Relentless Health Value

This episode is part of the "Inches Are All Around Us" series looking for all the little pockets—inches, if you will—that comprise the greater than $1 trillion in healthcare waste in this country annually. 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. Many of these inches, if we hack them out, will actually improve patient care because these inches are just like the friction that's in the middle. To this end, I started thinking about FQHCs (Federally Qualified Health Centers), which are (these FQHCs in this context, if you think about it) kind of a great laboratory for scrappy and amazing case studies about finding and cutting out waste with some serious fiscal discipline. The thing with FQHCs and why they are great places to I spy inches of waste is really because if an FQHC has a budget shortfall, they cannot solve it by cost shifting to commercial patients, commercial members, commercial plans. They have no commercial patients.  Also, they have a patient population that many would consider challenging, and they cannot restrict access. They gotta make do with what they have. They must have actually true fiscal discipline. They either figure out how to be efficient, or their patient population does not get care. But what tipped me over the edge to revisit this episode from 2021 with Gary Campbell—who is the CEO of an FQHC, by the way—I picked the show to revisit because of my conversation with Nikki King, DHA, that I had earlier this year (EP470). Nikki and I caught up, and she is now the CEO of an FQHC in Indiana. I had interviewed Nikki, by the way, about rural health a few years ago (EP338). So, go back and listen to that if anything I say today you find intriguing for other reasons. Tribe, this is interesting to think about what I'm about to tell you. Really. I've been thinking about it for six months. I wanna start out here recapping my aforementioned catch-up conversation with Nikki King as the lead-in to my conversation with Gary Campbell to follow. And to be specific here, Gary Campbell is the CEO of an FQHC in Virginia called Johnson Health Center; and Nikki King is CEO at Alliance Health Centers in Indiana. Let me tell you one thing that Nikki King did. There are many things that she did, but here's one that she told me about. Nikki realized after talking and listening to their patients that one of the biggest barriers to getting care at her FQHC for patients was no transportation. Also, as most FQHCs, they were short on funds. So, doing things like free Ubers or something like that was not an option. So, you know what Nikki did? She thought about where her patients are. For example, most referrals to their addiction treatment services came from the courthouse—a judge remanding, if that's the right word, someone to treatment. So, two birds with one stone style, Nikki marched over to the courthouse facilities person and asked if they had any open office space at the courthouse, you know, work from home and all of that. Maybe there were some open offices. Well, the courthouse did. They had some open offices. So, now rent-free or almost rent-free, I don't, I'm not sure, when a judge says to somebody, "Go get addiction treatment," that judge can also point down the hall and the patient can just walk over. Nikki did the same thing, setting up a clinic in a day care center. She set up a clinic in a homeless shelter and right by a big basketball court. You compare and contrast this, I don't know, "just get it done" approach to all of the times that you hear about "some cash-strapped entity" who decides the best thing to do immediately is new construction. Pay to build brick and mortar and then in perpetuity, of course, pay all the costs and the snow removal and the security and the utilities and repair for that new construction. And they could be an FQHC building new buildings—one of the less scrappy ones—but it also could be a big, consolidated health system or anybody in between. It's amazing how many times you hear "razor-thin margins," and then you hear "new construction" in the same sentence. I'm like, "Yeah … gotcha. Upsize." Call it my Pennsylvania Dutch and Bronx heritage. But yeah … head exploding. That was a tangent. Bottom line, however, I say all this to say FQHCs (the ones with great leadership, at least) are a wonderful case study to look for insights on how to operate in an environment that cannot rely on, again, raising commercial rates and cost shifting to balance the budget, right? Let's not forget, there are two very different ways to end up with no profit: One is genuine struggle. The other is simply being very good at spending every dollar that is given to you. For plan sponsors, this is a vital distinction, regardless of how loud anybody cries poor, any clinical partner who lacks fiscal discipline isn't struggling; they're inefficient. And we do not have a market in healthcare to be able to tell who's struggling versus who is inefficient. So, yeah … keep that in mind and listen to episode 490 and 492 after this one with Shane Cerone and Sam Flanders, MD, for more on the whole "there's no market" theme, as well as more on the fiscal discipline topic. But again, this is why FQHCs are such a good case study here, because there's an upper limit to how much money they have. In most circumstances—I mean, barring some big donation or something like that—but under most circumstances, they have a revenue cap that they have to be disciplined enough to work within. Okay … one last thing before we kick into the show today. I wanna be really clear here. Fiscal discipline isn't something that any individual doctor or nurse or other clinician can tackle in a vacuum. Or even any given administrator. It is a leadership imperative. Great leadership doesn't just manage the clinical side. It takes accountability for the administrative waste that keeps margins thin and prices high. So, here's actionable advice for anybody listening, regardless of what you may or may not have to do with FQHCs. If you're a plan sponsor looking for a clinical partner, consider, like, what Nikki King is doing and the thinking that Gary Campbell is gonna talk about as a benchmark. Real value comes from finding the organizations that treat fiscal discipline as kind of a mission critical strategy, because these days, with all the affordability issues, it is financial toxicity is clinical toxicity. I mean, maybe you can find an organization that actually does unit cost accounting. Listen to the show with Mick Connors, MD (EP495). Okay … as I said earlier, my guest today is Gary Campbell, who I spoke with in 2021—so this is a deep cut from the archives, but it's also a really great show. Gary, as I said earlier, is CEO of Johnson Health Center, which is an FQHC, in Lynchburg, Virginia. He's also the president of Impact2Lead. Also mentioned in this episode are Impact2Lead; Johnson Health Center; Nikki King, DHA; Alliance Health Centers; Shane Cerone; Sam Flanders, MD; Kada Health; Mick Connors, MD; Aventria Health Group; John Lee, MD; Beau Raymond, MD; Amy Scanlan, MD; Eric Gallagher; Eve Cunningham, MD, MBA; Joyce Gioia; Robert Pearl, MD; Peter Attia, MD; Jerry Durham; and Tom Nash. For a list of healthcare industry acronyms and terms that may be unfamiliar to you, click here.   You can learn more at impact2lead.com and follow Gary on LinkedIn.   Gary Campbell is the founder and owner of Impact2Lead, LLC, and the president and CEO of Johnson Health Center (JHC), where he has enjoyed a career centered on leading for/not-for-profit organizations and helping to unleash potential in others along the way. In 2011, he left Bayer and went to JHC; and in 2013, he launched Impact2Lead to provide transformation-consulting services to other firms across the United States. Since joining JHC, the center has enjoyed unprecedented success and growth by transforming the culture using his Impact Leadership model and becoming the first Federally Qualified Health Center to be recognized as an Employer of Choice by Employer of Choice International, Inc. The health center has achieved multiple workplace and community awards since that time and has enjoyed exponential growth during his years as the CEO. Gary currently speaks and consults nationally on leadership, workplace strategies, and motivational topics.   09:03 Why is there no opportunity to cost shift in an FQHC? 09:34 What happens when an FQHC is operating inefficiently? 10:00 "Have you workflowed it out? … You can overstaff yourself in a way that your cost per patient goes way up." 10:23 Why is taking a lean approach not an excuse to cut staff? 11:27 EP490 and EP492 with Shane Cerone and Sam Flanders, MD. 11:35 EP438 with John Lee, MD. 11:38 EP455 with Beau Raymond, MD. 11:40 EP402 with Amy Scanlan, MD. 11:42 EP405 with Eric Gallagher. 12:48 "The nurses are linchpins to everything." 13:44 LinkedIn post from Eve Cunningham, MD, MBA. 15:10 How does standardizing care lead to personalization of care? 16:34 "Our clinical teams see that we care." 16:53 "If you don't have a vision for where you want to be two and three years down the road, you're struggling." 17:09 "I want everybody to understand, What is their why?" 19:45 Lean & Meaningful by Roger E. Herman and Joyce L. Gioia. 24:44 "You have to project plan things out that you want." 25:51 "They don't teach leadership in most medical schools."—Dr. Robert Pearl 26:46 Outlive by Peter Attia, MD. 27:55 "Get to know these clinicians." 29:39 "From a core values perspective, you can make every single decision … on core values." 30:03 "We always start with those values. … They're embedded in everything we do." 30:20 How does an FQHC or private practices that are patient-oriented attract talent? 35:24 EP297 with Jerry Durham. 35:54 "First and foremost, be visible."   You can learn more at impact2lead.com and follow Gary on LinkedIn.   Gary Campbell discusses #provider #fiscalresponsibility on our #healthcarepodcast. #healthcare #podcast #financialhealth #patientoutcomes #primarycare #digitalhealth #healthcareleadership #healthcaretransformation #healthcareinnovation   Recent past interviews: Click a guest's name for their latest RHV episode! Zack Kanter, Mark Newman, Stacey Richter (INBW45), Stacey Richter (INBW44), Marilyn Bartlett (Encore! EP450), Dr Mick Connors, Sarah Emond (EP494), Sarah Emond (Bonus Episode), Stacey Richter (INBW43)  

Okay. This show today is part of our Relentless Health Value "The Inches Are All Around Us" series. This Inches Talk is a metaphor for finding all those little places where there is healthcare waste as a first step in an effort to excise all these little pockets of waste. 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. Shane Cerone said this phrase during episode 492, and I loved it because there are inches all around us for sure. And the thing with all these inches that we're gonna talk about today and last week and next week and the week after that, yeah, these are inches that actually you could cut them. And there are millions and billions of dollars, and you actually improve patient care. You improve clinical team experience. Also, you're cutting out friction and making it easier to do the right thing to care for patients. These are no-brainer kinds of stuff if your North Star is better and more affordable patient care, but they are also somebody else's bread and butter in a "one person's cost is another person's revenue" kind of way. So, yeah … what makes perfect common sense might not be as easy as it might look on paper, as we all know so well. So, last week we dug into all of the inches of expensive friction that develop when stakeholders interact—like, a clinical organization and a payer and a plan sponsor, self-insured employer. They try to get paid or pay. They try to direct contract because what will be found fast enough is that the data is not the data is not the data, as Mark Newman talked about last week (EP496); and a dollar is not a dollar is not a dollar. Again, you'll find this out fast enough. All of you know when you talk to entities up and down the patient journey or across the life of a claim, otherwise known as a healthcare transaction. It's mayhem to get a claim paid often enough. Each stakeholder comes in with their own priorities and views and accounting methods and various rollups. I like how Stephanie Hartline put it. She wrote, "Healthcare … moves through many hands without a rail that preserves truth along the way. Attribution breaks, and truth gets reassembled later. The difference isn't capability—it's infrastructure. Line-item billing ≠ line-item settlement." Or I also like how Chris Erwin put it. He wrote, "When the blueprint isn't standardized, you aren't scaling. You're just compounding chaos." And yeah, then all of a sudden when there's no through line, there's no rail that connects all the data to the data to the data, or all the dollars to the dollars to the dollars. Suddenly 30% of any given healthcare transaction goes to trying to straighten it all back out again—to reassemble it, as Stephanie said. It's like unleashing 100 chaos monkeys and then having to pay to recapture them all. Listen to the show with David Scheinker, PhD (EP363) from last year about "Hey, how about we all just use the same template and avoid a lot of this." Or read Zeke Emanuel's book about how the USA should potentially consider copying the Netherlands model because they have private insurance. But they cut admin costs 75% or something like that. Oh, right … through standardization. Jesse Hendon summarized this the other day. He wrote, "Providers don't need armies of coders to fight 50 different insurance rule books [when you have some standardization here]." I say all this to say after recording the episode with Mark Newman from last week, I have become intently fascinated by what goes on in this non-standardized or otherwise friction points between stakeholders. There are a lot of inches in this gray area land of confusion.   This show today digs into one of them, which is what does it take to process a claim? Just technically. What are the pipes involved to submit a claim and, again, get paid for it, which is a healthcare transaction—just simply the technology moving the data around—even if everything in the pipes is a non-standardized hot mess. Because just fixing up the processing and the pipes here—again, while this doesn't solve the entire data isn't a data isn't a data or a dollar isn't a dollar isn't a dollar problem—if we can just cut out some of the processing and the moving the data around costs, just this all by itself is $6 billion a year worth of inches. Plus, as an added bonus, fix up the pipes for better data flow and now patient care can be faster if, for example, the prior auth or etc. processes transpire faster. And clearinghouses have entered the chat. But you know, when clearinghouses come up, at least in my world, when the clearinghouse word gets dropped, it's usually accompanied by like a puff of smoke because no one is quite sure what those guys do all day. So, we all sort of look at each other in the conversation and move on. Lucky for me and possibly you if I've managed to suck you into my web of intrigue, I ran into Zack Kanter from Stedi, a new clearinghouse, who agreed to come on the pod here and aid my exploration into this demarcation zone between stakeholders. So, let's start here. What is a clearinghouse? Well, a clearinghouse is the same thing as a switch when we're talking about pharmacy data transfers, if you're familiar with that terminology and that's helpful. But either way, in the conversation with Zack Kanter that follows, Zack will explain this better; but clearinghouses are like a hub, maybe, that connects all the payers with all the providers. So, if you want an eligibility check or you wanna submit a claim or do a prior auth of the payer, whatever you're trying to do, get paid, you as an EHR system or a doctor's office or an RCM (revenue cycle management) company, you don't have to set up your own personal data connection with every single payer out there. You don't have to go through all the authentications and the BAAs (Business Associate Agreements) and map all the fields and set up the 100 SOC 2–compliant APIs (application programming interfaces). Instead, you can hook up to one clearinghouse, and then that clearinghouse connects with everybody else. So, most medical claims transactions have a clearinghouse in the middle, like an old-timey telephone operator routing your claim or denial or approval of that claim or eligibility check or whatever to the right place. And unfortunately, old-timey telephone operator is a pretty apt metaphor, depending on which clearinghouse you're using. Anyway, Zack Kanter told me that the price to just send and receive an electronic little piece of data in healthcare through a clearinghouse costs about 1,000 times more than any other industry would pay. Like, if you do an eligibility check, that's gonna cost 10 to 15 cents per. The trucking industry pays that much for 1,000 such data transfers. They would riot if someone asked them to spend a dollar for 10 data transfers. That'd be ridiculous in their eyes. But in healthcare, all these dimes add up to, again, $6 billion a year—them's some inches there—which also equal delays in payment and patient care. Now you might be thinking, "Oh, well, maybe it costs this much because healthcare is so much more complicated than trucking or whatever." Well, turns out the opposite is true: Because of HIPAA, ironically enough, healthcare is, in fact, much more standardized (we were talking about standardization before); but healthcare is actually much more standardized than many other industries due to HIPAA's administrative simplification rules, which mandate a universal language for transactions—the pipes I'm talking about now. So, actually, for as much as I was just kvetching about chaos monkeys, compared to other industries, the baseline construct here is actually much more orderly than, for example, the trucking industry or whatever, like Amazon or Walmart has to deal with with their millions of vendors. Now—and here's a really big point, especially for self-insured employers—you know who the main customer is for a lot of the more programmatic, the newer kinds of clearinghouses? I'll tell you: newer digital entities who do RCM (revenue cycle management) for provider organizations, and that can be great if you're a practice just trying to keep up with payer denials and expedite patient care. But look, all you plan sponsors and self-assured employers and maybe unions out there, the more RCM purveyors start working with programmatic clearinghouses, the more you not doing programmatic prepayment integrity programs with unconflicted third-party prepayment integrity vendors who are as hooked into the data streams and the clearinghouses as the RCM vendors are, the more, as I said last week, increasingly you're bringing an ever more rusty knife to a gunfight. So, that is certainly something to consider. There's a whole episode next week about this with Mark Noel from ClaimInsight. Or if you just can't wait, go back and listen to the show with Kimberly Carleson (EP480) just for the gist of it, or the one with Dawn Cornelis (EP285) from a few years ago. They're talking post-payment integrity programs, but a lot of the same rules apply. The show today is sponsored by Aventria Health Group, as usual. But I do want to say that we got some very appreciated financial support from Stedi, the only programmable healthcare clearinghouse. And here is my conversation about all of the inches that are all around us, specifically in the healthcare data pipes, with Zack Kanter, who is the CEO and founder over at Stedi. Also mentioned in this episode are Stedi; Shane Cerone; Mark Newman; Stephanie Hartline; Chris Erwin; David Scheinker, PhD; Zeke Emanuel, MD, PhD; Jesse Hendon; Mark Noel; ClaimInsight; Kimberly Carleson; Dawn Cornelis; Aventria Health Group; Preston Alexander; Eric Bricker, MD; and Kada Health. For a list of healthcare industry acronyms and terms that may be unfamiliar to you, click here. You can learn more at stedi.com. You can also follow Zack and Stedi on LinkedIn.   Zack Kanter is the founder and CEO of Stedi, the only programmable healthcare clearinghouse. Stedi has raised $92 million from Stripe, Addition, First Round, USV, Bloomberg Beta, and other top investors. He has previously appeared on podcasts, including In Depth by First Round Capital, Invest Like the Best, Village Global, and Rule Breaker Investing.   09:47 What things are being paid for that we might not be aware we're paying for in healthcare? 12:09 Why HIPAA actually makes healthcare more standardized than other industries. 15:35 How healthcare is ahead in some ways and behind in others. 18:03 Where do the 4 to 5 days come from in healthcare transaction processing? 20:39 Why these transaction delays affect care delay. 23:14 EP482 with Preston Alexander. 23:18 EP472 with Eric Bricker, MD. 27:10 How should the process work from the time a provider clicks "validate"? 30:19 Why is the clearinghouse the right place to solve all these issues? 31:41 Why are we where we are in terms of these issues? 35:28 Why people should be looking at their clearinghouse costs. 36:59 What to know about Stedi.   You can learn more at stedi.com. You can also follow Zack and Stedi on LinkedIn.   @zackkanter discusses #healthcaretransactions and #clearinghouses on our #healthcarepodcast. #healthcare #podcast #financialhealth #patientoutcomes #primarycare #digitalhealth #healthcareleadership #healthcaretransformation #healthcareinnovation   Recent past interviews: Click a guest's name for their latest RHV episode! Mark Newman, Stacey Richter (INBW45), Stacey Richter (INBW44), Marilyn Bartlett (Encore! EP450), Dr Mick Connors, Sarah Emond (EP494), Sarah Emond (Bonus Episode), Stacey Richter (INBW43), Olivia Ross (Take Two: EP240)

I'm gonna do a little series here called "The Inches Are All Around Us," and in this series, at least to start, all of the inches I'm gonna mention are full-on administrative waste—waste that is particularly egregious because it has nothing to do with patient care. That's why when Shane Cerone said, "The inches are all around us" in episode 492 about hospitals and hospital prices, I really perked up. Because by fixing this friction, this administrative waste, we can actually improve patient care and reduce costs simultaneously. 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. Along these same lines, I have also heard Zack Cooper, PhD, talk about the 1% steps to healthcare reform project, where he's like, look, find 10 or 30 or whatever 1% problems, and you'll probably transform healthcare faster than if you're trying to find a 10% or 30% solution. So, same idea. And finding these inches, these 1 percents, even in and of themselves, it's big dollars when it comes to how much the U.S. spends on healthcare, which is, by the way, projected to reach $5.6 trillion in 2025, according to NHE (National Health Expenditure) projections from federal actuaries. So, I decided to go on a bit of a quest for these inches—you know, get a bead on where they may be nestled for anyone looking on behalf of their plan or their country or their state maybe. To this end, also recall or be aware of the episode with David Scheinker, PhD (EP363). But David Scheinker in that episode gets into how much every industry pays something like 2% to administer a transaction. But in healthcare, the provider pays something like 14%, and the payer pays another 14% to submit and get paid for a claim, which is healthcare for a transaction. Don't get me wrong, it's the plan sponsors such as self-insured employers, members, and USA taxpayers who are ultimately paying for those two 14 percents. So that 28% of full-on administrative costs—most of which, we could agree, could go away and probably be better for patients, not worse—this, too, is coming out of the pockets of the ultimate purchasers of healthcare. Those costs are getting passed along. I say all this to say, to kick off this "the inches are all around us" exploration, I wanted to dig in a little more specifically into what goes on during these aforementioned transactions (ie, what this life of a claim kind of, like, looks like on the ground). I wanted to start here because, yeah, we haven't done this before; and this exploration is gonna continue into next week because we're gonna dip heavy into clearinghouses with Zack Kanter and what they do all day. And then after that, I'm talking payment integrity programs. I'm talking prepayment review programs with Mark Noel, because you know what? Employers don't wanna be bringing a knife to a gunfight. And I realized in the course of these conversations that any self-insured plan sponsor that is not doing, for real, payment integrity programs, for real, prepayment review, post-payment review.  I'm getting ahead of myself, but when you listen to the show next week with Zack Kanter, you will so totally see what I mean. Today, as I mentioned earlier, I am speaking with Mark Newman, who is the CEO and founder of Nomi Health. Nomi aims to simplify the act of buying and paying for healthcare for self-insured employers. Look 'em up if that sounds intriguing. I also do need to thank Nomi Health for so generously offering to donate to RHV to cover the expenses of producing this episode. So, thank you so much to Nomi Health. Okay, lastly here, just to set the basic framework for this conversation that follows, Mark gets into two main revelations, reasons that kind of sit behind all a large part of the waste and friction in healthcare transactions. Again, otherwise known as a claim getting paid. And these two reasons are data isn't data isn't data. In other words, as a claim moves through the system to different stakeholders, the data starts to change and morph and come and go. Different people have different use cases for that data, so it starts to get added and subtracted, but nobody really has the universal level to tote up the difference in any organized fashion. So, we talk about that first. Then Mark Newman doubles down with another reason for the friction and waste. Here's the second revelation: A dollar isn't a dollar isn't a dollar. And same kind of rules apply here. A plan sponsor might spend a dollar and, yeah, is that dollar spent or is that dollar accrued to spend? Which is kind of wonky, but also relevant. And if you didn't understand that, we'll get to it. And then just because a dollar gets spent doesn't mean the provider gets that dollar. And by the way, I don't just mean, oh, there's spread pricing. How shocking. I mean that a plan sponsor could roll up to a hospital and say, "We spent $10 million last year," and the hospital could say, "No, you didn't. You only spent five." And spoiler alert, in this case, it's not about spread pricing, although it might be. It's also about how much was the member responsibility that the members didn't pay. So, a dollar is not a dollar for a whole bunch of different reasons. This podcast is sponsored by Aventria Health Group, and today, it's also sponsored by Nomi Health. Also mentioned in this episode are Nomi Health; Shane Cerone; Zack Cooper, PhD; David Scheinker, PhD; Zack Kanter; Mark Noel; Aventria Health Group; Preston Alexander; Eric Bricker, MD; Sam Flanders, MD; Andrew Tsang; Sandra Raup; Stan Schwartz, MD; ZERO.health; Cristin Dickerson, MD; and Matt Christensen. For a list of healthcare industry acronyms and terms that may be unfamiliar to you, click here.   You can learn more at nomihealth.com or reach out to Mark at mark@nomihealth.com. You can also follow Mark and Nomi Health on LinkedIn.   Mark Newman is the co-founder and CEO of Nomi Health, on a mission to rebuild America's healthcare system to serve all stakeholders: providers, employers, and patients. A recognized healthcare innovator and entrepreneur, Mark previously founded and built HireVue into the world's largest provider of AI-driven talent assessment solutions before its acquisition by the Carlyle Group. His commitment to improving the healthcare system stems from a desire to address systemic issues that have long plagued the industry. Under his leadership since its inception in 2019, Nomi Health has focused on creating a more direct and transparent healthcare experience: reducing an organization's spend by over 30% per patient while increasing a provider's payments. Through Nomi Health, Mark continues to advocate for a more efficient, service-centered approach to healthcare that prioritizes known costs for employers, zero out of pocket for patients, and near-real-time payments for providers.   06:48 What is actionable to know about the life of a claim? 08:14 How data can change as it moves through the claims process. 11:45 Why a dollar isn't a dollar in healthcare. 18:50 Why employers are actually paying more than a dollar to access a dollar of healthcare (the medical loss ratio). 21:54 Why cutting out the "friction" is actually better for employees and members. 22:48  EP482 with Preston Alexander. 22:50 EP472 with Eric Bricker, MD. 23:36  EP490 and EP492 with Sam Flanders, MD, and Shane Cerone. 23:53 Infographic by Andrew Tsang showing 27 streams of income. 26:53 How do we fix these issues? 28:05 LinkedIn comment from Sandra Raup. 28:59 How Nomi Health is experimenting with a no co-payment, no deductible model. 31:29 INBW42 with Stacey on moral hazard. 32:26 EP486 with Stan Schwartz, MD. 32:31  EP485 with Cristin Dickerson, MD. 32:56 The Innovator's Dilemma by Clayton M. Christensen. 34:55 How does Nomi Health work with and help employers?   You can learn more at nomihealth.com or reach out to Mark at mark@nomihealth.com. You can also follow Mark and Nomi Health on LinkedIn.   @markhirevue discusses #plansponsor #healthspend and #clinicalorg pay on our #healthcarepodcast. #podcast #financialhealth #patientoutcomes #primarycare #digitalhealth #healthcareleadership #healthcaretransformation #healthcareinnovation   Recent past interviews: Click a guest's name for their latest RHV episode! Stacey Richter (INBW45), Stacey Richter (INBW44), Marilyn Bartlett (Encore! EP450), Dr Mick Connors, Sarah Emond (EP494), Sarah Emond (Bonus Episode), Stacey Richter (INBW43), Olivia Ross (Take Two: EP240), John Quinn

In this Part 2 episode of 'Relentlessly Seeking Value,' host Stacey Richter recaps the prominent themes 4 and 5 from 2025. The focus is on two major themes: the lack of transparency in data access leading to overspending and the necessity of shifting from volume-based to value-based purchasing in healthcare.  The discussion includes insights from numerous healthcare professionals and case examples to underscore these vital themes affecting both patients and providers. === LINKS ===

In this 'Inbetweenisode' of the Relentless Health Value podcast, Stacey Richter recaps the major themes covered throughout 2025 in healthcare.  In this Part 1, Stacey dives into three critical themes: the necessity of trusted relationships and simplicity, treating primary care as an investment rather than a cost, and the impact of perverse financial incentives and profiteering.  Various experts, including Dr. Kenny Cole, Ann Lewandowski, Jonathan Baran, and Yashaswini Singh, share insights on these subjects. The discussion highlights the pervasive lack of trust in the healthcare system, the financial implications of underfunded primary care, and the negative effects of misaligned financial incentives and profiteering within the industry. Check out the show notes using the link below for all of the mentioned links and episodes. === LINKS ===

In this encore episode of 'Relentlessly Seeking Value,' host Stacey Richter revisits an inspiring conversation with Marilyn Bartlett, a CPA who transformed the State of Montana's employee health plan from a $9 million deficit to a $112 million surplus within three years.  Known for her fiscal discipline and patient-first approach, Marilyn shares her strategic steps, from identifying waste in the system and securing quick wins to negotiating better deals with hospitals and ensuring long-term success. She emphasizes the importance of assembling a strong team, maintaining transparency, and staying focused on the ultimate goal of creating real health value. This episode is a must-listen for anyone looking to drive meaningful change in the healthcare industry. === LINKS ===

In episode 495 titled 'Wait. Flip that. A Crazy Revelation I Had About Trying to Fix US Healthcare,' host Stacey Richter speaks with Dr. Mick Connors, an emergency room pediatrician and healthcare entrepreneur, about a groundbreaking insight into the US healthcare system.  They discuss the paramount need to flip the way healthcare costs and outcomes are measured: moving towards unit-level cost accounting and whole-patient or whole-community outcomes assessment. The episode delves into the fundamental pitfalls of the current healthcare structure, emphasizing the misalignment between cost aggregation and patient-level outcome measurements. They explore the challenges faced by physicians in the current system, the role of investor mindsets, and the importance of dyad leadership and mission-driven practices to improve overall healthcare value. === LINKS ===

I was out drinking martinis with Cora Opsahl, director of 32BJ Health Fund, and Cora said, "Look, most plan sponsors' biggest expense is health system spend, hospital spend." I know this is an unexpected start to an episode about pharmaceutical pricing and value featuring Sarah Emond, CEO of ICER (Institute for Clinical and Economic Review). But yeah, 50% of most plan sponsors' spend these days goes to health systems. Fifty percent! One half! 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, if a patient who is adherent to a drug and that drug keeps that patient out of the hospital, why do I want to make a patient have excessive skin in the game to get that drug, which everybody knows at this point this "skin in the game" can cause said patient to not be adherent in many cases, cost being a very big reason patients give for not taking medications as prescribed. So then we have this not adherent patient who winds up in the hospital, via the ER often enough. The core issue here that surfaced, bottom line—and I'm not sure if this was in spite of the martinis or as a result of them—but while hospital spend is the largest health expense, high-value drugs that prevent hospitalization often face patient cost sharing and access restrictions, which leads to poor patient adherence and ultimately higher system cost potentially. So then Cora and I spent the next half hour debating when the statement is empirically true and when it's not. And you know what it all boils down to? What's the value of the drug? Do we even know what that means to start? But if it's determined that the drug is relatively high value, then the plan desperately should want to do everything possible to keep that patient on that medication, and cost sharing is a huge barrier to adherence. Today, as I said, I'm speaking with Sarah Emond, CEO over at ICER, and we get into all of this in the conversation that follows. In fact, most of the conversation that follows explores the tensions that exist in the current way that we sell and buy pharmaceutical products. I'm just gonna sum up these tensions in a list here at the top of this show. There's six of them that Sarah Emond and I discussed today by my counting, and each of these we explore in some depth. So, here's the list. Tension 1: The value of any given drug (in other words, what is the fair price for that drug considering the health gains that it delivers) versus the total cost to the plan for the total population taking that drug. GLP-1s have entered the chat. GLP-1s (by ICER's analysis, at least) are super high-value drugs that also can bankrupt plans due to the number of folks who may benefit from taking the drug. Definitely a tense tension to kick off our list here. Tension 2: The list or net price of a drug versus patient access and affordability. Again, this can be tense in an area of much misalignment. You can have a great well-priced drug with huge patient affordability and access challenges because drug net price and coinsurance amounts often have nothing to do with each other. Tension 3: Lifetime value of a drug versus a 3-, 2.5-year, whatever time horizon that many plan sponsor actuaries use in their value assessment. We discussed this today, but there's a Summer Short (SUMS7) on actuarial value horizons with Keith Passwater and JR Clark if you wanna dig in on this further. Tension 4: The tension between the societal value of a drug or even the patient's perceived value of a drug versus what an employer plan sponsor might perceive as the value. What is the formula used to determine value? What's in and what's out? So, that's a bigger conversation just beyond the time horizon for what's included in this calculation. Tension 5: Exacerbating the what's included in the value contemplation beyond just what you include in there is the tension between what is hypothetically of value and what is possible to measure. If you have pharma datasets and medical datasets separate in silos, who knows how many hospital readmissions were prevented by whatever drug? And how much presenteeism or absenteeism exists. I mean, it is an outlier, again, if anyone even knows the net price they paid for a drug, just to level set context here. Tension 6: Lowering financial barriers for patients to take drugs that are of value versus status quo goals and incentives. Like, for example, PBMs (pharmacy benefit managers) are often told that their goal is to reduce drug spend. Okay … so, how do I do that? Oh, reduce access either by prior auths or delay tactics or really high coinsurance, which is gonna reduce adherence by design. And it's someone else's problem—if I'm just thinking like a status quo PBM—if medical spend goes up, right? So, that's our last and not insignificant tension. And look, who comes out the loser in all of these tensions when they get tense? Patients. Not pricing based on value and not buying and setting up cost sharing based on value punishes patients and also plan sponsors or any other ultimate purchaser in the long term, given that the plan is but a population of patients if you start thinking about it in that context. Here is Sarah's advice in a nutshell: Pharma, sell. Pick your price based on something other than market power. And some pharma companies are actually dipping their toe into these waters and doing it. But then PBMs and plan sponsors have to hold up their end of the bargain here and buy drugs based on their value, not just the size of their rebates or some other discounting promise. And then we gotta continue the through line through to member affordability and access. High-value drugs should get preferred. So, right, do a high-value formulary. Listen to the show with Nina Lathia, RPh, MSc, PhD (EP426) on high-value formularies and then listen (after you're done with that one) to episode 435 with Dan Mendelson entitled "Optimized Pharmacy Benefits Are Required if You Want to Do or Buy Value-Based Care." Also, as I said, GLP-1s come up in this conversation, so … yeah, buckle up. One last thing, besides my normal thank you to Aventria Health Group for sponsoring this episode, I am so pleased to thank Payerset for donating to help Relentless Health Value stay on the air. Payerset is a price transparency company with a mission to create fair and equitable healthcare for everyone. Love that. Payerset empowers healthcare organizations, employers, and patients with the most complete set of healthcare price transparency data. They benchmark every negotiated rate and claim and delivering the actionable insights needed for smarter contract negotiations and a more transparent healthcare system. As I have said several times today, my conversation is with Sarah Emond, CEO of ICER. Also mentioned in this episode are Institute for Clinical and Economic Review (ICER); Cora Opsahl; 32 BJ Health Fund; Keith Passwater; JR Clark; Nina Lathia, RPh, MSc, PhD; Dan Mendelson; Aventria Health Group; Payerset; Antonio Ciaccia; Elizabeth Mitchell; Purchaser Business Group on Health (PBGH); Shane Cerone; Sam Flanders, MD; Mark Cuban; Morgan Health; and Tom Nash. For a list of healthcare industry acronyms and terms that may be unfamiliar to you, click here. You can learn more at ICER.org and follow Sarah on LinkedIn.   Sarah K. Emond, MPP, is president and chief executive officer of the Institute for Clinical and Economic Review (ICER), a leading nonprofit health policy research organization, with 25 years of experience in the business and policy of healthcare. She joined ICER in 2009 as its first chief operating officer and third employee and has worked to grow the organization's approach, scope, and impact over the years. Prior to joining ICER, Sarah spent time as a communications consultant, with six years in the corporate communications and investor relations department at a commercial-stage biopharmaceutical company and several years with a healthcare communications firm. Sarah began her healthcare career in clinical research at Beth Israel Deaconess Medical Center in Boston. A graduate of the Heller School for Social Policy and Management at Brandeis University, Sarah holds a Master of Public Policy degree with a concentration in health policy. Sarah also received a bachelor's degree in biological sciences from Smith College. Sarah speaks frequently at national conferences on the topics of prescription drug pricing policy, comparative effectiveness research, and value-based healthcare.   08:18 Why list prices are a lie. 10:59 How does the rebate model sometimes get in the way of paying for value? 12:50 Bonus clip with Sarah Emond. 13:14 EP491 with Elizabeth Mitchell. 13:20 EP490 and EP492 with Shane Cerone and Sam Flanders, MD. 14:37 The tension that is created between affordability and adherence. 15:03 When cost sharing makes sense in pharmaceutical drug pricing. 17:26 INBW42 with Stacey on moral hazard. 18:53 How GLP-1s are "wildly cost effective." 21:32 Why the sticker shock on cost-effective drugs is a failure in the system for paying for value. 22:38 ICER's report on GLP-1s. 26:59 EP385 with Dan Mendelson. 28:57 How employers and payers can have a value assessment approach and a health insurance system that allows access to cost-effective drugs. 29:48 How cost-effective prices are calculated. 31:55 One of the core value underpinnings for value assessment of drugs. 34:54 Why manufacturers and pharmacy benefit managers should work together more by referencing something like an ICER report. 36:55 EP426 with Nina Lathia, RPh, MSc, PhD. 38:21 "We can make different choices."   You can learn more at ICER.org and follow Sarah on LinkedIn.   @sarahkemond discusses #pharmaceutical #drugpricing on our #healthcarepodcast. #healthcare #podcast #financialhealth #patientoutcomes #primarycare #digitalhealth #healthcareleadership #healthcaretransformation #healthcareinnovation   Recent past interviews: Click a guest's name for their latest RHV episode! Stacey Richter (INBW43), Olivia Ross (Take Two: EP240), John Quinn, Dr Sam Flanders and Shane Cerone (EP492), Elizabeth Mitchell (EP491), Shane Cerone and Dr Sam Flanders (Part 1), Dan Greenleaf (Part 2), Dan Greenleaf (Part 1), Mark Cuban and Cora Opsahl

Not gonna give much of an introduction here because this is a short bonus level set, but I did just wanna call everyone's attention to the "arms race" created by our status quo purchasing and selling of many things, pharmaceuticals included. 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. For example, raise the list price of a drug to maximize rebates, because the higher the list, the bigger the discount you can give, which then exacerbates patient affordability because coinsurance is often based on list price. But then Pharma starts offering co-pay cards, which messes up the whole PBM (pharmacy benefit manager) plan to drive patients to their highest-rebate products (ie, the most profitable products). So then maximizers and accumulators enter the chat, and prior auths ramp up because plans start having to raise premiums after enough 340B drugs with high lists and no rebates, and then there's no cost containment and raise deductibles and around and around we go. Meanwhile, is this drug fundamentally worth the list price or even the net price? Is it an effective drug? What's the right price to be paying for this drug? Should be the operative question, right? Just like what's the quality and appropriateness of any medical service? Maybe we should just quit it and just pay for value. And with that, let me introduce Sarah Emond, CEO of ICER (Institute for Clinical and Economic Review), and I will let Sarah tell the rest of the story. Also mentioned in this episode are Institute for Clinical and Economic Review (ICER); Cora Opsahl; 32 BJ Health Fund; Payerset; Aventria Health Group; Dea Belazi, PharmD, MPH; and Tom Nash. For a list of healthcare industry acronyms and terms that may be unfamiliar to you, click here.   You can learn more at ICER.org and follow Sarah on LinkedIn.   Sarah K. Emond, MPP, is president and chief executive officer of the Institute for Clinical and Economic Review (ICER), a leading nonprofit health policy research organization, with 25 years of experience in the business and policy of healthcare. She joined ICER in 2009 as its first chief operating officer and third employee and has worked to grow the organization's approach, scope, and impact over the years. Prior to joining ICER, Sarah spent time as a communications consultant, with six years in the corporate communications and investor relations department at a commercial-stage biopharmaceutical company and several years with a healthcare communications firm. Sarah began her healthcare career in clinical research at Beth Israel Deaconess Medical Center in Boston. A graduate of the Heller School for Social Policy and Management at Brandeis University, Sarah holds a Master of Public Policy degree with a concentration in health policy. Sarah also received a bachelor's degree in biological sciences from Smith College. Sarah speaks frequently at national conferences on the topics of prescription drug pricing policy, comparative effectiveness research, and value-based healthcare.   02:28 What is ICER? 02:47 What does the Institute for Clinical and Economic Review do? 05:09 The importance of still showing up, even when others don't understand or disagree. 06:51 EP293 ("Game Theory Gone Wild") with Dea Belazi, PharmD, MPH. 09:04 Why it's important to think about population health and how our choices impact affordability for everyone.   You can learn more at ICER.org and follow Sarah on LinkedIn.   @sarahkemond discusses #ICER and the status quo of #pharmaceuticaldrug #pricing on our #healthcarepodcast. #healthcare #podcast #financialhealth #patientoutcomes #primarycare #digitalhealth #healthcareleadership #healthcaretransformation #healthcareinnovation   Recent past interviews: Click a guest's name for their latest RHV episode! Stacey Richter (INBW43), Olivia Ross (Take Two: EP240), John Quinn, Dr Sam Flanders and Shane Cerone (EP492), Elizabeth Mitchell (EP491), Shane Cerone and Dr Sam Flanders (Part 1), Dan Greenleaf (Part 2), Dan Greenleaf (Part 1), Mark Cuban and Cora Opsahl  

In this special Thanksgiving episode of Relentless Healthcare Value, the focus is on gratitude and giving thanks to various contributors within the healthcare community. Host Stacey Richter extends her 'baskets of thank yous' to colleagues, mentors, and partners committed to transforming healthcare.  These baskets recognize those who maintain respectful dialogues despite small disagreements, those who collaborate and pay it forward within the community, and those who support the concept of a 'demand curve' in healthcare markets.  === LINKS ===

This OG of directly contracted high-value networks or Centers of Excellence networks came up, name dropped and everything in the episode with Elizabeth Mitchell from PBGH, the Purchaser Business Group on Health, from two weeks ago. That was episode 491. So, welcome to this deep cut episode with Olivia Ross from way back, pre-pandemic times. This episode of Relentless Health Value revisits the concept of directly contracted high value networks or Centers of Excellence (ECEN) with Olivia Ross. The discussion explores the impact and potential of the ECEN network, emphasizing the importance of quality, price transparency, and multidisciplinary approaches in healthcare.  Olivia delves into the reasons why ECEN was significant in past PBGH projects and its current relevance, despite its eventual dismantling due to corporate changes. The episode highlights the benefits for employers in creating their own high-value networks and the positive outcomes from fewer unnecessary surgeries and better quality care. Additionally, it covers the rigorous process of selecting Centers of Excellence and how continuous quality improvement efforts benefit both employers and healthcare providers. === LINKS ===

Hello, all you great people trying to figure out how to do right by patients. Welcome to it. I was and am always extremely curious if any of what we talk about over here on Relentless Health Value has, in any way, percolated over to your average employer CEO—the ones who do not listen to this show, I mean. 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 is what I try to figure out during my conversation upcoming here with John Quinn from Wellnecity® today, and I score some advice to boot for employers in the face of any of these revelations that they may have. That's what's gonna go down today, and this whole endeavor is a decent plan, if I do say so myself, because John Quinn chats up a lot of employer CEOs. He's certainly got a bit of a catbird seat there. So, taking it from the top, I wanted to see how clued in these employer C-suites might be to a fundamental myth, which, if employer folks don't realize it is in fact a myth, it means that a whole lot of transformational power is going nowhere fast. And this myth is the mother of all myths: the "there is a market in healthcare" myth. We've been on a tear about this for three episodes now, at least as it relates to hospitals and health systems. I'm gonna refer everybody to LinkedIn because Luke Trocchio put up a, I don't know what you call it, a reel, highlighting something that Shane Cerone said in episode 490. And then I'm gonna tell you why whatever CEOs at self-insured employers are thinking here makes all the difference in the world. But what Shane said is this, "The myth is that we have a functioning marketplace, and we don't." Shane continues, "What I mean by [there is no actual healthcare market], as somebody who's been a CEO of multiple hospitals and health systems, hospitals don't compete on price for patients. It … doesn't work that way. And so, we don't really have a normal market incentive to reduce cost or, in this case, the price of services in order to remain competitive." Now look, and this isn't rocket science, but it needs to be said out loud. The reason there is no healthcare market largely is because self-insured employers have not insisted upon there being one. Is that fair? I don't know. And whether or not it's fair is irrelevant to this point. Self-insured employers pay for healthcare for, like, 160 million Americans. They are largely the demand curve. They are the demand side of any market that exists. Because you know something that doesn't our market make? You can't ask the supply side to create demand elasticity. You can't get a seller to get a buyer to buy or not buy at some price point. That would be like a comedy skit. Except in this case, you know, patients die or go bankrupt because they can't afford care. So, it's not really all that funny. But if in this country we are depending on health system prices being constrained by a market, and then you don't have a buyer who doesn't buy when the price is higher than the buyer wants to pay or a buyer who doesn't buy unsafe stuff or low-quality goods or services, you're gonna get sky-high prices. Welcome to it right now. Also, if there's no competition, again, no market. But competition a lot of times doesn't surface if there's no point in starting up a business because there's no demand for lower prices or higher-quality care. I mean, if no one cares if you have lower prices or higher quality, then how are you gonna attract patient volume or steal market share, right? Like, unless you're really good at marketing, I guess, or have accumulated market power. I'll say this again. If our whole, the whole healthcare sector pricing structure is built on the myth that there is a market and then there's no market and employers aren't filling for whatever reason, the vital demand side role that they have to play for there to be a market, then, right … hello, 37% renewals like we see coming up in New Jersey. Listen to the show with Kevin Lyons (EP487, Part 1). So, I say all this to say, do employer CEOs even know they have one job here? And I'm not talking about, again, whether or not this is fair, whether they're capable of pulling this off. I'm just distilling this whole thing down to this is the question that remains on the ground. So anyway, this is first and foremost what I go after John Quinn from Wellnecity to figure out today: Where's your average CEO in this learning curve? Now here's some demand curve optimism. The show from two weeks ago with Elizabeth Mitchell (EP491) from PBGH, the Purchaser Business Group on Health. In that show from a couple weeks ago, we talk about what PBGH members, who are very large employers, what they're up to. So, certainly go back and listen to that if you haven't. Okay, so with that, here's my conversation with John Quinn from Wellnecity, as I have mentioned; and you'll get two things out of this conversation. Number one, a level set on what employers' leadership teams are figuring out and why they are figuring this out. (Renewal shocks and employees complaining about affordability much?) But also how the mindset needs to shift in the C-suite for anything to really happen here. In other words, what's the assignment and what's some very top-line advice to get there? That's how I finish up the conversation with John Quinn today. Do just wanna note that Wellnecity so kindly offered to pick up some of the tab to produce this Relentless Health Value show, which, as I keep saying is … yeah, it is expensive to keep this train on the track. People often forget it's not just what goes into the recording, the hosting, the producing, the editing of a podcast, but there also is a whole Web site and an API feed and headshots and graphics and transcriptions and a proofreader. It's a whole thing, guys, even if the host is a volunteer with a day job. So, thanks much to Wellnecity for the contribution to the fund and for coming on the pod today. John Quinn is CEO of Wellnecity. Wellnecity does health plan management for employers that self-fund their health plan. The key role Wellnecity plays is how do they help those employers better manage the spend category called health benefits. This podcast, as I said, is partially sponsored by Wellnecity and also Aventria Health Group. Also mentioned in this episode are Wellnecity; Luke Trocchio; Shane Cerone; Kevin Lyons; Elizabeth Mitchell; Purchaser Business Group on Health (PBGH); Paul Holmes; Peter Hayes; Healthcare Purchaser Alliance; Mark Cuban; Lauren Vela; Cora Opsahl; Andreas Mang; Jon Camire; Eric Bricker, MD; and Christine Hale, MD, MBA. For a list of healthcare industry acronyms and terms that may be unfamiliar to you, click here. You can learn more at Wellnecity and follow John on LinkedIn.   John Quinn is the founder and CEO of Wellnecity, a health tech innovator on a mission to measurably improve the quality and affordability of employer-sponsored health plans in the United States. Under John's leadership, Wellnecity developed the groundbreaking Smart Hub platform, which integrates data from multiple vendors to simplify health plan management. Smart Hub enables organizations to measure ROI objectively, uncover savings, enhance member engagement, and reduce fiduciary risk. Building on this foundation, Wellnecity has launched its next-generation plan management platform, equipping HR leaders with real-time oversight, vendor accountability, and measurable ROI. The platform empowers leaders to act in the moment, redirecting spend, simplifying oversight, and delivering better healthcare for employees. John is also the author of Benefits Revolution: The Next Generation of Employer-Sponsored Healthcare and is widely regarded as a thought leader in the healthcare space. He believes healthier businesses are built on smarter healthcare for employees, and that data is the key to driving this transformation. Prior to founding Wellnecity, John spent 25 years at Andersen Consulting, Diamond Technology Partners, and McKinsey & Company. He advised Global 1000 companies and high-growth start-ups, helping them build new businesses, products, and channels. His expertise in digitized information and network effects has driven meaningful business model innovation. John is a sought-after speaker on topics such as the benefits revolution, the power of data, fixing what's broken, and health tech leadership. Helping organizations deliver innovation is his mission; fixing what's broken is his passion.   07:06 Why CEOs are looking more closely at healthcare spend. 08:06 EP397 with Paul Holmes. 08:21 How savings and health benefits are directly connected. 10:45 EP436 with Elizabeth Mitchell. 11:46 What missed earnings look like in relation to healthcare. 14:27 How costs have been shifting to employees for years, and why this doesn't work anymore. 17:36 EP475 with Peter Hayes. 18:23 What employers need to do instead of cost shift. 19:12 EP406 with Lauren Vela. 21:30 Why it's important to make health benefit changes at the speed of business, not at the speed of the benefits year. 26:17 Why is it important to put a finance function into your benefits? 27:10 EP488 with Mark Cuban and Cora Opsahl. 27:33 EP478 (Part 1) with Andreas Mang and Jon Camire. 27:35 Why daily data matters. 31:10 EP487 (Part 1) with Kevin Lyons. 31:21 Why it's important to hold vendors accountable. 31:47 Why it's important to move on from vendors who can't hold up to your scrutiny and needs. 33:46 EP472 with Eric Bricker, MD. 34:46 EP471 with Christine Hale, MD, MBA.   You can learn more at Wellnecity and follow John on LinkedIn.   John Quinn gives advice to #employer #CEOs on the #healthcaremarket on our #healthcarepodcast. #healthcare #podcast #financialhealth #patientoutcomes #primarycare #digitalhealth #healthcareleadership #healthcaretransformation #healthcareinnovation   Recent past interviews: Click a guest's name for their latest RHV episode! Dr Sam Flanders and Shane Cerone (EP492), Elizabeth Mitchell (EP491), Shane Cerone and Dr Sam Flanders (Part 1), Dan Greenleaf (Part 2), Dan Greenleaf (Part 1), Mark Cuban and Cora Opsahl, Kevin Lyons (Part 2), Kevin Lyons (Part 1), Dr Stan Schwartz (EP486), Dr Cristin Dickerson

In this episode, host Stacey Richter speaks with Dr. Sam Flanders and Shane Cerone about creating a high-quality hospital management model focused on surviving at 150% of Medicare costs. They discuss the inefficiencies in health systems and practical solutions to improve them without compromising quality.  The conversation covers the importance of empowering frontline staff, adopting continuous improvement models like Toyota's, and the critical role of employers in reshaping market dynamics through direct negotiation and price transparency. The episode emphasizes actionable steps for hospital executives, plan sponsors, and employers to drive significant improvements in healthcare efficiency and affordability. === LINKS ===

In Episode 491, Stacey Richter interviews Elizabeth Mitchell, CEO of the Purchaser's Business Group on Health (PBGH), about the PBGH Transparency Demonstration Project. They discuss the project's aim to provide jumbo self-insured employers with transparency in healthcare costs, quality, and safety data. Collaborating with Milliman and Embold and funded by the Peterson Center on Healthcare, PBGH's project reveals no correlation between higher prices and quality in healthcare services. The episode highlights the impacts on TPAs, consultants, and clinical organizations, and underscores the importance of employers using this new transparency data for strategic advantage and compliance with the Consolidated Appropriations Act. Richter and Mitchell delve into the broader implications for creating high-value networks and fostering market competition based on quality and affordability. === LINKS ===

In this episode of Relentless Health Value, host Stacey Richter speaks with Shane Cerone and Dr. Sam Flanders of Kada Health about three pervasive myths in the healthcare industry. They discuss the belief in a functioning healthcare market, the necessity of high prices for hospital survival, and the notion that reducing prices means lower quality care. Highlighting the inefficiencies and lack of competition in the current system, they address the importance of transparency and competition. This episode sets the stage for a follow-up discussion focusing on tangible solutions and improvements for the healthcare system. === LINKS ===

Ben Schwartz, MD, MBA, wrote an article recently, and yeah, he makes a really compelling point. Dr. Schwartz wrote, “Ultimately, the most successful care models are those that create value inherently. The goal isn't simply cost arbitrage; it's creating a sustainable system that makes value attainable. Care delivery innovation is about more than optimizing for VC [venture capital] returns or maximizing operational efficiency.” 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. That mention of value and how to achieve it for real—like, actually create a care model that delivers value inherently—is a great segue to introduce the show this week. It's a continuation of our mission/margin theme, and this week, we're talking about the margin part of the “no margin, no mission” cliché. So, taking this from the top, last week—and go back and listen to that show if you have not yet (and you can listen to both of these parts in no particular order; you do you)—but last week, we talked mission. That part about value and creating value inherently? The tie-in here to mission and margin could be a value equation, really. Like, mission divided by margin is how you calculate the value delivered (less carrier spread), but that's a whole other show with Cynthia Fisher (EP457). So, let me introduce my guest this week, who was also my guest last week: Dan Greenleaf, CEO of Duly, which is a multispecialty group in Chicago. So, last week Dan and I talked mission, as I said; but today we're talking margin, which is, again, gonna be the denominator of so many value equations. Last week in that mission show, quick review (or spoiler alert, depending on the order in which you may be listening to these shows), but last week, Dan Greenleaf broke mission, Duly's mission, into four quadrants. The four quadrants of mission being affordability, access, consumer experience, and quality. In this conversation today, the margin conversation, Dan Greenleaf emphasizes that achieving these four quadrants reduces friction for patients and clinicians that leads to not only better care outcomes but also financial sustainability (ie, margin). Margin can therefore be a function of mission. And again, as Dr. Ben Schwartz put it, “Ultimately, the most successful care models are those that create value inherently.” So, here we go. To be noted with one big fat fluorescent highlighter marker, a big part of this mission that comes up over and over again last week, it's about making prices reasonable and predictable and transparent for patients. Financial toxicity is a thing. Financial toxicity not only is clinical toxicity when so many people are delaying needed care. And look, I don't often quote Marjorie Taylor Greene, but recently she was in the New York Times and was quoted as saying, “The cost of health care is killing people.” This is what we should be focusing on. I just read the other day that one-third of adults in this country are currently delaying or forgoing care due to cost. One-third! Not one-third of low income or something like that. One-third of adults in this country are delaying or forgoing care due to fear of cost. In today's world, affordability and price transparency is part of what customer experience means—not just, like, lemon water in the waiting room. This is what struck me the most about the conversation from last week. But wait. Does affordable for patients spell trouble when it comes to the margin part of the operation? Will an affordability mission wreak havoc on margin? Is this business model doomed? Is there even a successful care model that creates value inherently that is sustainable? Such a good question, which is why I ask it to Dan Greenleaf right out of the gate. So, just to sum this all up in the conversation that follows, Dan Greenleaf gets into the challenges and the strategies involved in balancing mission-driven healthcare with financial realities. Duly's approach to being fiscally solid includes, well, I'm just gonna say many of the same types of efficiency things to maintain and retain margin that other more mainstream health systems might deploy. But I'd say there's a really striking difference in the why and the how. And the impact of this why and how is striking when you look at Duly's prices and the impact it has on its overall community. So, even though it's using similar types of strategies, maybe, as big consolidated health systems or other organizations, the impact and what it all adds up to is, again, very, very different. This is what I mean. At health systems, and maybe my head is just lost in a couple of anecdotal bits of evidence right now, but I just had two conversations in the past two days with physician leaders at big health systems (different ones), but both of these individuals said variations of the same theme. And if you wanna picture the scene, picture the saddest expressions, and one of them had a martini and the other one had a big-boy glass of wine. And both of them said, Look, my organization has lost sight of patient care, but also my organization has lost sight of, like, financial goals in most parts of the organization. All I seem to do all day is play politics with a whole lot of middle managers or even senior leaders jockeying for position and having turf wars within these sprawling bureaucracies. These are just great people who are trying so hard to do the right thing and are just struggling to find the foothold to do so within their own organizations. So, let's just say it was refreshing to hear Dan Greenleaf talk about an alignment of incentives and hook the margin up with the mission train in a really tight way throughout the entire organization. And to do this really well—achieve that mission/margin alignment across the whole entire organization—Dan underscores the value of clinician involvement in leadership and having, as I just said, aligned incentives with clinical teams. Keep in mind, this is the margin show, where clinical leadership came up and the number of doctors on their board and the level of physician ownership in the organization. I'm highlighting that this is the margin show here because usually so-called dyad leadership with physicians in leadership roles only comes up in mission conversations, right? Like, in situations where somebody wants the doctor to be the defender of mission and the battle to keep the MBAs in check. And I say this as the comic book stereotype, obviously. But yeah, it's true often enough. But then we have Dan, who is thinking about clinicians who have, again, aligned incentives across the organization so you don't have your physician leaders day drinking while I'm sitting across from them finding myself quoting Sun Tzu The Art of War and helping them craft the perfect PowerPoint slide to weaponize a reorg. Honestly, in my experience, there's no better way to waste metric assloads of money than in an organization where personal power grabs start to supersede anything that smells vaguely like an organizational imperative. And again, these just big bureaucracies at many health systems … yeah, too big not to fail at this is often the way of it. Then lastly, I grilled Dan Greenleaf about capital partners and how to manage to achieve private equity (PE) funding, where there's support for a model that delivers inherent value—a model that benefits both patients and providers as well as investors. And I'm saying this, keeping all of the things that Yashaswini Singh, PhD, said in that episode (EP474) about private equity a few weeks ago. Go back and listen to that. And by the way, Dan Greenleaf in this show has roughly the same ideas as Tom X. Lee, MD (EP445), founder of One Medical and Galileo told me, and also Rushika Fernandopulle, MD (EP460), founder of Iora. Great minds think alike. So, should figuring out how to work with PE be a topic of interest, there you go. Listen to my conversation today with Dan Greenleaf and then go back and listen to those other two shows. Dan Greenleaf, CEO of Duly, my guest today, has been in healthcare for 30 years. He's a six-time CEO: three public companies and has also run three companies backed by private equity and thus very aware of the many different funding mechanisms that exist in the marketplace. This podcast is sponsored by Aventria Health Group, but I do just wanna mention that Duly offered Relentless Health Value some financial support, which we truly appreciate. So, call this episode not only sponsored by Aventria but also Duly. And with that, here is my conversation with Dan Greenleaf. Also mentioned in this episode are Duly Health and Care; Benjamin Schwartz, MD, MBA; Cynthia Fisher; Cristin Dickerson, MD; Yashaswini Singh, PhD; Tom X. Lee, MD; Galileo; Rushika Fernandopulle, MD; Vivian Ho, PhD; Scott Conard, MD; Stanley Schwartz, MD; Vivek Garg, MD, MBA; and Dave Chase. You can learn more at Duly Health and Care and follow Dan on LinkedIn. You can also email Dan at dan.greenleaf@duly.com.   Daniel E. Greenleaf is the chief executive officer of Duly Health and Care, one of the largest independent, multispecialty medical groups in the nation. Duly employs more than 1700 clinicians while serving 1.5 million patients in over 190 locations in the greater Chicago area and across the Midwest. The Duly Health and Care brand encompasses four entities—DuPage Medical Group, Quincy Medical Group, The South Bend Clinic, and a value-based care organization. Its scaled ancillary services include 6 Ambulatory Surgery Centers, 30 lab sites, 16 imaging sites, 39 physical therapy locations, and 100 infusion chairs. Its value-based care service line provides integrated care for 290,000 partial-risk and 100,000 full-risk lives (Medicare Advantage and ACO Reach). Dan has nearly 30 years of experience leading healthcare services organizations. He is a six-time healthcare CEO, including prior roles as president and CEO of Modivcare; president and CEO of BioScrip, Inc.; chairman and CEO of Home Solutions Infusion Services; and president and CEO of Coram Specialty Services. Dan graduated from Denison University with a bachelor of arts degree in economics (where he received the Alumni Citation—the highest honor bestowed upon a Denisonian) and holds an MBA in health administration from the University of Miami. A military veteran, he was a captain and navigator in the United States Air Force and served in Operation Desert Storm.   09:56 How does Dan achieve his mission given the realities of margin? 14:49 How Duly Health's approach and incentives differ from other health systems. 16:04 EP466 with Vivian Ho, PhD. 16:28 EP462 with Scott Conard, MD. 16:31 Summer Shorts episode with Stan Schwartz, MD. 17:27 EP460 with Rushika Fernandopulle, MD. 17:29 EP445 with Tom X. Lee, MD. 17:30 EP407 with Vivek Garg, MD, MBA. 18:50 How having physicians on the hospital board greatly improves margin and mission. 20:04 How Dan explains his approach to his capital partners. 22:23 Fee for service vs. institutional care.   You can learn more at Duly Health and Care and follow Dan on LinkedIn. You can also email Dan at dan.greenleaf@duly.com.   @d_greenleaf of @dulyhealth_care discusses #margin creating a path to #mission in #multispecialtycare on our #healthcarepodcast. #healthcare #podcast #financialhealth #patientoutcomes #primarycare #digitalhealth #healthcareleadership #healthcaretransformation #healthcareinnovation   Recent past interviews: Click a guest's name for their latest RHV episode! Dan Greenleaf (Part 1), Mark Cuban and Cora Opsahl, Kevin Lyons (Part 2), Kevin Lyons (Part 1), Dr Stan Schwartz (EP486), Dr Cristin Dickerson, Elizabeth Mitchell (Take Two: EP436), Dave Chase, Jonathan Baran (Part 2), Jonathan Baran (Part 1), Jonathan Baran (Bonus Episode)  

This show today is a continuation of our mission/margin series because I wanted to drag into my investigation here what clinical organizations are up to, especially ones that have brought in professional capital, as they 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. Before I kick in here, let me just remind everyone of a few themes that we have been poking in the eyeballs in the past few months over here at Relentless Health Value. First, patients cannot afford care. Listen to the show with Mark Cuban and Cora Opsahl (EP488) mentioning middle-class wage stagnation. Listen to the show with Merrill Goozner (EP388). Listen to the show with Wayne Jenkins, MD (EP358). It is a crapshoot to get medical care these days. Roll the dice and hope you don't get a bankrupting bill at the end. There's no transparency (or very little) for patients. No accountability or interest from many. Not all but many take no responsibility for their financial impact on their patients or members. And look, I am in no way speaking for the vast majority of doctors or nurses or pharmacists or PAs or even really good administrators or anybody else involved in clinical care. In fact, if you listen to the show with Komal Bajaj, MD (EP458) about how many clinicians do not actually trust their leadership will do right by patients or even the clinicians themselves, then yeah. This is undeniably the broad stroke of this industry we all work in. Many take no responsibility for their financial impact on their patients or members. That is the first theme. Here's the second theme. It's this motto: If you can take it, take as much as you can get. And throwing no shade, but let's just get real about that. Right now, healthcare is an industry just like any other industry. And when I say industry, I mean the tax-exempt so-called nonprofits as much as anybody else. Said another way, corporate healthcare leaders, just like any other business leaders, have every incentive to see prices go up. That is just the way commerce works. Listen to the show with Jonathan Baran (EP483, Part 1), the ones with Kevin Lyons (EP487, Part 1 and Part 2). But what is different than most other commerce endeavors when it comes to healthcare, and Shane Cerone from Kada says this in an upcoming episode, he says, “We don't have a broken healthcare market. In many parts of the country, there is no healthcare market. The market does not exist.” And thus prices can go up like rocket ships, because self-insured employers—and also public plan sponsors a lot of times, like state health plans—are, on the whole, just such unsophisticated buyers, price elasticity is, like, nonexistent. No matter how high the price, plan sponsors still contract for who's ever in the network; and they and their members ante up and pay the price. Many good and maybe not-so-good reasons for this (not getting into them), but net net, the result is a nonmarket. Anyone who wants to debate my corporate healthcare entities or big consolidated healthcare entities act just like any other corporate entity, read the recent Substack by Preston Alexander. It's about hospitals raising capital with bonds. Preston Alexander wrote, “The financial design of the system has turned what should be a largely altruistic service, one designed for public good and societal benefit, and forced it to act like a financial institution.” And so, with those bonds, welcome Wall Street. What do Wall Street bankers think about patient care and access and community health? Oh, they don't think about those things at all. Municipal bond returns, baby. That's it. Bonds are an investment where people who invest in them, returns are expected, just like shareholders who want their dividends. Preston Alexander wrote, “Most larger health systems carry billions (that was a ‘b' back there) in bond liabilities.” It costs money to build buildings and add beds and consolidate, yo; but now they are subject to the same pressures as publicly traded companies. So then I got my hands on Dan Greenleaf, CEO of Duly, a multispecialty group in Chicago. I was absolutely intrigued from the starting gate because Dan told me that mission can actually beget margin in his view, and he even, at Duly, has private equity investors. So, yeah, I was all ears. Dan Greenleaf, who is my guest today, by the way, if you haven't figured that out, told me that because of, but not limited to, the trends above wildly high prices, high premiums, high deductibles, more consolidation, fewer options, scared, confused, and maybe outraged patients—listen to the show with Peter Hayes (EP475)—Dan said that, given this backdrop, actually focusing on mission is a huge competitive advantage. Justina Lehman (EP414) actually also said this in a show from a few years ago. Dan told me, Dan Greenleaf, when you succeed at mission, you can get yourself decent margin these days. So, in this first episode, we will talk about this mission of which Dan Greenleaf speaks; and then in part 2 coming at you next week, we'll get into how that all spells margin. Here's what I thought was super important about this whole mission/margin conversation, and Mick Connors, MD, in a show coming up, also touches on this: To achieve mission, you really have to define what mission means. Ben Schwartz, MD, MBA (EP481) said this, too, in so many words in the show from last summer. And that doesn't mean just have a gloriously well-written Web page, and you just can't have spreadsheets of random quality metrics either. You have to treat the mission like you treat any strategic imperative. You gotta break it down and figure out how you're gonna measure what you're actually doing. Rik Renard (EP427) talked about this one, too. At Duly, which Dan Greenleaf talks about in this episode, the focus is on four quadrants of mission: (1) affordability, (2) access, (3) consumer experience, and (4) quality. In this conversation, Dan emphasizes that achieving these four quadrants reduces friction for patients and clinicians and leads to better care outcomes and financial stability. To be noted with one big fat fluorescent highlighter marker is this: A big part of this mission, in almost each of these quadrants, is about making prices reasonable and predictable and transparent for patients. In today's world, that's what customer experience must include—not just, like, lemon water in the waiting room. That struck me the most. And all this focus on affordability really adds up across the community. In Chicago, lower-cost alternatives to hospital services can save up to $2 billion. That is also with a “b.” And the communities are also healthier. Crazy. Hey, make sure patients and members can afford and have access to quality healthcare, and the community gets healthier. Who would've thought? Dan Greenleaf, CEO of Duly, my guest today, has been in healthcare for 30 years. This podcast is sponsored by Aventria Health Group, but I do just wanna mention that Duly so kindly offered Relentless Health Value some financial support, which we truly, truly appreciate. So, call this episode also sponsored with an assist by Duly. Here's my conversation with Dan Greenleaf, and do come back next week for part 2 like I said earlier. Today we talk mission. Next week we talk margin. Also mentioned in this episode are Duly Health and Care; Merrill Goozner; Wayne Jenkins, MD; Komal Bajaj, MD; Jonathan Baran; Kevin Lyons; Shane Cerone; Kada Health; Preston Alexander; Peter Hayes; Justina Lehman; Vivian Ho, PhD; Mick Connors, MD; Benjamin Schwartz, MD, MBA; Rik Renard; Mark Cuban; Dave Chase; Patrick Moore; Sam Flanders, MD; and Tom Nash. You can learn more at Duly Health and Care and follow Dan on LinkedIn. You can also email Dan at dan.greenleaf@duly.com.   Daniel E. Greenleaf is the chief executive officer of Duly Health and Care, one of the largest independent, multispecialty medical groups in the nation. Duly employs more than 1700 clinicians while serving 1.5 million patients in over 190 locations in the greater Chicago area and across the Midwest. The Duly Health and Care brand encompasses four entities—DuPage Medical Group, Quincy Medical Group, The South Bend Clinic, and a value-based care organization. Its scaled ancillary services include 6 Ambulatory Surgery Centers, 30 lab sites, 16 imaging sites, 39 physical therapy locations, and 100 infusion chairs. Its value-based care service line provides integrated care for 290,000 partial-risk and 100,000 full-risk lives (Medicare Advantage and ACO Reach). Dan has nearly 30 years of experience leading healthcare services organizations. He is a six-time healthcare CEO, including prior roles as president and CEO of Modivcare; president and CEO of BioScrip, Inc.; chairman and CEO of Home Solutions Infusion Services; and president and CEO of Coram Specialty Services. Dan graduated from Denison University with a bachelor of arts degree in economics (where he received the Alumni Citation—the highest honor bestowed upon a Denisonian) and holds an MBA in health administration from the University of Miami. A military veteran, he was a captain and navigator in the United States Air Force and served in Operation Desert Storm.   08:32 What should mission be in multispecialty? 08:54 Are mission and margin mutually exclusive? 10:47 What are the four “vectors” of Dan's mission? 11:32 Why does affordability matter? 12:11 EP466 with Vivian Ho, PhD. 12:40 EP488 with Mark Cuban and Cora Opsahl. 13:32 Who are the three payers in the marketplace? 17:31 EP388 with Merrill Goozner. 19:19 How does access play into mission? 20:28 EP464 with Al Lewis. 21:07 EP467 with Stacey. 22:56 Why price transparency is important to consumer experience. 24:16 LinkedIn post from Patrick Moore. 29:06 EP481 with Benjamin Schwartz, MD, MBA.   You can learn more at Duly Health and Care and follow Dan on LinkedIn. You can also email Dan at dan.greenleaf@duly.com.   @d_greenleaf of @dulyhealth_care discusses #mission and #margin in #multispecialtycare on our #healthcarepodcast. #healthcare #podcast #financialhealth #patientoutcomes #primarycare #digitalhealth #healthcareleadership #healthcaretransformation #healthcareinnovation   Recent past interviews: Click a guest's name for their latest RHV episode! Mark Cuban and Cora Opsahl, Kevin Lyons (Part 2), Kevin Lyons (Part 1), Dr Stan Schwartz (EP486), Dr Cristin Dickerson, Elizabeth Mitchell (Take Two: EP436), Dave Chase, Jonathan Baran (Part 2), Jonathan Baran (Part 1), Jonathan Baran (Bonus Episode), Dr Stan Schwartz (Summer Shorts)

If you are listening to this prior to October 9, 2025, go to the 32BJ Changing the Playbook on Hospital Prices event, where Mark Cuban will be keynoting. Cora Opsahl will also be speaking, and I will be there listening. 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, trust, simplicity, and a chicken. Yeah, this is where this whole conversation with Mark Cuban and Cora Opsahl winds up. And it is a barnstormer because you know what some really good advice is for anybody trying to do right by patients and taxpayers and plan sponsors? It will take trust. It will take making the complicated as simple as possible. And also if you could pay with a chicken, like in the good old days, that would be messy—I can say with confidence, having grown up in Pennsylvania Dutch country, where there are many, many chickens—but also being able to pay with a chicken could also indicate that healthcare prices are reasonably chicken proportionate and that the doctor-patient relationship is good enough to break bread (or have chicken). That last part is really important, and Cora Opsahl says this at one point in the episode that follows. It doesn't matter how wonderful the transparency or the financing. If the prices are insane and there's no more reasonably priced options in any given market, then yeah. Shane Cerone says in an upcoming show, he says, “We do not have a broken healthcare market. We do not have a healthcare market. There is no market.” Okay … so, you could call this conversation a continuation of the episode with Ann Kempski (EP444), entitled “Two State Healthcare Laws Often Don't Go as Planned.” But it's not just healthcare laws that often don't go as planned. It's some very foundational constructs that we have built the healthcare sector upon that may also not go as planned. The healthcare sector is like a game of pachinko. You chuck an input into the mix, and it will bounce all around into all the perverse incentives and human beings and the non-market that we have. And who the heck knows what is gonna pop out the other side? It's like game theory at its most unpredictable. So, in healthcare, there are many, many examples of when the solution to a problem arguably creates worse problems than the problems the solution was trying to solve for. But we—Mark Cuban, Cora Opsahl, and I—are gonna shake our fists at two such solutions today: high deductible health plans (or just high deductibles in general) and then self-insured employers trying to solve the complexity of the healthcare industry by hiring consultants and middlemen, middle people, and other vendors to navigate the pachinko parlor (that is, our $4.9 trillion healthcare sector) on their behalf. Now, I am not in any way saying the spirit of these two endeavors—high deductibles and hiring consultants and middlemen—weren't wholehearted. They seem just like many other well-intentioned solutions: very logical on their face. What I am saying is there are many ways in the real world for even the most, again, genuine endeavor to turn into a money grab for those so inclined. While at the same time I'm saying all this, I'm also very much saying that there are some amazing consultants and middle folks such as independent third-party administrators, otherwise known as TPAs, and PBMs (pharmacy benefit managers) who are transparent and hold themselves accountable to the fiduciary responsibilities that their clients are held to in real terms—not just in marketing speak with 40 pages of disclaimers following. There are great folks out there, many of whom listen to this podcast and are part of our tribe on the regular. And to you, I say thank you for being here, because it takes all the knowledge and more from every one of the guests featured in these past 487 Relentless Health Value episodes plus treating every day like a school day to make sure that we all are not getting shanked from behind by some innocent-looking contract term that turns out to be anything but. The conversation that follows starts out talking about high deductibles; naturally segues into how third-party intermediaries can actually exacerbate the issues here; then we get into transparency, financing, clinical organizations taking on risk, and the benefits and challenges of direct contracts; then Mark lays out a vision for the future. Okay … I wanna get to this conversation. If you are a new listener here—and you might be because … yeah, Mark Cuban—let me just inform you that this podcast is largely listened to by those who work in the healthcare industry. So, you are going to encounter acronyms. You will also encounter me referencing earlier episodes because surveys say listeners really appreciate these callbacks to go get additional information about any given topic. You can get what amounts to a personalized Master's of Healthcare Administration curriculum if you follow the episode threads long enough. And that was a direct quote from a listener. About the acronyms: They are holy terrors, and we in the healthcare industry are chock-full of them. See the list of acronyms that come up so that you can follow along at home if this is your first day at our rodeo. Also in the show notes is a transcript of this show, along with links to all of the mentioned episodes. Okay … here's my conversation with Mark Cuban, who is Mark Cuban and also CEO and founder of Mark Cuban Cost Plus Drugs. Also, we have Cora Opsahl, who is health fund director of the 32BJ Health Fund and an expert in many things healthcare. Also mentioned in this episode are Shane Cerone; Ann Kempski; Mark Cuban Cost Plus Drugs; 32BJ Health Fund; Preston Alexander; Stanley Schwartz, MD; Elizabeth Mitchell; Kimberly Carleson; Andreas Mang; Jonathan Baran; Claire Brockbank; Dave Chase; Cristin Dickerson, MD; Green Imaging; Kevin Lyons; and Vivian Ho, PhD.   You can learn more at markcubancompanies.com and costplusdrugs.com and follow Mark on LinkedIn, Bluesky, Threads, and X. You can follow Cora on LinkedIn.   Mark Cuban, a native of Pittsburgh, PA; a graduate of Indiana University; and now a Dallas, TX, resident, has always been an entrepreneur. From selling and trading baseball cards, selling garbage bags and magazines door-to-door, to starting a business buying and selling stamps at age 16, there have been few years in his life when he wasn't starting or running a business. He got a job at one of Dallas's first retail software stores, Your Business Software. He spent nine months doing everything from learning how to code, supporting and installing every type of business software, and of course, making sure the store opened on time. That went well until he made the executive decision to turn over the store opening duties to a peer so he could pick up a check for a sale. He was fired. Mark decided it was time to start on his own. The next day, MicroSolutions was founded. Over the next seven years, MicroSolutions became a national leader in Systems Integration and custom applications for local and wide area networks. Growing to 80 employees, never having a losing month of operations and nearly $36M in annualized sales, in 1990, MicroSolutions was sold to CompuServe. At that point Mark “retired” to investing in public and private companies. His knowledge of the networking industry led to success and brought returns of 80% and more each year. Mark purchased the Dallas Mavericks for $285M. The Mavs would have the second-best record in the NBA during his ownership tenure. Mark sold majority control of the Mavs in 2023 but continues to be actively involved with the team. He first appeared as a “Shark” on ABC's Emmy Award–winning hit business show Shark Tank in 2011 and quickly established himself as one of the most popular and tough Sharks, investing millions of dollars in hundreds of small businesses. He's been nominated nine times for an Emmy for Shark Tank. His last appearance on the program was during season 16 in May 2025. In 2019, Mark co-founded costplusdrugs.com. Its launch on January 19, 2022, with transparent pricing and a limited markup, has fundamentally changed the pricing of medications in the United States. 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 SEIU 32BJ have easy and sustained access to affordable, high-quality healthcare. Cora has prioritized a data-driven approach, 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. In 2024, Cora conducted an innovative medical request for proposal, stipulating that all finalists have a signature-ready contract drafted by the 32BJ Health Fund prior to award. As a result, the Fund negotiated an agreement that brought unprecedented visibility and increased accountability to its benefit. In 2025, the Health Fund is focused on direct-contracting opportunities that allow it to carve out key benefits and ensure quality while managing spend. Cora is regarded as an expert in pharmacy benefit management and was recently appointed to the Board of Governors for the National Alliance for Healthcare Purchaser Coalitions and the Purchaser Advisory Council for the National Quality Forum and Joint Commission. She previously worked at Express Scripts, where she held a variety of roles, ranging from Medicare Part D to operations, strategy, and acquisitions. Cora earned an MBA from Saint Louis University.   06:25 What was the original rationale behind high deductibles? 07:38 How high deductibles are creating a class of functionally uninsured people. 09:29 EP482 with Preston Alexander. 10:20 “We're using health insurance as a proxy for healthcare.” —Mark 12:30 How providers are now in the debt collecting business rather than the healthcare business. 12:55 EP486 with Stan Schwartz, MD. 15:16 “We have a fundamental reasonability problem.” —Cora 16:07 EP425 with Marshall Allen. 18:25 Direct contracting versus self-funded employers. 19:27 EP436 with Elizabeth Mitchell. 19:30 EP480 with Kimberly Carleson. 19:33 EP372 with Cora Opsahl. 23:53 Why the current system doesn't allow the accountability that is needed. 24:39 EP452 with Cora Opsahl. 26:34 How direct contracting gives strength back to independent practices that high deductible plans take away. 27:46 Who pays, what's the price, and where does the power lie? 31:24 EP419 with Andreas Mang. 34:45 How it comes down to power and leverage when controlling healthcare costs. 38:13 EP483 (Part 1 and Part 2) with Jonathan Baran. 38:35 Why putting together a network and just buying healthcare—not discounts—is not as difficult as it seems. 40:10 Why we need to stop talking about disruption and start talking about change. 40:56 EP453 with Claire Brockbank. 41:02 EP484 with Dave Chase. 43:07 EP485 with Cristin Dickerson, MD. 44:32 EP487 (Part 1) with Kevin Lyons. 46:34 EP466 with Vivian Ho, PhD. 47:40 Why it's the incentives that are different between American hospitals and hospitals in a single-payer program. 50:25 The main takeaways from the conversation. 51:08 Why you can't fix the problems in healthcare without transparency.   You can learn more at markcubancompanies.com and costplusdrugs.com and follow Mark on LinkedIn, Bluesky, Threads, and X. You can follow Cora on LinkedIn.   @mcuban of @costplusdrugs and Cora Opsahl discuss trust and simplicity in #healthcare on our #healthcarepodcast. #podcast #financialhealth #patientoutcomes #primarycare #digitalhealth #healthcareleadership #healthcaretransformation #healthcareinnovation   Recent past interviews: Click a guest's name for their latest RHV episode! Kevin Lyons (Part 2), Kevin Lyons (Part 1), Dr Stan Schwartz (EP486), Dr Cristin Dickerson, Elizabeth Mitchell (Take Two: EP436), Dave Chase, Jonathan Baran (Part 2), Jonathan Baran (Part 1), Jonathan Baran (Bonus Episode), Dr Stan Schwartz (Summer Shorts), Preston Alexander

In episode 487, part two, host Stacey Richter interviews Kevin Lyons, a former police detective and current Executive Director of the New Jersey State Police Benevolence Association about the application of detective skills to analyze healthcare spending.  Following a discussion on the barriers driving up healthcare costs in part one, Lyons delves into techniques such as statement analysis and facial recognition to identify deceit and uncover where healthcare dollars are going. Lyons emphasizes the need for preparation, persistent questioning, and the importance of following the money, thereby encouraging a fearless approach to advocating for transparency and better healthcare management. === LINKS ===

In Episode 487 of Relentless Health Value, host Stacey Richter speaks with Kevin Lyons, a former police detective and current executive director at the New Jersey State Police Benevolence Association. They explore, in this two part episode, the significant challenges public sector employees face in obtaining cost-effective health benefits.  The discussion highlights key issues, including the influence of industry profit motives, governmental hiring practices, and media sponsorship biases. Lyons shares insights on the rapidly escalating costs of healthcare for state workers, with specific examples from New Jersey, emphasizing the need for innovative solutions and improved legislative action. The conversation sets the stage for a subsequent episode where Lyons will delve deeper into applying detective skills to uncover financial trails and propose effective changes. Tune in next week for  part 2 when Kevin talks about how he pulls out his notebook and uses what he learned as a detective to, first of all, figure out everything probably that we just talked about in this part one. But also, you can't solve for something unless you do what most investigators do, which is follow the money. === LINKS ===

In this episode of Relentless Health Value, host Stacey Richter sits down with Dr. Stan Schwartz, co-founder of ZERO.health, to explore the practical realities and benefits of direct contracting in healthcare.  Dr. Schwartz shares his journey from traditional healthcare to pioneering bundled payments and direct contracts, offering actionable insights for employers, providers, and anyone interested in making healthcare more affordable and predictable. The conversation covers the challenges of claims, cost variability, operationalizing direct contracts, and the impact on both patients and providers. Discover how employers and providers can use bundled payments to cut costs, simplify administration, and deliver $0 out-of-pocket care for patients. It was an honor to get Dr. Schwartz on the pod, and we are doubly thankful because he stepped up and offered to help support Relentless Health Value financially as well as spending his time with me and you. So, thanks to everyone over at ZERO.health for being part of the kind of folks who support shows like this one. Dr. Stan Schwartz is co-founder over at ZERO.health. ZERO gets members access to high-quality providers for $0 out of pocket, leveraging bundled payments and direct contracting. This episode, as I just said, is sponsored by ZERO.health, with an assist from Aventria Health Group. === LINKS ===

In episode 485, Stacey Richter interviews Dr. Cristin Dickerson on the topic of direct contracting for imaging services. They discuss the high costs of imaging, which can account for 6-11% of a plan sponsor's healthcare spend. The episode covers the potential for significant cost savings and improved patient access through direct contracting, bypassing traditional TPAs that may have conflicts of interest or contractual constraints.  Dr. Dickerson, who is the founding partner of Green Imaging, explains how her organization has successfully implemented direct contracting, providing affordable and high-quality imaging services nationwide. They also address common barriers such as complexity in coding and payment processes, the reluctance of TPAs, and the habitual referral to 'down the hall' services. The conversation highlights the importance of price transparency, patient education, and how Green Imaging supports plan sponsors in navigating these challenges. === LINKS ===

Right up front here, let me just state loudly that there are some amazing independent TPAs (third-party administrators) out there who have the expertise, the scrappy willfulness, and the deep desire to do right by their clients, their self-insured employer clients. 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 look, they may be facing some of the same headwinds that plan sponsors themselves face, like anticompetitive contracts, brokers who are up to no good, etc. So, just keep that in mind as you listen. And the main point of all of this if you are a plan sponsor is, find a good TPA partner, which, as Bryce Platt has said about consultants but same rules apply about TPAs here, the difficulty is being informed enough to tell the difference. So, the goal of this show is to help with that, the “be informed enough to tell the difference.” All of this being said, this is technically a Take Two; but we trimmed it down and welcome to a whole new intro. So, call this a refresher and an update about a really, really important topic from last year that is becoming extremely (maybe even more) relevant this year. Really relevant. Consider, for example, the show with Claire Brockbank (EP453) about carrier/TPA RFPs (requests for proposal) and all of the landmines that are really expensive, that are buried in some of these contracts. Then there was the Cynthia Fisher show (EP457) from last year about the millions, maybe billions of dollars in aggregate going missing in medical (ie, TPA or ASO [administrative services only]) spread pricing. We had “The Mystery of the Weekly Claims Wire” show with Justin Leader (EP433), again, revealing money that's being disappeared when the TPA is withdrawing dollars from plan sponsor checking accounts. And then there's the payment integrity episode with Kimberly Carleson (EP480) from a few weeks ago with just another wrinkle on this, namely TPAs or ASOs who insist on auditing themselves and how that turns out for members and plan sponsors. Oh, and last, but certainly not least, is the whistleblower show with Ann Lewandowski (EP476) on how a TPA arm of an EBC (employee benefit consultant) allegedly pocketed $20 million—$20 million of their client's pharma rebates—and used that $20 million to fund their executive bonus pool. What a time to be alive! All of this just highlights the huge stakes for plan sponsors to really understand what their TPA is all about. And when I say high stakes, I mean from both a legal standpoint and also just vast dollars in play here. But this episode with Elizabeth Mitchell is also, I'm gonna say, extremely relevant given just a few ripped from the headlines and news articles such as these. I'm gonna start actually with a post from Kimberly Carleson, and I like the comment by Jeff Evans, who wrote, “How does $8,710 equal $104,266?” Spoiler alert, it doesn't. Lots of missing dollars there. Someone's hands are in the cookie jar. Oh, look, the TPA has entered the chat. In a nutshell, and I'm quoting something Peter Hayes wrote, he wrote, “TPAs have received relatively little public attention. [There's an article in Health Affairs] that describes how TPAs impose hidden fees, benefit from their own form of spread pricing, and otherwise prioritize their own financial interests over those of their plan clients.” Also, here's a totally other issue. Let me quote Luke Prettol highlighting something Jason Shafrin had written about a paper by Jeff Marr, Daniel Polsky, and Mark Meiselbach. Let me slightly rephrase what Luke said. He wrote, “Employers pay, on average, a 4.7% [so almost 5%] price markup when hospitals are in their TPA's [Medicare Advantage] network.” Right? Dr. Eric Bricker talked about this in that episode (EP472) just how TPAs with MA (Medicare Advantage) business negotiate their commercial clients to pay higher rates so that then they can pay lower rates for their own MA members. As Luke wrote, “On its face, this overpayment does not appear to be solely in the interest of participants.” No kidding. Now, let's spin the wheel here. There are barriers for TPAs themselves, even the ones who have a deep desire to do the right thing. As Patrick Moore wrote, “Most TPAs still can't do [many of the things that employers might want because there are] PPO contracts.” So, is it a rock in a hard place situation? I mean, if the TPA has no other options than using a carrier's PPO (preferred provider organization) network with all its attendant contractual issues, then yeah, that is one definite challenge. Along these lines, let me read a post by Rina Tikia, because I think she sums up this really well. “When independent TPAs … push for transparency, they're blocked under the banner of ‘fiduciary risk.' “Meanwhile, the largest carriers and PBMs, with Cayman shell subsidiaries, DOJ kickback probes, [huge] hedge fund ties, [$10 million-plus] lobbying budgets, and antitrust violations continue unchecked. They are not only allowed to operate but celebrated as mainstream options. “Why the double standard? Political donations? Foundation smokescreens? Nonprofit status as a PR shield?” These are excellent questions. And here's another challenge: brokers. Ramesh Kumar Budhani wrote about this one, just how hard it is sometimes to find—for TPA, an independent TPA, trying to do the right thing—to find brokers who prioritize doing the right thing for employers and helping their clients save money. The summary of all of this: There are TPAs and there are ASOs who aren't even trying. They are going to ride the flywheel, the gravy train, and catch all of the dollars flying off of it for as long as they can manage to cling to it with all 10 of their fingers. Then there are TPAs, mostly indies, trying super hard to do the right thing. But how successful they are is going to depend on how boxed in they are by the PPO networks or the carriers that the brokers or even plan sponsors may insist on. Just how courageous they are and just how smart they are and experienced they are about the market and how it actually operates. So, the show that follows is about all of this, including how we can inspire TPAs, which, in the show that follows, subsumes ASOs kind of into it. But in the show that follows, I hope it's inspiring to create an environment so that the market demands TPAs that do all of the things, and we make inertia not a viable business strategy. Elizabeth Mitchell, my guest today, currently serves as the president and CEO of the Purchaser Business Group on Health. Also mentioned in this episode are Purchaser Business Group on Health; Bryce Platt; Claire Brockbank; Cynthia Fisher; Justin Leader; Kimberly Carleson; Ann Lewandowski; Jeff Evans; Peter Hayes; Luke Prettol; Jason Shafrin; Jeff Marr; Daniel Polsky; Mark Meiselbach; Eric Bricker, MD; Tom Nash; Patrick Moore; Rina Tikia; Ramesh Kumar Budhani; Mark Cuban; Harold Miller; Chris Deacon; Moby Parsons, MD; Benjamin Schwartz, MD, MBA; Mishe Health; Rik Renard; and Cora Opsahl. 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), advances its strategic focus areas of advanced primary care, functional markets, and purchasing value. She leads PBGH in mobilizing health care purchasers, elevating the role and impact of primary care, and creating functional healthcare markets to support high-quality affordable care, achieving measurable impacts on outcomes and affordability. At PBGH, 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 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 (the Maine Health Management Coalition), worked within an integrated delivery system (MaineHealth), and was elected to the Maine State Legislature, serving as a State Representative. Elizabeth served as vice chairperson of the U.S. 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 “Vital Signs” Study Committee on core metrics, and a guiding committee member for the Health Care Payment Learning & Action Network. Elizabeth holds a degree in religion from Reed College and studied social policy at the London School of Economics.   08:06 What is the overarching context for health plans in healthcare purchasing? 11:31 Why is it important to reestablish a connection between the people paying for care and people providing care? 13:47 What are the needs of a self-insured employer when managing employee benefits? 19:00 Is it doable for employers to set their own contracts? 21:24 Is transparency presumed? 22:39 Will the new transparency upon us actually expose wasted expense? 24:23 EP408 with Chris Deacon. 25:58 “This is not about individual bad actors. … The systems … that is not aligned.” 27:39 Are there providers who want to work directly with employers? 30:53 Why is it important that incentives need to be aligned? 32:42 EP427 with Rik Renard. 33:51 What's missing from the conversation on changing health plans?   You can learn more at PBGH and by connecting with Elizabeth on LinkedIn.   @lizzymitch2 of @PBGHealth discusses #TPA and #healthplan vs. #jumboemployer inertia on our #healthcarepodcast. #healthcare #podcast #financialhealth #patientoutcomes #primarycare #digitalhealth #healthcareleadership #healthcaretransformation #healthcareinnovation   Recent past interviews: Click a guest's name for their latest RHV episode! Dave Chase, Jonathan Baran (Part 2), Jonathan Baran (Part 1), Jonathan Baran (Bonus Episode), Dr Stan Schwartz (Summer Shorts), Preston Alexander, Dr Tom X Lee (Take Two: EP445), Dr Tom X Lee (Bonus Episode), Dr Benjamin Schwartz, Dr John Lee (Take Two: EP438), Kimberly Carleson, Ann Lewandowski (Summer Shorts)  

Today I am speaking with Dave Chase from Health Rosetta, and I'm asking Dave Chase three inferno-level burning questions—questions that, across the country, many self-insured employers are trying to find the answers to. 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. Now, an important underlying point that comes across loud and clear but remains unsaid, actually, in the conversation that follows is this: There are amazing brokers and EBCs (employee benefit consultants) and benefits advisors or TPAs (third-party administrators) who put their clients first and have the receipts (ie, they have data and they're willing to share it to prove this). And then there are those with the exact same titles, often enough, who are very much the opposite of this but super charming, I'm sure. I mean, it'd be a stretch to assume that the same roles don't apply to brokers or EBCs that apply for titles like hospital administrators where there's great ones and really not great ones; but everybody often gets lumped into the same category or even the term hospitals. Each of these terms is a broad stroke and contains multitudes. And do listen to the bonus clip from two weeks ago with Jonathan Baran for just more on this point. We dig into it for like 10 minutes or something. I also talk about this same concept in an upcoming episode with Mick Connors, MD. So, keep that underlying and unsaid theme in mind because a lot of these questions do boil down to, How do you figure out who's on the up-and-up and who's not? And if you need an example of the latter category, listen to the show with Ann Lewandowski (EP476) about the whistleblower lawsuit or the show with AJ Loiacono (EP379) about the myriad of brokers taking $7 or $14 per script written payable by the PBM (pharmacy benefit manager) and not reported on, as far as I know. This is very much still going on today, by the way, despite the CAA (Consolidated Appropriations Act) and the 5500 forms. Alright, so, first burning question, Question 1: After seeing J&J (Johnson & Johnson) and Wells Fargo sued for fiduciary breaches, what specific questions do I need to ask my benefits advisor to prove that my benefits advisor actually protects my interests? Okay, paraphrased, this question is employers trying to figure out what they can ask or how they can figure out if their benefits advisor or broker or employee benefit consultant is really as trustworthy as they'd like you to believe they are. There's been a whole bunch of shows that circle up on this. The thing is, though, the stakes are very, very high right now. So, yeah, I can see why this is turning into a burning question for anyone worried they might get sued personally unless they can figure out how to vet, for real in writing, who their broker, EBC, or advisor serves actually at the end of the day. Question 2 that I ask Dave Chase, and I'm not giving you the answers to these questions. You gotta listen to the show. But here's the second question I ask: How do I avoid personal liability when my TPA contract has hidden conflicts that could trigger an ERISA (Employee Retirement Income Security Act) lawsuit? Kind of a continuation of Question 1, but yeah, you can tell that self-insured employer teams are really digging in here and many, many are very aware of, first of all, the extent and depth of middle people doing things like, again, allegedly taking $20 million of employer clients' money and funding their executive bonus pool. So, yeah, definitely this is another doozy of a burning question. Also on these same topics, listen to the show with Justin Leader (EP433) and also the one with Cynthia Fisher (EP457) about spread pricing. Question 3 that I ask Dave Chase: My pharmacy costs keep climbing despite PBM guarantees. How do I tell if I am being systematically overcharged? Well, if your consultants are taking your rebates to fund their executive bonus pools, as I just mentioned there's a whole show about with Ann Lewandowski, or if they're taking $7 a script for every script that gets written for your members, which, yeah, that's afoot. I've seen the contracts and the cease and desists currently flying around our industry about that one. Or read that Osceola County lawsuit against their longtime brokers. Bottom line and end of this intro, informed employer teams are, for sure, wondering these questions. But even more than just wondering, what these questions signify to me, kind of at the macro level, they're realizing the danger of kind of sitting on that knowledge or just assuming that because everybody else is doing whatever, it's somehow safe—though status quo is getting kind of more and more dicey every single day. As some additional foreshadowing, this show finishes up with Dave Chase talking about the open-source resources that are available so that you too can create a high-performance health plan where members get higher-quality healthcare and, as Dave Chase says, the cost savings for free. There are links to many things that you can get from Health Rosetta and their sister company, Nautilus. Again, all the stuff is for free. Go to nautilushealth.org. That's their main Web site. Dave Chase, who has been on this podcast—I think this is his third time, although it has been a while—Dave Chase is co-founder and CEO of Health Rosetta. Also mentioned in this episode are Health Rosetta; Jonathan Baran; Mick Connors, MD; Ann Lewandowski; AJ Loiacono; Chris Deacon; VerSan Consulting; Justin Leader; Cynthia Fisher; Nautilus; Andreas Mang; Blackstone; Jon Camire; Claire Brockbank; Elizabeth Mitchell; Scott Haas; Paul Holmes; Chris Crawford; Luke Slindee, PharmD; Mark Cuban; Marilyn Bartlett, CPA, CGMA, CMA, CFM; Leah Binder; and Dawn Cornelis.   You can learn more at Health Rosetta and follow Dave on LinkedIn.   Dave Chase is on a mission to restore hope, health, and economic well-being to communities through healthcare transformation. As creator of the community-owned health plan (COHP) model, he is building a nationwide movement that turns health plans from drivers of wage stagnation into vessels for well-being and wealth creation. As founder of Health Rosetta, Dave has helped transform healthcare for thousands of employers covering more than five million Americans. What began with identifying just five successful health plans nationwide has grown into a movement with thousands of sustainable successes that deliver superior care at 20% to 50% lower costs. In 2024, his team launched Nautilus Health Institute, catalyzed with $4 million in Health Rosetta intellectual property and investment. Nautilus provides open-source standards, contracting templates, and technology infrastructure (including METL, an open-source healthcare data platform) that establish new market norms benefiting employers, clinicians, and communities. Dave's work in healthcare transformation has reached over 10 million people through best-selling books (The CEO's Guide to Restoring the American Dream, The Opioid Crisis Wake-up Call, Relocalizing Health), media, TED Talks, and TV/film appearances. He has received the World Health Care Congress's Lifetime Achievement Award for Health Benefits Innovation. Dave is dedicated to transforming healthcare through transparency, community ownership, and proven solutions that restore the American Dream.   06:36 What questions does a plan sponsor need to ask their consultant, EBC, or broker to ensure they are protecting the interest of the plan sponsor? 07:59 EP478 with Andreas Mang and Jon Camire. 08:49 EP453 with Claire Brockbank. 09:51 EP433 with Justin Leader. 09:53 EP436 with Elizabeth Mitchell. 11:03 How can plan sponsors avoid personal liability when their TPA has hidden conflicts of interest? 11:40 Tiara Yachts v. Blue Cross Blue Shield of Michigan lawsuit. 13:48 EP483 (Part 1) with Jonathan Baran. 14:18 EP457 with Cynthia Fisher. 16:18 The Marshall-Hickenlooper bill called the Price Tags Act. 16:50 Summer Short with Elizabeth Mitchell. 17:36 How do plan sponsors figure out if they are being overcharged for pharmacy benefits? 18:09 EP365 with Scott Haas. 20:18 EP397 with Paul Holmes. 20:22 EP465 with Chris Crawford. 20:37 EP429 with Luke Slindee, PharmD. 22:56 EP476 with Ann Lewandowski. 28:38 Where to find open-source resources to help guide plan sponsors with making better health plan decisions. 29:47 How the open-source trend is growing for health transparency. 30:48 What to look forward to at RosettaFest.   You can learn more at Health Rosetta and follow Dave on LinkedIn.   @chasedave discusses questions #plansponsors need to ask on our #healthcarepodcast. #healthcare #podcast #financialhealth #patientoutcomes #primarycare #digitalhealth #healthcareleadership #healthcaretransformation #healthcareinnovation   Recent past interviews: Click a guest's name for their latest RHV episode! Jonathan Baran (Part 2), Jonathan Baran (Part 1), Jonathan Baran (Bonus Episode), Dr Stan Schwartz (Summer Shorts), Preston Alexander, Dr Tom X Lee (Take Two: EP445), Dr Tom X Lee (Bonus Episode), Dr Benjamin Schwartz, Dr John Lee (Take Two: EP438), Kimberly Carleson, Ann Lewandowski (Summer Shorts), Andreas Mang and Jon Camire (EP479)

Okay, to review from Part 1 of this conversation, and if you didn't listen to it because you think you know how this whole skyrocketing healthcare costs thing works, let me tell you, I myself had a few revelations. So, go back and listen. 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 to be fair, if you didn't already, sure, fine. Listen to Part 2 here first and then do it backwards. It probably won't make that much difference, except you'll need to contend with me totally ruining the Part 1 suspense because here's the negative flywheel, starting with the axle. Employers and other plan sponsors have been convinced to buy discounts, including discounts or discounts by their other aliases: rebates and probably shared savings, too, I would throw in this category. This is the grease that keeps the flywheel spinning. What's the “why” there? It's a genius idea if you think about it. And if you're not fully understanding what I'm about to say, go back, for sure, and listen to Part 1 of this episode because this is a very fundamental concept that has come up over and over and over again on this podcast. Cora Opsahl (EP452) talked about it. Claire Brockbank (EP453); Eric Bricker, MD (EP472); Chris Crawford (EP465) for just four shows off the top of my head in the past, you know, eight months or so. Here's the concept: If you buy discounts, your costs will go up. Am I saying this theoretically? No, I'm not. Look at the last 20 years. Have costs gone up way higher than inflation? Yes, they have. What are we doing? We're buying discounts. So, it's hard to argue. Renewals every single year will just keep going up the longer that we buy discounts. We talk about this, Jonathan Baran and I, in Part 1, how carriers have created a really very self-serving buying framework where employers are trained to buy discounts. Discounts are the axle, and the buying of discounts becomes the top of our flywheel. And then some so inclined hospital system executives, there are certainly executives standing 10,000 feet from any bedside, so they really have zero idea how care or patients or even clinicians are impacted. But if plan sponsors buy discounts, those at health systems who are so inclined now have no real incentive to rein in prices or focus on appropriate care even. And if you are so inclined, if you're very margin focused as a healthcare executive, you know, first things first, go gut primary care. That is step one in every playbook, and we definitely talk about that in Part 1 of this episode. And also, again, in about 10 episodes from earlier this year. Another thing that you're gonna wanna do if your prime imperative is margin at a healthcare system is maximize the revenue off of every transaction. So, hey … hello, EHR systems. So now you have health system prices creeping up and up, unfettered, you know, just exacerbated by consolidation and a bunch of other different things. But you've got healthcare prices creeping up, you have volume the same or higher because we're not preventing chronic disease like you would with advanced primary care, for example. And now we're back at the “Oh wow, let me sell you another discount. And renewal is only 9% or whatever.” Thus, the flywheel spins. Alright, so let's turn this wheel around, shall we? Flip it 180. What's the fix? This is what Jonathan Baran talks about in the episode that follows, but he says, Hey, how about this? Instead of putting “get bigger discounts” in the middle of the flywheel, why don't we put “buy better member health”? That's a good start. Buy a health plan that delivers better member health at an affordable price. Buy the care, not buy a discount off of a price we can't see for net price we can't see. Is it insurance? I don't know. Right? Like, just buy the healthcare. Cutting to the chase, Jonathan Baran advocates for a paradigm shift where employers invest in primary care, adopt better benefit designs, more aligned to cost and quality so that members are incented toward better cost and quality, employee navigation services to guide employees to make more informed healthcare decisions. So again, by changing the focus from buying discounts to buying actual healthcare, Jonathan says, we can reverse the negative cycle and improve overall health outcomes. As I've said multiple times already, my guest today is Jonathan Baran. He has been, for a long time, a healthcare entrepreneur. Today he is co-founder and CEO of Self Fund Health in Wisconsin, committed to challenging the expensive healthcare system in Wisconsin. Self Fund Health, I am always so pleased to tell you, did make a really, really kind offer to help out RHV (Relentless Health Value) financially. You and the tribe here are really great folks who I truly, truly appreciate. So, please do support Self Fund Health if you are in Wisconsin. This podcast is sponsored by Self Fund Health today. Also mentioned in this episode are Self Fund Health; Cora Opsahl; Claire Brockbank; Eric Bricker, MD; Chris Crawford; Cynthia Fisher; Scott Haas; Peter Hayes; Matt McQuide; RxSaveCard; Mark Cuban; Ramy Khalil, MD; Candace Shaffer; and Tom Nash.   You can learn more at Self Fund Health and follow Jonathan on LinkedIn.   Jonathan Baran is a serial healthcare IT entrepreneur and the co-founder and CEO of Self Fund Health, a fast-growing health plan redefining how employers buy and manage healthcare. With a mission to eliminate waste and realign incentives in the healthcare system, Self Fund Health empowers employers to take control of rising costs by giving employees access to high-value providers at no cost, while replacing traditional insurance with real-time technology, dedicated nurses, and an aligned ecosystem of care. Prior to founding Self Fund Health, Jonathan was the co-founder and CEO of Healthfinch, one of the pioneering companies to build apps on top of electronic medical records. Healthfinch automated routine workflows for physicians using clinical data, significantly improving efficiency and patient care. Under Jonathan's leadership, Healthfinch raised over $15 million in venture capital and scaled to more than 50 employees. The company received national recognition, including being named a “Cool Vendor” by Gartner, a “Top Emerging Vendor” by KLAS, and one of Modern Healthcare's “Best Places to Work.” In 2020, Healthfinch was acquired by HealthCatalyst. Jonathan holds both a bachelor's and master's degree in biomedical engineering from the University of Wisconsin–Madison. He lives in Madison, Wisconsin, and continues to push the boundaries of innovation in employer-sponsored healthcare.   05:23 Where to start in reversing the flywheel. 06:57 Why investing in primary care is pivotal to containing healthcare costs. 10:02 EP453 with Claire Brockbank. 10:04 EP452 with Cora Opsahl. 10:07 EP457 with Cynthia Fisher. 10:12 EP365 with Scott Haas. 10:13 EP465 with Chris Crawford. 10:14 EP475 with Peter Hayes. 11:11 EP468 with Matt McQuide. 11:13 EP472 with Eric Bricker, MD. 12:14 “The most expensive thing in healthcare is the pen of the primary care doctor.” 13:04 How the role of the broker has to fundamentally change. 16:16 What will the single most challenging aspect of this restructuring become? 20:20 How self-funded employers can be amazing customers in containing the rising cost flywheel in healthcare. 22:56 How do EHRs and other medical record systems play into reversing the flywheel of rising healthcare costs? 23:57 Ramy Khalil, MD's post on interoperability. 24:59 Why is it important for employers to drive volume differently? 25:38 How Self Fund Health is helping in this regard.   You can learn more at Self Fund Health and follow Jonathan on LinkedIn.   @JonathanBaran discusses how to contain increasing #healthcarecosts on our #healthcarepodcast. #healthcare #podcast #financialhealth #patientoutcomes #primarycare #digitalhealth #healthcareleadership #healthcaretransformation #healthcareinnovation Recent past interviews: Click a guest's name for their latest RHV episode! Jonathan Baran (Part 1), Jonathan Baran (Bonus Episode), Dr Stan Schwartz (Summer Shorts), Preston Alexander, Dr Tom X Lee (Take Two: EP445), Dr Tom X Lee (Bonus Episode), Dr Benjamin Schwartz, Dr John Lee (Take Two: EP438), Kimberly Carleson, Ann Lewandowski (Summer Shorts), Andreas Mang and Jon Camire (EP479), Justin Leader (Take Two: EP433)  

In this episode Stacey Richter speaks with Jonathan Baran, CEO of Self Fund Health in a detailed exploration of what they term the 'Flywheel Downward Spiral' of American healthcare costs. The conversation delves into how electronic health records (EHR) and the incentives driving insurers, brokers, and hospital systems contribute to consistently rising healthcare premiums.  Key points include how insurers profit from high premiums, the misleading marketing focus on discounts rather than actual costs, and the role of EHR systems in maximizing hospital profits rather than improving patient care. The episode sets the stage for a subsequent discussion on reversing these trends, aiming to align healthcare outcomes with cost reductions. Self Fund Health, I am so pleased to tell you, as I am always so pleased to tell you, did make such a kind offer to help out Relentless Health Value financially. You and the tribe here are really, really great folks who I truly appreciate. Please support Self Fund Health if you are in Wisconsin. This episode is sponsored by Self Fund Health. === LINKS ===

In this bonus clip from Episode 483 of Relentless Health Value, host Stacey Richter discusses the efforts of individuals working within large healthcare organizations to improve patient outcomes despite systemic challenges.  Guest Jonathan Baran, co-founder and CEO of Self Fund Health, highlights how incentives within the healthcare system drive behaviors that often conflict with patient and member interests.  The discussion emphasizes the importance of not generalizing the intentions of all employees based on organizational actions and encourages a deeper understanding of underlying incentive structures to foster meaningful changes.  Self Fund Health, I am so pleased to tell you, as I am always so pleased to tell you, did make such a kind offer to help out Relentless Health Value financially. You and the tribe here are really, really great folks who I truly appreciate. Please support Self Fund Health if you are in Wisconsin. This episode is sponsored by Self Fund Health. === LINKS ===

In this episode, Stacey Richter talks with Dr. Stan Schwartz, co-founder of ZERO.health about the tension between mission-driven healthcare and financial incentives within the healthcare system. Highlighting examples like the Comprehensive Primary Care Initiative and other advanced primary care efforts, Schwartz shares insights on how health system economics, particularly the reliance on emergency room admissions, often undermine initiatives aimed at reducing costs and improving patient outcomes.  The discussion delves into the role of employer-sponsored health plans as potential change agents in the healthcare system, given their significant influence over commercially insured patients, who are highly attractive to providers. Dr. Schwartz underscores the importance of aligned financial incentives and collective action among employers to drive meaningful change in healthcare. If you would like to get a copy of the mentinoed personal integrity and “are you in healthcare for the right reasons” policy called the Guiding Principles Policy that Doug Geinzer and Amy Mecham from High Performance Providers put together.please either check your inbox for the newsletter this week that you just got when this show went live and find the link to download or sign up for the newsletter and I will include it again next week on Thursday. === LINKS ===

In this episode, Stacey Richter discusses 'Three Surprising Ways Carriers Make Lots of Money' with Preston Alexander. The episode highlights how carriers leverage financial strategies—like using premium dollars as float, intracompany eliminations, and upcoding in Medicare Advantage—to enhance their profits.  The discussion emphasizes the importance for plan sponsors and policymakers to understand these tactics to better manage healthcare costs. Alexander advises collaborating with unbiased consultants who are experts in health plan design to navigate these complex financial dynamics effectively. === LINKS ===

In this second take on episode host Stacey Richter speaks with Dr. Tom Lee, founder of One Medical and Galileo. The discussion centers on the survival of independent primary care practices in the current healthcare economy, the associated challenges, and the paradox of primary care.  Topics include reducing ER visits, managing downstream specialty spend, and the imbalance between CMS and commercial carrier payments to primary care practices.  Dr. Lee highlights the importance of 'enlightened leadership' and a 'value-focused mindset' in balancing efficient service operations with quality care. He also touches on the complexities of integrating technology and human-centered care, the importance of operational efficiency, and the challenges posed by current reimbursement models. For a bonus sidebar conversation with Dr. Lee, click here. === LINKS ===

This short bonus episode is a side bar conversation with Dr. Tom Lee discussing why retail clinics are struggling with Dr. Tom Lee.  They explore the shortcomings of retail clinics in providing longitudinal primary care, despite their convenience for minor urgent care and vaccinations.  Dr. Lee emphasizes that true primary care requires consistent, long-term patient relationships and complex management which many retail clinics fail to deliver. They also discuss the economic challenges of running such clinics and the importance of defining primary care's value proposition correctly. === LINKS ===

Balancing Mission and Margin in Healthcare: A Candid Conversation with Dr. Ben Schwartz In this episode, host Stacey Richter engages in a deep dive with Dr. Ben Schwartz to explore the phrase 'No Margin, No Mission' and its practical implications in the healthcare industry.  They discuss the complex relationship between profitability and mission-driven care, the challenges of value-based care, and the role of dyad leadership. The episode emphasizes the importance of transparency, regulatory measures, and trust in fostering a balance between mission and margin. Along the way, Dr. Schwartz shares insights from his new role at Commons Clinic and addresses broader systemic issues like regulatory capture and the subjective nature of defining value in healthcare. === LINKS ===

In this Take Two episode of Relentless Health Value, host Stacey Richter reflects on her conversation with Dr. John Lee to explore the challenging intersection between mission and margin in healthcare.  They discuss the nuances of cognitive dissonance faced by healthcare professionals, particularly when organizational priorities conflict with patient care. Dr. Lee shares insights on finding a sense of mission within the constraints of the current healthcare system, emphasizing the importance of incremental improvements, team-based care, and peer support.  The conversation also highlights real-world examples of systemic issues and practical advice on how individuals can contribute to meaningful change without feeling demoralized. This episode is part of an ongoing series addressing critical topics in healthcare, and listeners are encouraged to tune in next week for further discussions. === LINKS ===

Enhancing Payment Integrity in Health Systems: An In-depth Discussion with Kimberly Carleson. In Episode 481 of Relentless Health Value, host Stacey Richter speaks with Kimberly Carleson, CEO of US Beacon, about payment integrity within health systems. They delve into strategies some hospitals use to maximize revenue without raising rates and discuss the importance of accurate billing.  Key takeaways include the high prevalence of billing errors, which can lead to significant overcharges for plan sponsors, often due to documentation gaps and complex coding systems. Kimberly provides actionable advice for both healthcare providers and plan sponsors on how to mitigate billing inaccuracies and enhance transparency.  Emphasized points include the necessity of third-party claim audits, understanding legal rights under various acts, and the importance of maintaining clear communication and compliance with legal billing standards. === LINKS ===

Exploring the Complexities of Pharma Rebates with Ann Lewandowski In this Summer Short episode of Relentless Health Value, host Stacey Richter converses again with Ann Lewandowski about the intricate dynamics of pharmaceutical rebates, or as Lewandowski prefers, post-sale concessions.  The discussion delves into the nuances of these rebates, the impact they have on drug costs, and the hidden consequences for patients and plan sponsors.  They highlight articles and insights by Austin Chelko and Peter Hayes, touching on how rebates can disadvantage the pursuit of lower-cost generics and biosimilars, and can obstruct pharmacogenetic testing that ensures drug efficacy and safety.  The conversation also critiques the opacity of rebates, deemed trade secrets by pharma and PBM companies, and underscores the ethical and financial dilemmas posed by the current rebate-driven system. === LINKS ===

In this second discussion with Andreas Mang and Jon Camire of Blackstone, Stacey Richter has  an advanced discussion on the intricacies of stop-loss reinsurance for high-cost claimants.  This show today, for sure, it's for plan sponsors and anyone on or about plan sponsors; but also listen if you are serving high-cost claimants some other way. Because what you'll learn here today is some insights relative to how plan sponsors go about making sure that they can pay you—like if you work for, for example, some clinical organization. There's a, I don't know, 101 starting point of this conversation if you need it on stop-loss, which is episode 478 from a couple of weeks ago. This show is the, let's say, 201-level conversation that I'm having with Andreas Mang and Jon Camire about, as I said, stop-loss insurance and stop-loss insurance considerations. Emphasizing the importance of eligibility audits and aggregating buying power, the guests highlight best practices to avoid overpaying for coverage and ensuring comprehensive risk management. This episode is sponsored by Havarti Risk, which I am so thankful for. The show, Relentless Health Value, actually does cost an unexpectedly large sum of money to create and produce; so I always appreciate when somebody offers to sponsor a show or help sponsor a show. === LINKS ===

Stacey Richter has a second take on the original episode 433 since it is so relevant right now. Stacey engages in a compelling conversation with Justin Leader, CEO of BenefitsDNA, about the opaque practices of third-party administrators (TPAs) and their impact on healthcare costs.  They discuss the hidden fees tucked into weekly claims wires, including shared savings fees, prior authorization fees, prepayment integrity fees, pay and chase fees, and TPA adjudication fees.  The episode emphasizes the need for transparency, understanding hidden costs, and ensuring fiduciary responsibility for self-funded employers. Additionally, Leader shares insights from a Health Affairs article and mentions ongoing legal cases that highlight the financial discrepancies in TPA practices. === LINKS ===

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