cannot achieve the best option, either because you just can't or because the best option for one thing results in too many negative consequences elsewhere, then don't do the best option. Forget it. Do the second best (ie, the theory of second best). There is nothing wrong with that. Don't be a hero. Okay, so in summary, moral hazard is actually a thing and so is the opposite; and it's even more of an impactful thing because most people cannot distinguish high-value from low-value care. And if they meet their deductible that they have paid a lot of money to reach, of course, they are going to want to try to get through their checklist of medical appointments that they have been putting off. This is not a surprise. And it's not all bad, as long as the care that they are trying to go get is high value; and that matters if we're trying to cut costs. Because to cut costs for real and not in a squeezing of the balloon way, we need to direct or limit somehow what gets done to high-value care. And we got to do that without accidentally causing other problems, meaning think through Pareto optimality and possibly consider the theory of second best. I hope this has been helpful at some level. It's helped me. I feel better having vented. Also mentioned in this episode are Nina Lathia, RPh, MSc, PhD; Bill Sarraille; Scott Conard, MD; Wayne Jenkins, MD; Houston Business Coalition on Health (HBCH); Luke Prettol; and Steve Schutzer, MD. Additional studies mentioned: Moral Hazard in Health Insurance: What We Know and How We Know It Do People Choose Wisely After Satisfying Health Plan Deductibles? Evidence From the Use of Low-Value Health Care Services Healthcare and the Moral Hazard Problem Distinguishing Moral Hazard From Access for High-Cost Healthcare Under Insurance   For more information, go to aventriahealth.com.   Each week on Relentless Health Value, Stacey uses her voice and thought leadership to provide insights for healthcare industry decision makers trying to do the right thing. Each show features expert guests who break down the twists and tricks in the medical field to help improve outcomes and lower costs across the care continuum. Relentless Health Value is a top 100 podcast on iTunes in the medicine category and reaches tens of thousands of engaged listeners across the healthcare industry. In addition to hosting Relentless Health Value, Stacey is co-president of QC-Health, a benefit corporation finding cost-effective ways to improve the health of Americans. She is also co-president of Aventria Health Group, a consultancy working with clients who endeavor to form collaborations with payers, providers, Pharma, employer organizations, or patient advocacy groups.   04:05 Where did Stacey's rabbit hole spiral start? 05:40 What is the moral hazard of insurance? 09:31 EP358 with Wayne Jenkins, MD. 12:49 Why isn't moral hazard mitigated in insurance? 18:16 EP459 with Bill Sarraille. 20:51 “How do we conceptualize a solve?” 22:24 Why should we be striving for Pareto optimality? 25:20 What is the theory of second best?   For more information, go to aventriahealth.com.   Our host, Stacey Richter, discusses considerations for #plansponsors and others. #healthcare #podcast #changemanagement #healthcareleadership #healthcaretransformation #healthcareinnovation   Recent past interviews: Click a guest's name for their latest RHV episode! Chris Crawford, Dr Rushika Fernandopulle, Bill Sarraille, Stacey Richter (INBW41), Andreas Mang (Encore! EP419), Dr Komal Bajaj, Cynthia Fisher, Stacey Richter (INBW40), Mark Cuban and Ferrin Williams (Encore! EP418), Rob Andrews (Encore! EP415)  

This episode with Chris Crawford, CEO of RxSaveCard, is not about the when, why, or how of GLP-1s for weight loss or best-practice prescribing. This episode very, very specifically is about the how and why of the pickle plan sponsors get themselves into often enough where if they impose formulary restrictions to limit the volume of meds that they are paying for, then unit prices go up, which is a thing for GLP-1s. And this is critical just given how the costs associated with GLP-1s for weight loss contribute to some pretty significant increases in pharmacy trend for plan sponsors who choose to cover the GLP-1s for weight loss. Chris Crawford and Stacey Richter discuss the challenges plan sponsors face with the rising costs of GLP-1 medications for weight loss. They explore how plan sponsors' efforts to manage pharmacy trends often result in a tradeoff: lowering unit costs by increasing volume or vice versa. Chris also introduces a potential solution leveraging the growing cash marketplace, where employers can bypass traditional PBM contracts to achieve cost savings. Tune in for actionable insights into the perverse incentives in the pharmacy supply chain and innovative ways to navigate them. (Continued below the links) === LINKS ===

In this Relentless Health Value episode, Dr. Rushika Fernandopulle discusses with Stacey Richter his four-prong theory of change for transforming the American healthcare system. Key topics include the necessity of new payment models, process innovation, employing a relational technology infrastructure, shifting the cultural mindset towards team-based care, and emphasizing the importance of long-term partnerships. The conversation underscores the urgent need to move away from the current status quo to ensure better health outcomes and affordable care for all Americans. This is one of those episodes where we consider top-line strategic imperatives and key drivers. There was no better person to do this with than Rushika Fernandopulle, MD, who, in case you were unaware, was the founder of Iora Health, an advanced primary care group that was sold to One Medical and then to Amazon.  They discusses his four-prong theory and as Stacey says, "I can't leave well enough alone, so I plucked one more prong from our conversation and stuck it on the end." For a summary of this 5 prong approach, visit the show notes page where we also list all of the links mentioned in the episode. === LINKS ===

If you have zero clue what co-pay maximizers and/or co-pay accumulators are and the financial incentives involved for PBMs (pharmacy benefit managers) and plan sponsors here, after you're done listening to this episode, go back and listen to the show with Joey Dizenhouse (EP423). Also, the episode called “Game Theory Gone Wild” with Dea Belazi, PharmD, MPH (EP293). Both these shows could fill in some blanks. For a full transcript of this episode, click here. If you enjoy this podcast, be sure to subscribe to the free weekly newsletter to be a member of the Relentless Tribe. Here's the micro mini of the co-pay maximizer/accumulator deal. These are vehicles that are designed by vendors who are also sometimes called maximizers or sometimes they're also PBMs. But these programs are designed to get as much money out of Pharma as possible in the form of co-pay support. So, here's how the maximizers are supposed to maximize plan sponsors getting pharma money. Say, for some drug, the pharma company has, I don't know, $12,000 max in co-pay support available to patients in total per year. Pharma does always cap the dollars that are available for patients. So, in this hypothetical, $12k a year is available. What a forthright or well-run maximizer will do is figure out, you know, if there's $12k max available, then they'll set a co-pay—so there's variable co-pays for patients—so they'll set a patient co-pay of, like, $1000 a month, which adds up to $12k over 12 months of the year. Get it? Every single month, the patient has a $0 co-pay, but the plan maximizes the dollars that the plan gets. Or, you know, maybe they'll charge $1,025 a month so the patient has some small “skin in the game,” and the plan sponsor just banked $12k. Sounds great, right? Well, sure, when it works as promised … and we'll get to this in a moment. Accumulators, on the other hand, have no such “Hey, let's make sure the patient actually gets their meds” guardrails. They hear that the Pharma is offering $12k, and the accumulator vendor and their plan sponsor clients also are like, “Cool, let's get that money as fast as possible.” So, they make the co-pay for that drug, I don't know, like hypothetically $3000. Great, now the patient runs out of that co-pay money in May. And don't forget and/or let me inform you, for both maximizers and accumulators, dollars paid by the Pharma generally don't count to the plan deductible for the patient. So now, the patient walks into the pharmacy, if in an accumulator or in a poorly run maximizer program, they walk into the pharmacy in May and are told that if they want their drug, they're gonna need to pay the $3000 co-pay that was set out of pocket every month until they reach their deductible. With some of these co-pay maximizer/accumulator plans, the plan sponsor may be a little bit out of the loop relative to what is actually going on here. The plan sponsor may think that members are doing fine—you know, they're getting their drug every month—so they may be surprised to learn about this running out of money in May issue. And what is true more often than it's not true, this $3000 or whatever—hundreds or thousands of dollars—payment due co-pay, the patient learns about it at the pharmacy counter or while trying to get chemo. It comes as a complete surprise, the fact that they owe three grand or whatever. What patient just shrugs and pays up in that moment because they happen to have their entire deductible or thousands of dollars lying around and at the ready? What a shock to find this out at the pharmacy counter or at the infusion clinic. Some of these maximizer programs are also starting to veer back into accumulator zones, like they're doing things such as saying that the member must pay their out-of-pocket max or their deductible or 30% of the cost of the drug, right, like some number before the plan will allow the patient to use the co-pay reimbursement program to begin with. So, there's other things that are emerging right now, which, again, cause the patient to have a very, very large out of pocket in order for them to get a drug which they have been prescribed and—ostensibly, at least—need. Allegedly, and sometimes for sure, dollars raked in from Pharma make it across the PBM/maximizer, vendor, middleman trench all the way over to the plan sponsor. For sure, especially for the administrative only maximizer vendors … yeah, you're gonna have the dollars actually making it to the plan sponsor. But sometimes the vendor running these programs is paid spread, right? So, the more expensive the drug and the richer the co-pay card program, the more the vendor will make because they take a percentage of savings. So, the more expensive, the more savings, therefore, the more the vendor is gonna make. In these cases where the vendor is paid a spread, can I take Perverse Incentives for $600, Alex? Right? But in sum, again, there's a lot to this conversation with Bill Sarraille, so please do listen to the whole thing. Bill offers five main pieces of advice, so I'm just gonna cover them right here up front—spoiler alert, I guess, but just to keep them all in one place. 1. Look into what is going on with a maximizer and/or accumulator program. First of all, is the plan sponsor paying spread? And also, how are these programs being marketed to members and how aggressively? Because there are a lot of plan sponsors having way more negative impact than they suspect they are. So, that's point of advice #1: Really look into actually what is happening on the grounds with some of these programs. 2. Eliminate surprise. Any plan sponsor listening, and Brian Reid also says this very crisply in an episode a month or so ago (EP456). If a plan sponsor wants to do stuff like this—like force a patient to pay hundreds or thousands of dollars out of pocket—if at any point during the year they are gonna wind up with thousands of dollars in co-pay or coinsurance to get their Crohn's disease med or cancer med or whatever, be really up front about this at least. It's really important if we really want to make sure that patients are taking maintenance meds and getting the medications that they're prepared for the reality that, at a certain point during the year, they are going to have a really big bill. 3. There is legal risk here. So also, Bill's advice is check into whether accumulators and/or maximizers are unlawful under the ACA (Affordable Care Act) and/or by deceptive practices rules when maximizers or accumulators are teed up as a benefit. And it, again (reference point of advice #2), it's not explained that dollars they get from Pharma will be taken by the plan and not applied to the patient deductible. I was just reading about the crazy aggressive marketing tactics that some of these vendors are using to get members to sign up and … yeah, definitely look into deceptive practice rules. 4. If it's utilization management that we're trying to achieve here, then your utilization manager should be utilization managing. These maximizers are not meant to impact utilization management. Patients really cannot differentiate, as per study after study, it's very difficult for patients to differentiate high-value from low-value care or meds. So, pretty much the impact of having a patient with thousands or hundreds of dollars of out-of-pocket spend to get a med isn't going to be to ensure that the right people are taking the right med. Point is, use the right tool for the right job. So, if we're trying to keep patients away from low-value meds, the tool for that is utilization management. Also be aware, if the PBM says it cannot do utilization management or you'll lose your rebates and/or is pushing into a maximizer accumulator program to do this instead, that's kind of a clue that they cannot do it because they are taking money from Pharma to not have any restrictions on a drug. Read the article in the New York Times (you're welcome) about how PBMs took secret payments for the free flow of opioids, and Chris Crawford also talks about this sort of same-ish thing in an upcoming show relative to GLP-1s. But if you're trying to do utilization management, then do utilization management. 5. Use our understanding of this whole goings-on as a rationale or a way to tamp down perverse incentives. We want to wind up with patients getting charged a percentage of net prices, not a percentage of some wildly inflated list price with this whole accumulator maximizer contributing to, you know, just more wildly inflated list prices so the co-pay programs can be bigger and someone can make even more money off of the percentage of savings. And plan sponsors addicted to rebates now have another bucket of cash. Like, this is just another example of how perverse incentives pervade the system. And we should certainly be aware of that. Bill Sarraille was a healthcare attorney for many years. He retired from his law firm on the first of last year, and now he's doing the things he wanted to do before but couldn't because his billable rate was too high. Bill is teaching at the University of Maryland Law School and doing some regulatory consulting, etc. He's working with a variety of patient groups. Also mentioned in this episode are University of Maryland Francis King Carey School of Law; Joey Dizenhouse; Dea Belazi, PharmD, MPH; Brian Reid; Chris Crawford; Marilyn Bartlett; Scott Haas; Paul Holmes; and Tom Nash. You can learn more at University of Maryland Francis King Carey School of Law and by following Bill on LinkedIn. You can also sign up for his Substack.   Bill Sarraille is a professor of practice at the University of Maryland Francis King Carey School of Law, a regulatory consultant, and a retired senior member of the Healthcare Practice group at Sidley Austin LLP. Bill is a nationally recognized expert in healthcare, life sciences, drugs, medical devices, and patient access to treatments. He is widely known for his expertise in a broad array of healthcare matters, including rare disease treatment access barriers, pharmaceutical pricing, Anti-Kickback Law compliance, the 340B program, and managed care and PBM issues. During his years practicing law, Bill was recognized repeatedly by The Best Lawyers in America in both healthcare law and administrative law. He was also consistently listed as a leader in the field of healthcare law in Chambers USA: America's Leading Lawyers for Business. Bill also serves as the general counsel of the charity the Pharmaceutical Coalition for Patient Access, as an advisor to multiple patient advocacy groups on patient access issues, a compliance advisor to a coinsurance patient assistance foundation, and as the director of a rare disease society and Kalderos, Inc., a health IT firm with a focus on effectuating pharmaceutical discounts and rebates.   09:31 What should plan sponsors be aware of right now? 14:01 What is the justification for maximizers, and why is this at odds with the purpose of insurance? 18:05 Where does the issue of “fairness” land within cost containment? 20:00 Brian Reid's LinkedIn post on insurance company access challenges. 21:30 What are the real legal issues presented by some of these co-pay maximizers and co-pay accumulator programs? 27:06 How are these programs creating perverse incentives? 29:28 EP450 with Marilyn Bartlett, CPA, CGMA, CMA, CFM. 32:16 “If you're covered by the ACA, I think this is unlawful.” 32:57 What advice does Bill have in regard to these programs? 33:49 What potential litigations does Bill see coming in the near future in regard to these co-pay maximizers and co-pay accumulator programs? 38:38 EP365 with Scott Haas. 38:45 EP397 with Paul Holmes.   You can learn more at University of Maryland Francis King Carey School of Law and by following Bill on LinkedIn. You can also sign up for his Substack.   @HCLAWComment discusses #costcontainment on our #healthcarepodcast. #healthcare #podcast #pharma #healthcareleadership #healthcaretransformation #healthcareinnovation   Recent past interviews: Click a guest's name for their latest RHV episode! Stacey Richter (INBW41), Andreas Mang (Encore! EP419), Dr Komal Bajaj, Cynthia Fisher, Stacey Richter (INBW40), Mark Cuban and Ferrin Williams (Encore! EP418), Rob Andrews (Encore! EP415), Brian Reid, Dr Beau Raymond, Brendan Keeler  

In this Inbetweenisode titled 'End of Year Wrap Up and My Personal Charter Encore,' Stacey Richter extends heartfelt thanks to listeners and healthcare workers for their dedication.  She reflects on the challenges of maintaining personal integrity in a profit-driven healthcare system and introduces her personal charter. This charter, focused on ensuring net positive outcomes for patients, acknowledges that achieving transformational change in healthcare requires a collective effort.  Stacey discusses the complexities of balancing ethical decisions, financial constraints, and the broader impact on patient care, urging others to reflect on their own guiding principles. Here's her manifesto which she is now calling her Personal Charter below which she breaks down in this podcast episode: If the thing results in a net positive for patients, then I will do it. The timeframe is short-term or medium-term. And the assumption is that it will take a village and I am not alone in my efforts to transform healthcare or do right by patients. === LINKS ===

Are you on the board of directors of a company? Or are you a shareholder of a publicly traded company? Or are you a CEO or a CFO or in-house counsel who reports to a board of directors or these shareholders? Well, this show is for you. And it's about how the healthcare industry has become financialized at the same time that providing health benefits has become the second-biggest line item after payroll for most companies. We talked about that in a recent encore with Mark Cuban (EP418) also, as well as the show with Cora Opsahl (EP452) and Claire Brockbank (EP453) from 32BJ. For a full transcript of this episode, click here. If you enjoy this podcast, be sure to subscribe to the free weekly newsletter to be a member of the Relentless Tribe. So, this encore with Andreas Mang is really timely. And even if you've listened to the show when it originally aired a year ago, you may want to take another listen, because in the context of these recent shows, this one really slots right in there. And also, by the way, the one with Julie Selesnick (EP428) from last year talking about the legal jeopardy currently in play. So, this show isn't really about health benefits; it's about the business that these health benefits have become and how, if the CEO or CFO of an employer is not intimately involved in the financial layer wrapping around health benefits, then the company is getting really taken advantage of by those entities who are intimately familiar with the financial layer surrounding those healthcare benefits. And the employees of that company also are getting equally taken advantage of. This is not a case where paying more or less results in better or worse employee health or healthcare. It is a case where not minding the shop in the C-suite means that financial actors just take more of the pie and nobody wins but them. Employer loses; employee loses. Andreas Mang, my guest today, kicks off this interview talking about the conversation that will go down between himself and any CEO whose company gets bought by Blackstone. So, if you're a CEO and you're aspiring for this to happen, yeah … heads up. But he says it's kind of an unnatural act to dig into anything that smells like health benefits or health insurance. Some may not even realize that this whole financial layer has developed that sits above the healthcare benefits themselves. And they also may not think that there's anything that's possible that can be done. As far as both of these points are concerned, Andreas Mang gives a list of, as he calls them, easy things a C-suite can do to save 10% while improving employee satisfaction and health. Saving 10% or more, this can be a really big number. A lot of this is just enforcing purchasing discipline that is being used elsewhere. Here's Andreas's list recapped: 1. Have CFO engagement throughout the year. (We talked about that with Mark Cuban also.) 2. Be self-insured once you have reached a certain size. (Andreas gets into this in more detail during the show itself.) 3. Be very, very careful who you hire as your broker or benefits consultant. There are five things that need to be true: ·      They have the experience to do the job. ·      Flat-fee model compensation ·      No product pushing ·      Fees at risk (30% or more) ·      Simple termination provisions 4. Do carrier/ASO/TPA RFPs once every three years or thereabouts. 5. Do dependent eligibility audits. (Cora Opsahl talked a lot about this also in an earlier episode [EP372].) 6. Leverage pharmacy coalitions and stop-loss collectives. (In the show itself, Andreas offers some warnings because some of these coalitions and collectives are great and some are not.) But bottom line, just keep in mind, as Mark Cuban said (EP418), those that are taking your money, your company's money, are advantaged when you are confused. Where there's mystery, there's margin. If you can't convince 'em, confuse 'em and all that. This is a business strategy. Healthcare should not be this complicated. But yet, it has become so; and anyone who doesn't realize that is letting themselves and their employees really get taken advantage of. Unknown unknowns are not benign. As I have said several times already, Andreas Mang is my guest today. He is a partner at Blackstone, the private equity and alternative asset manager. His job is helping portfolio companies manage their U.S. healthcare benefits for their employees. Also mentioned in this episode are Blackstone, Mark Cuban, Cora Opsahl, Claire Brockbank, Julie Selesnick, Lauren Vela, and Tom Nash.   You can learn more at Blackstone and by connecting with Andreas on LinkedIn.   Andreas Mang is senior managing director, portfolio operations, and chief executive officer of Equity Healthcare, where he is involved in managing medical benefits spend across the Blackstone portfolio. Andreas brings 20 years of healthcare experience to Equity Healthcare, having held various roles in healthcare finance, operations, and strategy. Prior to joining Blackstone, Andreas was the vice president responsible for national provider network operations at CareCentrix, a PE-backed, leading home health benefit-management company. At Blue Cross Blue Shield of Massachusetts, he held a variety of roles, including a leadership role identifying and implementing administrative cost savings opportunities throughout the organization and ultimately designing a new corporate business model. In addition, he held roles as the manager of strategic financial planning at Harvard Pilgrim Health Care and was a senior consultant with Deloitte Consulting's Strategy and Operations group in Boston. Andreas has a bachelor's degree in healthcare management and policy from the University of New Hampshire and an MBA from the University of Rochester's Simon School of Business Administration. He currently serves on the board of DECA Dental.   04:55 Why Andreas starts every conversation with the question, “How's your healthcare company?” 07:38 Why is it important, as a self-insured employer, to treat your business as a small healthcare company? 09:16 Why is it unnatural for companies to be providing health insurance? 10:47 What can be achieved when there is alignment between employers and insurers? 12:41 What things can a company do to reduce spend by 10%? 14:14 Why is it better to have CFO engagement in the benefits plan throughout the year? 16:25 Why does self-insurance save 5% to 9% for companies automatically? 18:14 “The funding isn't a healthcare thing; it's a CFO thing.” 18:27 Why is it vital to have a reliable, trustworthy broker? 25:12 When is the last time your company has RFP'd their health plan? 27:39 Why does changing a health plan feel scary but is necessary? 28:31 What is a dependent eligibility audit? 31:20 Why are employers better together? 34:34 How do employers truly get a flat-fee model with brokers?   You can learn more at Blackstone and by connecting with Andreas on LinkedIn.   Andreas Mang of @blackstone discusses the financialization of #healthcarebenefits in our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthcareleadership #healthcaretransformation #healthcareinnovation   Recent past interviews: Click a guest's name for their latest RHV episode! Dr Komal Bajaj, Cynthia Fisher, Stacey Richter (INBW40), Mark Cuban and Ferrin Williams (Encore! EP418), Rob Andrews (Encore! EP415), Brian Reid, Dr Beau Raymond, Brendan Keeler, Claire Brockbank, Cora Opsahl

In Episode 458 of Relentless Health Value, host Stacey Richter speaks with Dr. Komal Bajaj about innovative strategies for addressing staffing shortages in the healthcare sector. They explore the importance of cultural alignment within organizations, emphasizing trust and shared values to retain staff.  Dr. Bajaj shares surprising findings from surveys indicating that healthcare workers are motivated by the goal of providing high-quality, planet-friendly care. The discussion highlights the interconnectedness of environmental sustainability and healthcare quality, presenting tangible ways to engage and empower healthcare workers while addressing both local community health and broader environmental concerns. The episode underscores the strategic importance of aligning organizational goals with the aspirations of the workforce to foster trust and mitigate staffing shortages. Stacey's guest today is Dr. Komal Bajaj. Dr. Bajaj is an ob-gyn who serves as the chief quality officer for a couple of hospitals in the Bronx, New York, that are part of the municipal health system of New York. She also now serves as medical director of sustainability for the municipal health system NYC Health + Hospitals. === LINKS ===

I'm putting a meme in the show notes. It's my second meme ever, so I'm clearly on a roll. As you can see, it's a picture of two kids taking a test; and the one kid is cheating off the other kid. It's a How to Do Spread Pricing test, and the kid with carrier has his eyes all over the PBM kid's test. For a full transcript of this episode, click here. If you enjoy this podcast, be sure to subscribe to the free weekly newsletter to be a member of the Relentless Tribe. Look, this is a thing now, medical spread. And similar to how PBM spreads adds up to millions, billions of dollars, medical spread is not change in the couch cushions. Did you see the lawsuit against Cigna? Cynthia Fisher mentions it in the conversation that follows. Spoiler alert, here's the numbers: Self-insured employer paid $4 million for a claim. In this case, there's a slide on this Cynthia Fisher gave me, by the way, if you want to see all this written out. So, the employer pays $4 million. The provider was paid—drumroll, please—$876,000. I'm pausing so that sinks in: $4 million paid by the employer; $876,000 of that makes it across the trench to the provider. What happened, you may be wondering, to the $3.2 million in the middle there that the self-insured employer wrote a check to their carrier for? If I'm the employer, I think I would sort of want to know where the $3.2 million went, because … yeah. I think anyone would be hard-pressed to explain how a prudent fiduciary is managing to pay millions of dollars of its plan members' money for services that actually cost a fraction of that. And this is just one claim. But you came here for a show about transparency. Why, you may be wondering, am I talking about medical spread pricing? It's not a super far leap, so many of you are probably there already; but let me quote Chris Deacon. She wrote, “As these conglomerates expand control over healthcare delivery and administration, radical transparency is our only bulwark. Patients and employers deserve to know exactly what they're paying for, without hidden fees disguised as care costs.” I don't think anyone would say that transparency alone is sufficient to transform healthcare, but it's definitely a start for sure. So, yeah … transparency. The reason why lawsuits about overpayments, big ones—and there's a bunch of them afoot right now, not just that Cigna one—but the reason that these are going down in the first place is because hospital prices and carrier prices are now somewhat available. And we have some plan sponsors—the ones who are worried about fiduciary duty, at least—these plan sponsors are able to cobble together the math to catch a glimpse of how much money is vanishing. Dollars they and their members are paying for medical claims that never make it to the care team providing the care. And who is shocked? Are you shocked? I'm not shocked. Let me read a sentence from a carrier contract that Justin Leader sent me the other day. Section 6.3: “Claim administrator's compensation for its services under the agreement shall include the difference between the net claim payments reimbursed to the claim administrator by the employer and the net amounts paid to providers by the claim administrator.” Translation: We are allowed to add spread pricing. We are able to arbitrage. We are able to mark up (or whatever you want to call it) by any amount we want, and you, plan sponsor, just signed up to pay for it. So, that happened. Listen to episode 433 with Justin Leader, by the way. The show is called “The Mystery of the Weekly Claims Wire,” otherwise known as the Not Transparent Weekly Claims Wire. So, look … transparency: We can talk about it in terms of medical prices. We can talk about transparency in terms of contracts. And actually also in terms of quality, but we don't get into that today. Bottom line, plan sponsors need enough access to billing data and hospital prices to calculate how much the middle folks are taking in spread, which is, as aforementioned, quite a thing. For more actual data on the magnitude of spread pricing goings-on, ask Dan Ross. That's my suggestion. He's got spreadsheets he can show you of how much plan sponsors are paying and how much providers are charging and how much is going missing in the middle. For even more on this, read the recent Owens & Minor lawsuit that just got filed, which is just a case study in how hard some of these middlemen/carrier entities are working to obscure and hide what they are doing. Because, yeah, sunshine is a great disinfectant, and that's what transparency is. Sunshine. Here's another interesting link from Chris Deacon. I say all this to say, this is the kind of transparency that Cynthia Fisher and I talk about in the show today: contract transparency, bill charges transparency, and hospital or medical price transparency for plan sponsors. We do not get into today consumers or patients using price information to shop, just FYI. We also do not get into, really, price convergence, which is what happens when hospital and carrier prices become available in a market and is often brought up on or about conversations about transparency. Okay, I will say just one thing about price convergence. There was some chatter in anti-transparency press releases from parties mostly that didn't want to be transparent at all, no way no how. But there was some talk a couple of years ago that if contracted prices became transparent, the healthcare industry would raise their prices to match the highest in the market and the result would be rising healthcare prices and greater total costs. That turns out, it seems, to be false. There's a study that shows that the bottom of the market (those with the cheapest prices) do, in fact, raise their prices but not as much as the top of the market lowers theirs. So, there is actually net savings. Read about the Turquoise Health study and an article that Forrest Xiao and team posted that shows this, and it's the first study of its kind, at least that I have seen. Okay, so contract transparency, data transparency, that's what's on deck to discuss today with Cynthia Fisher, as I have mentioned several times already, who has a long history as an entrepreneur in the healthcare space. So, Cynthia Fisher gets U.S. healthcare, and she gets being a plan sponsor and a fiduciary. She is founder and chairman of PatientRightsAdvocate.org, as well as Power to the Patients. Her focus is on ensuring that all healthcare shows prices up front so that we can have accountability and integrity in billing and at any point of care. Cynthia has said early and often that transparency protects the ultimate purchasers of healthcare—meaning plan sponsors, plan members, and patients—from overcharges, spread pricing, or otherwise. Where there's mystery, there is margin, as Anthony Ciaccia has said often. Cynthia's call to action is as follows, but listen to the show to hear her say it more eloquently. C-suites, CFOs, in-house counsel use purchasing discipline that your company probably uses elsewhere in the procurement of health benefits.  Cynthia Fisher also says as part of the call to action, refuse to sign blank checks to the healthcare industry and refuse anti-audit provisions. She also has a call to action for the accounting industry to stop ignoring auditing the health plans. And this matters just given the bald-faced fact right now that overcharges are party sized. Let me wrap up with this: There's a lot of brute force tactics out there being deployed by some plan sponsors that effectively keep plan members from getting the care they need because they are functionally uninsured. I've done multiple shows on this, and I link to some of them below. I just can't help to think, some of this brute force, you know, high-deductible health plans and some pretty savage cost containment strategies, might be unnecessary if middleman excess profits were eliminated. Well, I say this with some evidence, actually. Andreas Mang (EP419) was on the pod. He talked about saving 15% or more by being smart about contracts and plan assets at the financial and purchasing level. Brian Uhlig … was talking to him the other day. He was telling me he saved $80 million just doing contracts right. Also Claire Brockbank (EP453) talks about this; Cora Opsahl (EP452), too, from 32BJ. Those are two recent shows, again, about how much money can be saved by only signing contracts that ensure transparency. Also mentioned in this episode are Patient Rights Advocate, Chris Deacon, Justin Leader, Dan Ross, Forrest Xiao, Anthony Ciaccia, Andreas Mang, Brian Uhlig, Claire Brockbank, Cora Opsahl, Mark Cuban, and Mark Cuban Cost Plus Drug Company.   You can learn more at PatientRightsAdvocate.org.    Cynthia A. Fisher is founder and chairman of PatientRightsAdvocate.org, a nonprofit organization seeking healthcare price transparency, giving power to American consumers—patients, employers, and unions—to lower their costs of care and coverage through a functional marketplace and choice. Cynthia is best known for her pioneering work as founder and CEO of ViaCord, Inc., a leading price-transparent umbilical cord blood stem cell banking company which she started in 1993. In 2000, she co-founded and was president of the cellular medicines company ViaCell, Inc., of which ViaCord became a division. ViaCell went public in 2005, was acquired by PerkinElmer, and exists today under the ViaCord brand. Cynthia also serves on the public company boards of the Boston Beer Company, Inc. and Easterly Government Properties, Inc. She serves on the Florida Council of 100 and the board of the National Park Foundation, and she previously served on the board of directors of Water.org. Cynthia holds an MBA from Harvard Business School and a bachelor's and honorary Doctorate of Science degree from Ursinus College.   09:03 What is the goal of PatientRightsAdvocate.org? 10:28 Is American competitiveness being affected by healthcare spend? 13:47 Why is transparency a root cause to healthcare costs? 15:11 What's going on across the country to empower transparency in healthcare? 19:31 “I think people are fed up.” 21:22 The Cigna lawsuit in California. 26:36 How do employers navigate contracts against anti-steering? 28:54 EP419 with Andreas Mang. 29:33 EP452 with Cora Opsahl and EP453 with Claire Brockbank. 29:45 EP433 with Justin Leader.   You can learn more at PatientRightsAdvocate.org.   Cynthia A. Fisher of @PtRightsAdvoc discusses #medicalspreadpricing and #contracttransparency on our #healthcarepodcast. #healthcare #podcast #pharma #healthcareleadership #healthcaretransformation #healthcareinnovation   Recent past interviews: Click a guest's name for their latest RHV episode! Stacey Richter (INBW40), Mark Cuban and Ferrin Williams (Encore! EP418), Rob Andrews (Encore! EP415), Brian Reid, Dr Beau Raymond, Brendan Keeler, Claire Brockbank, Cora Opsahl, Dan Nardi, Dr Spencer Dorn (EP451)  

In this special Thanksgiving episode of Relentlessly Seeking Value, Stacey Richter discusses the significance of being 'givers' in healthcare, advocating for collaboration over transactional relationships to deliver real value to patients. She touches on the challenges and necessary shifts in healthcare market dynamics, emphasizing that true value is determined through bi-directional conversations between providers and end-users, like patients and plan sponsors. Stacey concludes with a call to action for listeners to reflect on their support networks and consider supporting valuable media and publications. To read the show notes with the mentioned links visit the epsiode page. If you enjoy this podcast, be sure to subscribe to the free weekly newsletter to be a member of the Relentless Tribe. I want to drop a thank you right here to those who have left a tip in our tip jar and/or offer up a monthly contribution. From the bottom of my heart, thanks for the support. Thank you to Dr. Scott Tromanhauser, Marilyn Bartlett, Ann Kempski, Dr. Matthew Bunte. Also, thank you to Brian Uhlig, Dr. William Gailmard, Dr. John Lee, Dr. Paula Muto, and Linda Krebs. Plus everyone else who left a lesser amount. You guys are my village, and this matters because, as it's been said by me and others a million times, it will take a village to transform healthcare. So, if you haven't already done so, because … yeah, Thanksgiving, consider who is on your own list of villagers to thank right about now in your world. So, yeah, long story long, all the more thanks to everyone who has donated to our tip jar, who has written a nice review on Apple Podcasts or Spotify, or who interacts with our posts on LinkedIn. Thank you. This is how pods like this and any of the publications that you like are able to continue. It's also, if you want to get really “why do givers succeed” about it, it's through these interactions that like 99% of guests I'd estimate who get invited on a podcast, probably any podcasts, come from, or who likely get their name in any publication come from. As I said, this is true for this pod at least. But I would say that who are most hosts or most reporters going to reach out to when they need information or insight and are looking to quote somebody? It's gonna be somebody that they know. It's gonna be somebody that they like. So, giving, the healthcare industry. This is the actual point I wanted to make before I completely distracted myself. And I talked about this at length actually at a recent thINc360 panel about delivering better patient outcomes. So, collaborate, give. And thank you to all of you who do both of these things every day, despite the cognitive dissonance and corporate forces and the lack of time and resources that may plague your efforts. I appreciate you very, very much. And it is this gang—the Relentless Tribe, that listens to this show—it is you who will transform healthcare. It's really you. And again, from the bottom of my heart, I thank you. 01:33 How do you calculate the number of people you've helped? 02:46 Why is giving so important within healthcare? 03:16 Interview with Adam Grant. 05:47 How can you be a better giver? 07:50 Who is in charge of the bidirectional conversation of value? 11:35 Why is collaboration so important to value and being a giver? 12:58 Why is it important that plan sponsors are a part of all this giving and collaboration? 13:22 Encore! EP415 with Rob Andrews. 14:34 Summer Shorts 8 with Larry Bauer, MSW, MEd. 15:08 INBW39 with Stacey on the narcissism of small differences. 15:12 EP399 and EP400 with Stacey.

This show from last year was one of the most popular episodes of the past year. And it's also extremely relevant right now, given all of the PBM (pharmacy benefit manager) goings-on, as well as ongoing litigation like the J&J lawsuit, etc. Listen to the show with Julie Selesnick (EP428) for more on that one. For a full transcript of this episode, click here. If you enjoy this podcast, be sure to subscribe to the free weekly newsletter to be a member of the Relentless Tribe. Also, Brian Reid (EP456) in the episode from a couple of weeks ago. And he talks about how Mark Cuban's way of communicating and framing some of the issues with the big PBMs and just all of the perverse incentives in the drug supply chain. He says this way of communicating is “the chef's kiss.” So, besides the insights here that follow being relevant in and of themselves, there's also some lessons just in how those issues are teed up and communicated that we all can learn from. CEOs and CFOs … hey, this show is for you. Let's start here: What do all of these numbers have in common: $140,000, $3 million, $35 million, and $3 billion? These are all actual examples of how much employers, unions, and some public entities saved on healthcare benefits for themselves and their employees. The roadmap to saving 25% on pharmacy spend and/or 15% on total cost of care in ways that improve employee health and satisfaction always begins when one thing happens. There's one vital first step. That first step is CEOs and/or CFOs or their equivalents roll up their sleeves and get involved in healthcare benefits. Why can't much happen without you, CEOs and CFOs? Here's the IRL: In 2023, the healthcare industry has been financialized. There is a whole financial layer in between your company and its healthcare benefits. And unless the C-suite is involved here and bringing their financial acumen and organizational willpower to the equation, your company and your employees are currently paying hundreds of thousands, maybe millions, of dollars too much and doing so within a business model that deeply exacerbates inequities. There are people out there who are very strategically taking wild advantage of a situation where CEOs/CFOs fear anything to do with healthcare in the title and don't do their normal level of due diligence. You think it's an accident that this whole space got so “complicated”? HR needs your help. Bottom line, if you are a CEO or CFO and you do not know everything that Mark Cuban and Ferrin Williams talk about on the pod today … wow, are you getting shellacked. Mark Cuban uses a different word. Healthcare benefits are, after all, for most companies the second biggest line-item expense after payroll. But don't despair here, because all of this information is really and truly actionable. Others out there are cutting zeros off of their spend and actually doing it in ways that are a total win for employees as well. My guest today, Mark Cuban, is a CEO, after all; and when he looked into it, it took him T-minus ten minutes to figure out just the order of magnitude that his “trusted” benefits consultants and PBM and ASOs (administrative services only) and others were extracting from his business. He pushed back. So can you. But just another reason to dig into that financial layer wrapping around your employee health benefits right now, you might get sued by your employees. Below is an ad currently being circulated on LinkedIn by class action attorneys recruiting employee plan members to sue their employers for ERISA (Employee Retirement Income Security Act of 1974) violations. It's the same attorneys, by the way, from those 401(k) class action lawsuits. I've talked to a few CEOs and CFOs who are scrambling to get ahead of that. You might want to consider doing so as well. Now, for my HR professional listeners, considering that some of what Mark Cuban says in the pod that follows is indeed a little spicy, let me just recognize that the struggle is real. There are multiple competing priorities out there in the real world, for sure. And bottom line, because of those multiple competing priorities out there in the real world, it's really vital that everybody work together up and down the organization in alignment. Lauren Vela talks a lot about these realities here in episode 406. This is a longer show than normal, but it's also like a show and a half. Mark Cuban talks not only about his work with Mark Cuban Cost Plus Drugs, which is a company that buys drugs direct from manufacturers and sells them for cost plus 15%, a dispensing fee, and shipping. It's kind of crazy how so often that price is cheaper, sometimes considerably cheaper, than the price that plan members would have paid using their insurance—and the price that the plan is currently paying the PBM. Most Relentless Health Value Tribe members (ie, regular listeners of this show) will already know that, but what is also fascinating that Mark talks about is what he's doing with his own businesses and the Mavericks on other fronts, like dealing with hospital prices. In this show, we also talk the language of indie pharmacies, fee-only benefits consultants, TPAs (third-party administrators), PBMs, and providers doing direct contracting. There are, in fact, entities out there trying to do the right thing; and Mark acknowledges that. Ferrin Williams, PharmD, MBA, who is also my guest today, is chief pharmacy officer at Scripta and an expert in pharmacy benefits. She adds some great points and some context to this conversation. Scripta is partnering with Mark Cuban Cost Plus Drugs. Scripta has a neat Med Mapper tool and also services to help employees find the lowest costs for their prescriptions. If you are a self-insured employer, for sure, check out Scripta. Here are links to other shows that you should listen to now if you are inspired to take action. I would recommend the shows with Paul Holmes (EP397); Dan Mendelson (EP385); Andreas Mang (EP419); Rob Andrews (EP415); Cora Opsahl (EP372); Lauren Vela (EP406); Peter Hayes (EP346); Gloria Sachdev, PharmD, and Chris Skisak, PhD (EP390); and Mike Thompson (EP389). Also Mark Cuban mentions in this show the beverage distributor L&F Distributors. Thanks to Ge Bai, Andreas Mang, Lauren Vela, Andrew Gordon, Andrew Williams, Cora Opsahl, Kevin Lyons, Pat Counihan, David Dierk, Connor Dierk, John Herrick, Helen Pfister, Kristin Begley, AJ Loiacono, and Joey Dizenhouse for your help preparing for this interview. Also mentioned in this episode are Mark Cuban Cost Plus Drug Company; Scripta Insights; Julie Selesnick; Brian Reid; Paul Holmes; Dan Mendelson; Rob Andrews; Peter Hayes; Gloria Sachdev, PharmD; Chris Skisak, PhD; Mike Thompson; and Scott Conard, MD. You can learn more at Mark Cuban Cost Plus Drug Company and Scripta Insights. You can also connect with Scripta and Ferrin on LinkedIn.   Mark Cuban has been a natural businessman since the age of 12. Selling garbage bags door to door, the seed was planted early on for what would eventually become long-term success. After graduating from Indiana University—where he briefly owned the most popular bar in town—Mark moved to Dallas. After a dispute with an employer who wanted him to clean instead of closing an important sale, Mark created MicroSolutions, a computer consulting service. He went on to later sell MicroSolutions in 1990 to CompuServe. In 1995, Mark and longtime friend Todd Wagner came up with an internet-based solution to not being able to listen to Hoosiers basketball games out in Texas. That solution was Broadcast.com—streaming audio over the internet. In just four short years, Broadcast.com (then Audionet) would be sold to Yahoo! Since his acquisition of the Dallas Mavericks in 2000, Mark has overseen the Mavs competing in the NBA Finals for the first time in franchise history in 2006—and becoming NBA World Champions in 2011. Mark first appeared as a “Shark” on the ABC show Shark Tank in 2011, becoming the first ever to live Tweet a TV show. He has been a star on the hit show ever since and is an investor in an ever-growing portfolio of small businesses. Mark is the best-selling author of How to Win at the Sport of Business. He holds multiple patents, including a virtual reality solution for vestibular-induced dizziness and a method for counting objects on the ground from a drone. He is the executive producer of movies that have been nominated for seven Academy Awards: Good Night and Good Luck and Enron: The Smartest Guys in the Room. Mark established Sharesleuth, a research and investigation Web site to uncover fraud in financial markets, and endowed the Electronic Frontier Foundation's Mark Cuban Chair to Eliminate Stupid Patents, an effort to fight patent trolls. Mark gives back to the communities that promoted his success through the Mark Cuban Foundation. The Foundation's AI Bootcamps Initiative hosts free Introduction to AI Bootcamps for low-income high schoolers, starting in Dallas. Mark also saved and annually funds the Dallas Saint Patrick's Day Parade, the largest parade in Dallas and a city institution. In January 2022, he started Mark Cuban Cost Plus Drug Company as an effort to disrupt the drug industry and to help end ridiculous drug prices because every American should have access to safe, affordable medicines. Ferrin Williams, PharmD, MBA, is chief pharmacy officer of Scripta. With 15+ years' experience in the pharmacy industry, Ferrin brings a unique perspective to Scripta that spans the retail pharmacy, pharmacy benefit manager (PBM), and broker/consulting sectors. Her expertise ranges from pharmacy operations and services to innovative clinical programs, pharmacy audit, alternative payer funding, and specialty drugs. As chief pharmacy officer, Ferrin leads the company's clinical strategies organization responsible for devising innovative cost-containment strategies for prescription drugs, ensuring Scripta clients, members, and their providers are provided with best-in-class clinical insights and tools. Ferrin earned her bachelor's, Doctor of Pharmacy, and MBA degrees from the University of Oklahoma.   06:29 What was Mark Cuban's own journey as a self-insured employer with Cost Plus Drug Company? 07:44 What did Mark find when he decided to go through and look through his company's benefit program? 09:12 “When you think it through, you start to realize that money is being spent primarily by your sickest employees.” —Mark 10:02 How do you get CEOs and CFOs of self-insured employers to realize that their sickest employees are the ones subsidizing their checks? 13:00 What is the role of insurance in healthcare? 14:30 “If you can't convince them, confuse them and hide it.” —Mark 15:24 The reality behind getting a rebate check. 16:21 Why are rebates going away, and why isn't that changing PBM earnings? 19:05 How do you get CEOs and CFOs to dig into their benefits plan? 20:59 Does morally abhorrent move the needle? 21:33 “What we're trying to do is just simplify the [healthcare] industry.” —Mark 24:19 What's been changing in consumer behavior? 25:04 “Transparency is a huge part of building that trust.” —Ferrin 25:19 Why CEOs and CFOs really have the power to change healthcare. 32:29 What are Cost Plus Drugs' plans to expand? 39:21 Where is the future of the prescription drug market going? 42:09 What will happen to the prescription drug market in 10 to 20 years? 48:40 The wake-up call self-insured employers should be acknowledging now. 52:02 Where is the real change in the healthcare industry going to come from?   You can learn more at Mark Cuban Cost Plus Drug Company and Scripta Insights. You can also connect with Scripta and Ferrin on LinkedIn.   @mcuban and Ferrin Williams provide advice for #CEOs and #CFOs of #selfinsuredemployers on our #healthcarepodcast. #healthcare #podcast #digitalhealth #valuebasedcare #healthcareoutcomes   Recent past interviews: Click a guest's name for their latest RHV episode! Rob Andrews (Encore! EP415), Brian Reid, Dr Beau Raymond, Brendan Keeler, Claire Brockbank, Cora Opsahl, Dan Nardi, Dr Spencer Dorn (EP451), Marilyn Bartlett, Dr Marty Makary  

In this episode, Stacey Richter speaks with Rob Andrews, CEO of the Health Transformation Alliance (HTA) and former Congressman, about the strategic steps jumbo employers can take to achieve improved health outcomes while reducing cost. They delve into the importance of using data to discern effective practices, negotiate contracts, and hold intermediaries accountable. To Read The Show Notes With All Mentioned Links, Visit the Episode Page. If you enjoy this podcast, be sure to subscribe to the free weekly newsletter to be a member of the Relentless Tribe. The discussion highlights maternal health as a critical area of focus, with successful interventions shown to reduce NICU admissions and overall healthcare costs. Andrews emphasizes the role of self-insured employers in driving systemic changes that align financial incentives with health outcomes. This encore is very relevant after the shows with Cora Opsahl (EP452), Claire Brockbank (EP453), and Marilyn Bartlett (EP450). Getting better health for the 160 million Americans covered by commercial insurance is all about rates, rights, and power. 07:34 How did Rob get to his current role? 09:08 The problem of maternal health and mortality rate, and how self-insured employers wind up directly and indirectly paying for this. 10:27 Why economic consequences move the needle, and why sometimes they don't. 12:26 Why the best way to address costs isn't to re-shift costs but to address them directly. 13:22 Why compensation that isn't dependent on outcomes is a problem. 16:23 “Strategy's not what people say; it's what they do.” 18:21 How do you operationalize saving money with better outcomes? 26:26 How do employers turn conflict into collaboration? 28:20 What is the win-win-win structure among employers, payers, and providers in Rob's eyes? 30:53 To whom should the task of risk adjustment fall? 34:43 “Better contracts do improve outcomes.”  

This show is going to be a little bit different because what we're going to do today is offer some advice to those who may work at a pharma company. But before we get into this advice portion of the discussion, let's start here. For a full transcript of this episode, click here. If you enjoy this podcast, be sure to subscribe to the free weekly newsletter to be a member of the Relentless Tribe. Probably we're gonna have people listening to this episode who maybe are not in our normal tribe of Relentless Health Value listeners. While there are, for sure, regular listeners who work at pharma companies, there might be some newbies on the scene here. And to you, I say welcome. I hope that you feel right at home here. You know what, though? Many of us, including myself often enough, are slightly uncomfortable. Because this is the place where we all kind of look at ourselves in the mirror. We all live in glass houses, after all—everyone in the healthcare industry. There's no devils and no angels here. And the trick is maximizing the good and minimizing the not so good so that we all wind up with the highest net positive possible for patients. So, around here, we do not shy away from saying what needs to be said so that we all can find a way forward to serve the patient. We cannot solve problems, after all, that we have not taken a cold, hard look at. Yeah. So, today I am speaking with Brian Reid. I have been very much looking forward to speaking with Brian Reid, who many may know from his really great newsletter and really insightful LinkedIn posts. Brian Reid's advice, which he delivers in the episode that follows in sum. Spoiler alert here, but I also will say that he is much more eloquent than me, and the nuances are a thing. So, please do listen to the whole show. But Brian's piece of advice number one for Pharma (and really any product or service frankly), but piece of advice number one is this: Get a really solid bead on what value means—not just to PBMs (pharmacy benefit managers) or contract pharmacies or wholesalers who are middlemen but to the ultimate purchasers, the ones whose wallets the money is actually coming out of to pay the bill. Meaning, plan sponsors, such as self-insured employers or unions, patients themselves or members, and taxpayers. Again, how does value accrue to the ultimate purchasers like plan sponsors, patients/members, or taxpayers? Everybody else in the drug supply chain, let's be clear, is in the middle pushing money around that came out of somebody else's wallet. These middlemen have their own interests that may, for sure, may or may not be aligned with the interests of the ultimate purchasers. Getting value realized by patients will depend on understanding what the value is to these ultimate purchasers and then not getting derailed by any middleman who may not be so aligned. As a sidebar on this number one piece of advice, the whole “what's your value” and influence coloring this value equation made by ultimate purchasers is the prevailing beliefs of these ultimate purchasers, relative to Pharma, how they perceive the pharma industry. Whether it's earned or not—and this is not what we're gonna discuss today—but earned or not, Pharma does not have a great reputation with these folks right now. And this matters. Brian has a lot to say on this topic, which is fascinating. So, you should listen. Number two piece of advice that Brian Reid delivers in the podcast that follows that we talk about: Consider inching into the fray around benefit design. Rightfully so, there's always a lot of talk about patient affordability at pharma companies; but if I was gonna point to one thing that impacts affordability more than anything else, it'd be benefit design. There's only a small, underfunded cadre right now of folks out there (Mark Cuban aside, actually); but there's only a really small number of folks who never have any money who are really helping plan sponsors understand the impact on patients of some of the choices that they are making. I mean, personally, I could think of 10 things to do right off the top of my head that could help plan sponsors not get inadvertently screwed in this realm alone, just thinking they're saving money when, in reality, they are harming patients and not saving money. There's probably a lot of opportunities to communicate these kinds of things that are really win-win collaborations. Number three piece of advice that we talk about in the conversation that follows with Brian Reid: Keep an eye on hospital consolidation and vertical integration in the payer space. Consolidation raises prices and impedes patient affordability. This is as per study after study after study. Consolidation raises prices and sometimes considerably. Here's a part B to this third piece of advice about consolidation. There's sometimes wild swings in prices at different large, consolidated health systems in the exact same geography. Listen to the show with Cora Opsahl (EP452) for more about how their health plan, as just one example, saved $30 million a year just pushing a huge expensive health system, consolidated one, out of their network and navigating patients to more affordable sites of care. This matters to pharma companies because hospital system prices are currently crushing in many areas of the country, really impacting patient affordability. But there are better or worse options from an affordability standpoint in some of these geographies. To state the obvious, if an infusion of the same drug costs 10 times more if a patient shows up in one care setting versus another, that latter place, not affordable for patients. And by the way, that is not hyperbole of any kind. There are plenty of examples where literally an infusion of the same drug, same dosage will cost 10 times more if a patient goes one place versus another. But, again, it's not affordable. The patient cost share might be 10 times higher if it's coinsurance, if the patient goes to that latter place. And that latter 10x more of the cost place also just added 10x the cost to the PAP program or the foundation debit column. All of this is really relevant to Pharma. And just to pile on here because now I'm on a roll, another reason why this matters, these striking price variations between care settings, if we're talking about product value, and if the price the patient or the plan sponsor is paying is 10x the cost of the ingredients, nobody's doing that math and separating out the cost of ingredients from the, you know, total cost of the infusion. It is one lump sum number. So, if we're defining value as outcomes divided by cost and now the cost to the plan sponsor is 10x, product value just got reduced by 10x. Just in case anyone is confused here, and you probably know this, but many forget that the whole ASP (average selling price) plus 6% provider reimbursement—so, if that's what you're thinking and you're wondering how the 10x transpires—that ASP plus 6% provider reimbursement is only for Medicare kinds of plans. Hospitals can and do negotiate much higher reimbursements for commercial plans, and those carriers that have commercial lines of business and also MA (Medicare Advantage) books of business even allegedly actually negotiate higher commercial reimbursements so that they can get lower Medicare Advantage rates. Right, and you can see why, because the MA dollars are coming out of their own capitated pockets, whereas the commercial rates are being paid for by the ultimate purchasers, the plan sponsors. Also mentioned in this episode are Reid Strategic; Mark Cuban; Cora Opsahl; Bruce Rector, MD; Shawn Gremminger; Nina Lathia, RPh, MSc, PhD; Autumn Yongchu; Erik Davis; and Marty Makary, MD, MPH. Additional related episodes: EP380 with Mark Miller, PhD, on pharma communications. EP371 with Erik Davis and Autumn Yongchu on buy and bill versus pharmacy bagging. EP426 with Nina Lathia, RPh, MSc, PhD, on cost containment versus value-based drug purchasing. EP435 with Dan Mendelson from Morgan Health on how employers should consider pharma purchasing. EP365 with Scott Haas on PBM contracts and drug rebates. EP293 with Dea Belazi, PharmD, MPH, from AscellaHealth on co-pay cards, co-pay accumulators, and co-pay maximizers.   You can learn more by subscribing to Brian's newsletter and by following him on LinkedIn.   Brian Reid has nearly three decades of experience in healthcare journalism, public affairs, and public relations with a specialty in explaining the economics of the healthcare system. He is the founder of Reid Strategic, a communications consultancy, and a senior fellow at the Center for the Evaluation of Value and Risk in Health (CEVR) at Tufts Medical Center. At Reid Strategic, Brian counsels industry leaders on the best way to communicate on complex policy, access, pricing, and reimbursement issues in ways that critical audiences can understand. Brian's core belief is that we can't build a better healthcare system until everyone understands the system we have today. Reid Strategic offers communications strategy and execution around corporate, brand, and policy challenges, from prelaunch approaches to lifecycle management. Prior to founding Reid Strategic, Brian built and led Real Chemistry's Value+Access Communications practice, the largest such group dedicated to issues of value. Brian has written extensively for a range of audiences. At Reid Strategic, he publishes the daily Cost Curve newsletter; and his past experience includes coverage of the health science/policy beat for Bloomberg News, creation of patient education materials for the National Institutes of Health, and features in publications ranging from the Washington Post to Nature Biotechnology to Men's Health. He has a bachelor's degree in biology and political science from Emory University and a master's degree from the Columbia University School of Journalism.   08:29 Why is it important to understand the term “value” in respect to medicine? 10:07 Why is it important to consider all the players affected by the idea of this “value”? 11:06 Who are the ultimate purchasers in Pharma? 12:23 Findings of the Kaiser Employer Health Benefits Survey. 14:52 Why does it matter that we consider what value looks like to all players affected by Pharma? 16:46 EP300 with Bruce Rector, MD. 18:38 EP448 (Part 1) with Shawn Gremminger. 20:04 What does Pharma need to do to showcase their value when PBMs are often “locked in” at the moment? 23:11 Why Brian is celebrating companies that put their prices in their press releases. 32:31 Why does Pharma have an obligation to explain their value? 33:16 EP426 with Nina Lathia, RPh, MSc, PhD. 33:39 Why is it important for Pharma to keep an eye on hospital monopoly behavior? 35:55 EP370 with Erik Davis and Autumn Yongchu. 37:44 Why Pharma needs to capitalize on alignment.   You can learn more by subscribing to Brian's newsletter and by following him on LinkedIn.   Brian Reid, of Reid Strategic, discusses #pharma and #patientaffordability on our #healthcarepodcast. #healthcare #podcast #financialhealth #primarycare #patientoutcomes #healthcareinnovation   Recent past interviews: Click a guest's name for their latest RHV episode! Dr Beau Raymond, Brendan Keeler, Claire Brockbank, Cora Opsahl, Dan Nardi, Dr Spencer Dorn (EP451), Marilyn Bartlett, Dr Marty Makary, Shawn Gremminger (Part 2), Shawn Gremminger (Part 1), Elizabeth Mitchell (Summer Shorts 9)  

A rate critical to attain better care for patients, I'm gonna say, is enlightened leadership—maybe dyad leadership—at a clinical organization. I am saying this because without enlightened leaders, it'd be harder to build from the blueprint that Beau Raymond, MD, talks about today on the show. For a full transcript of this episode, click here. If you enjoy this podcast, be sure to subscribe to the free weekly newsletter to be a member of the Relentless Tribe. I'd say an enlightened leader is someone—and this is my definition, but it's a term that Tom Lee, MD, brought up first in an earlier episode (EP445)—an enlightened leader really cares about providing better patient care at an affordable price. They have a manifesto to that end, if you will. They also have studied, likely, and understand how change management works because every improvement requires change. They get the bit about people, processes, and technology being intertwined and what operational excellence means. Further, they are probably doing or considering many of the things that Robert Pearl, MD, talked about in episode 412. On the opposite end of the spectrum, there's a new term floating around called administrative harm. There's a study. Admin harm refers as much to what administrators—who I refuse to call leaders at this context because I'm talking about the not good administrators, so let's be clear—but I'd say administrative harm results from what the administrators choose not to do as much as what they choose to do. It is actually a thing to be an enlightened leader, especially in these profit-driven times. It's really tough, actually, and nothing anyone should take for granted. So, maybe this whole show is kind of a shout-out to the enlightened leaders out there. Thanks for doing what you do. Okay, so this said, and it needed to be said, let's talk blueprint for better care in the conversation that follows. Dr. Beau Raymond says, step 1, right out of the gate, set clear goals. Then step 2, engage others throughout the organization to together build the framework needed to achieve said goals. Engaging frontline folks and others is really the only way that any proposed framework will actually work in the real world. Listen to the shows with Karen Root (EP381) and Ashleigh Gunter (EP447) for just one proof point after another that what I say is based in fact. Step 3 of the blueprint to better outcomes that Beau Raymond, MD, talks about today is get your data. We talk a lot about plan sponsors and the getting of data, but same thing applies to clinical organizations. For clinical organizations, the getting of data means longitudinal data. The need for longitudinal data has come up in multiple shows, most recently the one with Dan Nardi (Spotlight Episode), and this is just one example of why getting the whole bag of data really matters. Dan said on that earlier show, it's often a thing that oncologists are unaware of how many of their patients are winding up in the ER for nausea after chemo, which, by the way, is the most common cause for readmission. And the reason for this is lots of patients travel to their oncologist but go to a local ER in a different health system. The show with Brendan Keeler (EP454) about the Particle v Epic lawsuit in general dustup over who gets the data is super relevant here. That's what I was thinking when I was talking with Dr. Raymond, and maybe it just popped in your head, too. Or just continuing this topic of the importance of longitudinal data, how many specialists, in almost any specialty, see a patient and then don't know what happened to that patient subsequently? Or even primary care in transactional models? So, step 3 here is get your data and also, as part of that, figure out how to make sure everybody understands the data and also understands that it is fair. Eric Gallagher (EP405), Dr. Raymond's dyad counterpart over at Ochsner, talked about this some in that episode. So did Kenny Cole, MD (EP431), interestingly, also from Ochsner. Amy Scanlan, MD (EP402) mentions it as well. Step 4 in the blueprint to measurably better outcomes that I discuss with Dr. Beau Raymond, data collection and data management probably need to be system-wide because … yeah, longitudinal and etc. But the “What are you gonna do now with the insights that you derived from the data?” is pretty local. The obstacles and enablers are going to be different depending on the geography. For example, an area with a large Vietnamese population and a big variation in colorectal screening rates as a priority, just logically, is gonna have a program that is in no way suited to roll out in an area with, say, a large Black or African American population with high hypertension rates. Priorities and programs are just different depending on the geography. So, step 4 here is, ask each region, based on the data, what fixes they're going to own. What will they take ownership on and commit to improving? What I thought was interesting in this interview is kind of the way that equity comes up between ethnic groups or between genders. In and of itself, obviously, striving for equity is critical. But also, if you're trying to improve quality across the board and you see disparities in care, figuring out what is going on with the group experiencing the worse outcomes is also just operational excellence. You don't want to be a solution looking around for a problem, after all; so, you need to figure out the actual problems for the actual people experiencing the problems to avoid that. Those are the only solutions that are actually gonna work. Step 5 is to learn from each other. Maybe not a whole program is flat-out transferable from one geography to another, but that doesn't mean that nothing is transferable either. As usual, it's about being thoughtful and nuanced and finding that productive middle. At Ochsner, they do these cool weekly primary care huddles to share learnings and goings-on that Dr. Raymond explains in the show that follows. Throughout all of these steps in this blueprint, there is obviously a need to align how the practice or system is getting paid for the time and capital expenditures, of course. And Dr. Raymond addresses this and interestingly says something similar to what Dr. Tom Lee (EP445) and Scott Conard, MD (EP391) have said on earlier shows: that a lot of times compensation for improving care, if you do it in an operationally excellent way, can be revenue positive for systems with a combination of both FFS (fee for service) and value-based reimbursement. Underline, however, the part about having an enlightened leader who cares about clinical quality for that to work out. Dr. Beau Raymond, my guest today is chief medical officer for Ochsner Health Network. Ochsner Health Network, by the way, includes Ochsner and some other health system partners. There's also a bunch of small independent practices of one to two docs. Ochsner patients, in case you are unaware, are in the entire state of Louisiana, a little bit of Mississippi, Alabama, and also Texas. Also mentioned in this episode are Ochsner Health; Tom X. Lee, MD; Robert Pearl, MD; Karen Root, MBA, CCXP; Ashleigh Gunter; Dan Nardi; Brendan Keeler; Eric Gallagher; Kenny Cole, MD; Amy Scanlan, MD; Scott Conard, MD; Joshua Liu, MD; Eboni Price-Haywood, MD, MPH, MMM, FACP; and Chris Skisak, PhD.   You can learn more at Ochsner Health Network and by following Dr. Raymond on LinkedIn.   Sidney H. “Beau” Raymond, MD, MMM, FACP, is a board-certified internist now serving as the chief medical officer of Ochsner Health Network and medical director and executive director of Ochsner Accountable Care Network. Prior to joining Ochsner, Dr. Raymond was vice president, physician practice administrator, and chief medical information officer at East Jefferson General Hospital (EJGH). His experience included serving on the steering committee and later as a board member for Gulf South Quality Network. Beyond the administrative roles at EJGH, Dr. Raymond was involved with medical staff committees, including serving as chief of staff. He is also a past president of the Jefferson Parish Medical Society. Dr. Raymond earned a bachelor's degree in biology from Loyola University, earned a medical degree from the Louisiana State University School of Medicine, and completed his residency in internal medicine at LSU-New Orleans. He has also earned a Master of Medical Management from Tulane University.   07:50 What is step 1 of improving care for healthcare leaders? 10:44 Why is it important to be flexible while keeping your goals in sight? 11:48 Dr. Eboni Price-Haywood's article on disparities in COVID. 12:29 How is equity a data point to achieving overall care improvement? 15:01 “If you can't measure it … accurately, you're not going to be able to do anything differently.” 20:52 What strategies have been successful in using data to improve healthcare outcomes? 23:17 Why did Ochsner Health avoid looking at the individual physician standpoint in regard to an equity standpoint? 30:40 Why engaging patients in their healthcare actually improved patient visits and did not necessarily reduce patient visits. 34:49 “It's really about engaging with the patient.”   You can learn more at Ochsner Health Network and by following Dr. Raymond on LinkedIn.   Sidney H. “Beau” Raymond, MD, MMM, FACP, discusses #leadership on our #healthcarepodcast. #healthcare #podcast #financialhealth #primarycare #patientoutcomes #healthcareinnovation   Recent past interviews: Click a guest's name for their latest RHV episode! Brendan Keeler, Claire Brockbank, Cora Opsahl, Dan Nardi, Dr Spencer Dorn (EP451), Marilyn Bartlett, Dr Marty Makary, Shawn Gremminger (Part 2), Shawn Gremminger (Part 1), Elizabeth Mitchell (Summer Shorts 9), Dr Will Shrank (Encore! EP413)  

You know why I'm interested in the Particle v Epic EHR (electronic health record) systems lawsuit? It's because … data. Say I'm thinking about this like, say, a plan sponsor and I want data so I can do better population health or do care navigation to help my members avoid downstream bad things or steer and tier to high-quality docs and point solutions and, and, and … For a full transcript of this episode, click here. If you enjoy this podcast, be sure to subscribe to the free weekly newsletter to be a member of the Relentless Tribe. To do anything that has anything to do with population health, I need data. And when I say data, we often think claims data as plan sponsors; and we think about getting it from carriers. But where does the claims data originate? Oh, right … the gleam in the eye of a lot of claims data is EHR data. Someone typed something into an EHR system that metamorphosized, ultimately, into a claim that wound up in a carrier's dataset. Plan sponsors want the claims part of the claims data, obviously, to see prices; but they also want those underlying data elements that indicate the health of their members. Said another way, they want the insights gleaned from some clinician somewhere who typed something into an EHR system that turned into codes that drove claims. So, yeah … Particle v Epic. Particle was getting EHR data and passing it on to other parties, and we get into the what's and the who's and the commentary. But bottom line, what I wanted to get into today is this: Will this lawsuit result in more access to data for downstream entities who need it, or less? What are the implications here of Epic shutting down access to its EHR data to Particle and Particle filing an antitrust lawsuit saying Epic did this because Epic wanted to use their monopoly power here to advantage their own payer platform business? Oh, the plot thickens. Payer platform business? For an EHR system. What is that exactly? More intrigue. What's going on there? Because, yeah, probably a lot of plan sponsors and patients are, I'm gonna say, unaware of this part of the equation as to what data the carriers seem to have and where are they getting it from and what things they may be doing with it that plan sponsors and/or members who are their customers may or may not be aware of. Knowledge is power here, especially in the fight over trying to get data out of carriers who won't hand it over when the carriers themselves are getting that data through interoperability networks that potentially plan sponsors also qualify for. Chucking that in there as a point to ponder. This whole “I'm intrigued” bit here, though, was not rhetorical. I really am/was intrigued—so intrigued, as a matter of fact, that I called Brendan Keeler to come on the pod and talk this out with me. Brendan, by the way, has written a very detailed account of the Epic/Particle dustup. There is a part one and a part two. Before we kick in here, though, I did just want to make at least one point on background. First, so many, many people want to get their mitts on EHR data for good reasons and maybe not-so-good reasons from the standpoint of the patients whose personal health information is being fought over here. The basic rule is that to get EHR data, you have to be involved in the treatment of the patient. So, this is the current governance as it stands. You have to be involved in the treatment of the patient if you want EHR data. So involved in the treatment, actually, that you have to have your own treatment data to share back. This is called reciprocity, right? Like, how can you say that you're treating a patient if then you don't have any data as to that treatment? On-site clinics, by the way, are providing treatment—just saying, in case anybody is thinking the same thing I'm thinking right now. Okay, back to the lawsuit. The real kicker of this whole Particle v Epic and Epic cutting off Particle thing, as far as I'm concerned, is over the secondary use of said treatment data once someone gets it (ie, someone gets EHR data transmitted to them because they are doing something or other to treat the patient, but now they have that data). And at that point, is it a free-for-all what they do with it? Can they, I don't know, sell it to anyone they want? Said another way, what if I realize I need EHR data for, I don't know, I'm a lawyer trying to do lawyer things or I'm public health entity or whatever. It doesn't matter. If I throw a medical professional in a room and cook up something this person is doing, that could be considered treatment if you squint at it. Tricky, right? Now I can get EHR data. So, yeah … there's that motto “If you ain't cheatin', you ain't tryin',” which Pryce Ancona said, ironically, on Health Tech Nerds the other day; and I cracked up. But it's so not funny. Because you have some people—maybe or maybe not—kind of violating, let's just say, the spirit of the endeavor. And then you have others who really, really need the data to do something really, really good who can't get it. Is this because of a monopoly entity doing monopoly antitrust stuff? We discuss, but massive spoiler alert, where this conversation is going is, okay, so does this lawsuit ultimately make it easier or harder to get data for righteous good reasons? And Brendan Keeler suggests this case, this lawsuit, actually could be a good thing because what it will do at a minimum is pave the path to get data and really delineate a good use case from some of this profit motivated back-and-forth where patient information is getting fought over and the patient has little to no control over what goes on and neither do plan sponsors. He uses the term increased data liquidity, which is a term I think I will heretofore adopt because it will make me sound smart. Data liquidity. Lastly, lastly, lastly here, just as context in case anyone indulges in further reading and winds up confused, there are so-called interoperability frameworks out there, such as Carequality or CommonWell or eHealth Exchange. These interoperability frameworks are also in this mix. We do not have all day, and thus we don't get into these in the conversation that follows. But just be aware, they're on and about the scene. For the full skinny on what interoperability frameworks are and do, listen to episode 376 with Lisa Bari, MBA, MPH. Brendan Keeler, my guest today, as a matter of fact, is on the steering committee of the Carequality interoperability framework. Brendan Keeler has had a long history in this whole exact space, so he was the perfect guest to dig in on this topic in a really well-balanced way, I'm gonna say. Brendan is currently the interoperability and data liquidity practice lead at HTD Health. Also mentioned in this episode are HTD Health; Pryce Ancona; Lisa Bari, MBA, MPH; Health Tech Nerds; and Tom Nash. You can learn more at HTD Health and by following Brendan on LinkedIn. You can also sign up for his Health API Guy newsletter on Substack.   Brendan Keeler is the Portland-based interoperability practice lead for HTD Health, a leading strategic consultancy and development agency. He provides subject matter expertise and executive partnership for all projects related to integration, interoperability, and connectivity, working with digital health, tech-enabled care, payers, providers, pharmaceutical clients, and more. He previously held product positions at Epic, Redox, Zus Health, and Flexpa. He also advises digital health start-ups and authors Health API Guy, providing analysis on industry trends in interoperability and health tech regulation. Reach out to contact him here or via social media.   07:21 Who can gain access to EHR data? 10:31 Are there limits to how EHR data can be used secondarily? 11:36 Can EHR data be shared secondarily? 15:47 Part one and part two of Brendan's comprehensive account of the Epic/Particle dustup. 15:57 What was the dispute that started Epic v Particle? 18:21 What are the two viewpoints in this dispute with Epic's actions? 26:16 What progress has been seen since this lawsuit began? 28:00 Who else will be impacted by the likely rule cementing from this lawsuit?   You can learn more at HTD Health and by following Brendan on LinkedIn. You can also sign up for his Health API Guy newsletter on Substack.   @healthapiguy discusses #plansponsor and #publichealth access to #healthdata on our #healthcarepodcast. #healthcare #podcast #financialhealth #primarycare #patientoutcomes #healthcareinnovation   Recent past interviews: Click a guest's name for their latest RHV episode! Claire Brockbank, Cora Opsahl, Dan Nardi, Dr Spencer Dorn (EP451), Marilyn Bartlett, Dr Marty Makary, Shawn Gremminger (Part 2), Shawn Gremminger (Part 1), Elizabeth Mitchell (Summer Shorts 9), Dr Will Shrank (Encore! EP413), Dr Amy Scanlan (Encore! EP402)

In this episode, host Stacey Richter delves into the complexities of the Third Party Administrator (TPA) Request for Proposal (RFP) process with guest Claire Brockbank from 32BJUnion.  The discussion highlights the critical role of contracts in managing health plans effectively and the potential pitfalls of accepting contracts crafted by TPAs without thorough review. Drawing from Claire's experience, they explore tactics like starting with your own contract paper in RFP processes to gain negotiation leverage, and the benefits of employer coalitions in navigating health care complexities. To Read the full article which includes mentioned links visit the episode page. If you enjoy this podcast, be sure to subscribe to the free weekly newsletter to become a member of the Relentless Tribe. Real-world examples underscore the financial impacts of poorly negotiated contracts and highlight successful strategies for health plan sponsors to optimize costs and services. The episode aims to empower employers with tools and insights to negotiate effectively and ensure their health plan contracts align with their strategic goals, ultimately paving the way for better population health management and cost-effective care delivery. As but one example—and Cora Opshal spoke about this last week and Claire talked about this today—it's about how allowing upside-down payments, for example, that are in a lot of ASO contracts, this allowing of upside-down payments. I mean, it turns out that 32BJ spent around $10 million paying more than the bill was for one year. If somebody signs that contract as handed to them by the carrier, then the plan is now contractually obligating themselves to pay more than the price the clinical practice was charging. So, doc sends bill for $100, and the carrier pays that practice $200 on behalf of the plan sponsor. So now the plan sponsor is paying $200 for a $100 bill. Is this conflict of interest? Is it imprudent? Is it not reasonable? Said another way, is that a bit of a fiduciary breach on the plan sponsor? So it's understandable why the team at 32BJ pushed back and pushed back hard. We all can see why the leading edge of plan sponsors and more and more C-suites are hotfooting it into conference rooms to plan their RFP process and doing it in the way that Claire Brockbank talks about today. For an open-source contract and some other free tools, please do head over to the 32BJ Insights Web site. 05:36 How does the initial contract writing affect how events in your healthcare plan will go? 06:56 What happens if a plan sponsor or employer doesn't do the contracting right? 10:42 How much could be saved by doing contracting right? 11:01 EP433 with Justin Leader. 12:22 How do you start an RFP process with your own contract? 14:06 What Claire Brockbank recommends doing to do a TPA RFP process in a way that's best for you. 19:46 What factors do carriers need to get an ASO or TPA to respond to using your contract? 21:11 Open-source contract available from 32BJ. 21:57 Why it's important to really probe brokers, despite loyalty to your broker/consultant. 24:30 Who are the reliable agents and experts when carriers are looking to start this process? 26:24 EP428 with Julie Selesnick. 27:56 What's the silver lining to this effort? 29:17 Why is it important to make it clear why you're doing what you're doing for your lawyers and any other support team you need? 31:39 What does “good” look like in this process? 34:15 Why is it important to continue to hold your ASO accountable?

Last time Cora Opsahl was on the show, Michelle Bernabe, RN, KAT, wrote a comment on LinkedIn I thought encapsulated the gist of it all so well. She wrote, “[Cora] first became a mentor/ally through Relentless Health Value episode 372. … It opened a doorway to a whole group of very relentless people.” For a full transcript of this episode, click here. If you enjoy this podcast, be sure to subscribe to the free weekly newsletter to be a member of the Relentless Tribe. I want to start there because it's a nice comment, but it's also a call to action. Think about this and think about it not in the context of being a “stakeholder” and not in the context of being an organization but in the context of humans who work at these various organizations who, combined, comprise the bucket of companies that we lumped together using the old stakeholder word. All of these individuals are making choices every day, and all of these choices, they could be made with integrity and with the patient or member in mind … or not. In real life, right now, the overwhelming majority of members/patients in this country get their clinical care and the pleasure of paying for that care or drugs within the current ecosystem we have here in the USA. For any of us, or all of us who work within that traditional ecosystem, it is up to us to choose our own legacy here. It's probably why you listen to this show in the first place, actually. There are so many RHV (Relentless Health Value) listeners who are pushing for patients against the riptide that is the profit motives of the organization that they work for. It's hard. But yeah, it's all about finding our people and supporting each other. Okay, so let's get to the “between a rock and a hard place” portion of this discussion. Hospitals and ASOs (administrative services organizations)/carriers/TPAs (third-party administrators) often enter into or sometimes enter into what amounts to anticompetitive contracts with each other. Listen to episode 395 with Brennan Bilberry for the rundown on that one. But meanwhile, the CAA, the Consolidated Appropriations Act from 2021, holds employer plan sponsors accountable and responsible to ensure that plan assets are spent prudently, that costs paid are reasonable, and that there's no conflict of interest (COI). This is the definition of what a fiduciary is supposed to do, by the way—prudent, reasonable, and no COI. Anticompetitive contracts between a carrier and a hospital are the very definition of COI. And when that COI results in higher, maybe unreasonable, prices and non-prudent spend, well, plan sponsors are put between a rock and a hard place if they stick with their existing vendors. Rosa Novo from Miami-Dade County Public Schools put this really succinctly on a panel at a 32BJ event recently. She said what amounts to, I have no choice but to actually do the right thing here, for many reasons, but one of them is I do not look good in orange. She said, my personal butt is on the line here. And furthermore, who do class action lawsuits make look bad when their company or CEO or CFO are personally sued over conflicted benefits? See the Wells Fargo lawsuit, J&J lawsuit, etc. It sucks that employers or plan sponsors get put into this pickle by their own vendors. And that's what we're talking about today. This is a conversation that starts out talking about rates (ie, prices), edges into rights (ie, plan sponsor rights), and ends up all about power. And by the way, if you're a plan sponsor, especially in New York City, maybe doing the right thing here means hatching a plan to steer and tier in your benefit design, figuring out how to, for reals, help support the efforts of 32BJ to advantage pretty much every patient near and far. The pushback I often hear to doing something like this often involves the perception that plan members are too rich to care about reasonable prices, prudent plan spending, and COI. And yeah, to state the obvious, these same people are also sophisticated enough to smell a fine opportunity for a class action lawsuit; and also, they probably do care, as more and more studies suggest. Sorry if I just stumbled onto a sacred cow. Cora Opsahl, my guest today, is the director of the 32BJ Health Fund, serving over 200,000 folks. Their ability to kick NewYork-Presbyterian, a big, consolidated, very expensive hospital, out of their network in 2018 enabled them to offer maternity benefits for $40 in total out-of-pocket for members. And also, employees got their biggest raise ever; employers got a premium holiday and a 3% rate increase for a bunch of years after that; and yeah … this is where we start the conversation today. And yeah, it's a freakin' tangled web we weave; and this tale is a perfect case study of it. It makes me even more invested in remembering my own manifesto (that was episode 400) to ensure that I can feel good about what I personally have accomplished and what I have been a part of and the net impact of my own personal actions, since I, too, very often work in the belly of the beast. Furthermore, you will find links to a template health savings calculator for plan sponsors and also a template contract (again for plan sponsors) that 32BJ has made available. More on that in the show that follows. Also mentioned in this episode are 32BJ Benefit Funds; Michelle Bernabe, RN, KAT; Brennan Bilberry; Rosa Novo; Marilyn Bartlett; Cynthia Fisher; Zack Cooper, PhD; Claire Brockbank; Andreas Mang; Chris Deacon; Elizabeth Mitchell; and Purchaser Business Group on Health.   You can learn more at health.32bjfunds.org and by following Cora on LinkedIn.   Cora Opsahl is the director of the 32BJ Health Fund, a self-insured Taft-Hartley benefit fund that sets comprehensive design parameters to ensure the 200,000 members and families of Service Employees International Union 32BJ have easy and sustained access to affordable, high-quality healthcare. Since becoming director of the Health Fund in 2021, Cora has prioritized a data-driven approach to healthcare, focusing on reducing trend; solving the affordability challenge on behalf of union members; and most important, keeping members at the center of every decision. Under her leadership, the 32BJ Health Fund has saved more than $35 million annually—which it has reinvested in new and better benefits, including the first fertility benefit for members—by removing NewYork-Presbyterian hospitals and physicians from its network, transitioning to a new pharmacy vendor and pharmacy group purchasing coalition, and establishing an expanded Centers of Excellence program. Most recently, Cora conducted an innovative medical request for proposal (RFP), stipulating that all finalists must have a signature-ready contract drafted by the Health Fund prior to award. By including the Health Fund–drafted contract in the RFP process, the Fund was able to negotiate an agreement that brought unprecedented visibility and increased accountability to the 32BJ Health Fund benefit. Cora is regarded as an expert in pharmacy benefit management and previously worked at Express Scripts, where she held a variety of roles, ranging from Medicare Part D to operations to strategy and acquisitions. She earned an MBA from Saint Louis University.   06:16 Why is it imperative for employers to do something differently when it comes to being plan sponsors? 09:22 How analyzing claims data allowed 32BJ Health Fund to reshape their benefit design. 12:09 What anticompetitive rights did 32BJ run into that limited 32BJ Health Fund from managing their benefit design? 14:12 How do these anticompetitive rights have quality implications as well as cost implications? 18:43 How did 32BJ Health Fund remove NewYork-Presbyterian from their network, and how much did it save 32BJ Health Fund per year? 19:46 What did the healthcare savings allow the unions and employers to do? 20:46 Study by Zack Cooper, PhD. 21:26 Why rising healthcare costs has pushed 32BJ Health Fund to move beyond benefit design to manage healthcare spend. 24:15 Why 32BJ Health Fund wants to control the contracting process. 26:00 EP419 with Andreas Mang. 27:18 What are 32BJ Health Fund's four non-negotiables? 33:17 Wall Street Journal article on health insurance contract. 35:30 Upcoming episode with Claire Brockbank. 36:14 What is the challenge that exists in our current healthcare environment? 37:43 Cora's advice on how to get high-quality healthcare at an affordable price.   You can learn more at health.32bjfunds.org and by following Cora on LinkedIn.   @CoraOpsahl discusses #fiduciaryresponsibility in #healthcare on our #healthcarepodcast. #podcast #financialhealth #primarycare #patientoutcomes #healthcareinnovation   Recent past interviews: Click a guest's name for their latest RHV episode! Dan Nardi, Dr Spencer Dorn (EP451), Marilyn Bartlett, Dr Marty Makary, Shawn Gremminger (Part 2), Shawn Gremminger (Part 1), Elizabeth Mitchell (Summer Shorts 9), Dr Will Shrank (Encore! EP413), Dr Amy Scanlan (Encore! EP402), Ashleigh Gunter, Dr Spencer Dorn (EP446)  

In this Spotlight Episode host Stacey Richter discusses the management of oncology side effects with Dan Nardi, CEO of Reimagine Care. Highlighting the challenges cancer patients face, especially following chemotherapy which often leads to nausea and readmissions, the conversation delves into how Reimagine Care facilitates at-home integrative cancer care.   Their services focus on proactive and reactive support via AI-driven tools like 'Remy' to assist patients outside of clinical environments. This approach aims to reduce emergency visits and improve patient outcomes while easing the workload on healthcare providers. The discussion underscores the role of patient reported outcomes and the integration of technology with human care to improve the quality of oncology treatment pathways.   To Read the Full Article Notes with Mentioned Links, Visit Our Episode Page . If you enjoy this podcast, be sure to subscribe to the free weekly newsletter to be a member of the Relentless Tribe. Note from Stacey Richter: Pulling off a show like this one is not cheap, and my Aventria business partner Dave Dierk and I are happy to fund the vast majority of it. But yeah, breath of fresh air, and thanks much to the team over at Reimagine Care for their sponsorship. My one disclaimer is that I have not personally vetted the solution, but there is a white paper available where you will also find some insights from Reimagine Care's work with Memorial Hermann Health System. 03:38 Why is it really important to keep track of oncology patients and their side effects? 04:27 Why is cancer treatment such a complex care journey? 05:57 Are there outcome and financial issues that compound when an oncology patient is left to navigate their care journey on their own? 08:53 What is difficult in navigating cancer treatment care pathways, and what does Reimagine Care tackle within that? 09:55 EP157 with Ethan Basch, MD. 10:17 How does Reimagine Care proactively check in with oncology patients to help them navigate their care pathways? 12:41 How does Reimagine Care measure their performance, and how did their work affect patient outcomes? 13:28 The Reimagine Care white paper. 14:57 How do providers feel about Reimagine Care services? 17:37 Where can technology really make a difference in cancer care?

Before we kick in to the show today, I just want to make two points. Here's the first point. Together, we can do it. No one said transforming healthcare and elevating patients over profits would be easy. And it is not. It's really, really hard. I just want to say thanks for all that you have accomplished, Relentless Health Value (RHV) tribe members. These are the things that matter to, really, our entire country, friends, family, patients, members, and in so many ways is really worth it. For a full transcript of this episode, click here. If you enjoy this podcast, be sure to subscribe to the free weekly newsletter to be a member of the Relentless Tribe. Second point I want to make is to thank everybody who has left a tip in our tip jar. Some people have even left recurring donations, which, wow, my faith in humanity is restored when I see my people offering their financial support this way. I feel this way because (a) I don't usually ask for financial support on the pod, even though it's something that is certainly on my mind a lot, and (b) those who offer financial support, at least at this time, don't get anything other than knowing that their help helps this podcast continue, which, again, just warms my heart. The show today is a companion, I'm gonna say, to episode 446, also with Dr. Spencer Dorn. In the first show, we didn't talk about the impact of EHR (electronic health record) systems; and in a similar vein today, we're not gonna talk about the impact of artificial intelligence. I'm phrasing this in this kind of odd way because that earlier conversation with Dr. Dorn was about Kranzberg's First Law of Technology. And this one is, too, where Melvin Kranzberg says, “Don't ascribe any given technology a label of good, bad, or even neutral.” Point being, let's not sit around blaming or crediting a technology for downstream consequences. After all, I mean, if we're thinking about just EHR instances, there's EHR instances where it takes 60 clicks for a doctor to order a patient Tylenol—60 clicks! Then, same EHR system installed in a different hospital? It can take 2 clicks. Those excess 58 clicks aren't because of the technology itself. They're because the technology was configured poorly by humans involved in configuring the technology. And if that technology then results in burnout or moral injury or someone insisting on measuring 58 quality measures in the most labor-intensive way possible, that's a function of how that tool is used or configured, not anything inherent in that technology itself. So, yeah … watch where those fingers are pointing. And all of this is equally relevant to artificial intelligence. As Dr. Dorn says, there's no intrinsic property of the technology—any technology—that determines the outcome. It's how we use it, how we implement it, how we put it into daily practice that really ultimately is the arbiter of what happens and how it impacts lives. I'd also just add even if the tech itself has some glitches or hallucinates, someone decided to use it in the current form it's in. So … yeah. So, the first takeaway from this short show focused on artificial intelligence is gonna be the same, really, as it was in episode 446 about EHRs. Do not ascribe any given technology a label of, as I said, good, bad, or even neutral. That is, as I just said, Kranzberg's First Law of Technology; and it applies here, too. Second major takeaway—and again, this is the same as in that earlier show about EHRs, but today we're talking about AI—if you're thinking about the ultimate impact of the people and the processes that have some technology in their midst (technology, again, such as AI, artificial intelligence), the ultimate impact will not be a black-and-white binary. We talk about some of these nuanced not binaries in the 10 minutes that follow, but for more, I've put some links below for some newsletters et cetera to check out. One last thing before we get into the show today. Speaking of AI, I asked Google about myself; and this is what the Google AI bot replied: “Richter is also co-president of Aventria Health Group, a consultancy, and QC Health, a public benefit corporation.” Okay, so far so good. “She has also been recognized for her work on Relentless Health Value by winning the Edward R. Murrow Award.” Hmmm … Just for the record, I did not win the Edward R. Murrow Award, which is actually a really prestigious broadcast media award. So … yeah. This podcast is, in fact, factually sponsored by Aventria Health Group. And with that, here is my conversation with Dr. Spencer Dorn about, but not about, artificial intelligence. Dr. Spencer Dorn is a practicing gastroenterologist. He also helps lead a large academic practice and works in healthcare IT and clinical informatics. Artificial intelligence links from the past couple months to check out, as promised: AI Health Uncut newsletter by Sergei Polevikov, ABD, MBA, MS, MA

Yeah, I made a meme for the show with Marilyn Bartlett. My very first meme ever. In this meme, I picture that Olympic silver medalist shooter from Turkey who showed up in a T-shirt and his hand in his pocket versus the others with all their fancy equipment that, turns out, may or may not be necessary, regardless of who might swear up and down that complexity requires even more complexity and plenty of expensive gear to shoot straight. Point being, it's amazing what a dedicated CPA with a spreadsheet and their eye on the target can accomplish in the real world when they just do their thing and follow the dollar. For a full transcript of this episode, click here. If you enjoy this podcast, be sure to subscribe to the free weekly newsletter to be a member of the Relentless Tribe. And with that, Marilyn Bartlett has entered the chat. Marilyn Bartlett isn't called the “Queen of Healthcare” for no good reason, and nobody is joking when they say this. She was probably the first person (or one of the first, at a minimum) to truly identify the amount of money getting sucked out of the wallets of taxpayers and employers and plan members and into the pockets of the healthcare and insurance and consulting industries. She is a through and through numbers person but also deeply cares. She is truly a senior stateswoman in our field. Let's start from the beginning here. But you'll have to listen to the interview that follows for the end and most of Marilyn's really sage advice and words of inspiration for any of you, for all of us, trying really hard to fix healthcare and, any day of the week, taking two steps forward and/or five steps back. It's what Mike Tyson was talking about when he said, “Everybody has a plan until [you] get punched in the face.” And yeah, I'd say pretty confidently that everyone in the Relentless Health Value tribe trying to fix healthcare has been there at some point or another. So, here's where I begin the conversation with Marilyn Bartlett today. One day in 2014 or 2015, Marilyn was minding her own business as a CFO at a regional TPA (third-party administrator) firm about ready to retire when the state of Montana reached out. They asked if she would consider being the plan administrator for the state employee health plan, which was, turned out, headed for bankruptcy. Marilyn took the job, and she took the state health plan from $9 million in the hole—they were in debt $9 million—to $112 million to the good. Well, meanwhile, plan members got better benefits. Think about that: $9 million in the hole to $112 million in the good. In fact, the plan had so much money in 2018 when Marilyn left that the state took some of it to pay for other things in the budget. This is truly mind blowing. I mean, get a CPA with their eye on the ball, and this is the difference that is possible to be made in a state health plan. It also just needs to be said that this same state plan, the one that was going bankrupt, clearly had seen over $100 million of taxpayer money exit stage left and wind up in the bank account of their vendors. Now might be a good time to mention something that Chris Deacon wrote about: the Federal Employees Health Benefits Program. This is a $55 billion program, once again funded by taxpayers. As per an OIG (Office of the Inspector General) audit, there are no written policies or procedures over approval and payment of funds to the carriers via ACH (Automated Clearing House). Wait, what? This is just one example, along with a whole lot of other things that kind of make you go, “Hmmm … can a CPA with a spreadsheet please get in there and do your thing?” In the conversation that follows, I ask Marilyn to tell me what she did in roughly three short years to do her thing and save the state of Montana over $100 million while improving benefits of the state workers. And she tells me, short version, she created a why—that's step one. Step two, she looked at her spreadsheets and financial analyses and quantified the situation. She was able to identify a few big hairy problems, which she then hit fast and hard with solutions. This is gonna accomplish a couple of things if you do this, find a solution for a big enough problem. First, it creates a quick win; and quick wins are needed to get some momentum to get started. Second, she knew that by solving big hairy problems, the solutions would have an outsized impact given the scope of these original problems. This is kind of Strategy 101. And then step three, she dug in on assembling the right team with the right skills to make it through what amounts to a change management process, I'm gonna say. What did Marilyn not do in those three years? She did not get captivated or sidetracked by any, I'm gonna call it, transformational theater—which is not easy because a lot of transformation theater has more glitter than a Las Vegas show and is really hard to look away from. It's as magical as most magical thinking. Also, Marilyn stayed the course in the face of what I am sure were many opportunities for personal gain that would have not been a win-win for the state of Montana or its employees. To emphasize how one should not take this for granted, I was talking to a benefits leader the other day and you know what she told me? She said she always goes with this one carrier every year because if you go with that one, when you get invited to their box at the NFL games, you can go out on the field afterwards. I mean, it's really fun to meet the players. Unfortunately, for so many in positions of power, when doing the right thing by taxpayers and/or plan members stands between them and box seats, the right thing gets escorted out of the building. Mentioned in this show, we have Cora Opsahl and Claire Brockbank, who both will be featured in upcoming shows about RFPs (request for proposals) and best practices and how they can go right and also occasionally take a left turn. Check the links to episodes about pharmacy benefits and PBMs (pharmacy benefit managers). I might think of some others, but you'll definitely want to listen to the show with Paul Holmes (EP397); the one with Mark Cuban and Ferrin Williams, PharmD, MBA (EP418); and also AJ Loiacono (EP379). Also mentioned in this episode are Chris Deacon; Cora Opsahl; Claire Brockbank; Mark Cuban; Ferrin Williams, PharmD, MBA; AJ Loiacono; and Shawn Gremminger. You can learn more by connecting with Marilyn on LinkedIn.   Marilyn Bartlett, CPA, CGMA, CMA, CFM, serves as a consultant focused on lowering healthcare costs and empowering employer health plans and state policymakers with data to support cost-saving initiatives. She recently developed the Hospital Cost Tool for the National Academy for State Health Policy (NASHP), an interactive online tool which utilizes hospital Medicare Cost Report data to calculate various hospital metrics used to support hospital and health system financial analysis and health policy. As administrator of the Montana State Employee Health Plan, she disrupted the status quo by implementing Medicare rate reference-based contracting with all Montana hospitals, enhancing primary care through near-sight health centers, moving to a transparent, pass-through PBM, eliminating duplication of vendor services, and improving data access and analytics. These efforts increased plan reserves from actuarial projections of -$9 million to $112 million in two years. For her efforts, Fortune magazine selected Marilyn as #13 of the World's 50 Greatest Leaders.   06:45 What gave Marilyn the confidence to fix Montana's state health plan? 08:11 Why Marilyn knew she would have enough power to make the changes needed in Montana's state health plan. 09:11 What Marilyn achieved in her time as the administrator of the Montana State Employee Health Plan. 10:38 What were the “quick wins” Marilyn was able to achieve when she first took over as administrator? 17:33 Stay tuned for an upcoming episode that covers RFP in detail. 17:50 How Marilyn structured her plan for the Montana State Employee Health Plan. 21:21 What's the key to setting yourself up for success when doing what Marilyn was able to achieve? 25:02 Why putting together your own team is so important. 29:07 What happened when Marilyn left the Montana State Employee Health Plan? 31:08 Have the costs of the plan gone up since Marilyn's time working on it?   You can learn more by connecting with Marilyn on LinkedIn.   Marilyn Bartlett discusses #healthplan finances on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthcareleadership #healthcaretransformation #healthcareinnovation #vbc   Recent past interviews: Click a guest's name for their latest RHV episode! Dr Marty Makary, Shawn Gremminger (Part 2), Shawn Gremminger (Part 1), Elizabeth Mitchell (Summer Shorts 9), Dr Will Shrank (Encore! EP413), Dr Amy Scanlan (Encore! EP402), Ashleigh Gunter, Dr Spencer Dorn, Dr Tom Lee, Paul Holmes (Encore! EP397), Ann Kempski

So, I had a chance to read Dr. Marty Makary's new book, which is called Blind Spots; and here's why I wanted to get him to come back on Relentless Health Value and talk to you, people of the healthcare industry. It's because of something that he said on page 127 and which I've been mulling over for probably years, actually. To Read The Full Article Including Links Mentioned, click here. If you enjoy this podcast, be sure to subscribe to the free weekly newsletter to be a member of the Relentless Tribe. It's this idea of what is appropriate care and how good are we at ensuring that patients/members get said appropriate care. Lots of people are of the same minds because appropriate care has come up in the show with Ben Schwartz, MD, MBA (EP434); John Lee, MD (EP438); Spencer Dorn, MD, MPH, MHA (EP446); Tom Lee, MD (EP445).  I mean, an estimated 21% of all medical care is potentially unnecessary. And unnecessary is, of course, one category of things that are not appropriate. This is according to a national survey of physicians: 25% of diagnostic tests, 22% of all medications, and 11% of all procedures are unnecessary/inappropriate. This is billions of wasted dollars doing stuff that shouldn't be done, and it's not appropriate care. But think about this: How many visions for how to fix healthcare and how to reduce waste depend upon a broad-stroke assumption that we will materially ensure that patients are getting best-practice (ie, appropriate) care? That we cut down on over-medicalization and surgeries on the back end and add appropriate preventative stuff and optimal medical therapy to the front end? Dr. Makary and I delve into the challenges of ensuring patients receive appropriate care, touching on medical dogma, financial, business, and legal incentives, and the importance of measuring practice patterns. Dr. Makary provides practical advice for clinical leaders, payers, and plan sponsors on promoting transparency, improving health literacy, and steering members towards higher performing providers. To Read The Full Article Including Links Mentioned, click here. 07:32 What is appropriate care? 10:19 Why what we think might be appropriate care might not be appropriate care. 10:34 Why is medical dogma damaging to appropriate care? 12:45 Why we need less absolutism in medical practice. 13:37 How is groupthink prevalent in medicine? 14:02 Why do we resist new ideas? 17:43 How do providers figure out what to believe and what not to believe? 20:59 “If you leave it to the medical profession to fix itself … so far, it's not going well.” 22:33 How does supporting health literacy affect appropriate care? 30:23 “People need to find their care based on quality and price.” 34:28 What proportion of medical care is deemed unnecessary right now?  

Maybe you've already caught Part 1 of my conversation with Shawn Gremminger, and if so, you're ahead of the game. But if not, no worries—here's the deal: I decided to split this deep dive into the 340B program with Shawn into two parts. So, feel free to jump into one or both—it's totally up to you. To Read The Full Article Including Links Mentioned, click here. If you enjoy this podcast, be sure to subscribe to the free weekly newsletter to be a member of the Relentless Tribe. These episodes don't have to be listened to in order, so you're good to start here with Part 2. Let's get into it!" Right now, we are going to talk about how 340B impacts employers and commercial plans and other plan sponsors. So, if all you want to hear about is the why—as in, Why do employers care about what amounts to a program that is or was supposed to be for low-income Americans and Medicaid?—you are in the right place. As just one example of the why should employers care if you are teetering on the edge of proceeding, did you know that if an employee or a member of a commercial plan gets a drug at a contract pharmacy participating in 340B, the employer does not get the rebate? The employer is gonna pay the list price for that med. Wait, what? Yeah, details follow because Shawn Gremminger is gonna get into this and many other reasons why employers or anyone in the commercial market (or taxpayers, really) should care about this, as some may call it, Medicaid program. The fact is, 340B is currently so gargantuan that it creates market distortions that bleed into the prices and possibly the quality of healthcare for everybody, all Americans. And that could really matter to employer or Taft-Hartley plan sponsors. After you listen to this show, if you want to drill in a little deeper on the “what the what” and the history of 340B, head back and take in Part 1 of this episode 448. Shawn Gremminger gives the skinny on how the program morphed over the years into a $53 billion juggernaut and is credited (or blamed) for all kinds of healthcare market consolidation and many other weird and unusual consequences that make me admire some of the folks who are truly gold medal winners in the sport of financial engineering. If you want a summary of the points Shawn makes for why employers should care, it is your lucky day, because here you go. Here's the four distortions in the market that Shawn talks about which impact employers: To continue reading, please view our show notes/full article. 09:11 Why do employers care about 340B, which is a Medicaid program? 11:30 Why do I care as an employer, even if I'm not Pharma? 12:44 Why is 340B causing employers to pay significantly more for healthcare? 14:36 Study by Zack Cooper, PhD. 15:06 Why are there distorted pricing models at 340B hospitals? 21:22 Why do employers need to stop playing the blame game?

So, after some pondering, I decided to release this conversation with Shawn Gremminger about 340B in two parts. So, listen to one, listen to both, pick your poison. Shawn Gremminger came up with three really important takeaways relative to 340B, which is a feat unto itself, considering how sprawling this conversation can be. So, if you came here for some concise and actionable takeaways, you have come to the right place. To Read The Full Article Including Links Mentioned, click here. If you enjoy this podcast, be sure to subscribe to the free weekly newsletter to be a member of the Relentless Tribe. This first part you are listening to right now zeros in on Shawn's first takeaway: whether or not the original intent, or the presumed original intent, of the 340B program has actually been met. Many do not realize that 340B began life as a caterpillar. It originally, actually, was conceived as a lowly bureaucratic fix. But over the past 15 years, it has gone into a chrysalis and emerged into a 500-pound gorilla that sits in the corner of a lot of rooms, actually—probably more than many people realize. All of that being said, when you're done listening to this first part of the convo, you should be able to competently assess whether or not 340B does, in fact, adequately help underserved communities get better healthcare—because 340B is supposed to help safety-net healthcare providers stretch scarce resources. The second part of the show, which is a separate episode called Part 2, is how all of this impacts employers and commercial plans. And there's two more takeaways there. So, if you already have the gist of how we got from the beginnings of 340B to where we are in 2024 already and all you want to hear about is why do employers care about what amounts to a low-income program or was purported to be a low-income program, feel free to zip over to the second show and cut to that chase. If you're still with me for this Part 1—and I hope you are, because … wow, it's a wild and tangled journey—here's an outline of where this first part of the discussion is headed. So, for the sake of posterity and having this introduction transcribed in your inbox (be sure to sign up for the free newsletter), here you go. Here's the outline. Visit the full article to read more. 05:25 Shawn's three takeaways from the 340B program. 06:04 What is the intent of the 340B program? 08:22 Read the full 32-page report of the Energy and Commerce Committee.  09:17 Why does Medicaid have to get the best price? 13:26 Why was there a shift in how the 340B program looked starting in the mid-2000s? 15:11 Why do more than half of acute care hospitals now qualify for 340B? 18:18 How has hospital consolidation affected 340B? 20:37 What is the misalignment between how a hospital qualifies for 340B and how it benefits said hospitals? 24:11 How is a 340B designed for hospitals to make a profit? 28:45 Why isn't there a real patient definition in 340B? 31:46 Why is 340B still popular among policymakers? 33:05 Are 340B dollars being used in underserved communities? 33:57 EP394 with Vikas Saini, MD, and Judith Garber, MPP.

I was talking to one health plan sponsor, and she told me if she sees any charges for value-based care anything on any one of the contracts that get handed to her, she crosses them off so fast it's like her superpower. For a full transcript of this episode, click here. If you enjoy this podcast, be sure to subscribe to the free weekly newsletter to be a member of the Relentless Tribe. What, you may wonder? Shouldn't employers and plan sponsors be all over value-based care–type things to do things preventatively because we all know that fee-for-service rewards, downstream consequences–type medical care, no money in upstream. Let's prevent those things from happening. Listen to the show with Tom Lee, MD (EP445); Scott Conard, MD (EP391); Brian Klepper, PhD (EP437). My goodness, we have done a raft of shows on this topic because it is such a thing. So, why wouldn't a plan sponsor be all over this value-based care opportunity? Now, I'm using the value-based care words and big old air quotes. Let's just keep that very much in mind for a couple of minutes here. I'm stressing right now that value-based care isn't a one-to-one overlap with care that is of value. So, let me ask you again, why wouldn't a plan sponsor be all over this air-quoted value-based care opportunity? Let me count the ways, and we'll start with this one. Katy Talento told me about this years ago. She said, it's not uncommon for dollars that a plan sponsor may pay to never make it to the entity that is actually providing the care to that plan sponsor's plan members. So, I'm a carrier and I say, I'm gonna charge you, plan sponsor, whatever as part of the PEPM (per employee per month) for value-based care or for a medical home, or pick something that sounds very appealing and value-like. Some of that money—not all of it, because the carrier's gonna keep some, you know, for administrative purposes—but whatever's left over could actually go to some clinical organization. Maybe it's the clinical organization that most of the plan's members are attributed to. Or maybe it's some clinical organization that the carrier is trying to make nicey nice with, which may or may not be the clinical organization that that plan sponsor's patients/members are actually going to. Like, the dollars go to some big, consolidated hospital when most of the plan's members are going to, say, indie PCPs in the community, as just one example. So, yeah, if I'm the plan sponsor in this mix, what am I paying for exactly and for how many of my members? I've seen the sharp type of plan sponsors whip up spreadsheets and do the math and report back that there ain't much value in that value-based care. It's a euphemism for, hey, here's an extra fee for something that sounds good, but … The end. Then I was talking to Marilyn Bartlett the other day and drilled down into some more angles about how this whole “hey, let's use the value-based care word to extract dollars from plan sponsors” goes down. Turns out, another modus operandi beyond the PEPM surcharge is for carriers to add “value-based fees” as a percentage increase or factor to the regular claims payments—something like, I don't know, 3.5% increase to claims. These fees are, in other words, hidden within billing codes. So, right, it's basically impossible to identify how much of this “value-based” piece of the action is actually costing. These fees are allowable, of course, because they're in the contract. The employer has agreed, whether they know it or not, to pay for value-based programs or alternative pay, even though the details are not at all, again, transparent. And that not at all transparent also includes stuff like, what if the health systems or clinical teams did not actually achieve the value-based program goals? What if they failed to deliver any value-based care at all for the value-based fees they have collected? How does anybody know if the prepaid fees were credited back to the plan sponsor, or if anything was actually accomplished there with those fees? Bottom line, fees are not being explicitly broken out or disclosed to the employers. Instead, they are getting buried within overall claims payments or coded in a way that obscures the value-based portion. So, yeah, charges for value-based care have become a solid plan to hide reimbursement dollars and make carrier administrative prices potentially look lower when selling to plan sponsors like self-insured employers. Justin Leader touches on this in episode 433 about the claims wire, by the way. Now, caveat, for sure, it's possible that patients can get services of value delivered because someone uses that extra money. And it's also possible that administrative costs go up and little if any value is accrued to patients, right? Like one or the other, some combination of both. It goes back to what Dr. Tom Lee talked about in episode 445. If there's an enlightened leader who gives a “shed,” then indeed, patients may win. But if not, if there's no enlightened leader in this mix, it's value based alright for carrier shareholders who take bad value all the way to the bank. Al Lewis quotes Paul Hinchey, MD, MBA, who is COO of Cleveland-based University Hospitals. And Dr. Hinchey wrote, “Value-based care has increasingly become a financial construct. What was once a philosophy centered on enhancing patient care has been reduced to a polarizing buzzword that exemplifies the lack of alignment between the financial and delivery elements of the healthcare system.” And then on the same topic, I saw William Bestermann, MD, he wrote, “The National Academy of Medicine mapped out a plan to value-based care 20 years ago in detail. We have never come close to value-based care because we have refused to follow the path. We could follow it, but we don't, and we never will as long as priorities are decided by businessmen representing stockholders. It is just that simple.” Okay, now. Let's reset. I'm gonna take a left turn, so fasten your seatbelts. Just because a bunch of for profit and not-for-profit, nothing for nothing, entities are jazz-handing their ways to wealth by co-opting terminology doesn't mean the intent of value-based care isn't still a worthy goal. And it also doesn't mean that some people aren't getting paid for and providing care that is of value and doing it well. There are, for sure, plenty of examples where an enlightened leader was able to operationalize and/or incentivize care that is of value. Occasionally, I also hear a story about a carrier doing interesting things to pay for care that is of value. Jodilyn Owen talked about one of these in episode 421. Justina Lehman also (EP414). We had Larry Bauer on the show (EP409) talking about three bright spots where frail elderly patients are getting really good care as opposed to the really bad care that you frequently hear about when you even say the words frail elderly patient. And all of these examples that he talked about were built on a capitated model or on a model that facilitated patients getting coordinated care and there being clinicians who were not worried about what code they were gonna put in the computer when they helped a patient's behavioral health or helped a patient figure out how they were gonna get transportation or help them access community services or whatnot. There are also employers direct contracting with health systems or PCPs and COEs (Centers of Excellence) and others, contracting directly with these entities to get the quality and safety and preventative attention that they are looking for. And there are health systems and PCPs and practices working really hard to figure out a business model that aligns with their own values. So, value-based care—the actual words, not the euphemism—value-based care can still be a worthy goal. And that, my friends, is what I'm talking about today with Elizabeth Mitchell, president and CEO of the Purchaser Business Group on Health (PBGH). PBGH members are really focused on innovating and implementing change. We talk about some of this innovation and implementation on the show today, and it is very inspiring. Elizabeth argues for for-real alternative payment models that are transparent to the employer plan sponsors. She wants prospective payments or bundled payments, and she wants them with warranties that are measurable. She wants members to get integrated whole-person care in a measurable way, which most health plans (ie, middlemen) either cannot or will not administer. Elizabeth says to achieve actual care that is of value, cooperation between employers, employees, and primary care providers is crucial (ie, direct contracts). She also says that this whole effort is really, really urgently needed given the affordability crisis affecting many Americans. There's been just one article after another lately about how many billions and billions of dollars are getting siphoned off the top into the pockets of the middlemen and their shareholders. These are dollars partially paid for by employees and plan members. We have 48% of Americans with commercial insurance delaying or forgoing care due to cost. If you're a self-insured employer and you're hearing this, don't be thinking it doesn't impact you because your employees are highly compensated. As Deborah Williams wrote the other day, she wrote, “Co-pays have gotten high enough that even higher-income patients can't afford them.” And she was referencing a study to that end. So, yeah … with that, here is your Summer Short with Elizabeth Mitchell. Also mentioned in this episode are Purchaser Business Group on Health; Tom X. Lee, MD; Scott Conard, MD; Brian Klepper, PhD; Katy Talento; Marilyn Bartlett; Justin Leader; Laurence Bauer, MSW, MEd; Al Lewis; Paul Hinchey, MD, MBA; William Bestermann, MD; Jodilyn Owen; Justina Lehman; and Deborah Williams.   You can learn more at PBGH and by connecting with Elizabeth on LinkedIn.   Elizabeth Mitchell, president and CEO of the Purchaser Business Group on Health (PBGH), supports the implementation of PBGH's mission of high-quality, affordable, and equitable healthcare. She leads PBGH in mobilizing healthcare purchasers, elevating the role and impact of primary care, and creating functional healthcare markets to support high-quality affordable care, achieving measurable impacts. Elizabeth leverages her extensive experience in working with healthcare purchasers, providers, policymakers, and payers to improve healthcare quality and cost. She previously served as senior vice president for healthcare and community health transformation at Blue Shield of California, during which time she designed Blue Shield's strategy for transforming practice, payment, and community health. Elizabeth also served as the president and CEO of the Network for Regional Healthcare Improvement (NRHI), a network of regional quality improvement and measurement organizations. She also served as CEO of Maine's business coalition on health, worked within an integrated delivery system, and was elected to the Maine State Legislature, serving as a state representative and chair of the Health and Human Services Committee. Elizabeth served as vice chairperson of the US Department of Health and Human Services Physician-Focused Payment Model Technical Advisory Committee, board and executive committee member of the National Quality Forum (NQF), member of the National Academy of Medicine's (NAM) “Vital Signs” Study Committee on core metrics and now on NAM's Commission on Investment Imperatives for a Healthy Nation, a Guiding Committee member for the Health Care Payment Learning & Action Network. She now serves as an appointed board member of California's Office of Healthcare Affordability. Elizabeth also serves as an advisor and board member for healthcare companies. Elizabeth holds a degree in religion from Reed College, studied social policy at the London School of Economics, and completed the International Health Leadership Program at Cambridge University. Elizabeth was an Atlantic Fellow through the Commonwealth Fund's Harkness Fellowship program.   10:36 What are members and providers actually asking for in terms of value-based care? 10:56 Why won't most health plans administer alternative payment models? 12:17 “We do not have value in the US healthcare system.” 12:57 Why you can't do effective primary care on a fee-for-service model. 13:30 Why have we fragmented care out? 14:39 “No one makes money in a fee-for-service system if people are healthy.” 17:27 “If we think it is not at a crisis point, we are kidding ourselves.”   You can learn more at PBGH and by connecting with Elizabeth on LinkedIn.   @lizzymitch2 of @PBGHealth discusses #valuebasedcare on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthcareleadership #healthcaretransformation #healthcareinnovation #vbc   Recent past interviews: Click a guest's name for their latest RHV episode! Dr Will Shrank (Encore! EP413), Dr Amy Scanlan (Encore! EP402), Ashleigh Gunter, Dr Spencer Dorn, Dr Tom Lee, Paul Holmes (Encore! EP397), Ann Kempski, Marshall Allen (tribute), Andreas Mang, Abby Burns and Stacey Richter

My conversation today is with Will Shrank, MD. Dr. Shrank led the evaluation group at CMMI (Center for Medicare and Medicaid Innovation). He has spent time in the private sector, first at CVS Health and UPMC (University of Pittsburgh Medical Center) as chief medical officer of the health plan in Pittsburgh, and then as the chief medical officer for Humana. Now he is a venture partner at Andreessen Horowitz and doing some consulting for CMMI. To read the full article and show notes which include mentioned links, visit the episode page.  If you enjoy this podcast, be sure to subscribe to the free weekly newsletter to be a member of the Relentless Tribe. We start out this conversation talking about waste in healthcare. In fact, Dr. Shrank was on a team who did a study about waste in the US healthcare system. (The article is, unfortunately, paywalled.) In that study, it says estimates suggest we have upwards of a trillion dollars of waste a year. This waste can be categorized into administrative and clinical failures. Dr. Shrank emphasizes the need for aligning incentives with higher quality care, paying for patient outcomes, and highlights the potential rising power of PCPs. The discussion covers the progress made towards value-based care, the challenges faced by the current fee-for-service model, and the future landscape of primary care and healthcare delivery. In sum, we have a waste problem in this country. Aligning incentives might be one way to curb that waste. 06:54 Can we cut healthcare waste while improving patient care? 07:33 What does “healthcare waste” consist of? 07:46 What are the six categories of “healthcare waste”? 10:23 EP363 with David Scheinker, PhD. 10:37 How much money does Dr. Shrank estimate is wasted each year in healthcare? 13:09 Where is that healthcare waste going, and why does it happen? 20:07 Uncaring by Robert Pearl, MD. 21:18 “We've built a backbone of extraordinary waste on a fee-for-service chassis.” 22:16 EP409 with Larry Bauer, MSW, MEd. 24:24 EP359 with Dan O'Neill. 26:02 Dr. Shrank's warning to providers out there. 30:03 Summer Shorts 2 with Scott Conard, MD. 31:41 Why there might be a generational shift among younger providers looking to work with different models.

This encore episode is with Amy Scanlan, MD. It was, in fact, one of our most popular episodes of the past year. It is still just as relevant today in a slightly different way. It's interesting how things which were said maybe a year ago have shades of meaning which become evident as time goes on. So, I liked this show a lot in the second listen with the advantage of time passing. To read the show notes with mentioned links and a transcript, head over to our site. If you enjoy this podcast, be sure to subscribe to the free weekly newsletter to be a member of the Relentless Tribe. Complicating fact of current life, it's becoming increasingly obvious that in order to stand up a practice that can take advantage of value-based care payments—payments where primary care docs mainly at this time can get paid more and likely more fairly to care for patients well—you need a lot of infrastructure. You need data, you need tech, you need a team. Translation: You need money, maybe a lot of money, to invest in all of this. These are the external realities that hit anyone trying to do right by patients from every direction. But on the other hand (or maybe different fingers on the same hand), as Dr. Amy Scanlan says in this healthcare podcast, physicians are the backbone of this system. Dr. Scanlan talks in the interview today about the opportunity, and maybe the responsibility, that physicians have here for patients; but also the Eric Reinhart article comes up again about rampant physician moral injury (unpaywalled link with my compliments). Right now might be a great time to read something from Denver Sallee, MD. He wrote to me, and he wrote, “Like many physicians, I did not have much understanding of the business side of medicine, as I mistakenly thought as long as I helped take great care of patients that I was doing my job. More recently, it became apparent to me that by ceding the management of medicine to nonclinical administrators and to companies interested primarily in value extraction for the benefit of shareholders that I needed more education in order to truly help patients.” Today as aforementioned, I'm talking with Amy Scanlan, MD, who is chief medical officer of the clinically integrated network (CIN) that is the joint venture between Intermountain Health and UCHealth in Colorado. We talk about what it's like to be in the kind of messy middle of transformation to integrate care in a clinically integrated network, trying to figure out how to help physician practices and the CIN itself navigate the external environment in a way that empowers different kinds of practices at different points in their transformation journey that empowers physicians to be in charge, and considering clinical and financial outcomes (ie, the business of healthcare). Dr. Scanlan brings up four main factors to consider when plotting strategy from here to there. Listen to the episode or read the show notes to learn about the four factors. 06:35 How is Dr. Scanlan thinking about the transformation process and the shift to value? 09:16 “It is really trying to think about, how do we help practices get there?” 11:48 “The hard part is the in-between spaces.” 13:21 EP407 with Vivek Garg, MD, MBA. 14:12 “Team-based care done badly is really just a series of handoffs.” 15:52 “We have to get to that point where the culture of collaboration is more pervasive.” 19:58 “How do we as healthcare providers step in and solve this problem?” 20:06 Why do providers have a responsibility to step in and try to fix the healthcare system? 20:22 Article (unpaywalled) by Eric Reinhart, MD, PhD. 21:51 Why do physicians need to be accountable for the cost of care as well as outcomes? 23:38 Why does physician burnout give Dr. Scanlan hope? 24:26 What is the solution to changing fee-for-service incentives? 25:43 What are some of the challenges facing changing incentives? 27:16 Why is data so important? 28:54 EP393 with David Muhlestein, PhD, JD. 30:13 “It's important to understand that we are in the middle of this change.” 31:18 Dr. Scanlan's advice for those trying to stand up a CIN.  

In Episode 447, Stacey Richter interviews Ashleigh Gunter, president of Translucent Healthcare Consulting, to discuss the indispensable role of change management in healthcare transformation. They emphasize that creating an effective change strategy involves great leadership, a clear case for change, influential change champions, over-communication, and continuous measurement and celebration of successes. The conversation highlights the importance of understanding and aligning with the 'why' that drives healthcare professionals and the necessity of a multi-faceted approach beyond just implementing technological solutions like EHR systems. Visit the Episode Page to read the show notes with mentioned links. If you enjoy this podcast, be sure to subscribe to the free weekly newsletter to be a member of the Relentless Tribe. I saw a bar chart by Phil Ballentine the other day in Nikhil Krishnan's Out-Of-Pocket newsletter that showed, in the USA, in 2024, there are 18,982 live instances of Epic. Each one of those 18,982 live instances are all different: different workflows, separate data, different ways to do the same thing. So, even if having an “Epic strategy” actually was a complete master plan to change behavior in clinic, healthcare has no “nationwide, everywhere it's all the same, so figure out your thing once and you're good to go” thing going on. There are 18,982 differences of opinion out there, but here's the actual and big kahuna real reason why I'm leery. An Epic strategy is not equivalent to a change management strategy. That's the real point that I want to make. It's necessary, very necessary even, but not sufficient. You want to make the way as easy as possible once the “why” goes down and the case for change is made, but even if it's one click and not your usual 14 to 60 clicks, there's no “why” there. There's no automatic case for change that slithers out of anybody's API like a spontaneous miracle. I said this last week, too. Lots of things are really pretty easy. Lots of things are in Epic. Yet no one uses them. I mean, let's talk about actually reading most of the best-practice alerts that pop up. How about consistent use of SmartSets in the majority of those 18,982 instances? Anyway, I couldn't be more pleased to have learned a thing or two from Ashleigh Gunter about change management and how to do this whole thing right. This conversation happened actually a while ago. It's re-edited for 2024—call it a supercut—specifically considering change management at hospitals or physician organizations. Ashleigh Gunther is president of Translucent Healthcare Consulting. She is also an expert in change management and how to align employees and staff so that an organization can move forward together. One quick spoiler before we proceed: According to Ashleigh, there's five steps to effective change management that will ensure success: 1. Having great leadership 2. Creating a case for change. This includes the whole “why” thing. 3. Finding champions—engaging people who have to change so that they can contribute and be supportive 4. Overcommunicating 5. Measuring how things are going and also celebrating small triumphs If you continue to be interested in this topic, do go back and listen to the show with Karen Root (EP381) on shepherding innovation through a large company. Before we kick in to the show today, let me remind you, if you haven't done so and you appreciate the show, could I ask you to please leave a rating and review on Apple Podcasts or Spotify? We haven't had any of them this month, and it is important for the show to get found and for me and the team to stay motivated over here. While you're there, be sure to Follow the show. 09:22 How does change management go wrong in healthcare? 09:56 “Communication [of change] in and of itself isn't change management.” 10:53 How does change management work on the provider organization side? 15:33 “You want to ensure you are educating the operational folks.” 16:35 What is change management? 17:36 What does great leadership look like in change management? 18:55 “Leadership sets the tone.” 19:04 What makes change management so hard? 19:31 “What's the company reason to make this change happen?” 20:51 What are change champions, and why do you need to create them when changing your benefit plan? 21:57 Crossing the Chasm by Geoffrey A. Moore. 23:21 Why is it important to overcommunicate change? 26:47 Why is it important to measure your successes and communicate those after a change?

This show is about getting or not getting patient outcomes and getting them in an efficient or not efficient way that is in alignment or not in alignment with the values of clinicians trying to care for their patients in the best way that they can. And I'm beginning this conversation with this preface, lest anyone lose track of the ends which we seek, which are Quadruple Aim–type goals. For a full transcript of this episode, click here. If you enjoy this podcast, be sure to subscribe to the free weekly newsletter to be a member of the Relentless Tribe. I'm starting here so that we don't get confused between what is a goal and what is a means to achieve a goal because today we're sort of gonna talk about technology, but we're really not gonna talk about technology. And if we're not gonna talk about technology, then, of course—because go big or go home on this show—we're not gonna talk about the mother of all healthcare technology: EHR systems (electronic health records). Ah, so cryptic, but let's proceed. I want to dig in here because this is really important, actually, to everybody, including (and especially) anyone buying healthcare services such as employers. It's also a level set for anyone involved in or about the purveyance of said healthcare services. Here's my first point. Conversations about technology may be unduly focused on technology, and this includes EHRs. I saw a Tweet recently by Joshua Liu that struck me because it really mirrors my own experience working with clinical teams. Joshua wrote, “Let me show you … why studies evaluating the same tech can have very different outcomes. Why the very same tech implemented with different workflows and people can lead to wildly different results.” See the great (and pretty funny, actually) visual that Joshua Liu made about this, but the point is this: Technology is not a thing unto itself. It is not a magic pill like those gelatin caps that you can buy at toy stores and when you toss them in the bathtub, they expand into surprisingly large foam dinosaurs. I mean, you can buy any given healthcare, digital technology, anything … and what doesn't pop out of the box along with purchase are any sort of “why” for an end user to actually use the thing, or implementation plans, processes, change management, empowered people who are bought in, adequate training, adequate staffing levels, and ongoing communication. So, look … here's the point. Unlike the bass, it's not all about the tech. There are people; there are processes. I say all this to say, it's weird to me; and Spencer Dorn, MD, MPH, MHA, my guest today, said pretty much the same thing. It's weird to me how we evaluate technology, and this includes EHRs and patient portals, which we talk about today, and even AI, which we will talk about in a shorter episode that will air in September. But it is so very, very common to talk about tech like it exists in a vacuum and is an end unto itself. For example, you hear often enough people talking about optimizing the EHR. Maybe instead, the title of the conversation should be “Optimizing the Patient-Doctor Encounter” or “Optimizing Patient Health” or “Optimizing the Ability of Clinicians to Work Together as a Team.” Tech is certainly a vehicle to achieve these goals. But whether said tech is a force of good or bad or something in the middle, or succeeds or fails, isn't inherent in the tech itself. As Dr. Dorn says, there is no intrinsic property of the technology that determines the outcome. It's how we use it, how we implement it, how we put it into daily practice, is really, ultimately, the arbiter of what happens and how it impacts lives. I'd also add, just to be a bull in the china shop, even if the tech itself has some glitches, someone decided to make everyone use it in its current form. So … yeah. Therefore, first takeaway from this show is going to be don't ascribe any given technology a label of good or bad or even neutral. This, by the way, is Kranzberg's First Law of Technology, which, of course, comes up because you know me … I cannot miss any opportunity to nerd out over something like Kranzberg's First Law of Technology. And that wraps up takeaway one: Technology by itself is not good or bad or even neutral. Reference Kranzberg's First Law of Technology. Thank you, Melvin Kranzberg. Second major takeaway is that if you're thinking about the ultimate impact of people and processes that have some technology in their midst, technology such as an EHR system, the ultimate impact will not be a black or white binary. Let's just acknowledge that we as humans love binaries, especially polarized binaries, because it's very tidy. Putting things in clear boxes removes ambiguousness that our lizard brains just do not like. But I'm keeping in mind what Tom X. Lee, MD, said on episode 445 last week. Most things in life, IRL, are somewhere in the gray murky middle. And if we understand that, we can make that middle space productive. Dr. Lee called it the productive middle. Here's how I'd put it: Don't be an edgelord. It's generally not a fact-based place to be, but also, it's not productive. Dr. Spencer Dorn and I discuss all of the above, and he makes some great points and he's very articulate. Here's the three dimensions (lots of nuances). Listen to the show for a ton of nuances, but just top-line: 1. EHR-embedded operations have the capacity to empower clinicians with information and/or overwhelm clinicians with information. Most likely what's going on will be somewhere in the middle of these two poles. 2. Impact, which is so often stated as a binary that is actually not a binary but, again, a continuum. An EHR deployment may extend or diminish human connections between docs and patients and between clinicians working together. 3. Not a binary but a continuum is whether operations with EHRs (or any tech really) make clinicians more effective and efficient or less effective and efficient from a clinician standpoint. Dr. Spencer Dorn, my guest today, is a gastroenterologist practicing in North Carolina. He spends his time doing a few different things. That includes taking care of patients. He also helps lead a large academic practice. And lastly, Dr. Dorn works in healthcare IT and clinical informatics. So, therefore, the perfect guest to talk about this whole topic with today. This is a really interesting conversation, so I hope you listen to it. Also mentioned in this episode are UNC Department of Medicine; Joshua Liu, MD; Tom X. Lee, MD; Robert Wachter, MD; and Shawn Gremminger. You can learn more at the UNC Department of Medicine Web site and by following Dr. Dorn on LinkedIn.   Spencer Dorn, MD, MPH, MHA, is vice chair and professor of medicine at the University of North Carolina (UNC), where he works to develop care models that best support clinicians and meet patients' needs, serves as a UNC lead informatics physician, conducts clinical trials, and examines the broad forces shaping healthcare. Clinically, he works with adults experiencing disorders of gut-brain interaction and GI motility.   06:15 Breaking down Kranzberg's Laws of Technology. 08:16 How do EHRs go right? 12:49 “EHRs empower us with information, yet they also overwhelm us with information.” 16:00 How do EHRs bring healthcare workers closer together? 19:35 The Digital Doctor by Robert Wachter. 21:33 “The whole point of healthcare is to help people live healthier, happier lives.” 22:41 How the same EHR deployed in different places can be more or less efficient. 25:51 Why the problem is not necessarily the EHR but actually operational. 28:51 How technology has also changed our expectations on timing and value.   You can learn more at the UNC Department of Medicine Web site and by following Dr. Dorn on LinkedIn.   Spencer Dorn, MD, of @UNC_SOM discusses #patientoutcomes using #healthtech on our #healthcarepodcast. #healthcare #podcast #financialhealth #primarycare #patientoutcomes #healthcareinnovation   Recent past interviews: Click a guest's name for their latest RHV episode! Dr Tom Lee, Paul Holmes (Encore! EP397), Ann Kempski, Marshall Allen (tribute), Andreas Mang, Abby Burns and Stacey Richter, David Muhlestein, Luke Slindee, Dr John Lee, Brian Klepper

I wanted to talk with Dr. Lee because so many RHV (Relentless Health Value) listeners are trying to figure out how to sustain primary care as a stand-alone entity when the most obvious and most common way to make enough money in primary care is to drive and maximize the dollars from downstream volume of high-priced service lines, which, if you think about it, undermines the entire point of primary care. To read the full article, show notes as well as the links mentioned visit our episode page. While there, consider signing up for our free weekly newsletter. In Episode 445 of Relentless Health Value, Stacey Richter interviews Dr. Tom Lee, founder of One Medical and Galileo, about the sustainability of standalone primary care practices in 2024. Dr. Lee also was a founder at Epocrates They discuss the paradox of primary care, the economic challenges of running an independent practice, and the importance of enlightened leadership with a value-focused mindset. Dr. Lee emphasizes innovative service operations, cutting hidden waste, and balancing human-centered care with efficient processes. The conversation explores various facets of primary care, including access, longitudinal patient care, and the role of technology. Tune in to understand how primary care can thrive amidst economic and systemic challenges. 07:02 What is the paradox of primary care? 09:19 Why is it hard to run an independent primary care practice? 10:01 What are the barriers to running an independent primary care practice? 10:41 Can you have fee for service and value? 12:25 “Value is more about a mindset.” 13:22 What hidden waste is there in a primary care practice? 15:11 What do you need to have a value-focused mindset? 17:14 Why does access precede quality? 18:20 Why have retail clinics failed in being longitudinal primary care destinations? 20:29 What is a longitudinal primary care destination and why does it matter? 23:48 What are the nuances of a service business that make them challenging for managers? 24:35 How do you find the balance between fee for service and value? 31:17 EP438 with John Lee, MD. 32:14 How can you invest in quality without a value-based contract? 34:19 How do you address the trade-off between fee-for-service finances and investing in value-based care? 35:36 Where is the “productive middle”? 36:27 Dr. Tom Lee's message to payers. 39:55 Dr. Tom Lee's message for policymakers.  

Today is an encore because I am going on vacation next week. It always feels a little bit like a time warp because by the time this show will air, I will be back from vacation. This show with Paul Holmes was one of the most popular episodes of 2023 and definitely is just as relevant now. A lot of the things that Paul talks about are worth repeating or listening to again. For a full transcript of this episode, click here. Before we kick in, though, I'm gonna repeat something that Ge Bai, PhD, CPA, says a lot: There's no angels and there's no devils in the healthcare industry. But we are talking about for-profit entities. And if there's one thing that's generally true about a for-profit entity, especially one that is publicly traded, it's gonna do whatever it can get away with. It becomes up to the customer to set expectations and using the purchasing discipline that they probably use everywhere else in the business because it basically is good business to have purchasing discipline. Before we kick into the episode, just a couple of things. Thing one, if you haven't, do subscribe to the weekly email that goes out describing the show. Here's just one reason to do so. It's really efficient because what is transcribed in that email is the whole beginning half (usually) of the introduction. So, if later on you are trying to remember which episode you heard something in, you can just search your email and find the show. How you subscribe is go to relentlesshealthvalue.com, hang out for probably 15 seconds, and there will be a pop-up. And while you're on the Web site, here's something else you could do. Go to the lower right-hand corner of the Web site. You will notice a little button. It's an orange button. There's a microphone. Click on that; say something like your name, your company name, maybe a word or two about Relentless Health Value; and then encourage others to subscribe to the weekly email that goes out, similarly to what I just did. Then what our team will do is take that recording and potentially use it at the end of some of the shows so we can hear somebody else talk besides myself. So, please do go over to the Web site, click on that little microphone, and record something that you might want to share with the other members of the Relentless Tribe. And with that, here's your encore. If this were a video show, I would stare into the camera with steely eyeballs right now and say that I have a special message for employer CFOs. If you aren't a CFO, pretend that you are so that you get the full effect here. So, now that we're all CFOs, let's pull up the company P&L (Profit and Loss) statement. This is what keeps us all up at night, right? Making sure that the net profit line at the bottom looks good. We could decide to lay off a few people. Reorg something or other. Beat up a vendor. We also could go over and have a strident conversation with sales leadership about what they can do to jack up their sales revenue. Top line begets bottom line and all that. Or, here's another idea: In this healthcare podcast, I am speaking with Paul Holmes, who is an ERISA (Employee Retirement Income Security Act) attorney with a specialty in PBM (pharmacy benefit manager) contracts, especially the PBM contracts from the big PBMs that get jammed in employer plan sponsor faces by whomever and which they are told look fine and that the employer plan sponsor should just go ahead and sign. Now, if we, meaning all of us CFOs, sign that paper, or someone on our benefits team signs the paper … fun fact, our company just spent 30% to 40% over market for our pharmacy benefits. That contract we just signed contains all kinds of expensive little buried treasures—treasures accruing to the PBM and other parties, to be clear, and coming at our expense. There's 17-ish very common treasures in your typical PBM contract, and none of us will ever spot them unless we know what we are looking for. But let's dig into this for a sec, especially for all of us newly minted CFOs because the real ones already did this math. Say our company spends whatever—we're a bigger company, and we spend $100 million a year on our drugs. That's a minimum of $30 million that we got taken for … $30 million a year. Because of the huge dollars at stake (30% to 40% of drug spend), it's certainly the advice of almost anybody that you talk to who's an expert in PBM contracts to have a third party—not your EBC (employee benefit consultant), which we'll get into in a sec, but somebody else (a third party)—review every PBM contract. I mean, what's the worst that can happen for anybody considering having an independent third party review their PBM contract? It costs a couple grand in lawyer fees, and they give it a stamp of approval. Knowledge is power, and now we know. But let's just say this third-party review doesn't happen. We all go with a “devil may care” about this whole PBM overcharging us by 30% to 40% possibility. And let's say the PBM contract is, in fact, a ride on the Hot Mess Express but we don't know it. Here's two pretty bad downsides, especially now, this year, since the passage of the CAA (the Consolidated Appropriations Act). Number one bad thing: Plan sponsors may get sued as per the CAA for ERISA violations. It's not just the company paying that extra $30 million, or 30% to 40%, right? It's also employees. This is risk exposure, bigly. Just like it was on the 401(k) side of the house, which Paul Holmes, my guest today, mentions later on in the interview. He talks about just how much those lawsuits cost and, yeah, exposure. As I mentioned three times already, today I am speaking with Paul Holmes about PBM contracts in all their stealthy glory. The one thing I came to appreciate is that these things are works of art … if you're into those paintings of pretty flowers where, if you look hard enough, you spot a skull tucked in the greenery (memento mori). Paul is a longtime ERISA attorney. He has dedicated his career to helping plan sponsors in their negotiations with PBMs and trying to help them reduce drug spend, especially drug spend that isn't actually paying for drugs. Here's a link to an article we discuss about how a school district in Florida is suing their longtime EBC for taking $2 million a year in alleged secret payments. We also mention an episode with AJ Loiacono (EP379). And along similar lines, Jeff Hogan mentioned on LinkedIn the other day, “It's pretty amazing that just in the course of the [past few] weeks, I'm reading, seeing, and hearing about big new CAA breach of fiduciary duty cases.” So, Paul Holmes says this more eloquently, but if you're a plan sponsor, definitely get your PBM contract reviewed and maybe consider working with an EBC who's happy to sign the disclosure statement that your lawyer has provided without disclaimers. Also mentioned in this episode are Ge Bai, PhD, CPA; AJ Loiacono; and Jeffrey Hogan.   You can learn more by emailing Paul at pbh@williamsbarbermorel.com.   Paul B. Holmes, JD, is a seasoned ERISA lawyer with nearly 40 years of specialization in that field. Paul joined Williams Barber & Morel Ltd. recently, after 31 years with Nixon Peabody LLP and Ungaretti & Harris LLP. Paul is one of the few ERISA lawyers in the United States, concentrating his practice on PBM contracting and oversight. Paul represents large employers, Taft-Hartley welfare funds, and governmental units in their selection, contracting, auditing, and disputes with large pharmacy benefit managers (PBMs). This work includes active oversight of the request for proposal (RFP) process for selecting a PBM, the negotiation and customization of PBM contracts, and legal audits of PBM compliance with their contracts. Paul provides insightful guidance on the prudent selection of independent pharmacy benefit consulting firms (who do not receive indirect compensation from PBMs), which independence is expressly required under Section 202 of the Consolidated Appropriations Act of 2021 (CAA). Recent efforts have focused on reducing wasteful drug spend promulgated by large PBMs in dozens of categories. These include the preference of Humira® biosimilars, reducing off-label utilization of GLP-1s, reducing huge markups on certain specialty generics, and customizing PBM formularies and clinical protocols to better control spend. He was selected, through a peer-review survey, for inclusion in The Best Lawyers in America® (2020 and 2021) in the field of Employee Benefits (ERISA) Law. Paul received his bachelor's degree from Bradley University and his Juris Doctor degree from the University of Illinois College of Law.   07:41 What are Paul's usual observations when a PBM contract crosses his desk? 08:34 “If you just sign … one of their model contracts …, you're probably gonna pay 30% to 40% above market on your drug spend.” 12:11 What is a PBM lawyer? And why is it important to find an ERISA PBM lawyer? 17:12 EP379 with AJ Loiacono. 17:40 Who is on the hook for the cost of the PBM contracts? 21:05 What's the problem with most ERISA lawyers today? 22:56 Lawsuit about PBM contract. 27:43 What's Paul's advice for benefits consultants? 31:40 How much might a plan sponsor be paying their consultant versus what a consultant might be making from a PBM?   You can learn more by emailing Paul at pbh@williamsbarbermorel.com.   Paul Holmes discusses #PBMContracts on our #healthcarepodcast. #healthcare #podcast #financialhealth #primarycare #patientoutcomes #healthcareinnovation   Recent past interviews: Click a guest's name for their latest RHV episode! Ann Kempski, Marshall Allen (tribute), Andreas Mang, Abby Burns and Stacey Richter, David Muhlestein, Luke Slindee, Dr John Lee, Brian Klepper, Elizabeth Mitchell, David Scheinker (Encore! EP363)  

For a full transcript of this episode, click here. Unintended consequences is a thing. ERCowboy wrote on Twitter a while back, “In any complex system, the likelihood of unintended consequences vastly outweighs the predictability of intended ones.” In this healthcare podcast, we're talking about two state laws where this is apropos: CON (Certificates of Need) laws and then COPA (Certificates of Public Advantage). Turns out, states actually have pretty much power to impact the competitive landscape in their state. They have a lot of levers they can pull. States really can make a difference in terms of improving real competition on value and on cost and quality. So, these two laws are, in a way, their attempt to do so. Before we kick into what's going on here, I think it is important to point out that these laws on their face aren't an obviously and overtly terrible mistake. This isn't like equivalent to accidentally putting ChapStick in the dryer. There were good people who spied a problem and had an idea for how to fix it. I'm reminded of something I read by Nicholas Kristof on a totally different topic, but he wrote, “The central problem is not so much that the effort was unserious as it's more focused on intentions than on oversight and outcomes.” And that pretty much sums up, I think, the gist of what's going on here. And I can say that because here we are in a position to Monday morning quarterback. So, I've invited Ann Kempski on the pod to point out what hindsight may reveal about these well-intentioned efforts, the CON and COPA laws. First up, let's talk about Certificate of Need laws, or the CONs. Currently, we have 35 states and Washington, DC, that operate CON programs with wide variations by state. The National Conference of State Legislatures has a good overview of each state's laws. Why did these laws originally get put into effect? They got put into effect to cut down on supply-driven demand that was considered to potentially raise total cost of care—because in healthcare, unlike Econ 101, more supply doesn't mean lower prices. In the real world, if you have more supply, volume goes up and total cost of care goes up, too. So, it could be considered good thinking to limit the amount of supply. Except there's four problems that wind up happening often enough, which is why some states are busy repealing these CON laws. We cover these four problems in the show that follows. Spoiler alert: What happens a lot of times is that the big get bigger. Consolidated entities have an upper hand, and we all know consolidated entities are generally not known for their competitive prices or their desire to rationalize volume. So, yeah … we dig into this and parse it out into, as I said, four main problems; but this is most commonly where it all winds up (ie, total cost of care does not go down). I have included links that Ann Kempski shared with me, including a statement from the Federal Trade Commission (FTC) and Department of Justice detailing the anticompetitive effects of state CON laws. There's also a document written by a former FTC commissioner that highlights how state CON laws can inhibit competition. And then lastly, a systemic review of 90 studies that find the costs of CON laws exceed their benefits. Okay, so let's move on to our number two state law that often does not go as planned; and this is the Certificate of Public Advantage, or the COPA, laws. Approximately 19 states have them, and these laws attempt to immunize hospital mergers from antitrust laws by replacing competition with state oversight. The idea here is that a state tells the FTC to stand down and gives their seal of approval to a merger to stop it from getting scrutinized for antitrust violations. So, like, a big dominant health system gets an okay to buy a rural hospital. Meanwhile, everybody realizes this will lead to a situation where there is a dominant health system and that dominant health system will reduce competition. But the state may choose to do this because … public advantage, as in the “PA” in COPA, Certificate of Public Advantage. But they'll do this because the state has decided that the public advantage of allowing the possibly problematic anticompetitive merger to move forward, the public advantage is a bigger advantage than having competition. Hmmm … what could go wrong here? Well, several things that Ann Kempski discusses in the show that follows. The Federal Trade Commission strongly advised the states against enacting these laws. Here is a link to this article that was on the FTC Web site. I was so thrilled to get the chance to chat with Ann Kempski, who knows so much about these topics. Ann Kempski is an independent healthcare consultant with a background in the labor movement, advocating for healthcare workers and purchasers for many years. Ann Kempski collaborates with clients to strengthen primary care, enhance union health funds, and reduce commercial prices. She often partners with academics from Johns Hopkins to analyze hospital transparency data for insights into market trends. Before we jump into the episode, we've had a loss in our community. We've had actually several, one of them being Marshall Allen, another one being Suzanne Delbanco. I know our guest today worked alongside of and really admired Suzanne. Ann Kempski says: “Suzanne was a kindred spirit and a real inspiration for me and many others. She founded two very influential nonprofit organizations: first, The Leapfrog Group and then, second, Catalyst for Payment Reform, which is dedicated to empowering purchasers to be more effective purchasers in the healthcare marketplace.” Additional Resources on State Laws and Policies That Promote Hospital Consolidation, Inhibit Competition Certificate of Public Advantage (COPA) Laws A recent story from Tennessee highlights the weak oversight and observed in COPA-related hospital mergers. Competition and Antitrust in Healthcare “Is There Too Little Antitrust Enforcement in the US Hospital Sector?” by Zarek Brot-Goldberg, Zack Cooper, Stuart Craig, and Lev Klarnet, April 2024 Catalyst for Payment Reform publications and white papers The Great Reversal: How America Gave Up on Free Markets, by Thomas Philippon, 2019   Also mentioned in this episode are Nicholas Kristof; Marshall Allen; Suzanne Delbanco; Brian Klepper, PhD; and Gloria Sachdev, PharmD.   You can learn more by following Ann on LinkedIn.   Ann Kempski is an independent health policy consultant with 30 years of experience as an analyst, advocate, and strategist advancing health reforms related to coverage, quality, and payment in public programs and commercial insurance. She has served in leadership roles in several organizations, including Kaiser Permanente, SEIU (Service Employees International Union), and the State of Delaware. Ann currently supports organizations and efforts to strengthen primary care payment and transition away from fee for service, promote competition in commercial healthcare prices and coverage, and expand access to evidence-based behavioral health services. Ann is especially grateful to collaborate with and learn from talented graduate students and faculty at Johns Hopkins Bloomberg School of Public Health on research and policy analysis to understand commercial market and price dynamics and provider behavior. She has an undergraduate degree in economics from the College of William & Mary and a master's degree in industrial and labor relations from Cornell University.   06:20 Ann remembers Suzanne Delbanco. 06:55 EP224 with Suzanne Delbanco. 07:40 What are state Certificate of Need laws? 08:44 Why are states getting rid of these CON laws? 13:26 Why CON laws are created. 15:43 EP437 with Brian Klepper, PhD. 16:09 What are the conflicts of interest and problems that arise when CON laws are created? 20:55 What happens when states get rid of these CON laws? 24:10 How are Certificate of Public Advantage laws different from CON laws? 27:58 Why does the research show that COPAs don't usually accomplish their goals? 31:34 What encouraging current events are happening in the realm of COPA laws? 32:08 Gloria Sachdev, PharmD, of Employers' Forum of Indiana.   You can learn more by following Ann on LinkedIn.   @kempann discusses #COPA and #CON state #healthcarelaws on our #healthcarepodcast. #healthcare #podcast #financialhealth #primarycare #patientoutcomes #healthcareinnovation   Recent past interviews: Click a guest's name for their latest RHV episode! Marshall Allen (tribute), Andreas Mang, Abby Burns and Stacey Richter, David Muhlestein, Luke Slindee, Dr John Lee, Brian Klepper, Elizabeth Mitchell, David Scheinker (Encore! EP363), Dan Mendelson    

To read the full show notes with links mentioned, be sure to visit our episode page and consider signing up for our free weekly newsletter. 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. 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.”