Podcast appearances and mentions of Marshall Allen

“You know, Marshall was known in the healthcare space, but there's 100 million Americans who don't know anything about the healthcare space. And those are the people that we're really trying to serve." - Sonja AllenSonja Allen is the Managing Director of the Marshall Allen Project and the Allen Health Academy, and as many of you know, she was also married to our dear friend, the late Marshall Allen. Sonja joined me to discuss how she's continuing Marshall's mission of helping Americans fight back against our healthcare system, using the MAC, an AI clone of Marshall Allen.She also shared the story of her and Marshall's lives together, including how they met and how he found his passion for healthcare journalism, and I'm humbled to have had the chance to capture a permanent record of it for the world. Marshall was a dear friend and an inspiration, and I was honored to have him on the show. I hope you'll tune in this week to hear how we can all continue his legacy.Chapters:(00:00:00) Continuing Marshall Allen's Legacy | with Sonja Allen(00:03:40) Sonja's Experience Growing Up In Kenya(00:08:43) Meeting Marshall Allen(00:16:04) Marshall's Career Transformation(00:30:58) The MAC - The Marshall Allen AI Clone(00:33:53) Empowering Healthcare Navigation Using The MAC(00:42:55) Informing Americans Of Their Healthcare RightsKey Links for Social:@SelfFunded on YouTube for video versions of the podcast and much more - https://www.youtube.com/@SelfFundedListen/watch on Spotify - https://open.spotify.com/show/1TjmrMrkIj0qSmlwAIevKA?si=068a389925474f02Listen on Apple Podcasts - https://podcasts.apple.com/us/podcast/self-funded-with-spencer/id1566182286Follow Spencer on LinkedIn - https://www.linkedin.com/in/spencer-smith-self-funded/Follow Spencer on Instagram - https://www.instagram.com/selffundedwithspencer/

CBS News has obtained a list of Justice Department cutbacks showing the Trump administration is pulling funding from local initiatives that many say are vital to public safety. Homeland Security Secretary Kristi Noem spoke with "CBS Mornings" co-host Tony Dokoupil along the U.S.-Mexico border in El Paso, Texas, where she discussed the Trump administration's immigration crackdown, sending dozens of migrants to a maximum security prison in El Salvador, the "part of our process we need to fix," and more. Jen McCabe, a key witness in Karen Read's retrial, told a Massachusetts jury on Tuesday about a frantic phone call from Read in the early hours of January 29, 2022, screaming that her boyfriend, John O'Keefe, was missing. Read is accused of hitting O'Keefe with her car and leaving him to die.Southwest Airlines is outlining its new fare bundles that passengers can expect to soon see. Southwest will introduce a new cabin that offers extra leg room. For now, the seat will be free, but early in 2026, the airline will switch to assigned seating. Plus, starting in May, most passengers will have to pay to check a bag. CBS News senior transportation correspondent Kris Van Cleave has more. As President Trump marks 100 days in office, CBS News' Caitlin Huey-Burns sits down with voters in Georgia and North Carolina to hear their thoughts on his performance so far. At 100 years old, Sun Ra Arkestra bandleader Marshall Allen is celebrated by the National Endowment for the Arts as a living legend in jazz. CBS News national correspondent Jericka Duncan sat down with him. Geena Davis, star of "Thelma & Louise," shares how her new book, "The Girl Who Was Too Big for the Page," encourages kids to stand tall and embrace who they are. Comedian and commentator Samantha Bee joins "CBS Mornings" to talk about her one-woman show, inspired by her own experience with menopause and the lack of honest conversation around it. To learn more about listener data and our privacy practices visit: https://www.audacyinc.com/privacy-policy Learn more about your ad choices. Visit https://podcastchoices.com/adchoices

Send us a textFascinating, sometimes unexpected pairings and groupings are the name of the game on this week's @weheardwonders podcast. Iain and Andrew share their favourite musical mash-ups, before moving on to review five collaboration-heavy new projects. Bobby Gillespie lives out his noirish, faded glamour fantasies alongside Mr & Mrs of French garage-rock The Limiñanas; DARKSIDE expand to a trio and jam out; Richard Russell and assorted friends turn existential on the latest Everything Is Recorded document; Sun Ra acolyte Marshall Allen enlists Neneh Cherry and proves it's never too late to take centre-stage; while Japanese folk singer Ichiko Aoba and composer Taro Umebayashi once again take a deep dive into the fantastical. Something dark and devilish has The Vinyl Word. Listen to We Heard Wonders on your podcast platform of choice; tell your friends; like, subscribe and recommend; catch up with previous editions and support the show by buying us a Coffee (link in the show's bio).www.buymeacoffee.com/weheardwondersSupport the showwww.instagram.com/weheardwonderswww.buymeacoffee.com/weheardwonders

Nick brings us a Three For Thursday for Roberta Flack, who passed this week at the age of 88. She grew up in Arlington, VA, and upon graduating high school at the age of 15, she received a full music scholarship to Howard University. She began singing professionally in 1968, was signed to Atlantic Records, and went on to have a whirlwind of a successful career in the 1970s. Her voice touched a generation and she will be missed.Songs: Roberta Flack - “Compared to What”Roberta Flack - “Killing Me Softly (With His Song)”Roberta Flack & Donny Hathaway - “I (Who Have Nothing)”Heard it through the GREGvine that Christina Ricci really hates Live, but particularly “Lightning Crashes.” Also, Marshall Allen, current bandleader of Sun Ra, releases his debut album at age 100, breaking all sorts of records. Finally, the Red Hot Chili Peppers recorded music catalog is for sale, you can own it today for clean $350 million.Song: Bob Dylan “One More Cup of Coffee (feat. Scarlet Rivera)”Jay brings a listener inspired (thanks Mr. Lentz!) BienVenue for a long-gone Baltimore music spot: The Painters Mill Music Fair. It began as a tent in a parking lot in 1960, with the 2500 person venue constructed in 1967. A venue of that capacity hosted some pretty large acts in the years to come. Dave Brubeck, James Brown, Bob Dylan, Frank Zappa, Chick Corea, Bruce Springsteen, and more over the next fifty-five years. It was also where Greg Allman played his final show with the Allman Brothers. In 1991, the venue burned to the ground when a burglar attempted to access the safe with a butane torch.Song: Frank Zappa - “What's New in Baltimore? (Live at Painters Mill Star Theatre)”

歪波音室会于每个月月底整理当月新发行的作品来分享，并分为「华语」与「外语」两个部分，希望你能从中遇到喜欢的新鲜有趣的音乐。也欢迎你在评论区分享本月听到最好的新歌，一起查漏补缺，多多益善，不再歌荒！希望你会喜欢 :)

8e émission de la 61e session...Cette semaine, cool jazz, jazz modal et post-bop! En musique: Dorothy Ashby with Frank West sur l'album Hip Harp  (Prestige, 1958); Shelly Mane sur l'album 2-3-4  (Impulse!, 1962) Duke Pearson sur l'album Prairie Dog  (Atlantic, 1966); The Albert Mangelsdorff Quintet sur l'album Now Jazz Ramwong  (CBS, 1964); John Surman sur l'album Flashpoint and Undercurrents  (Cuneiform, 2025, enr. 1969); Marshall Allen sur l'album New Dawn  (Mexican Summer, 2025)...

Andy talks about 100yo saxophonist Marshall Allen's Guinness World Record-setting debut solo album, community theater, and being too busy to eat healthy. On Rachel's Chart Chat, Rachel from Des Moines delivers part 1 of her look at Stars on 45 and the Medley Craze. Follow Rachel on Last.fm here.

Möglichst viel verschieben von dem, was als möglich gilt: Bartees Strange definiert Indie-Rock neu, John Glacier verflüssigt Grime zu Zeitlupen-Poesie und Marshall Allen (Sun Ra Arkestra) macht mit 100 Jahren sein erstes Soloalbum (das bedeutet Weltrekord!). Heute bleibt kein Sound auf dem anderen. +++ PLAYLIST+++ · 22:55 - ANGELS AND DEMONS AT PLAY von MARSHALL ALLEN · 22:48 - LOVE IN OUTER SPACE von SUN RA · 22:37 - NEW DAWN von MARSHALL ALLEN FEAT. NENEH CHERRY · 22:31 - BUFFALO STANCE von NENEH CHERRY · 22:26 - STREET PULSE BEAT von SPECIAL INTEREST/BOY HARSHER · 22:22 - F.U. von JAMIE XX FEAT. ERYKAH BADU · 22:18 - MAN MADE OF MEAT von VIAGRA BOYS · 22:13 - THE ONION MAN von FOMIES · 22:09 - CONFUSION von FOMIES · 21:55 - DOLLAR STORE von BEN KWELLER FEAT. WAXAHATCHEE · 21:50 - JULIE von HORSEGIRL · 21:46 - I CAN'T STAND TO SEE YOU von HORSEGIRL · 21:43 - BACKWASH von GILLA BAND · 21:38 - SLIP ANGLE von THE NULL CLUB FEAT. VALENTINE CAULFIELD · 21:35 - TOUT RESONNE von VENDREDI SUR MER · 21:31 - RETROVISEUR von BARRIO COLETTE · 21:29 - LA GATA von MORTORI · 21:24 - TERRIBLE LUCK von PETER KERNEL · 21:20 - DRAGGIN' von HANNAH COHEN · 21:16 - ELEPHANT von JASMINE.4.T · 21:11 - NO FRONT TEETH von PERFUME GENIUS FEAT. ALDOUS HARDING · 21:07 - SLIP AWAY von PERFUME GENIUS · 21:04 - THE BARREL von ALDOUS HARDING · 20:59 - AJALA von EZRA COLLECTIVE · 20:56 - DON'T FALL IN von KAE TEMPEST · 20:52 - H.O.O.D. (2025 MIX) von KNEECAP · 20:49 - NOTHING GREAT ABOUT BRITAIN von SLOWTHAI · 20:47 - MONEY SHOWS von JOHN GLACIER FEAT. EARTHEATER · 20:44 - FOUND von JOHN GLACIER · 20:39 - EMOTIONS von JOHN GLACIER · 20:36 - NORF GUN von BARTEES STRANGE · 20:30 - WANTS NEEDS von BARTEES STRANGE · 20:27 - MY FAULT von STAY INSIDE · 20:23 - BOOMER von BARTEES STRANGE · 20:19 - SOBER von BARTEES STRANGE · 20:15 - LOVERS von BARTEES STRANGE · 20:10 - WOLF LIKE ME von BARTEES STRANGE/ANJIMILE/KARA JACKSON · 20:05 - MR. NOVEMBER von THE NATIONAL

Episode 735: February 16, 2025 playlist: Scanner and Nurse with Wound, "Conium Maculatum" (Contrary Motion) 2025 United Dairies / Alltagsmusik Mary Lattimore, "Morning Song" (Morning Song) 2025 [self-released] FACS, "Sometimes Only" (Wish Defense) 2025 Trouble In Mind Whitney Johnson and Lia Kohl, "73|74" (For Translucence) 2025 Drag City Mount Vernon Arts Lab, "Hobgoblins" (Seance at Hobs Lane) 2001 Via Satellite / 2025 Ghost Box Kevin Richard Martin / Dis Fig, "Silent" (Silent) 2025 Intercranial Miki Yui, "Summer Night" (As If) 2025 Hallow Ground Lucrecia Dalt, "cosa rara (ft. David Sylvian)" (cosa rara) 2025 RVNG Intl. Ali Omar, "The Last Straw" (Hashish Hits) 2025 Efficient Space Kara-Lis Coverdale, "Kvinne med gresskar" (Jordsvingninger) 2024 Smalltown Supersound Ida, "Down On Your Back" (Will You Find Me?) 2000 Tiger Style / 2025 Numero Group Hanne Lippard, "Tennis" (Talk Shop) 2024 Dischi Fantom Haswell and Hecker, "UPIC Diffusion Session _23" (UPIC Diffusion Session _23) 2025 Editions Mego Marshall Allen, "New Dawn (feat. Neneh Cherry)" (New Dawn) 2025 Mexican Summer Email podcast at brainwashed dot com to say who you are; what you like; what you want to hear; share pictures for the podcast of where you're from, your computer or MP3 player with or without the Brainwashed Podcast Playing; and win free music! We have no tracking information, no idea who's listening to these things so the more feedback that comes in, the more frequent podcasts will come. You will not be put on any spam list and your information will remain completely private and not farmed out to a third party. Thanks for your attention and thanks for listening.

Bartees Strange. Denison Witmer. The Sun Ra Arkestra's Marshall Allen. NPR Music's Stephen Thompson welcomes Nate Chinen of Philadelphia's WRTI to discuss the best new releases out on Valentine's Day.Featured albums:• Bartees Strange, 'Horror'• Denison Witmer, 'Anything At All'• Marshall Allen, 'New Dawn'• Sullivan Fortner, 'Southern Nights'• John Patitucci, 'Spirit Fall'Check out our longer list of albums out Feb. 14 and stream our New Music Friday playlist at npr.org/music.Credits:• Host: Stephen Thompson• Guest: Nate Chinen (WRTI)• Producer: Simon Rentner• Editor: Otis Hart• Executive Producer: Suraya Mohamed• Vice President, Music & Visuals: Keith JenkinsLearn more about sponsor message choices: podcastchoices.com/adchoicesNPR Privacy Policy

This week we focus on a most auspicious debut album, which offers a welcome opportunity to appreciate Marshall Allen for being more than the flamekeeper of the Sun Ra legacy, and the launch of the Year of Women in Jazz with a groovy single by Rosa Brunello. The playlist also features Massimiliano Cignitti's tribute to Edda Dell'Orso, the mesmerizing singer on many Ennio Morricone soundtracks, and much more! The playlist features Ludivine Issambourg; Rosa Brunello; Marshall Allen [pictured], Neneh Cherry; Michel Jonasz; Massimiliano Cignitti; Adam Baldych; Achim Kaufmann, Michael Moore. Detailed playlist at https://spinitron.com/RFB/pl/20115121/Mondo-Jazz [up to "Snake Hip Waltz"]. Happy listening!

JazzOmania #117 par Stéphane Kochoyan avec Canal 30, Stellar Média & Jazz70  JazzOmania, la playlist des nouveautés discographiques et des plateformes musicales, Tous les Jazz d'hier, d'aujourd'hui et de demain... Il n'est jamais trop tard : Marshall Allen, le sax baryton de Sun Ra vient de publier à l'âge de 100ans son premier album en leader,  voici le titre "New Dawn" avec en invité la chanteuse Neneh Cherry (notre photo DR). Bientôt la St Valentin, évitez les menus ringards des restaurants choisissez d'écouter du bon jazz ! Les 13 et 14 Février à Pau, les Egarés groupe Victoires du Jazz "Meilleur concert de l'année" (Ballaké Sissoko , Vincent Ségal, Vincent Peirani, Émile Parisien) et à Nîmes à la Milonga del Angel le groupe world - cumbia "Onda Ya" dans l'ambiance "club" de la MILONGA DEL ANGEL 47 rue de l'Occitanie 30000 Nîmes Tarif réduit : 16€ (adhérents Jazz70, étudiants, écoles de musique, demandeurs d'emploi) Tarif normal : 20€ Réservations : par mail sur associationjazz70(at)gmail.com ou Fnac Possibilité de diner sur place, réservations restaurant par téléphone 0663906918   La playlist #117 de Stéphane Kochoyan 01 - Paul Gonsalves, Clark Terry & Joe Gordon  - I've Found a New Baby 02 - Marshall Allen feat Neneh Cherry  - New Dawn 03 - 20Syl & Christophe Panzani  - Dreams 04 - Paolo Fresu - Orange 05 - Ben L'Oncle Soul - I Got  home 06 - Sylvain Daniel - No Sex In Verneuil 07 - Thomas Leleu - Leleuland 08 - Gabi Hartmann - Into My World 09 - Les égarés, Ballaké Sissoko , Vincent Ségal, Vincent Peirani, Émile Parisien - Esperanza 10 - Onda Ya - Xote das meninas 11 - Pat Metheny - (It's Just) Talk 12 - Emmet Cohen - Emmetís Blues 13 - Lizz Wright feat Meshell Ndegeocello - Your Love 14 - Miles Davis - Introduction by Andre Francis (Live at Festival Mondial Du Jazz Antibes_Juan-Les-Pins, France - July 28, 1963) 15 - Miles Davis - If I Were A Bell (Live at Festival Mondial Du Jazz Antibes_Juan-Les-Pins, France - July 28, 1963) #Jazz #Podcast #Jazz70 #TousLesJazz #MilongaDelAngel #Nîmes #Pau #JazzaPau #SaintValentin        

Episode 733: January 31, 2025 playlist: Dead Pioneers, "Po$t American" (Po$t American) 2025 Hassle The Legendary Pink Dots, "Blood Money" (So Lonely in Heaven) 2025 Metropolis Amulets, "Lifelike (feat. Midwife)" (Not Around But Through) 2025 Beacon Sound Laraaji, "Joyous Dance '82" (Staying: Leaving Records Aid to Artists Impacted by the Los Angeles Wildfires) 2025 Leaving Open Head, "Fiends Don't Lose" (What Is Success) 2025 Wharf Cat 400 Lonely Things, "Many Ran" (Children of Eidolon) 2025 Room40 Gnod and White Hills, "Nothing NEU! Under the Sky" (Drop Out III) 2025 Thrill Jockey Marshall Allen, "African Sunset" (New Dawn) 2024 Mexican Summer Papa M, "Pink Holler" (Live From A Shark Cage) 1999 Drag City Antony and the Johnsons, "As Tears Go By (live)" (Unreleased) 2006 unreleased Email podcast at brainwashed dot com to say who you are; what you like; what you want to hear; share pictures for the podcast of where you're from, your computer or MP3 player with or without the Brainwashed Podcast Playing; and win free music! We have no tracking information, no idea who's listening to these things so the more feedback that comes in, the more frequent podcasts will come. You will not be put on any spam list and your information will remain completely private and not farmed out to a third party. Thanks for your attention and thanks for listening.

The Rendezvous is back for #Jazzuary Pt. 3! LIVE from the beach, fresh off NYC's Winterjazz Fest! Expect Spiritual Jazz, Classics, & fresh sounds from Dana & Alden, The Brkn Record, Butcher Brown, Setenta, Chris Bangs, Marshall Allen, and James Brandon Lewis. For more info and tracklisting, visit: thefaceradio.com/the-rendezvous/. Tune into new broadcasts of The Rendezvous, LIVE, Sunday from 2 - 4 PM EST / 7 - 9 PM GMT on The Face Radio and Totally Wired Radio. Dig this show? Please consider supporting The Face Radio: support.thefaceradio.com. Connect: https://linktr.ee/kurtispowers

The Rendezvous is back for #Jazzuary Pt. 3!LIVE from the beach, fresh off NYC's Winterjazz Fest!Expect Spiritual Jazz, Classics, & fresh sounds from Dana & Alden, The Brkn Record, Butcher Brown, Setenta, Chris Bangs, Marshall Allen, and James Brandon Lewis.For more info and tracklisting, visit: thefaceradio.com/the-rendezvous/.Tune into new broadcasts of The Rendezvous, LIVE, Sunday from 2 - 4 PM EST / 7 - 9 PM GMT on The Face Radio and Totally Wired Radio.Dig this show? Please consider supporting The Face Radio: support.thefaceradio.com.Connect: https://linktr.ee/kurtispowers Support The Face Radio with PatreonSupport this show http://supporter.acast.com/thefaceradio. Join the family at https://plus.acast.com/s/thefaceradio. Hosted on Acast. See acast.com/privacy for more information.

The Rendezvous is back for #Jazzuary Pt. 3!LIVE from the beach, fresh off NYC's Winterjazz Fest! Expect Spiritual Jazz, Classics, & fresh sounds from Dana & Alden, The Brkn Record, Butcher Brown, Setenta, Chris Bangs, Marshall Allen, and James Brandon Lewis.For more info and tracklisting, visit: thefaceradio.com/the-rendezvous/.Tune into new broadcasts of The Rendezvous, LIVE, Sunday from 2 - 4 PM EST / 7 - 9 PM GMT on The Face Radio and Totally Wired Radio.Dig this show? Please consider supporting The Face Radio: support.thefaceradio.com.Connect: https://linktr.ee/kurtispowers Support The Face Radio with PatreonSupport this show http://supporter.acast.com/thefaceradio. Join the family at https://plus.acast.com/s/thefaceradio. Hosted on Acast. See acast.com/privacy for more information.

Episode 726: December 9, 2024 playlist: The Legendary Pink Dots, "So Lonely in Heaven" (So Lonely in Heaven) 2025 Metropolis Body Mepha, "Scout (excerpt)" (Prayer in Dub) 2024 Hausu Mountain B. Rupp, "Please Continue" (Pop Music) 2024 Accidental Meetings Kenneth Kirschner, "April 27, 2023 – III" (April 27, 2023) 2024 Room40 David Grubbs, "The Snake on Its Tail" (Whistle from Above) 2025 Drag City Klara Lewis, "4U (Lokalfragan Remix)" (Thankful Remixes) 2024 Editions Mego HTRK, "Ha" (Marry Me Tonight) 2008 Blast First Petite / 2025 Ghostly William Ryan Fritch, "Moities" (Adhesion) 2024 Lost Tribe Lifted, "Specials" (Trellis) 2024 Peak Oil KRM and KMRU, "Otherness" (Otherness EP) 2024 Phantom Limb Dead Pioneers, "My Spirit Animal Ate Your Spirit Animal" (My Spirit Animal Ate Your Spirit Animal) 2024 Hassle Laurie Anderson, Marshall Allen, "The Wuz" (Outer Spaceways Incorporated : Kronos Quartet and Friends Meet Sun Ra) 2024 Red Hot Email podcast at brainwashed dot com to say who you are; what you like; what you want to hear; share pictures for the podcast of where you're from, your computer or MP3 player with or without the Brainwashed Podcast Playing; and win free music! We have no tracking information, no idea who's listening to these things so the more feedback that comes in, the more frequent podcasts will come. You will not be put on any spam list and your information will remain completely private and not farmed out to a third party. Thanks for your attention and thanks for listening.

Episode 136 Sun Ra and Stockhausen—An Imaginary Encounter in Electronic Music Playlist   Time Track Time Start Introduction –Thom Holmes 14:28 00:00 Karlheinz Stockhausen,  “Es (It)” (1969) from Aus Den Sieben Tagen (from the Seven Days) (1973 Deutsche Grammophon). Composed by, electronics (Filters, Potentiometers), spoken voice, technician (Sound Direction), liner notes, Karlheinz Stockhausen; Elektronium, Harald Bojé; Piano, Aloys Kontarsky; Drums, Percussion (Tam-tam, Flexatone, Guero, Bamboo Flute, Jew's Harp, Rolf Gehlhaar; Drums, Percussion (Tam-tam, Flexatone, Guero, Jew's Harp, Alfred Alings; Viola, Johannes G. Fritsch. The Elektronium was an electronic instrument in the form of an accordion, invented by Hohner in 1952. From the cycle of compositions entitled Aus den Sieben Tagen. Es (10th May 1968). This is the complete cycle for the work consisting of 7 albums recorded at the Georg-Moller-Haus (Loge) in Darmstadt, from the 26th to 31st August 1969. This is different than the earlier recordings from Cologne that were released separately. Comes in a sturdy box together with a tri-lingual 20-page booklet. Each record is packed in its own cover. 23:04 14:30 Sun-Ra and his Astro Infinity Arkestra, “Space Probe” (1969) from My Brother The Wind Vol. 1 (2017 Cosmic Myth Records). Moog Modular Synthesizer solo, two keyboards, Sun Ra; Moog programming and mixing, Gershon Kingsley.” Recorded at Gershon Kingsley's New York studio before Sun Ra had acquired a prototype Minimoog from Bob Moog the following year. 17:45 37:30 Sun-Ra and his Astro Infinity Arkestra, “The Code Of Interdependence” (1969) from My Brother The Wind Vol. 1 (2017 Cosmic Myth Records). Moog Modular Synthesizer solo, two keyboards, Sun Ra; Moog programming and mixing, Gershon Kingsley; Drums, Danny Davis, John Gilmore; Oboe, Marshall Allen; Tenor Saxophone, John Gilmore. Recorded at Gershon Kingsley's New York studio before Sun Ra had acquired a prototype Minimoog from Bob Moog the following year. 16:50 55:16   Opening background music: Sun Ra and his Solar Myth Arkestra, “Seen Three Took Four” from The Solar-Myth Approach Vol. 1 (1970 Actuel). Piano, Minimoog, Electric Organ, Clavinet, Sun Ra; Tenor Saxophone, Percussion, John Gilmore; among a huge host of others. Introduction to the podcast voiced by Anne Benkovitz. Additional opening, closing, and other incidental music by Thom Holmes. My Books/eBooks: Electronic and Experimental Music, sixth edition, Routledge 2020. Also, Sound Art: Concepts and Practices, first edition, Routledge 2022. See my companion blog that I write for the Bob Moog Foundation. For a transcript, please see my blog, Noise and Notations. Original music by Thom Holmes can be found on iTunes and Bandcamp.

A band leader sampler. Veteran sidemen Eddie Bert, Peter Erskine, Don Menza and Marshall Allen provide inside stories about Glenn Miller, Stan Kenton, Buddy Rich, Sun Ra and Joe Zawinul. Maria Schneider weighs in on the role and responsibility of a leader.

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

Caitlyn Mai expected her share of a recent surgery bill to be about $2,000, with insurance covering the rest. Then she started getting alerts on her phone from the hospital that she owed $139,000 — the full cost of her surgery. But Caitlyn, a legal assistant in Oklahoma, instinctively knew a cardinal rule of the American healthcare system — “never pay the first bill.” It's a lesson we first heard from the journalist Marshall Allen, whose 2021 book Never Pay the First Bill serves as a how-to guide for anyone facing down a potentially bogus medical bill, and whose passing earlier this year left a giant hole in the hearts of many. This episode is an extended version of a recent installment of the NPR and KFF Health News series Bill of the Month. Here's a transcript of this episode. Send your stories and questions. Or call 724 ARM-N-LEG.Of course we'd love for you to support this show. Hosted on Acast. See acast.com/privacy for more information.

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

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

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

To read the full show notes with links mentioned, be sure to visit our episode page and consider signing up for our free weekly newsletter. Episode 443 of Relentless Health Value pays tribute to the late Marshall Allen, an investigative journalist dedicated to exposing injustices within the American healthcare system. Hosted by Stacey Richter, the episode features Dave Chase, founder of Health Rosetta, who shares memories and insights into Marshall's tireless work in investigative reporting. The episode highlights Marshall's impact on healthcare legislation, his significant contributions to ProPublica, and his book 'Never Pay the First Bill,' which empowers patients and employers to fight back against corrupt billing practices. The episode also includes an earlier interview with Marshall, focusing on his perspective as an investigative reporter, the exploitation within the healthcare system, and the importance of patients and employers demanding transparency and fairness. The episode encourages listeners to continue Marshall's legacy by subscribing to the Marshall Health Academy and purchasing access for employees. 09:28 What's the point of view that Marshall is coming from with his investigative reporting? 09:57 “How does this affect the people who are paying for it and the people who are undergoing the care?” 10:49 “There's a lot of good people working within this very messed up system.” 11:03 Why are patients considered outsiders in the healthcare system? 11:45 “What's happened in healthcare is that the stakeholders treat each other more as the customer.” 13:45 What is upcoding? 17:18 “These are schemes that have been created within the industry to increase revenue.” 17:46 “This system is not set up for the benefit of the patient.” 18:13 “On the financial side, the industry is actually oppressing the American people.” 19:14 “We have been expected to pay whatever aggregate sum is thrown at us.” 20:21 Why have patients been so passive toward this crooked healthcare system so far? 22:05 What's the difference between making a profit and profiteering? 29:45 What are the first-order and second-order consequences of what's happening in health care right now, and which of these consequences will actually drive change? 30:45 “When you tell the truth about what's going on … they become so ashamed … that they change their behavior.” 32:00 “The patient … is not their most important customer.” 32:50 “The sleeping giant is the employers.”

Almost immediately, he found himself as sideman for notable locals such as Kermit Ruffins, Michael Ward and The Reward, and Sun Ra trumpeter, Michael Ray.  In 1992 he co-founded the New Orleans Klezmer All-Stars(NOKAS), a pioneering klezmer ensemble that infused that music with the vibrancy and energy of the funk, jazz and brass music of New Orleans. To date he has had opportunity to play with most of New Orleans' greatest musicians from across all genres.  NOKAS was playing some of his compositions, but by 1993 he found himself seeking outlets for his compositions in other styles and forms.  After playing with a plethora of combos and experimenting with many great local musicians he formed Naked On The Floor and eventually The Naked Orchestra. Naked on the Floor (quintet) and the Naked Orchestra (18-24 piece creative orchestra) play Freilich's original compositions exclusively and still play regularly in New Orleans. He has appeared at the New Orleans Jazz and Heritage Festival 24 times as well as headlining the Berlin Jazz Festival with NOKAS. He has appeared at numerous other festivals inside and outside the country including Bonnaroo, the Ann Arbor Jazz Festival, The American Folklife festival at the Washington Monument, collaborations with poet, Andrei Codrescu at the Holocaust museum in NYC and many others. Other notable work includes appearances with Sam Rivers, Burton Greene, Marshall Allen, The Wild Magnolias and backing songwriters such as Robbie Robertson. He has done arrangements for a wide range of recordings from, Peter Stampfel to Hal Willner's presentation of U@ doing music of T-Rex. He is featured on over 21 recordings ranging from Klezmer to Afro-Cuban and avant-garde orchestra music. Recently he put out two CD's of a large orchestra playing his original compositions, a small group, and played on Marianne Faithfull's latest release.  Many of these recordings are either Big Easy or Offbeat entertainment award winners across a number of categories.  He also has music featured in films and TV shows (Andy Richter conquers the Universe, The Dukes of Hazzard(Warner Home Video) as well as commercials for companies such as Southwest Airlines and Mercedes.    n 2016 he produced and arranged an album, NOLA? for legendary Basque artist, Fermin Muguruza. Rearrangements of Muguruza's classic work utilizing the great players and sounds of New Orleans. That led to a very successful European run for the Basque New Orleans Orchestra. Other arranging credits include Hal Wilner and U2 tribute to T. Rex and Grammy Award winner, Peter Stampfel's 100 songs of the 20th century project.      His work includes 4 completed and performed operatic works: a comic-satirical opera, Bang the Law, about a couple of New Orleans lawyers and their movements through New Orleans class detritus after Hurricane Katrina, a two movement orchestral fantasy about Elias Cannetti at carnival, formation of a new quintet to play new original compositions, an octet reduction of Peter and the Wolf for a New Orleans Contemporary Art Center/Guggenheim foundation presentation; a second opera, ee me & cummings thee which premiered in New Orleans in Nov. 2011.   2019 saw the completion of two operas. One a hyper-collaborative project with writer, Bernard Pearce, The Coronation, on the selecting of queen bees. In June 2019 he wrote an operetta on the Dirty Letters of James Joyce to Nora Barnacle, titled Darling, Please do not be offended at what I wrote.  He is the subject of the one hour radio documentary Jonathan Freilich's Freedom Double-O Naked Klezmer Jazz Latin Boogaloo: The Radio Documentary by award winning documentarian, David Kunian and was the 2008 Louisiana Governors' Music Fellowship Award recipient.  This year he figured as a Rising Star guitarist in Downbeat's Critics Poll.  Freilich was born Oct.13, 1968 in Philadelphia, Pa.  He spent most of his early years, up until a late teenager in London, England before moving to Los Angeles in 1985.  Thereafter, he moved to Santa Cruz, Ca in 1987 before the 1989 move to New Orleans.  Currently, he is residing in Los Angeles after completing further studies in composition at California Institute of the Arts. Aside from music, Freilich is also a certified Iyengar yoga instructor and co-owner of a studio in New Orleans for many years.

On this week's Talkhouse Podcast we're diving deep into a chat inspired by two tribute albums to an incredibly influential musician, Sun Ra. Joining us are Meshell Ndegeocello and David Harrington. And oh man, do I have my work cut out for me in trying to introduce these incredible people and their careers—I won't even scratch the surface. Meshell Ndegeocello's biggest foray into the public consciousness, strangely enough, came on a duet with John Mellencamp in the mid-'90s, but that's not at all indicative of her wide-ranging career, which also includes everything from go-go music to neo-soul to jazz to rapping on a Madonna song. These days, the Grammys had to create an entirely new category for what she does: She just won the first-ever Grammy award for Alternative Jazz for last year's The Omnichord Real Book. It's no surprise given her musical serachings that Ndegeocello is also deeply inspired by Sun Ra, the legendary out-there jazz composer and performer who traveled through time and space until leaving our planet in 1993. His legacy lives on, though, and Ndegeocello recently released Red Hot & Ra: The Magic City, which features new compositions, old sounds, and a fresh look not just at Ra's work but his musical spirit. It's hard to explain, but check out “Bedlam Blues” from The Magic City right here. Today's other guest is David Harrington, founding member of Kronos Quartet, which has been expanding the music world for 50 years. I'd be a fool to try and sum up everything they've done and everyone with whom they've performed over the years, but do yourself a favor and Google them if you're not familiar. I'll just say that Kronos has pushed the envelope from just about every conceivable angle and expanded the scope and understanding of classical music, pop music, experimental music and much more. They've done film scores that you've definitely heard and deep dives into fringe classical compositions that you almost certainly haven't. So it's no wonder that they, too, like Ndegeocello, have found the wonder and mystery in Sun Ra's music, and that they've put together their own tribute in the Red Hot and Ra series. Theirs is called Outer Spaceways Incorporated: Kronos Quartet and Friends Meet Sun Ra. The friends on their volume of the series include Laurie Anderson, Marshall Allen, Laraaji, Moor Mother, Terry Riley, and more. Check out “Outer Spaceways Incorporated,” which features Georgia Anne Muldrow, right here. I should mention too that both of these albums are being released by the Red Hot organization, which has been raising money and awareness for good causes—initially AIDS research, and now that and more—since 1989. The Red Hot and Ra series is just the latest in a long line of albums that push musical boundaries while also serving humanity, so kudos to them—and to former Talkhouse host Elia Einhorn, who's been working with the Red Hot folks on these Sun Ra tributes. In this great conversation, Harrington and Ndegeocello talk, naturally, about Sun Ra, and they get granular with it, touching on MLK's "I Have A Dream" speech and its relationship to this music. They also chat about bringing more women into composition—a Kronos mandate since the beginning—as well as how finding Sun Ra changed Ndegeocello's musical path completely. Harrington also shares a great story about rehearsing with Ornette Coleman. Bonus! Enjoy. Thanks for listening to the Talkhouse Podcast, and thanks to Meshell Ndegeocello and David Harrington for chatting. If you liked what you heard, please follow Talkhouse on your favorite podcasting platform, and check out all the great stuff at Talkhouse.com. This episode was produced by Myron Kaplan, and the Talkhouse theme is composed and performed by the Range. See you next time! This episode is brought to you by DistroKid. DistroKid makes music distribution fun and easy. To learn more and get 30% off your first year's membership, visit: distrokid.com/vip/talkhouse

May News You Can Use 1) Paging Dr. Malware 2) Ransomware Crisis in Healthcare - Major health systems like Ascension facing increasing ransomware attacks, leaving patients stranded 3) Despite Change Healthcare breach serving as a wake-up call, healthcare organizations continue to struggle with complex tech infiltrations. 4) AI Consent Controversy: ChatGPT's new voice model is under fire for allegedly using an actor's voice without approval 5) Study reveals patients prefer video consultations with professional backdrops over home settings 6) Honoring the late Marshall Allen, an advocate against medical billing injustices To stream our Station live 24/7 visit www.HealthcareNOWRadio.com or ask your Smart Device to “….Play Healthcare NOW Radio”. Find all of our network podcasts on your favorite podcast platforms and be sure to subscribe and like us. Learn more at www.healthcarenowradio.com/listen

A special episode soaked in summer sun, featuring funky gems from 1970s Venezuela and Panama, soulful tropical vibes from contemporary Brazil, Latin grooves from Eddie Harris, cosmic jazz from the great Marshall Allen, and more! Step inside the One Room Paradise and dig the warm sounds.Tune into new broadcasts of One Room Paradise, the 2nd & 4th Sunday from 7 - 8 PM - EST / 12 - 1 AM GMT. (Monday)For more info visit: https://thefaceradio.com/category/one-room-paradise////Dig this show? Please consider supporting The Face Radio: http://support.thefaceradio.com Support The Face Radio with PatreonSupport this show http://supporter.acast.com/thefaceradio. Join the family at https://plus.acast.com/s/thefaceradio. Hosted on Acast. See acast.com/privacy for more information.

On today's MinistryWatch podcast we remember Marshall Allen, an investigative journalist who was a friend and supporter of MinistryWatch. To read a transcript of this podcast, click here. You'll also find there links mentioned in today's episode. The producer for today's program is Jeff McIntosh. Until next time, may God blss you.

Carmen reflects on the lives of Alice Stewart, Marshall Allen, and Suellen Leonard. Three Christians who were well known in media who all died recently at young ages. She talks about the brevity of our earthly life, but also our future eternal life.  Pastor Alfonso Espinosa, author books like "Faith that Shines in the Culture," joins Carmen to help us apply the mind of Christ to some recent news headlines. Faith Radio podcasts are made possible by your support. Give now: Click here  

At the end of this very special empowering episode, you're going to know how to get help paying your medical bills - without paying to get help paying your medical bills! Marshall Allen, journalist and author of Never Pay the First Bill: And Other Ways to Fight the Health Care System and Win joins Dr. Virgie to share a big secret to successfully fight bogus medical bills - for free. You can do this! crushmedicaldebt.com/free-resources dollarfor.org patientadvocate.org singlecare.com

For a full transcript of this episode, click here. I'm gonna encore this episode with David Scheinker, PhD, for several reasons; but here's a big one: Why are we as an industry not doing what David Scheinker suggests in this episode? Why are we not doing, I don't know, kinds of logical things to reduce admin burden in this country when everyone agrees admin burden is a problem? But let me back up for a moment for context. Two things happened since this show originally aired. One is that I was invited to a fireside chat by the Advisory Board to talk with Abby Burns, one of the amazing hosts over at Radio Advisory; and we talked about value in the healthcare industry. And if you define value as benefit divided by costs, and you can cut costs—like cut admin burden costs in half—then you have created some really nice communal value, which we talked about at length during that aforementioned fireside chat. Here's the other thing that happened since this show originally aired. I read the book by Mike Leavitt, mainly because Steve Schutzer, MD, kept talking about it. The title of the book is Finding Allies, Building Alliances. Maybe I will do a book report about this at some point, but let me share a couple of key quotes just to get the party started here. Mike Leavitt wrote, “A diverse alliance, well led and well managed, can bring resources to bear on a problem that no organization can match—even the largest of organizations. The synergy of resources—from financial to intellectual—can deal effectively with a wide range of issues confounding organizations today.” I found that very interesting. Here's the second quote, which deals with what the top reason is that such diverse alliances may wish to hook up. “[It's] a common pain: A shared problem that motivates people and groups to work together in ways that could otherwise seem counterintuitive.” Hmm … so, back to administrative burden. Let's review the facts that David Scheinker, PhD, shares in the interview that follows. He says any given transaction will cost provider organizations 14% of the total transaction costs to manage to get paid. Yes, it costs 14% of a transaction merely to get paid for the transaction. This is a big reason why both Peter Hayes, in the episode with him (EP424), and also Marshall Allen (EP425) talk about for why cash prices can be a whole lot less than going through insurance prices because you can skip a lot of insurance burden. Now, on the payer side, add to that 14% an additional 5% to 15% to pay said transaction. That 30% of healthcare is waste stat that keeps getting tossed around. Listen to the show with Will Shrank, MD (EP413) for more on that. But, yeah … here's 20% to 30% of every transaction that is waste. And we haven't even gotten into redundant care or inappropriate back surgery yet. Our industry spends up to 30% of our money just trying to get paid and pay. Here's a case study for you. You know who has already solved for this whole “it's really hard to get paid and pay” dilemma? Derivative traders. It used to cost derivative traders $100,000 to do a contract, any given contract. And they worked together and got this down to $5000 by doing some of the stuff that David Scheinker talks about in the show. And, I don't know, I feel like the healthcare industry could also do this, too, if they wanted to. But there are a whole bunch of reasons why our industry cannot seem to get together and be as ruthlessly practical as derivative traders—or banks, who have figured out how to work together to process credit cards to reduce their own common pain. Here are but a few of the reasons, potentially, why the healthcare industry doesn't get together to reduce administrative burden in some of the ways that Dr. Scheinker talks about. 1. Some organizations actually make a lot of money off of that transactional waste. As but one example—and not to just pick on one, but we don't have all day—how about some RCM (revenue cycle management) companies who may or may not be owned by the same vertically integrated stacks as the payers themselves? As I have said any number of times, one person's—or potentially an entire country's, as the case may be—one party's waste, is somebody else's honeypot; and I am not sure if this is any exception. 2. Legacy technology and data systems and all the sunk costs therein 3. As Kaye Davis and Katrina Hubbard reminded me about the other day, there are some serious regulations in healthcare due to everybody being a vendor of CMS that adds a layer of regulatory complication to many collaborations. Also, state laws sometimes have an unintended side effect of making it tough to collaborate. Now, are there any precedents for this type of collaboration in the healthcare industry? Yeah, actually Surescripts, which, don't forget, was created by an alliance of PBMs (pharmacy benefit managers) who worked together because they all wanted to enable e-prescribing and needed a joint platform to do it. Look, I could say a lot about this one, but nonetheless, so much of what gets talked about in the show today with Dr. David Scheinker is very, very actionable. Just want to note that since David Scheinker was on the show, he and his team have done some major research over the past few years into ways that contracts can be standardized. If enough of you reach out and say that you're interested, we, for sure, can have David come back on the show and discuss. David Scheinker, PhD, is a clinical professor of pediatrics. He's the executive director of systems design and collaborative research at Stanford Children's Health. He also founded and directs SURF Stanford Medicine. And with that, here is your original episode. Administrative costs in the United States have a bad rap. You don't have to look too far to find an article about how there's now, like, 10 administrators for every 1 physician in this country. Or 3 to 4 billing people for every physician. Or consider what Dan O'Neill was talking about in episode 359. He was talking about IPAs (independent physician associations) and other managed care entities. As Dan mentions, contracting with some of these IPAs is like an “I love 1990” flashback. The contracting process transpires via mail. Not email, mind you. Mail. Like, stick-a-stamp-on-the-envelope mail. So, in sum, there's a lot of pretty well-founded complaining about administrative costs in this country. A lot of this administrative stuff is truly inefficient and a fantastical waste of time. So, here we are freaking out about staffing shortages, overlooking that doctors at the heights of their careers are spending some percentage of their time not counseling, treating, or diagnosing patients but twiddling their thumbs on hold with one insurance company or another slowly burning out by the inefficiency of it all. Or doing pajama time, and we all know that too much pajama time means also burnout on a silver platter. So then, let's get granular here. If we're trying to quantify admin costs, how you do that is to quantify how much each transaction costs. How much does it cost to send a bill and get paid for it? How much does it cost to file an appeal and a denial of a prior auth? Add all those transactions together and you get the full cost of the administrative burden. In this healthcare podcast, we're digging into a paper about admin costs written by David Scheinker, PhD (my guest today); Barak Richman, PhD, JD; Arnold Milstein, MD, MPH; and Kevin Schulman, MD, MBA. I have the pleasure of speaking with David Scheinker, PhD (as I mentioned), who is the lead author on this paper. Just to underline a major takeaway from this conversation with Dr. David Scheinker, he reiterates a recommendation to eliminate a big proportion of administrative costs. I guess I should say spoiler alert here, but the major takeaway/recommendation is this: Standardize healthcare contracts between payers and providers. Every payer and every provider finds one contract template and uses it. I don't mean one template per payer or per provider, although that probably would be a revelation in and of itself. But I mean that all payers use one basic provider contract. A couple of specifics here: The template that I'm referring to (and that Dr. David Scheinker is referring to) consists of parameters. What do I mean when I say parameters? Consider what Airbnb does when you're looking for a place to stay, as an example. How many bedrooms (that's a parameter)? How many bathrooms (that's a parameter)? How many amenities (that's a parameter)? After everybody picks their standard set of parameters, at that point, all parties can negotiate and come up with whatever they want for what is the price of an extra bedroom or whatever value you're gonna assign to that parameter. Go nuts there, but from a data collection and analytic perspective and a getting paid perspective, it is way easier to do it that way—meaning it's way easier to execute and report when all of the contracts use the same parameters. Also, you can build tech to do a lot of that because you don't have to write algorithms with exponential variables. Also mentioned in this episode are Abby Burns; Michael Leavitt; Steve Schutzer, MD; Peter Hayes; Marshall Allen; William Shrank, MD; Kaye Davis, MPH; Katrina Hubbard; Dan O'Neill; Barak Richman, PhD, JD; Arnold Milstein, MD, MPH; and Kevin Schulman, MD, MBA. You can learn more by connecting with David on LinkedIn and following him on X (Twitter).   David Scheinker, PhD, started his career as a research mathematician and switched to healthcare operations to work on an interdisciplinary team and have a more immediate impact. He is a clinical professor of pediatrics, the executive director of systems design and collaborative research at Stanford Children's Health, and a member of the Clinical Excellence Research Center (CERC) at Stanford University. He founded and directs SURF Stanford Medicine, which brings together students and faculty from the university with physicians, nurses, and administrators from the hospitals. He studies clinical care delivery, hospital operations, sensor-based and algorithm-enabled telemedicine, the socioeconomic factors that shape healthcare, and healthcare policy.   10:39 What's the quantitative administrative cost in an average transaction? 11:05 What's the quantitative administrative cost in a healthcare transaction? 11:58 What does the healthcare billing and administration cost add to the US's overall healthcare spend? 12:53 Is it possible to cut billing and administrative costs in healthcare? 14:17 “In some ways, the problem for healthcare should be simpler.” 15:30 What does the complexity of the current system look like in a doctor's office? 18:42 How did David go about studying healthcare administrative costs? 21:34 “It doesn't have to be simple; it should be standardized.” 24:50 What would be the pushback on standardizing contracts in healthcare? 25:43 Why is it possible to gain more value by losing customization in contracts? 27:20 “Never let a good crisis go to waste.” 27:41 “It's much easier in healthcare to build something new than to change something that exists.” 30:47 What benefits does telemedicine have to cutting administrative costs? 32:17 What is another significant benefit of using standardized contracts? 33:26 Why haven't standardized contracts become a common thing in the current healthcare system?   You can learn more by connecting with David on LinkedIn and following him on X (Twitter).   @David_Scheinker of @SURFStanfordMed discusses administrative burden on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthcareleadership #healthcaretransformation #healthcareinnovation   Recent past interviews: Click a guest's name for their latest RHV episode! Dan Mendelson, Dr Benjamin Schwartz, Justin Leader, Dr Scott Conard (Encore! EP391), Jerry Durham (Encore! EP297), Kate Wolin, Dr Kenny Cole, Barbara Wachsman, Luke Slindee, Julie Selesnick

For a full transcript of this episode, click here. Here's a great musing that I read on LinkedIn: How will alternative primary care models fare when growth mode gets balanced with profitability and VC-supported burn rate is transformed to Big Retail bottom-line expectations? Mission v. margin. I'm gonna add to this: How will alternative primary care models, or even just doing good primary care, fare when it encounters the current system rife with perverse incentives of all kinds, including, yeah, for sure, Big Retail bottom-line expectations but also Big Health System and Big Payer bottom-line expectations and current business models? This show from last year was wildly popular—maybe one of our most popular shows—and relisten to it in the current context of what's going on right now in the primary care and MSO (Managed Services Only) space. Coming up, I'm gonna probably do a whole show on this if I can get my act together; but this encore is really relevant right now. One piece of podcast business before we get into the episode: Please sign up for our weekly email if you haven't already, especially if you consider yourself part of the Relentless Health Tribe. I am mentioning this not only because it's a great way to keep track of our shows because you can do an email search to remember where you heard something, since a good deal of the show intros are in the emails, but also, there's a plan afoot to hold some Zoom meetings to talk about different topics etc—and you won't be notified of such goings-on unless you're subscribed. You can unsubscribe whenever you want, by the way; and I am way too busy to send more than one email a week or spam if that was a concern. On Relentless Health Value, I don't often get into our guests' personal histories. There are a bunch of reasons for this, which, if you buy me beer, we can talk podcast philosophy and I will tell you all about my personal, very arguable opinion here. Nevertheless, in this healthcare podcast, we are going rogue; and I am talking with Scott Conard, MD, who shares his personal story. You may ask why I decided to go this route for this particular episode, and I will tell you point-blank that Dr. Conard's experience, his narrative, is like the perfect analogue (Is analogue the right word [allegory, composite example]?). His story just sums up in a nutshell what happens when a PCP (primary care provider) does the right thing, manages to improve patient care for real, and then at some point gets sucked into the intrigue and gambits and maneuvering that is, sadly, the business of healthcare in the United States today. Before we kick in, I just want to highlight a statement that Scott Conard makes toward the end of the show. He says: So, this isn't about punishing or blaming aspects of care that are being overrewarded today. It's really about what's the path forward for corporations, for middle-class Americans, and for primary care doctors who don't choose to be part of a big system. We have to figure out how to solve this problem. I hope people don't hear this and think that there are horrible people at some not-for-profit hospital systems, for example. There are some great people at not-for-profit health systems, but they have some really screwed-up incentives. A few notable notes from Dr. Scott Conard's journey and words of wisdom that I will just highlight up front here: He says that as a PCP, you actually can produce high-value care in a fee-for-service model … if you think differently and you change practice patterns. I have heard this from others as well, including most recently David Muhlestein, PhD, JD, who says this in an episode (EP393). As Dr. Scott Conard says later in this episode, healthcare organizations must embrace the art of medical leadership. So, I guess that's a spoiler alert there. Another point that Dr. Conard makes very crisply toward the end of the show is that doctors can kinda get pushed and pulled around in this mix. You have docs just trying to provide good care, and they work for one entity that gets bought and now it's some other entity … and what's happening upstairs and the prices being charged or somebody somewhere deciding not to make prices transparent, or deciding to sue low-income patients for unpaid medical bills or what charity care to offer or not to offer. These are not doctors in clinics making these calls, and we need to be careful here not to homogenize what some of these health systems are choosing to do like some kind of democratic vote was taken by everybody who works there. Health systems, hospitals, are many-celled complex entities. And a third takeaway—there are a bunch of takeaways in this show, but a third one I'll highlight here from Dr. Conard's story—is the old fiduciary responsibility code word being used by health system administrators as a euphemism for strategies that might need a euphemistic code word because the strategy has questionable community benefit. In the case study that we talk about today, the local health system managed to raise healthcare spend in North Texas by $100 million year over year. Employers and employees in North Texas communities wound up paying $100 million more year over year in healthcare one particular year. This was prices going up. It also was removing a big systemic initiative to keep heads out of hospital beds. Reiterating here, we are not talking about doctors here particularly because, of course, the vast majority of doctors are trying to prevent avoidable hospitalizations. But suddenly in North Texas, physicians did not have the population health efforts and the team really standing behind them helping to prevent avoidable hospitalizations. That sucks for everybody trying to do the right thing, and, as has been said, burnout is moral injury in a cheap Halloween costume. Moral injury happens when you have good people, clinicians, doctors, and others who realize that what is going on, at best, is not helping the patient. Also mentioned in this episode are Benjamin Schwartz, MD, MBA; David Muhlestein, PhD, JD; Brian Klepper, PhD; Al Lewis; Robert Pearl, MD; Karen Root, MBA, CCXP; and Wendell Potter.   You can learn more by emailing Dr. Conard at scott.conard@converginghealth.com.   Scott Conard, MD, DABFP, FAAFM, is board certified in family and integrative medicine and has been seeing patients for more than 35 years. He was an associate clinical professor at the University of Texas Health Science Center at Dallas for 21 years. He has been the principal investigator in more than 60 clinical trials, written many articles, and published five books on health, well-being, leadership, and empowerment. Starting as a solo practitioner, he grew his medical practice to more than 510 clinicians over the next 20 years. In its final form, the practice was a value-based integrated delivery network that reduced the cost of care dramatically through prevention and proactive engagement. When this was acquired by a hospital system, he became the chief medical officer for a brokerage/consulting firm and an innovation lab for effective health risk–reducing interventions. Today, he is co-founder of Converging Health, LLC, a technology-empowered consulting and services company working with at-risk entities like self-insured corporations, medical groups and accountable care organizations taking financial risk, and insurance captives to improve well-being, reduce costs, and improve the members' experience. Through Dr. Conard's work with a variety of organizations and companies, he understands that every organization has a unique culture and needs. It is his ability to find opportunities and customize solutions that delivers success through improved health and lower costs for his clients.   06:54 What triggered Scott's career journey? 07:31 What caused Scott to rethink what is good primary care? 08:11 Why did Scott realize that he is actually a risk-management expert as a primary care doctor rather than someone who treats symptoms? 09:25 EP335 with Brian Klepper, PhD. 09:53 How did Scott's practice change after this realization? 10:04 What is a “Whole-Person Risk Score”? 11:08 Scott's book, The Seven Numbers (That Will Save Your Life). 13:05 “You start to move from a transactional model to a relationship model.” 15:31 Did Scott have any risk-based contracts? 16:08 Why is it so important to look at total cost of care and not just primary care cost? 21:08 Scott's book, The Art of Medical Leadership. 22:13 EP381 with Karen Root. 30:43 Why did Scott move over to help corporations? 33:10 EP364 with David Muhlestein, PhD, JD. 33:51 “Everybody thought they were honoring their fiduciary responsibility, and the incentives are completely misaligned.” 34:31 EP384 with Wendell Potter. 34:43 “It's the system that's broken; it's not bad people.”   You can learn more by emailing Dr. Conard at scott.conard@converginghealth.com.   @ScottConardMD discusses #primarycare #marginvsmission on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthcareleadership #healthcaretransformation #healthcareinnovation   Recent past interviews: Click a guest's name for their latest RHV episode! Jerry Durham, Kate Wolin, Dr Kenny Cole, Barbara Wachsman, Luke Slindee, Julie Selesnick, Rik Renard, AJ Loiacono (Encore! EP379), Nina Lathia, Marshall Allen

For a full transcript of this episode, click here. This show has implications for provider organizations of all stripes, especially those looking to succeed in value-based care or those who need patient trust and relationships for any other reason, including just patient volume. This episode also is for provider organizations who are trying to prevent clinician burnout better. It's also for practices trying to get themselves into narrow networks where patient satisfaction is surveyed at some point in the process, and this includes Centers of Excellence networks. You know what the rate critical is that I talk about on the show today with Jerry Durham that rarely, if ever, gets talked about in any of these contexts? It's not some fancy data artificial intelligence thing or something else the doctor needs to be clicking on or nurses need to step up and handle. Nope. I'm talking about the front desk. What an overlooked secret to success or a clinician and clinical failure point! Consider that what goes on on or about the front desk is either gonna set up the doctor or other provider for success or make it really really hard for them. This is what I talk about today with Jerry Durham in this encore episode from a couple of years ago that is still so incredibly relevant because the insights that Jerry shares are so often overlooked and they impact both patients but also doctors and other clinicians in ways we don't often think about but, in this era of staff shortages and burnout, I'd suggest maybe we should. Here's something I never really understood: how physicians and nurses more often than not get to be responsible for the entire patient journey, including, start to finish, patient satisfaction. But if you just take one look at any random poorly rated physician's reviews, they're usually littered with complaints about the front desk in the practice. Negative reviews, of course, are not limited to front desk diatribes; but there's often a lot of front desk commentary in them. It has always seemed to me to be a common and strange phenomenon in healthcare provider practices where the front desk is like a totally separate little fiefdom with a different mission statement and goals from the healthcare providers in the same exact office. Isn't that odd when you think about it? I mean, first, the front desk is literally physically separated from everybody else. No matter which direction you approach from, there's at a minimum a half-wall barrier surrounding them. Sometimes, in directions most likely to receive an attack, I suppose, there's been added a big glass barrier. Liliana Petrova pointed this out in episode 236 of the Relentless Health Value podcast, and it was really the first time that I had thought about it at all and also thought about the implicit message this sends not only to patients but also to clinicians. That whole physicality of the setup, it just screams, “We over here have nothing to do with the mission or vision of anyone else in this place. We have our own thing going on over here, and to do it, we need to be protected from you all and all of your chicanery and untoward goings-on, you doctors and nurses and patients!” So, I was really inspired the first time I heard Jerry Durham from The Client Experience Company talking. His message, as I understood it, was that a practice really on board with helping patients achieve the best patient outcomes and, nothing for nothing, erode clinician burnout includes the front desk in their thinking. Jerry has said that there's four phases in the patient life cycle, as he calls it, which is sort of a synonym for the patient journey: 1. Marketing 2. The moment that a patient/person engages with the clinic or office 3. Provider interactions 4. The post course of care So, all of these phases—all four of them—are critical to both patient outcomes and experience but also, really, to business success. So, you kind of almost have to do well by doing good. The front desk is mostly responsible for that phase two: what happens when that person/patient engages with your office or clinic. In this healthcare podcast, as mentioned, I'm talking with Jerry Durham. He's a former physical therapist and practice owner who has worked with a whole lot of PT (physical therapy) practices and also other MSK (musculoskeletal) specialties among other clients. His message transcends the specialty, however. In this healthcare podcast, we get into a lot of aspects in terms of how a front desk can work for or against patient experience and outcomes. One of them is how a front desk can help secure a patient's relationship with a practice. Without a relationship and trust, patient outcomes are meh at best. But a lack of trust is a big hairy factor behind disparities in outcomes among different ethnic groups, for example, as one point to ponder. Also mentioned in this episode are Liliana Petrova and Julie Rish, PhD. You can learn more at clientexperiencecompany.com or by emailing Jerry at jerry@jerrydurhampt.com.   Jerry Durham is a healthcare consultant and physiotherapist with a singular passion for leveraging the entire healthcare practice team toward improved patient outcomes while increasing the practice bottom line. Jerry has 30+ years' experience as a physiotherapist, including 20+ years of business ownership, including practice ownership, business consulting, and a virtual front desk sales solutions for healthcare practices. Jerry has spent a lot of time on the front line of physio practices answering calls and learning why patients think and act the way they do when interacting with the front desk team. He has learned how to leverage the information at first contact carried all the way through to a completed plan of care, and these are the systems that lead to greater patient outcomes and greater practice success. Jerry defines these systems as “the rules of client engagement.”   05:49 What is the patient life cycle? 06:48 What are the milestones of the patient life cycle? When does it start? 10:05 “This isn't a business solution; this is a patient-driven solution.” 10:21 “What is best for the patient is best for business.” 13:25 “The takeaway there is that your team members are all driving toward the same goal.” 14:34 How does the front desk impact health outcomes? 16:41 What is the objective of a front desk to reduce provider burden? 20:03 EP236 with Liliana Petrova. 21:18 “There's actually three roles at the front desk.” 30:37 EP228 with Julie Rish, PhD.   You can learn more at clientexperiencecompany.com or by emailing Jerry at jerry@jerrydurhampt.com.   @Jerry_DurhamPT discusses #patientengagement and #clinicianteam success on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthcareleadership #healthcaretransformation #healthcareinnovation   Recent past interviews: Click a guest's name for their latest RHV episode! Kate Wolin, Dr Kenny Cole, Barbara Wachsman, Luke Slindee, Julie Selesnick, Rik Renard, AJ Loiacono (Encore! EP379), Nina Lathia, Marshall Allen, Stacey Richter (INBW39)  

For a full transcript of this episode, click here. First of all, I just want to start out this pod and really thank everyone listening and for showing up for a show like this one. You do it and you are here because you care about patients/members. It's just so easy to feel like we'll never be able to do enough, and that's a rough, rough feeling. Please take a moment to truly hear how grateful I am for you being here and for doing all that you do and that you try to do. I saw on the interwebs the other day a Marcus Aurelius quote. What he said was, “Be satisfied with even the smallest progress.” And I think this is really important to remember because nobody working in the healthcare industry, especially today, is ever probably gonna get anything close to a perfect solution. So instead, just aim for progress—even the smallest amount—and feel good about that, please. This show is an important one for anybody either in the business of healthcare delivery or buying healthcare delivery services. It's an exploration of what works and what doesn't work and how what works can easily become what doesn't work in the face of the real world. This peril of cutting clinical “waste” perilousness all starts with the whole “Hey, let's make some money, so we gotta scale and be efficient. We gotta do our thing at as low as possible a cost and maybe grow as fast as possible. We gotta keep our investors happy or pay off the debt we got saddled with or pay that giant management fee we're being charged or compensate the C-suite at the level they've grown accustomed to.” So again, the “let's be efficient and get everything repeatable” has entered the building. The first point my guest today, Kate Wolin, ScD, makes about all of this—and this is exactly the same point that Rik Renard made in episode 427—efficient to what endgame? Now, it turns out, surveys show, only a small, small percentage of healthcare delivery solution providers are measuring outcomes of pretty much any kind. So, how do we even know if cutting so-called waste is actually waste at all? I mean, in the absence of any actual measures—here's a hypothetical for you—someone could look around: “Hey, I see these nurses. They're all just sitting around chatting with patients and, I don't know, talking about throw rugs? What is this? An episode of HGTV? Who cares if a patient with diabetic neuropathy has throw rugs in their hallway? Let's tell these nurses chop-chop, get them on the computer using AI to be efficient, right? Let's get rid of that clinical waste.” I just made a point in the most sarcastic way possible, but the bottom line is this: It's actually really efficient to not engage patients in these ways, right? Patients, they talk slow, they ask questions that seem irrelevant, and they're time-consuming. It's very efficient to not build relationships or foster trust or, I don't know, assess fall risks … but whatever is going on is also going to fail in that model—from a patient outcome standpoint at least. Here's a quote from Sergei Polevikov, with some light edits. He wrote on LinkedIn: Primary care is not scalable in the same way as Scrub Daddy or Bombas Socks. That's something not taught in MBA and CFA programs. Someone should have told Walgreens, CVS, Amazon, and Walmart. They also probably should tell a whole bunch of point solutions and payers. Also, some health system execs or pharmacy leaders might also want to get that memo. What I really liked about the conversation with Kate Wolin in this healthcare podcast is that she retains optimism in the face of all of this. She offers advice for how to navigate the balance between mission and margin in a way that's better for patients and also sustainable financially. She talks about three points: 1. Founders and investors being in alignment and the essential nature of that 2. The importance of having clinical leadership and a team dynamic that enables innovation but in a clinically sound way 3. How you gotta measure what matters and do it in a way that inspires a mission-driven culture If we're talking about relevant shows to listen to next after you listen to this one, please do not forget episode 331. This is where Al Lewis teaches us how to evaluate wellness vendors and health solutions, but it also teaches us how to be a good wellness vendor or health solution. Also, do come back and listen to the encore with Jerry Durham next week about front desks and the total care experience. Lots of really bad avoidable things happen if the front desk isn't considered—and it isn't often considered. For sure, also listen to the show with Kenny Cole, MD (EP431); that's a must-listen. Then again, the show with Rik Renard (EP427) came up several times in this episode. The show with Jodilyn Owen (EP421) also gets brought up; that's a great cautionary tale there to keep in mind for mission-driven entrepreneurs and investors. And then, I also recommend J. Michael Connors, MD. He writes a lot of stuff in a newsletter along these lines. Last, last, last … Please go to our Web site and subscribe to the weekly email. I am planning on doing a few invite-only sessions for email subscribers. Plus, the weekly email is a really very convenient way to get the episode transcripts and stuff. And if you don't get it, you're making your life less efficient. So, go fix that. Kate Wolin, my guest today, trained as a behavioral epidemiologist and has done research in chronic disease prevention and management. She launched and led a digital health start-up and sold it to Anthem. She's been in the digital health start-up space largely at the intersection of science and product strategy ever since. Also mentioned in this episode are Rik Renard; Sergei Polevikov; Walgreens; Amazon; Walmart; Al Lewis; Jerry Durham; Kenny Cole, MD; Jodilyn Owen; J. Michael Connors, MD; Carly Eckert, MD; and Mike Pykosz. You can learn more by following Dr. Wolin on LinkedIn.   Kate Wolin, ScD, is a behavioral epidemiologist who left academic medicine to launch and lead a digital health start-up, which she bootstrapped to profitability before selling to Anthem. She has since been a C-suite leader, investor, and advisor to digital health start-ups and enterprise organizations on bridging clinical and behavioral science with product strategy and execution. She has been named as a Forbes Healthcare Innovator That You Should Know and a Notable Woman in STEM by Crains. Dr. Wolin is a Fellow of the Society of Behavioral Medicine and the American College of Sports Medicine and teaches entrepreneurship at Kellogg.   06:24 Irrespective of money, what works in clinical care and population healthcare? 09:51 EP361 with Carly Eckert, MD, PhD(c), MPH. 10:26 Why is creating a gathering place and sense of community important in clinical care? 12:46 “Sometimes, we make this about the clinical provider. It always makes me think about the rest of the people in an ecosystem that create trust.” 13:49 EP297 with Jerry Durham. 14:11 Where can things go wrong when we start to think about the margin in respect to the clinical care that works? 16:47 EP427 with Rik Renard. 19:35 “We're actually very unspecific in what we're trying to achieve a lot of times in these digital health programs.” 24:00 “Are you aligned as a founder, as a business with your investors on the pace of growth and what is feasible … ?” 25:30 Why is Dr. Wolin optimistic about achieving growth and still providing value? 28:17 Why is it important to ask why something is being done? 30:39 EP421 with Jodilyn Owen. 34:35 How are people motivated, and how can you use that to reduce turnover? 35:21 Why measuring what matters and communicating that is important.   You can learn more by following Dr. Wolin on LinkedIn.   Kate Wolin, ScD, discusses #clinicalwaste on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthcareleadership #healthcaretransformation #healthcareinnovation   Recent past interviews: Click a guest's name for their latest RHV episode! Dr Kenny Cole, Barbara Wachsman, Luke Slindee, Julie Selesnick, Rik Renard, AJ Loiacono (Encore! EP379), Nina Lathia, Marshall Allen, Stacey Richter (INBW39), Peter Hayes  

Never pay the first bill, at least that's what podcast guest and medical investigative journalist Marshall Allen advises. At some point, every NICU family has to deal with an insurance company, government agency, medical billing office or all three. Learn how to speak a language that billing offices understand, advocate for your rights and save yourself money, headaches and long hours on hold with medical stakeholders.  

For a full transcript of this episode, click here. There's this meme that's going around on the interwebs with the caption, “Sometimes the shortest distance in between two places isn't a straight line.” What? Yeah, because actually there's three dimensions in the real world. So, when we all consider the real world, understanding the contours of reality and aligning with them is the only way to devise a winning strategy—not only if you're timing rubber balls getting dropped off straight or curved slopes. I'm saying this because I've seen (and you've seen) a whole lot of great ideas fail because someone draws a very elegant straight line on a whiteboard, calls it the fastest and most efficient way to get from here to a desired outcome … and then the plan ultimately fails. What contours am I talking about taking into account right now? Oh, pretty much the entirety of US healthcare. If you combine the complexities and perverse incentives of the industry itself plus the art and science of medicine plus epidemiology and social determinants and I'm probably forgetting other dimensions, you have contours that are mountain ranges. Not considering the reality of those elevations and just thinking there's some kind of straight line here to be found is really a kind of delusion. Now, investors and C-suites may like these delusions, but let's just get real: It's not gonna actually work out as written. One case study that I am talking about is digital health solutions or pharma companies even or pretty much anyone who thinks that the fastest way to increase sales is to talk about the product, let's just say as one example. That's the straight line to growth: Talk about the product. Another one is stripping away things that feel like they're a waste of time in the name of efficiency without actually checking if you're cutting into essential stuff. I talk about this at length with Kate Wolin, ScD, in an episode coming up. Jodilyn Owen has a thing or two to say on this point in episode 421 also. But let me be clear: I'm not talking about anyone listening to the show today making this mistake, at least wholesale. We all make it incrementally; it's hard to avoid. But you get this. That's why you're here. You get that the fastest path anywhere is truly understanding the problems faced by customers. And then it's showing how the product or whatever you're doing helps solve those problems. No one cares how efficient or safe your thing is if it's accomplishing something that no one cares about, no one gets paid for, and/or can figure out how to deploy or use. This is what the entire episode last week, episode 430 with Barbara Wachsman, was about. Why is all of this relevant? It's actually what makes Relentless Health Value relevant, frankly. Many listeners—and shout-outs to Nate Walker and MaryCarol Evans—say that this is why they listen to Relentless Health Value and what Relentless Health Value helps them with: finding those contours, understanding reality so that it can be aligned with. And on the show today, Kenny Cole, MD, I gotta say, could be really impactful in this regard as well as in others. Nate Walker wrote, “[Relentless Health Value] inspires me every day to stay true to my desire to make a difference in healthcare for patients by adding transparency and helping to connect the dots within this fragmented system.” MaryCarol Evans has alluded to the same thing multiple times as well and often highlights that Relentless Health Value helps her think through and identify the small things that are possible—she says there's plenty of them—that have a huge impact on the lives of plan members. Dr. Kenny Cole is from Ochsner Health System, and I love this conversation today because it has lessons for anybody working in a clinic or managing a clinic who wants to learn from a master. But it also is really interesting for anyone who's trying to work with, alongside of, or sell to a clinical practice or health system that is pulling away from the status quo, that is standardizing care and working as a team, one that is earning the trust of its patients, and also one that is figuring out how to reinvent the business model of healthcare such that clinical pathways and care flows are aligned with financial viability. That's really, obviously, the holy grail here. We talk today about how to achieve clinical and financial success, even if the financial models are all over the map. We talk about how to create a practice model or a clinical model that might appeal to clinicians and keep them from being burnt out while, at the same time, ensure that patients are getting the kind of outcomes everyone can be proud of and the place doesn't go bankrupt either. This episode reminded me a lot of the conversation with Scott Conard, MD (EP391)—there's lots of complementary points. The shows with David Carmouche, MD (EP316, AEE15, EP343) from when he was at Ochsner are also pretty relevant here. Some of the points that Dr. Kenny Cole makes today also align very much with what Rik Renard (EP427) was talking about a few weeks ago. But regardless of where you sit or what you're trying to do, this show is a great one to really get a bead on the lay of the land to find the actual shortest path between here and there, which is not gonna be (most likely) an obviously straight line. Dr. Kenny Cole makes, I'm gonna say, four main points by my counting; and they are as follows: 1. Clinical teams have to deliver care wherein outcomes are measurable, and it has to be done in such a way that those clinical teams are accountable for the outcomes that are generated. 2. Clinical teams need to really see with their own two eyes and believe that a clinical goal that they've been given is possible. 3. Care flows are critical here, which means getting everyone on the same page about what best-practice care looks like and operationalizing how that clinical excellence will be achieved. 4. Building trust with patients and connecting with patients cannot be underestimated, and care flows need to not only standardize care so that it can be delivered quicker and easier but also facilitate patient relationships. Dr. Kenny Cole is a primary care internist. He sees patients one day a week. The other days, he serves as a system vice president for Ochsner Health, which is a large integrated delivery system. In this role, he designs and develops new care models. If I'm making recommendations for what to listen to next, I'd go with episode 412 with Robert Pearl, MD—he talks about a model to lead healthcare transformation and clinical excellence. Then episode 391 with Dr. Scott Conard gets into what happens in the real world when the financial model is misaligned with excellent care. Lastly, episode 343 with Dr. David Carmouche. Oh, two last things and new topics: First, thanks to Santos-L-Halper, Nina Lathia, and KC64789 for some really nice reviews this month. I read them. They make me happy. Thanks so much for leaving them. And lastly, heads up that Rule of Three (ro3) has an annual March Healthcare Classic that is currently ongoing. It's pretty cool what they do. They have a very august panel that debates which trends will reign supreme in their impact on healthcare in 2024. The committee includes: ·      Dr. David Carmouche, SVP Healthcare Delivery, Walmart Health ·      Eric Gallagher, CEO, Ochsner Health Network ·      Leah Binder, CEO, The Leapfrog Group ·      Anisha Sood, Chief Financial & Strategy Officer, First Choice Health Follow along with the experts through the ro3 March Healthcare Classic at https://ro3.com/healthcare-classic/. Also mentioned in this episode are Jodilyn Owen; Barbara Wachsman; Nate Walker; MaryCarol Evans; Scott Conard, MD; David Carmouche, MD; Rik Renard; Robert Pearl, MD; Nina Lathia, RPh, MSc, PhD; Josh M. Berlin; Rule of Three, LLC; Eric Gallagher; Leah Binder; Anisha Sood; John Rodis, MD, MBA, FACHE, CPHQ; Bob Matthews; Marty Makary, MD, MPH; Sanat Dixit, MD, MBA, FACS; and Rob Andrews. You can learn more at Ochsner Health. You can also follow Dr. Cole on LinkedIn.   Kenny Cole, MD, began his role as System VP, Clinical Improvement, for Ochsner Health in New Orleans in September 2019. He is a practicing primary care internist with advanced degrees from LSU Health Sciences Center and Dartmouth, as well as executive training from Harvard Business School. Prior to joining Ochsner Health, Dr. Cole was the chief clinical transformation officer for Baton Rouge General Medical Center, where he designed, developed, and implemented a completely reimagined multidisciplinary team-based model of primary care that focused on aligning clinical with financial outcomes. His current work at Ochsner Health built on that prior foundation to design and help develop Ochsner 65 Plus, a group of redesigned primary care clinics focused on the needs of older adults.   07:38 Is there an optimal care pathway where there might be a lot of treatment variability? 11:01 Why doesn't Dr. Cole like the terms “noncompliant” and “nonadherent”? 11:45 EP412 with Robert Pearl, MD. 13:50 Why is it important to start with the end in mind? 17:20 How do you scale clinical excellence? 20:21 EP315 with Bob Matthews. 21:15 EP242 with Marty Makary, MD. 23:49 Why is it important simply to demonstrate what's possible for better health outcomes? 24:58 EP427 with Rik Renard. 26:10 How do we reinvent the business model of healthcare? 27:50 EP415 with Rob Andrews. 30:06 EP391 with Scott Conard, MD. 38:37 Dr. Cole is published in various healthcare journals; check out his most recent article.   You can learn more at Ochsner Health. You can also follow Dr. Cole on LinkedIn.   Kenny Cole, MD, discusses #accountability for #healthoutcomes on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthcareleadership #healthcaretransformation #healthcareinnovation   Recent past interviews: Click a guest's name for their latest RHV episode! Barbara Wachsman, Luke Slindee, Julie Selesnick, Rik Renard, AJ Loiacono (Encore! EP379), Nina Lathia, Marshall Allen, Stacey Richter (INBW39), Peter Hayes, Joey Dizenhouse  

For a full transcript of this episode, click here. We have been spending a bunch of time here on Relentless Health Value talking about PBMs (pharmacy benefit managers) lately and pharmacy benefits, but we are moving into a new topic area. It sort of kicked off three weeks ago with the pod with Rik Renard (EP427) on the importance of care flows if you are a digital health vendor trying to get consistent outcomes. But then I actually went back to the PBM/pharmacy benefits topic to talk with Luke Slindee, PharmD (EP429) and Julie Selesnick (EP428) because, you know, the J&J lawsuit. But now we're back on the “let's talk about digital health and point solutions” bus. I wanted to talk today about the trend to sell to employers and advice for digital health solutions who want to sell to employers, but there's a little bit of advice here for employers themselves. At a minimum, this conversation affords a little bit of transparency to employers about what's going on on the other side of the table. So, as I just said, in this healthcare podcast we talk about selling to employers. Why sell to employers is probably a first question. Well, one reason Barb offers is because that's where the money is. It's like that Willie Sutton quote. Someone asked him why he robbed banks, and he replied, “Because that's where the money is.” I mean, hospitals know this. Have you seen their commercial rates and their multiples over Medicare? Payers know this, too. Payers who use their ability to raise commercial rates as leverage to get lower MA (Medicare Advantage) rates for themselves … they know this. So, yeah. Why wouldn't a point solution entrepreneur take a page out of that business model? It's saying the quiet part out loud, but … yeah, I guess it's good to know when you're the numero uno healthcare industry sugar daddy (or sugar mommy, as the case may be). Every employer listening right now has already opened up their phone and started an email to me. Barb gets into four pieces of advice for entrepreneurs looking to sell to employers: 1. There has to be a market that has a need for what you are selling, and there won't be a market with a need unless the problem you're solving for is big enough—and right now, I am recapping things that Barb says on the show—because when she talks about whether the problem is big enough, she means as per the employer and maybe because the fallout from that big problem accrues to the employer in a way that the employer fully appreciates. As I say in the pod that follows, the ground is littered with entrepreneurs, often really smart people who oftentimes I truly admire. These are individuals who found a problem for patients (or sometimes even clinicians) and solved for it and then discovered that no one will pay them for whatever they've done, because we can't forget that, in the healthcare industry, one person's waste is somebody else's profit. There is show after show here at Relentless Health Value that showcases the sacred honeypots where these perverse incentives lie, so if you are an entrepreneur, please follow the dollar and see where it leads before getting too far. That would be my advice. I'd recommend the show with Rob Andrews (EP415) and the one with Jodilyn Owen (EP421) as a great place to start. One comment about the whole “it's gotta be a need that employers appreciate” point that Barb makes which caught my ear, she rhetorically asks, “Should HR purchasers be buying solutions that improve health and well-being?” And the short answer is no. Barb says none of that should be the primary driver. The primary driver, Barb mentions, should be about optimization of human capital to drive business outcomes. She says every decision a business makes should be about maximizing business outcomes. Now, I could take this a bunch of different ways; and viscerally it has, again, kind of a “quiet part out loud” vibe. But in certain ways, it also means buying decisions should be bigger than just cutting costs. First of all, no one is arguing here that cutting wasteful spending isn't always a good thing; but neither are cost-containment strategies that undermine employee health to the extent that they can't complete their work role or their job. Listen to the show with Nina Lathia, RPh, MSc, PhD (EP426) for more on this cost containment versus value-based purchasing, specifically in the pharmacy benefit space, but same rules apply pretty much everywhere. 2. Be truly differentiated in terms of what you're trying to sell. Barb gives a bunch of examples of “secret sauces” she thinks are kind of compelling right now. 3. Navigate the internal politics of the employer. And this is kind of Selling 101, but find a champion and help them navigate their own organization. We talk at length about how long the sell process can take, especially in some of these jumbo employers. 4. Manage your investors as closely as you manage your possible clients. And this is an interesting point that also comes up in the conversation with Kate Wolin, ScD, that's coming up in a few weeks. Also in this conversation, we have a sidebar about PMPM (per member per month) and performance guarantees and just some nuances about how to get paid. Oh, and one last point here: If you are an entrepreneur who is thinking about selling to brokers, employee benefit consultants, or practice leads, do listen to the show with AJ Loiacono (EP379), which I encored a couple of weeks ago. My guest today, Barbara Wachsman, has had experience in every single element of the healthcare ecosystem. She has worked in public health. She's worked for an HMO. She's worked for a hospital system. She's run benefit consulting practices and also spent the last dozen or so years at Disney running strategy and benefits. Today she is a limited partner in several private equity funds at Frazier Healthcare Partners. Oh, and hey, you might want to subscribe to our weekly email, which includes this introduction transcribed as well as links to the full episode transcribed. We also sometimes send out invitations to Zoom meetups and other ways to get involved or support us in our quest to get Americans better healthcare. So, go to relentlesshealthvalue.com and get yourself on that list Also mentioned in this episode are Rik Renard; Luke Slindee, PharmD; Julie Selesnick; Rob Andrews; Jodilyn Owen; Nina Lathia, RPh, MSc, PhD; Kate Wolin; AJ Loiacono; Elizabeth Mitchell; David Claud, MD, PhD; Al Lewis; Kenny Cole, MD; and Cora Opsahl.   You can learn more at Frazier Healthcare Partners. You can also follow Barbara on LinkedIn.   Barbara E. Wachsman, MPH, is the former director of strategy and engagement for enterprise benefits for the Walt Disney Company. In this position, she led the strategic initiatives and designed the programs that addressed Disney's long-term healthcare and goals and objectives, headed operations of large on-site clinics and full-risk physician partnerships, and was the creator of the Strategy Lab, the home for innovation in healthcare delivery. She is a speaker on the national stage regarding direct contracting and the value of primary care. Barbara currently serves as a senior advisor to an $8 billion growth-buyout private equity firm specializing in healthcare and as head of employer strategy for a virtual primary care company with a unique medical practice model. She sits on the Boards of the Duke-Margolis Center for Health Policy Institute and the QueensCare Foundation, serving the low-income and underserved population of Los Angeles. She remains a senior advisor and founding member of the Employer Healthcare Innovation Roundtable (EHIR) and is a faculty member of the EHIR Academy. Barbara serves on the Executive Committee of the American Board of Medical Specialties and on the Advisory Boards of several healthcare start-ups as well as the corporate board of a large metabolic health company. She is also an advisor to the Purchaser Business Group on Health and to the Silicon Valley Employers Forum. Barbara received her Master of Public Health and Master of City Planning/Architecture degrees from the University of California, Berkeley, and is a Phi Beta Kappa graduate of Scripps College, where she received her bachelor of arts degree.   06:55 Why have people cottoned on to selling to employers, and is it a good direction to focus? 07:28 What are the three ways healthcare gets paid for in America? 07:46 Where is the profit in the healthcare system? 08:32 What does an entrepreneur really need to understand in order to sell to employers? 13:05 “It really is about producing a productive employee.” 17:49 Why it's not enough to understand the market but you must also differentiate. 21:01 What's the biggest misunderstanding entrepreneurs have about per member per month? 24:10 What companies are standing out right now as differentiators? 28:02 Why is it important to also show that you are improving quality? 28:51 EP331 with Al Lewis. 28:55 EP427 with Rik Renard. 29:33 EP372 with Cora Opsahl. 30:07 Why is it important to find a strong champion who will advocate for you as a partner? 35:05 Why is it important to manage your investors and set appropriate expectations around the timeline of a sale? 36:21 What's the lesson to be learned behind Livongo?   You can learn more at Frazier Healthcare Partners. You can also follow Barbara on LinkedIn.   Barbara Wachsman discusses #digitalhealthvendors selling to #employers on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthcareleadership #healthcaretransformation #healthcareinnovation   Recent past interviews: Click a guest's name for their latest RHV episode! Luke Slindee, Julie Selesnick, Rik Renard, AJ Loiacono (Encore! EP379), Nina Lathia, Marshall Allen, Stacey Richter (INBW39), Peter Hayes, Joey Dizenhouse, Benjamin Jolley

For a full transcript of this episode, click here. In this healthcare podcast we're talking about pharmacy acronyms or terms like AWP and WAC, and, not really an acronym, but we'll also talk pharmacy list prices, rebates, discounts. We also have NADAC, but that's slightly off to the side for reasons we'll get to in a sec. Most of these acronyms refer to a number with a dollar sign in front of it, and it's hell on wheels to figure out if and/or to what extent that number reflects what is going on in the real world, especially if you are a patient or a plan sponsor and all you see is the list price that Pharma puts out on one side of the storyboard, and then what the patient pays or (if you're lucky) what the plan pays for the drug on the way other side of the whole chain of events. What's a black box a lot of times for patients and plan sponsors is what goes on in the middle, wherein many middle people get their mitts on the transaction. Real quick here, let's run through the Mister Rogers' neighborhood of all of these middle people right now; and we're gonna do this really briefly. Most of you are already going to know most of this, but I just want to remind you so that when my guest today, Luke Slindee, and I kick into the conversation about the acronyms and the terms and we try to follow the dollar … yeah, you can put a name to a face. Alright, so first we have pharma manufacturers. The pharma manufacturer—and this is largely gonna be true whether it's a branded drug or a generic pharma manufacturer—but the manufacturer sets a list price. This list price is gonna be called an AWP or a WAC price, and we're gonna get into the differences and what those terms actually mean in the show that follows. But Pharma decides their price point. They go to wholesalers with that price. Wholesalers say they want a discount to purchase the product. Some kind of rebate or discount is negotiated. Now the wholesalers have the drug, and they get calls from pharmacies. Pharmacies have patients who have scripts for that, so the pharmacies need to buy the drug. What price does the pharmacy now pay the wholesaler for the drug? Short answer: It's nuts. It's nuts how the wholesalers decide what to charge the pharmacies for the drug. We talk about that in the interview that follows, but suffice to say that now we have the list price turning into whatever price the pharmacies wound up paying to get the drug from the wholesalers for. Any way you cut it, the wholesalers are making some money. Okay … now we get to the part where we're figuring out how much the patient or the plan sponsor will pay to pick up that drug that started at the pharma manufacturers and went to the wholesalers and now is at the pharmacy. How much are the patients gonna pay? How much are the plan sponsors gonna pay? If you spend any time in the real world (not the drug supply chain world), what you'd expect to happen next is that the patient would go into the pharmacy and the pharmacist would charge a markup and/or a dispensing fee on the price that they bought the drug from the wholesaler for. That'd be normal. And this can be the case when patients pay cash. Listen to the show with Mark Cuban (EP418, along with Ferrin Williams, PharmD, MBA), who started a pharmacy called Cost Plus Drugs. Get it? Their prices are cost plus. You have had other pharmacies for years doing similar things, like Blueberry in Pittsburgh. They get the drug. They buy it from a wholesaler or etc. But they buy the drug for some price, and then they sell it to their customers (ie, patients) at their cost plus. But most of the time in pharmacy supply chain world, things don't work that way because many patients have insurance. When a patient walks into the pharmacy, someone has to figure out how much the patient owes and how much their insurance will cover, right? So, enter PBMs (pharmacy benefit managers). They originally started out doing this math (ie, adjudicating claims), figuring out what the out-of-pocket will be for the patient and then what the insurance will cover. Then drugs started to get really expensive and a few other developments, and then, all of a sudden, we have PBMs negotiating with Pharma for how much of a rebate the PBM is going to demand for the PBM to put the manufacturer drug on formulary. The PBM also is determining how much they will pay the pharmacy for said drug on behalf of plan sponsors, in addition to doing the math for how much the patient will pay. So, let me say that again because it kind of begs a “what now?” with eyebrows sky-high as the appropriate response to what I just said, especially if you think through the ramifications here, ramifications which I discuss at length with Vinay Patel (EP241); Benjamin Jolley, PharmD (EP422); Scott Haas (EP365); Paul Holmes (EP397); and others. So, again, the PBM is not just adjudicating claims. They are also negotiating rebates from Pharma so plan sponsors do not have to pay the full amount that the wholesalers paid Pharma and that the pharmacies paid the wholesalers, which maybe is a lot of money. The PBMs are like, “Hey, Pharma. You need to give me a piece of your action because we, the PBM, have big market power. I serve 100 million patients or something. So, if you want access to my 100 million lives, you gotta shell it out. You gotta shell me out some rebates.” So, fine, Pharma gives the PBM some amount of money in the form of a rebate. And it has to work that way, if you think about it, because the drug was originally sold to the wholesaler. You see what I'm saying? So, the pharma company has to give the PBMs a separate rebate amount. This is in addition to how much the PBM told the plan sponsor the plan sponsor owes for the drug, which is also paid to the PBM. But now, PBM is also still in charge of adjudicating the claim. So, they're telling the pharmacy how much to charge the patient. Somehow or another also, the PBM also got itself in charge of deciding how much money the pharmacy itself would be reimbursed by that PBM. In the rest of the world, the pharmacy might tell the PBM, “Hey, this is the price.” But not in pharmacy supply chain world. In pharmacy supply chain world, the PBM tells the pharmacy how much it's gonna pay. The end. And this, my friends, is how so often pharmacies get themselves in the pickle of having to pay the wholesaler one price to get the drug while they get reimbursed a totally different price to dispense the drug. And because independents have very little negotiating leverage on actually either side of that equation, they so very often buy high and sell low. Please listen to the shows with Benjamin Jolley (EP422) and Vinay Patel (EP241), where we get into this in a lot of detail. But I just want to emphasize this point: All of that whole drug supply chain I just went through, where the manufacturer sells to the wholesaler who sells to the pharmacy and the PBM pays the pharmacy and the patient is paying something and the plan sponsor is paying something—many of the middleman transactions in there happen under the cover of darkness a lot of times. If I'm a plan sponsor, do I have any idea how much the PBM paid the pharmacy for any particular drug? Unless you're good at looking at the NADAC numbers (more on this coming up), no. I do not have any idea what a fair price for that drug actually is and how much people are making on the back of that drug as it goes through the supply chain. And this, my friends, is how come spread pricing can exist. Because spread pricing is when the PBM charges the plan sponsor more than they are paying the pharmacy, pocketing the difference, and then calling what they pocket a trade secret—even if it's the plan sponsor whose butt is on the line to make sure that what the PBM is pocketing is fair and reasonable compensation. I mean, if only J&J had listened to this show (EP428). Here's a link to the lawsuit, which is about J&J paying ridiculous amounts in spread pricing. If what I just said is really confusing, I'm gonna validate that and say, “Yeah, it is really confusing.” And to a certain extent, that might be the main point. Where there's mystery, there's margin and all of that. Here's what Dawn Cornelis said on LinkedIn in response to an article about the lawsuit: “Data accessibility lies at the heart of mitigating a fiduciary lawsuit. It all begins with gaining access to your data. But let's be clear—it's not an easy feat. The major hurdle? Procuring accurate data from your TPA [third-party administrator]. And that's just the first step. The subsequent challenge involves analyzing this data, a task best handled by a skilled healthcare data analyst—yet another formidable undertaking.” The one acronym in this whole stew that is not questionable at all is the NADAC. So, let's talk about the NADAC for a moment, the National Average Drug Acquisition Cost Price Benchmark. I was really thrilled to get Luke Slindee to be my guest today—or one reason I was so thrilled—is because Luke works for the accounting firm who, on behalf of CMS (Centers for Medicare & Medicaid Services) and the federal government, administers this NADAC, the National Average Drug Acquisition Cost. (Here's a good NADAC explainer if you're interested.) In brief, NADAC was jointly developed by the Centers for Medicare & Medicaid Services, and it calculates the average price that pharmacies pay for prescription drugs. NADAC is based on a retail price survey. My guest today, as aforementioned, is Luke Slindee. He is a second-generation pharmacist. His family owned a pharmacy in Minnesota when he was growing up. Now he is a senior pharmacy consultant for Myers and Stauffer, which is the accounting firm that calculates the NADAC Price Benchmark on behalf of CMS and the federal government. Also mentioned in this episode are Mark Cuban; Ferrin Williams, PharmD, MBA; Blueberry Pharmacy; Vinay Patel; Benjamin Jolley, PharmD; Scott Haas; Paul Holmes; Dawn Cornelis; Capital Rx; Myers and Stauffer LC; Adam Fein; Joey Dizenhouse; Steven Quimby, MD; and Antonio Ciaccia.   For additional information, go to data.medicaid.gov. You can also follow Luke on LinkedIn.   Luke Slindee, PharmD, is a second-generation pharmacist with a background in independent pharmacy, chain pharmacy, data analytics, and prescription drug pricing. He currently supports public drug pricing transparency benchmarks and is an advocate for pharmacy reimbursement reform and antitrust enforcement in healthcare.   09:52 Why is it important for plan sponsors to understand the going rate for every point in the supply chain? 10:21 How do manufacturers come up with a list price? 10:40 What does AWP stand for? 10:59 What does WAC stand for? 11:06 How are AWP and WAC numbers chosen by the manufacturer? 13:22 What is the difference between AWP and WAC? 14:54 How much are wholesalers paying to manufacturers? 16:43 How much is the pharmacy paying for branded drugs from a wholesaler? 17:34 Why might pharmacies be buying drugs for less than what wholesalers are paying? 18:17 Substack article by Benjamin Jolley, PharmD, on this topic. 19:22 EP423 with Joey Dizenhouse. 20:33 Why do things get weird when a PBM gets involved? 21:58 How does all of this work for generic manufacturers? 25:20 EP344 with Steven Quimby, MD. 26:15 How did Civica Rx come about? 32:21 What's the difference between the NADAC and the AWP value? 36:04 Luke discusses the downstream effects to pharmacies.   For additional information, go to data.medicaid.gov. You can also follow Luke on LinkedIn.   Luke Slindee discusses #followingthedollar through #WAC, #AWP & #NADAC on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthcareleadership #healthcaretransformation #healthcareinnovation   Recent past interviews: Click a guest's name for their latest RHV episode! Julie Selesnick, Rik Renard, AJ Loiacono (Encore! EP379), Nina Lathia, Marshall Allen, Stacey Richter (INBW39), Peter Hayes, Joey Dizenhouse, Benjamin Jolley, Emily Kagan Trenchard (Encore! EP392)

For a full transcript of this episode, click here. This show is different, so if you've already listened to or read all about the gory details of the J&J and/or the DOL v BCBS lawsuits, this is not gonna be a repeat of that information. Julie Selesnick, my guest today, does cover the very, very top line about these two cases. But after that, we move on fast—because what I wanted to get to today was not the potential landslide of legal action that may or may not be confronting plan sponsors or payers or even brokers today. I did not want to really even talk about the CAA (Consolidated Appropriations Act) and its inarguable adjacency here. I just feel like there's been a lot of talk about these topics already. What I wanted to get to, and fast, is … now what? If I'm a plan sponsor or actually, again, an EBC (employee benefit consultant) or broker, now what? What should I be doing and thinking about right now? To that end, I could not have been more thrilled to get a chance to talk to Julie Selesnick, who is an attorney deeply entrenched in helping plan sponsors and others understand and comply with fiduciary responsibilities. I want to get to this interview quickly (the conversation with Julie), so this intro is gonna be on the short side; but let me just summarize a few of the points that Julie makes during the interview that follows. First, we talk about the first step for pretty much everybody: Get your data, plan sponsors. But once you have that data, you also kinda have to use it. You can use it to ensure that you're paying claims right, which is what most do. As a result of these two lawsuits, it's also increasingly clear that you also have to use that data to ensure that the prices you're paying for things (like generic specialty meds, for example) are fair and reasonable. To get the data now, you may have to renegotiate administrative services agreements; and you might need to take a closer look at the disclosure agreements you're getting as a result of the CAA. And, by the way, it's not just brokers or EBCs who have to complete these disclosures. It's all covered entities that you, plan sponsors, paid more than $1000 to. Then we get into … okay, once you have the data and you've analyzed it, what are some in general things that could very well need to happen? And if the reason that they don't happen is because they weren't even considered, then plan sponsors have some risk exposure; and the brokers/EBCs who serve them might have some conflicts of interest. And it would be very interesting what would or could happen if a plan sponsor was able to back into those conflicts of interest, because if data clearly shows that something should be happening and it is not—and it is not even on the docket to be considered—if I'm a plan sponsor, I'm for sure gonna be wondering why. And maybe I'm gonna look into that and fast. Listen to the show with AJ Loiacono (EP379) from two weeks ago for more on some of the more egregious broker/EBC conflicts of interest, which could explain, potentially, the J&J lawsuit as well as definitely explains the earlier one in Osceola. And also, by the way, if you're sitting there wondering to yourself how exactly J&J managed to pay upwards of $10,000 for a drug that can be purchased for cash for something like $50, listen to the show next week with Luke Slindee, PharmD. We run through the exact pharmacy supply chain machinations that make all of this (and more) possible. But I got off track. What I was talking about is the things that could easily wind up being called for when the data is analyzed: 1. Carving out specialty generics, especially drugs or infusions, from the larger pharmacy benefit manager 2. Your payment integrity vendor should not be the same vendor who is processing claims. Talk about a conflict of interest. I do not need to be an attorney—and I need to know absolutely nothing about anybody's data—to tell anybody who's listening that if you have the same vendor or two vendors with the same parent company who are both processing your claims and then auditing their own work … yeah, fix that. 3. Shut down any cross-plan offsetting. And we get to this in the show if you don't know what cross-plan offsetting means. Lastly, we get into a bunch of stuff that plan sponsors might want to consider as they consider how to administer their plan, like, for example, setting up a health and welfare committee that has an independent fiduciary expert on said committee. I'm gonna say that's a good idea! As I have mentioned, my guest today is Julie Selesnick. Julie is senior counsel over at Berger Montague's Employee Benefits and ERISA group. Also mentioned in this episode are AJ Loiacono; Luke Slindee, PharmD; Justin Leader; Chris Deacon; Bridget Mulvenna; Mark Cuban; Olivia Webb; and Dawn Cornelis. You can learn more at Berger Montague. You can also follow Julie on LinkedIn.     Julie Selesnick has been practicing law since 2001 and has over 20 years of experience in complex dispute resolution forums representing plaintiffs and defendants. Julie has a wide variety of litigation, arbitration, and mediation practice, including first-chair jury and bench trial experience, representing some of the largest companies in the United States as well as small companies, labor unions, individuals, and classes of plaintiffs. Julie's current practice is a mix of class litigation on behalf of individuals, union funds, and employers, and a legal consulting practice advising self-funded health plans and service providers to self-funded health plans on minimizing litigation and regulatory risk, issues arising under ERISA, fiduciary obligations and best practices, and CAA compliance, including negotiating service provider contracts and business associate agreements, drafting plan documents and advising on plan design; helping health plans gain access to participant claims data, helping service providers draft and plan fiduciaries obtain § 408(b)(2)(B) compensation disclosures, assisting plans with ensuring their prescription drug data collection and reporting is properly conducted and copies are provided to plan fiduciaries, and ensuring proper review, MHPAEA Comparative Analysis reports on nonquantitative treatment limitations.   05:48 What's happening with the J&J lawsuit? 07:38 What's going on with the DOL v BCBS case? 08:49 What do these cases mean for plan sponsors? 09:21 Why is engaging with claims data critical? 12:30 EP408 with Chris Deacon. 14:20 EP379 with AJ Loiacono. 16:58 What's one solution to avoiding a conflict of interest? 18:02 Why there's still not a total understanding about what to do with claims data once acquired. 20:58 NADAC (National Average Drug Acquisition Cost) to check pharmacy prices. 21:31 What advice do plan sponsors need to know that never gets recommended to them when dealing with conflicting interests? 27:02 EP337 with Olivia Webb. 28:41 EP285 with Dawn Cornelis. 30:24 “As a fiduciary, your money should only go to pay your plan's benefits, not to other plan benefits.” 30:59 What's Julie's advice to advisors? 33:17 “Giving nonconflicted advice … is something you really can only do if you have no conflicts.” 35:57 What's Julie's advice for administering whole plans?   You can learn more at Berger Montague. You can also follow Julie on LinkedIn.   Julie Selesnick discusses advice based on the J&J and DOL v BCBS lawsuits on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthcareleadership #healthcaretransformation #healthcareinnovation   Recent past interviews: Click a guest's name for their latest RHV episode! Rik Renard, AJ Loiacono (Encore! EP379), Nina Lathia, Marshall Allen, Stacey Richter (INBW39), Peter Hayes, Joey Dizenhouse, Benjamin Jolley, Emily Kagan Trenchard (Encore! EP392), Cora Opsahl (Encore! EP372)  

For a full transcript of this episode, click here. Hey, Relentless Health Value Tribe, thanks so much for being here this week. I gotta say, I really appreciate all of you who write and tell me that you kick off your Thursdays by listening to this show every week. You just pop open your app and you listen to the show. Because yeah, we're a pretty sure thing over here. If the guest was boring or if the guest was talking about stuff that I already know and probably you already know, the guest would not be on the show. So, listening to Relentless Health Value every week is a hugely easy way to just keep up with what's going on and, at the same time, get a pretty holistic deep dive into how all of the various parts of the industry fit together and how they ultimately impact patients and anybody who is at risk to pay for their care. One thing that you'll notice about the guests who we invite to come on Relentless Health Value, they are usually not the ones who are merely going to recite a very well-curated point of view that is fully in line with some marketing pitch. It would be easy enough, honestly—it would be so much easier—to just invite all of the bigwigs who we get pitched. I get 50 pitches a day from PR teams who want to get their executives to come on the show because they want to get their message out to you, Relentless Health Value Tribe. You, for sure, have a reputation of being industry movers and shakers. Although it would be super easy for me to phone it in and let them have their way with you, I've never been one to take the easy way. I want to find those individuals to be guests who are willing to share actionable insights to actually tell the truth. I'm really not into someone hijacking this platform for their own self-interest when that self-interest is not aligned with anything that I would consider a win-win for patients. You'll probably find more actionable insights here than listening to talk tracks, even if you're just listening to figure out what to include in your pitch to some of these industry insiders. I'm gonna tell you that repeating their marketing spin or their party line isn't probably gonna sell much. What they will say in public and what they really want to do are so very often sadly at counterpoint. So, come here for the real story. Alright, so let's get to the conversation that we're gonna have today, which is about and for digital health vendors' or virtual care providers' point solutions (they go by many names) and also for anybody who is a customer of said solutions. If we're taking it from the top here, let me just make a Captain Obvious point. These digital health vendors, they kind of have to perform better than the traditional community health providers. Otherwise, they have no reason to exist, really, right? Purchasers would just go with the local gang of care providers. So then, what does “perform better” actually mean? Let's discuss. I'd say perform better means to offer better measurable patient outcomes probably, both clinically and patient reported. I'd also say it means to offer more affordability. Also, better engagement, accessibility, and maybe all of this at a better cost profile for purchasers such as employers or health plans that are taking on actual risk. So, if all things are equal, again, why the heck would an employer or other purchaser even bother? It couldn't even be considered, honestly, a member benefit from a regular benefit perspective if the local standard of care is superior or just as good. Now, if any clinical entity is looking to actually achieve better performance in any or all of the ways that I just mentioned with any level of consistency and in a way that is profitable for them and their investors, you got to do a few things. And one of them is to design and implement care flows, care processes, pathways—again, you can pick a name and define it how you like. But bottom line, there needs to be a standardized way to deliver high-quality care that is measurable. Here's Ali Khan, MD, MPP, who is chief medical officer over at Oak Street Health, talking about this. He says: “At Oak Street Health we think about standardization as a 70/30 split. It is important that the largest aspects of what your care team does are standardized. (...) The bulk of the work that we do is to make sure not only that we set standards, but that we also disseminate standards, coach standards, review standards, and then update and iterate those based on the things we learned. Our standards are constantly evolving and improving.” Okay, so said another way, gotta have and use care flows. This doesn't seem like rocket science, but yeah, that is a blue's clue for what's coming up here. So, how are most digital health vendors doing when it comes to care flows performing better? Rik Renard and Thomas Vande Casteele from Awell have done a survey with a group called Health Tech Nerds and have dug into the usage of care flows among, specifically, digital health vendors. Given everything aforementioned, I wasn't surprised to hear that 84% of digital health vendors use care flows in 2023 … 84%. But it was kind of shocking, to be honest, to hear that in 2023, only 16% use care flows that they feel are based on evidence and the science of medicine. If you don't follow the latest science, then outcomes, both clinically as well as probably patient-reported outcomes, won't be of the “perform better” variety. Oh, boy. Also, only 7% of respondents have the ingredients to build a 360-degree picture of how their flows impact finances and quality of care. And I say that because only 7% can and do measure four things. And here's the four things: 1. Performance metrics such as patient engagement and compliance rates 2. Financial metrics such as revenue per patient/per member 3. Clinician-reported outcomes 4. Patient-reported outcomes, or PROMs Seven percent. That is less than one out of ten of these digital health vendors. There are other higher, but still pretty sad, percentages that measure combinations of the above four factors; but only 7% measure all of them. And if you don't or can't measure what you're doing, then you wind up with what my guest Rik Renard calls black box care, which is another way of saying if you don't measure it, you can't manage it. Because think about it, if you have black box care, well, the solutions to perform better are also a black box. If you don't know the problem, good luck finding the solution to it. A few things as we contemplate all of this. First of all, as Stacy Mays pointed out to me, if that digital health vendor is working for different payers or different purchasers, those different payers or purchasers might demand different care flows; and those different care flows might ladder up to different ultimate goals. The hard part about being a digital health vendor employed by a payer or a purchaser is that your customer is the boss of you. So, complication. The other relevant conversation I had is with David Claud, MD, PhD, who told me that many employers/customers evaluating healthcare vendors, like on-site clinics, do not have the clinical expertise to meaningfully evaluate the quality of care; so, they tend to focus more on cost and service. When this happens, you kinda wind up with a race to the bottom, where being really nice and being cheap are more important than actually delivering high-quality care that no one can measure anyway. And the last point that I'll bring up is what Sanat Dixit, MD, MBA, FACS, brought up the other day; and I love how he put it. He said doctors don't tend to caucus well. And coming up with care standards and best practice care flows means getting everybody to walk the same pathways. Bottom line, it's really pretty hard to be a digital health entrepreneur these days. Coming up here, I have a conversation with Barbara Wachsman. Barbara was the managing director over at Disney. She's worked for PE (private equity) as well as being executive director over at PBGH, the Purchaser Business Group on Health. So, that's upcoming in a couple of weeks. But the point that Barbara makes, which I think is really apropos here, she said that, in the United States, we desperately need really talented and great digital health vendors, great entrepreneurs, ones who actually can deliver real results and do it at a fair price. So, my hope is that we get better at these care flows. Now, I say all this to say, let's take the conversation today as an opportunity for both entrepreneurs, vendors, as well as customers like employers and other purchasers or payers. It's an opportunity to recognize and work together where there's room for improvement and also place value on achieving that headroom. As I mentioned earlier, in this healthcare podcast I am speaking with Rik Renard from Awell. Rik has a background in nursing and healthcare management. He joined Awell four years ago and now manages strategic accounts. For more on this topic, listen to the show with George Mathew, MD, MBA, FACP (EP253).   Also mentioned in this episode are Ali Khan, MD, MPP; Oak Street Health; Thomas Vande Casteele; Stacy Mays; David Claud, MD, PhD; Sanat Dixit, MD, MBA, FACS; Barbara Wachsman; George T. Mathew, MD, MBA, FACP; Yubin Park, PhD; Jessica H. Green, MPH; Thyme Care; Better Health; Wellinks; Bob Matthews; Emily Kagan Trenchard; Robert Pearl, MD; and J. Michael Connors, MD.   You can learn more at Awell and CareOps. You can also follow Rik on LinkedIn and X (formerly Twitter).   Rik Renard transitioned from a nurse practitioner to a start-up operator. Currently leading strategic accounts at Awell, Rik focuses on helping large care organizations make their care flows work harder than their care teams. As the coauthor and driving force behind CareOps, a vibrant community of over 4000 healthcare professionals focused on enhancing care flows, he imparts insights on designing and improving care flows. His expertise is grounded in over five years of hands-on experience, during which he has successfully implemented over 50 care flows in various medical areas, including oncology, musculoskeletal disorders, and cardiovascular care. These efforts have significantly improved patient outcomes and efficiently freed up time for healthcare teams. Holding a master's degree in health care management and policy from Ghent University, Rik combines his educational background with real-world experience to make a tangible impact in healthcare.   09:26 Why should clinicians care about care processes and care flows? 12:05 Why do care flows and care processes have a bad reputation? 12:31 What components does a good pathway include? 14:51 Why pathways need to be looked at as a process of continuous reconfiguration. 17:15 Who did Awell survey about care processes and flows? 18:42 How many clinicians were using care flows, and what did those care flows look like? 25:45 EP315 with Bob Matthews. 26:44 EP392 with Emily Kagan Trenchard. 28:21 EP412 with Robert Pearl, MD. 30:01 “Just document something.” 30:14 What was a shocking find from this care process survey? 31:06 Is AI the answer? 34:13 Why is it important to get the foundation of data correct before introducing AI? 34:51 How should employers use this information to vet vendors?   You can learn more at Awell and CareOps. You can also follow Rik on LinkedIn and X (formerly Twitter).   @rikrenard discusses #digitalhealthvendors and #patientoutcomes on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthcareleadership #healthcaretransformation #healthcareinnovation   Recent past interviews: Click a guest's name for their latest RHV episode! AJ Loiacono (Encore! EP379), Nina Lathia, Marshall Allen, Stacey Richter (INBW39), Peter Hayes, Joey Dizenhouse, Benjamin Jolley, Emily Kagan Trenchard (Encore! EP392), Cora Opsahl (Encore! EP372), Jodilyn Owen    

For a full transcript of this episode, click here. Here on Relentless Health Value, we have done a bunch of shows lately on how some weird PBM (pharmacy benefit manager) and pharmacy goings-on impact plan members, patients, and also independent pharmacies. During the conversation with Benjamin Jolley, PharmD (EP422), for example, Benjamin mentioned that he thinks some of these contract terms that really hurt independent pharmacies are signed by employers at the urging of their brokers or employee benefit consultants (EBCs). Think about this. You have these huge vertically integrated PBMs who own their own retail pharmacies and/or mail order. You have EBCs that work with employers who, a lot of times, do not understand the contracts that they are signing. This is a recipe for what AJ Loiacono talks about on the podcast encore today: just how much those EBCs and brokers are, in some cases, being compensated to get employers to sign contracts that allow PBMs to corner the market and take all the profit. Even if you listened to this encore in 2022, you might want to revisit it and consider what AJ says in the context of these recent shows with Ge Bai, PhD, CPA (EP420); Joey Dizenhouse (EP423); Mark Cuban and Ferrin Williams, PharmD, MBA (EP418); and Benjamin Jolley, PharmD (EP422), as I just mentioned. Also keep in mind the shows with Scott Haas (EP365) and Paul Holmes (EP397) from earlier … Olivia Webb (EP337) as well. This show with AJ Loiacono is different than others you may have heard with him because in this healthcare podcast, we are not talking about PBMs. We're talking about brokers and EBCs. So, say I'm a self-insured employer. Here's the big question: Is my broker or EBC helping me make the right decisions, or is he or she helping me make decisions that will make them the most money? While there are some amazing and totally above-board EBCs and brokers out there, unfortunately, caveat emptor is a thing. Buyer beware, that is. Too many self-serving and I'm sure very charming sharks are out there circling plan sponsors. It is currently a fact that some EBCs and brokers and even TPAs (third-party administrators) or PBMs or others take hidden kickbacks or fees or percentages. They make a lot of money, maybe the most money, in these secret ways. All this money, money paid in secret backroom deals—let's not lose track, these dollars increase the total prices paid by plan sponsors and employees. Now, I say this to say that my guest today, AJ Loiacono, calls 2022, right now, a “magical moment” for plan sponsors—and for straight-shooting EBCs and PBMs and all the others who are actually doing the right thing by their clients also. It's because of the Consolidated Appropriations Act (CAA), which states quite clearly that plan sponsors can ask their healthcare and benefits service providers to disclose the money that they are making off of the plan—all of the money, not just the direct fees. The CAA went into effect December 2021, and contrary to what some people have said or may believe, it is in force right now. The field memo went out on 12/31/2021. So, the CAA is the rule right now. And in fact, the CAA makes it imperative under ERISA (Employee Retirement Income Security Act) to do what I just said: Plan sponsors must disclose the monies that they are paying out on behalf of employees and ensure that those fees are reasonable and free from conflict. If you're the fiduciary of the plan, you gotta disclose all these indirect and direct compensations of the people that you are paying or the people that you are paying who may be kicking back dollars to other people you are working with, unbeknownst to you. The Department of Labor is putting as much emphasis right now on healthcare as they put on 401(k) plans in the early 2000s, so this is a big deal—or it should be—for plan sponsors. So obviously, in order to comply with the CAA, self-insured employers should be requesting from their EBCs and brokers or others that they disclose, in writing, how much money they are making off the plan. You can see why this disclosure would be necessary if the plan sponsor is responsible to determine if those payments are reasonable and seem to be free from conflict, right? You can't evaluate something you do not know about, and if you don't know about it, the plan sponsor is the one at risk. Ignorance is not an excuse here. Here's one example: What if the EBC or TPA is collecting a $40 payment per prescription from the PBM? Wait … what? Some plan sponsor is paying $40 per script in, I guess you'd call it, a commission? Yes, that is a rumored example—$40/Rx. It is basically full-on arbitrage, and if anyone disagrees, let me know why and how it's not. Or let's say the EBC is making, say, $6 per script payable by the PBM, and this sum should be mailed quarterly to a PO box in another state. This was a condition, by the way, for a PBM to win an RFP (request for proposal) that the EBC wrote and picked the winner of. Yeah, you as the plan sponsor really probably want to know that this is going on because it's your butt on the line. So, in sum, the CAA is in effect right now. Penalties can be levied right now against plan sponsors. For a deep dive into the CAA, listen to the show with Christin Deacon (EP342) from 2021. So, what's the process if I'm an employer plan sponsor? Step 1: Request in writing the dollars that your EBC or broker is making off of you. Similar to the advice that you'll hear often on this show, ask for actual dollars, not a percentage of this or that. Ask for how much money did you (broker or EBC) make off each program that you recommended to us, and what did that total up to. Once you make that request, the EBC/broker/TPA (whoever you're asking) has 30 or 90 days to respond, depending on who you ask. But if they do not respond, then you, the employer, should report them to the Department of Labor. Keep this in mind: Once that EBC or broker is reported for failure to comply by anybody, meaning likely some other employer, it is only a matter of time before that information becomes public. And the second that info becomes public, I guarantee you that there's some attorney out there just waiting to file a class action lawsuit against every other self-insured employer who uses that EBC/broker because everybody else out there is now out of compliance. Right? I'm not a lawyer and I am certainly not a class action ambulance chaser, but even I can figure out that strategy. AJ Loiacono is the CEO of Capital Rx, which is a PBM 2.0, as they call it. To see how the CAA is playing out, you can read about one real-life example of a school district's lawsuit against an insurance consultant. Also mentioned in this episode are Benjamin Jolley, PharmD; Ge Bai; Joey Dizenhouse; Mark Cuban; Ferrin Williams, PharmD, MBA; Scott Haas; Paul Holmes; Olivia Webb; and Chris Deacon. You can learn more at cap-rx.com and find resources through law firms.   AJ Loiacono is a serial entrepreneur with over 20 years of experience in pharmacy benefits, finance, and software development. As the CEO of Capital Rx, his mission is to upgrade America's healthcare infrastructure to deliver the highest level of client service and patient engagement while reducing total cost of care. AJ has spent his career studying the pharmaceutical supply chain and developing solutions that have continually redefined the pharmacy benefit industry to achieve this goal. Before Capital Rx, AJ was a co-founder of Truveris, where he served for eight years as CEO, CIO, and a board member, leading the company to record growth (Deloitte FAST 500 and Crain's Fast 50). Prior to Truveris, AJ co-founded SMS Partners, a joint venture with Realogy (RLGY), and in 2010 exited the partnership with a buyout. In his first venture, AJ started Victrix, a pharmaceutical supply chain consultancy, which was successfully sold to Chrysalis Solutions in 2007.   07:09 Who can get in trouble for mismanaging employee funds? 07:48 “When you talk about conflicts of interest, they're everywhere.” 13:13 “You're paying for access.” 13:34 Why is it important to request that they disclose direct and indirect compensation? 14:04 What are the layers to these hidden fees and compensations? 18:13 What is a reasonable fee for a good plan admin? 19:27 “I think people need to take a step back and say, ‘How many different ways are they getting compensated?'” 24:50 “The compensation is not just unreasonable, but if they were to move it, they would lose access to an entire column of revenue.” 25:06 “For every good broker consultant, there's a horrible individual lurking out there and it's easy to figure out: Ask for them to disclose their fees.” 28:08 “You can't win if you can't even pay the house fee to come in.” 31:35 Why do you need to ask for disclosure, and what do you need to ask specifically? 32:21 What are some of the characteristics of a good plan consultant?   You can learn more at cap-rx.com and find resources through law firms.   AJ Loiacono of @cap_rx discusses #ebcs, #brokers, and #plansponsors on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthcareleadership #healthcaretransformation #healthcareinnovation   Recent past interviews: Click a guest's name for their latest RHV episode! Nina Lathia, Marshall Allen, Stacey Richter (INBW39), Peter Hayes, Joey Dizenhouse, Benjamin Jolley, Emily Kagan Trenchard (Encore! EP392), Cora Opsahl (Encore! EP372), Jodilyn Owen, Ge Bai  

For nearly 20 years, the Centers for Disease Control and Prevention (CDC) has operated a data gathering site, called the National Healthcare Safety Network. In 2020, CDC made it mandatory for nursing homes to report COVID cases. Suddenly thousands of nursing homes had to enroll in the network. It didn't go well, but things have improved since then. For the latest, Federal Drive Host Tom Temin talked with Health and Human Services Assistant Regional Inspector General, Marshall Allen. Learn more about your ad choices. Visit megaphone.fm/adchoices

For nearly 20 years, the Centers for Disease Control and Prevention (CDC) has operated a data gathering site, called the National Healthcare Safety Network. In 2020, CDC made it mandatory for nursing homes to report COVID cases. Suddenly thousands of nursing homes had to enroll in the network. It didn't go well, but things have improved since then. For the latest, Federal Drive Host Tom Temin talked with Health and Human Services Assistant Regional Inspector General, Marshall Allen. Learn more about your ad choices. Visit podcastchoices.com/adchoicesSee Privacy Policy at https://art19.com/privacy and California Privacy Notice at https://art19.com/privacy#do-not-sell-my-info.

For a full transcript of this episode, click here. Here's something Randy Vogenberg, PhD, wrote the other day; and I made some light edits: Research has documented the unintended impacts of poor pharmacy benefit strategy. Examples include increasing costs of care, bankruptcies, and member satisfaction declines. And, yeah … agreed. Also, probably health problems if we're talking about a member unable to access a drug they really need. I heard the other day about how so many patients who have had organ transplants have a hard time getting their transplant rejection meds. What?! I just can't even with that one. On the other hand, you could have a plan that pays for all manner of drugs, cost-effective or not, appropriate or not. And now we have premiums that no one can afford, and everybody loses for the exact opposite reason. These are the downsides that happen when pharmacy purchasing gets itself into a suboptimal place. And this can happen for many reasons, but one of them is when there is not a concerted effort to buy pharmaceuticals in a value-based way. Now, here's some reasons why employers may have a rough time paying for value (ie, paying a fair price for drugs that work). Here's one reason: Most employers do not have the power to influence the price of a medication. So, any given employer could decide, based on some cost-effectiveness analysis, that the price of a drug is too high. But it's not like they can march into Pharma HQ and haggle. It's more of a take-it-or-leave-it kind of thing. Here's a number two reason why value-based pharmacy purchasing can be tough: Pharmacy spend is siloed a lot of times from medical spend. So, the pharmacy vendor is only concerned about cost and denies access to even drugs that are proven to reduce medical spend. Why wouldn't they do that? The PBM (pharmacy benefit manager) was hired to reduce pharmacy spend. The end. Who cares how many ER visits or disease exacerbations transpired? That's the medical director's problem, not theirs. Here's the number three reason why value-based purchasing is rough: The time horizon an employee is with an employer, which is not one day—and it's not a lifetime. Why did I say one day? I have heard more than once that the actuarial time horizon that some pharmacy plans use to determine if a drug is cost-effective is one day. If the drug doesn't accrue any benefits in one day, well then, it's a cost. It's not effective. On the other hand (and also problematic in the real world), sometimes cost-effectiveness analyses are done with a timeframe of the patient's lifetime. And, yeah … there aren't many employers who have employees for a lifetime—like, they're 85 years old and still on the employer's dime—so the time horizon can't be too short. But if it's a really expensive med that will, at most, prevent something that's not gonna happen anytime soon (heart failure, kidney failure, a stroke), these are things that an employer may pay for but likely is never gonna see the cost benefit of because that benefit will happen 30 years from now when the patient is on Medicare. And here's a fourth reason why value-based purchasing is tough: The FDA is approving drugs based on evidence from one study (ie, not a ton of evidence). And these drugs are also really expensive. So, some of the above issues are solvable; some are less solvable. With this in mind, let's tick through some advice that my guest today, Nina Lathia, suggests if you want to offer members a value-based formulary. 1. Have a stated goal. And maybe that stated goal is to meaningfully improve health of plan members while maintaining access, satisfaction, and affordability for said plan members and the plan. 2. Think holistically about healthcare spend, not just pharmacy spend. 3. Know what the value-based price of a drug has been calculated to be. I talked about this at length in the show with Anna Kaltenboeck (EP303). Also, Bryce Platt, PharmD, has written about this a lot. 4. Look into risk-based deals with Pharma and/or installment payments and/or some of these other interesting payment models that are emerging. Luke Prettol linked to one of them the other day. 5. Set good decision-making precedents that include shared decision-making with members/patients. This means communicating with employees and plan members about what you are doing to make good drug purchasing decisions and evaluate the clinical pros and cons of expensive drugs for any given patient. There are genetic tests now that can be done to determine if a drug is ever going to work for a patient, were these tests even done. I mean, from a patient standpoint, some of these drugs have horrible side effects; and they might be being prescribed by a doc who's not an expert in that condition. If I'm a patient and there's a genetic test I could take before I pay a ton of my own money and subject myself to what might be some pretty nasty side effects (you know, all the things that you hear about at the ends of those pharma ads on TV, right?), this could be, in the right hands, a patient benefit. This feels very different from prior auths administered by a vendor doing all kinds of stuff, where it's hard to make any connections to clinical value or patient upside, even if you squint at it sideways and use your imagination. And, yeah … this is easy to say and really hard to do. One definition I want to chuck in here for you: If we're talking about a cost-effectiveness analysis, cost-effectiveness analyses calculate how effective is the drug, minus side effects at diminishing the so-called burden of illness—burden of illness meaning the financial and health costs of the disease itself or its exacerbations. Nina Lathia, my guest today, is a pharmacist by training who has worked in hospital pharmacies. She earned a PhD in health economics. Currently she's doing consulting work, helping purchasers make value-based decisions about pharmacy spend and managing formularies. Specialty Pharmacy Playlist: https://lnns.co/uNZ3moCaQMb Hit the subscribe button to add it to your podcast player. Also mentioned in this episode are Randy Vogenberg, PhD; Anna Kaltenboeck; Bryce Platt, PharmD; Luke Prettol; Olivia Webb; Pramod John, PhD; Scott Haas; Aaron Mitchell, MD, MPH; Keith Hartman, RPh; Erik Davis; Autumn Yongchu; and Berkley Accident and Health.   You can learn more by emailing Nina at nina.lathia@healthcaredecisionmaking.com. You can also connect with her on LinkedIn.   Nina Lathia, RPh, MSc, PhD, has spent over 15 years helping healthcare payers achieve value on their drug spend. As the chief executive officer of Healthcare Decision Making, Nina works with public and private healthcare payers, helping them to make evidence-based decisions about their pharmaceutical benefits that lead to improved health outcomes and long-term financial sustainability of their health plans. Her focus is on providing independent, actionable advice for healthcare payers on reimbursement decisions related to expensive new drug therapies. Nina is a frequent public speaker and commentator on employer-sponsored pharmacy benefits design, value-based healthcare decision-making, and evidence-based medicine. Nina honed her skills in value-based assessment of drug therapies when she was a senior technical advisor at the National Institute for Health and Care Excellence (NICE) in the United Kingdom from 2014 to 2017. She has also worked as a clinical lecturer at the University of Toronto. Her work has been published in a number of high-impact peer-reviewed journals. Nina holds a master's degree and doctorate in health economics from the University of Toronto.   06:34 What does cost containment mean? 07:43 Why is it important to consider health outcomes? 10:00 What does value-based purchasing mean in Pharma? 11:09 What are the principles of cost-effectiveness analysis? 12:50 Pharmacy plan time horizons versus employer time horizons. 14:42 Why is it increasingly important for payers to take a more global look at health and cost outcomes? 16:14 Why is the first step establishing a value-based price for drugs? 16:43 Why is the second step thinking about risk-sharing agreements with manufacturers? 18:57 LinkedIn article by Bryce Platt, PharmD. 19:20 What should an employer do if there's only one drug option and the price is too high? 21:20 What's a specialty carve-out solution? 21:26 EP352 and EP353 with Pramod John, PhD, of VIVIO. 22:10 Why should employers get more comfortable with saying “no” to certain drugs? 25:36 Why is patient engagement key? 28:23 What does “good” look like for employers implementing drug-spend changes? 29:51 EP337 with Olivia Webb.   You can learn more by emailing Nina at nina.lathia@healthcaredecisionmaking.com. You can also connect with her on LinkedIn.   Nina Lathia discusses #costcontainment and #valuebasedpurchasing in #pharma on our #healthcarepodcast. #healthcare #podcast #healthcareleadership #healthcaretransformation #healthcareinnovation   Recent past interviews: Click a guest's name for their latest RHV episode! Marshall Allen, Stacey Richter (INBW39), Peter Hayes, Joey Dizenhouse, Benjamin Jolley, Emily Kagan Trenchard (Encore! EP392), Cora Opsahl (Encore! EP372), Jodilyn Owen, Ge Bai, Andreas Mang  

For a full transcript of this episode, click here. This show today is for physicians or other clinicians or providers who are still taking insurance—those who are going about their day being pretty normal ... but at the same time, they're noticing one and/or two things potentially going on. Here's thing one: They may be seeing patients struggling to afford care, especially patients with commercial insurance and huge deductibles. And/Or thing two: They may have patients actually coming in and asking to pay cash. It's definitely becoming known in some circles that about half the time the cash price for something is actually cheaper than the “negotiated” rate with an insurance carrier. And this has really become an actionable insight for patients who haven't yet met their deductible, and some high percentage of patients—maybe upwards of 90% of patients—won't meet their deductible in any given plan year. So, all of this is probably some pretty obvious foreshadowing, but let's run through two maybe quick reasons why a practice might want to contemplate ways to make it easier for patients to pay cash when it is, in fact, cheaper for that patient to pay cash than it is for them to go through their insurance. Now, a clarifying point here: We are not talking here about that patient always paying cash heretofore … like, never using their insurance ever again, even if they get hit by a bus. No. We're talking about the patient coming in for some office visit or service, and today, they want to pay with a wad of money they take out of their wallet and hand you. That is the end of the transaction that we're talking about here. So, here's the first of let's just say two reasons that a practice might want to entertain taking cash from insured (technically, at least) patients. First reason: We have a situation in this country where 48% of insured commercial patients say that they are delaying or forgoing care due to cost or fear of cost. Sometimes I say this 48% number to a clinician, and they will reply, “Well, that's not in my practice or in my hospital; our patients show up.” To which I reply, “Yeah, because the patients abandoning care are not the patients that are coming in. They are abandoning care.” Now, the second reason a “normie” practice might want to be thinking about how to help patients get the best possible price here is maybe less intuitive, but it's a financial motivation for the practice. I just saw Eric Vanderhoef. He wrote on a Listserv recently, and this is what he wrote: Patient no-shows and cancellations cost healthcare providers as much as $7500 per month. That's a loss of $375 per patient. Hmmm … okay. Keep this in mind: The whole cancellations costing providers upwards of $7500 a month would help reduce this. Coincidentally, I was talking to Paula Muto, MD (she's the founder of UBERDOC) about this exact same topic the other day—just the crazy no-show rates that many practices experience—and she made some really good points, which are exactly in line with the Tebra report Eric Vanderhoef referenced above. She said that if a patient knows exactly how much a physician visit is going to cost—because they're paying cash and the price is set between the doctor and the patient, so the price is the price, the end—no-shows will go down, and this is especially true when the appointment is tomorrow and not six months from now when appointments are booking these days. It's kind of not normal for anybody to know what's gonna be happening in lives six months from now, so no wonder patients fail to show. Dr. Muto is recommending maybe having a couple of slots open every day for patients who want to pay cash. Doing this could help improve some—not all, for sure, but some—practice cash flow issues which are caused by the no-show thing or the getting paid by the insurance carrier net whatever months later after a billing fight kind of thing. And it's also a win-win for patients with high-deductible plans, especially those patients who are coming in asking to pay cash. In the conversation today, Marshall Allen, my guest, explains how to, in a simple enough way, operationalize the ability of a practice to take cash. There's a form that you'll need for insured patients. You'll actually need a cash price. It's also a marketing opportunity. For example, you can get listed with entities that connect consumers to practices that take cash, like UBERDOC, but there's also a growing movement of employers, especially in some parts of the country, who are looking around for providers who will do direct contracting or cash prices. In fact, I just saw a study the other day: “New polling conducted by Marist … found that 94 percent of adults agreed that hospitals, insurance companies and doctors should ‘be legally required to disclose all of their prices, including discounted prices, cash prices, and insurance negotiated rates across hospitals and across plans in an easily accessible place online.'” Alright, if I know you, you are thinking right now about all of the reasons why this won't work. So, let me head you off at the pass. My guest today, Marshall Allen, solves for the most common issues that everybody brings up, including the big kahuna issue, the “I am contractually forbidden by a health plan to allow patients to pay cash.” You will need to listen to this podcast for the answer. Now, there are, of course, other hairballs to untangle that we do not address today. As Marshall Allen says, there are layers of dysfunction here. One bit of weirdness is something that David Schreiner, PhD, told me about the other day. David is CEO of Katherine Shaw Bethea Hospital in Dixon, Illinois; and he's also the author of a new book entitled Be the Best Part of Their Day: Supercharging Communications With Values-driven Leadership. David said that sometimes hospital payer contracts have the payer reimbursing the hospital for a percentage of overall charges. Yes, you heard that right. The hospital totes up, using their charge master rates, the total amount of billings for the entire year; and the carriers pay a percentage of that total. So, the hospital has a big incentive to keep charge master rates as high as possible. If some patients pay lower cash amounts, then their carrier reimbursement (the hospital's carrier reimbursement) will drop. Probably some math there, I guess, because if it's determined that patients aren't actually showing up for services due to cost, then they might be getting paid a percentage of zero by the carriers; but point taken still. There are, for sure, considerations to be thought through; and, for sure, having contracts like this is one of them. I was talking to Lauren McAteer the other day, and she told me when she worked for a hospital and went to meetings, sometimes she'd bring in a hospital gown and hang it over a chair in the conference room to make it harder to not consider the patient perspective and think about how decisions impacted patients. Good idea, because where there's a will, there's often a way. My guest today, Marshall Allen, probably needs no introduction. But I ask Marshall for the skinny on how he started Allen Health Academy, and you will hear him introduce himself. So, in the interest of eschewing redundancy, let's do this thing. Also mentioned in this episode are Eric Vanderhoef; Paula Muto, MD; David L. Schreiner, PhD; Lauren McAteer, CCXP; Benjamin Jolley, PharmD; David Scheinker, PhD; William Shrank, MD; Jerry Durham; Leon Wisniewski; Cristin Dickerson, MD; and Dutch Rojas. You can learn more by signing up for Marshall's newsletter at marshallallen.substack.com. You can also go to Allen Health Academy or to Marshall's site.     Marshall Allen has spent more than 17 years investigating the healthcare system as a journalist. He is the founder of Allen Health Academy and the author of Never Pay the First Bill: And Other Ways to Fight the Health Care System and Win. His book and his health literacy videos, The Never Pay Pathway, are helping working Americans save hundreds and thousands of dollars—per healthcare encounter. Marshall is a two-time finalist for the Pulitzer Prize and winner of the Harvard Kennedy School's Goldsmith Prize for Investigative Reporting and dozens of other journalism awards. For more information, visit allenhealthacademy.com and sign up for his newsletter at marshallallen.substack.com.   07:04 What Allen Health Academy is doing. 11:01 What's the problem with the system now? 14:19 EP363 with David Scheinker, PhD. 14:27 EP413 with Will Shrank, MD. 14:34 What's the hack Marshall Allen shares for insured patients paying cash? 15:06 How can patients cite HIPAA to pay cash instead of using their insurance? 19:00 What's the first recommendation Marshall Allen has when dealing with healthcare billing? 21:26 EP297 with Jerry Durham. 21:48 What are the other benefits of a clinic accepting cash payments? 25:36 Why do we need to have more direct pay happening? 26:36 How should a medical provider set a cash price? 27:12 Research tools for fair pricing: fairhealthconsumer.org, BILLY, colonoscopyassist.com, Jason Health, Green Imaging. 32:36 How do you find the win-win between a patient and a doctor? 32:51 What's the final tier of partners in creating more direct-pay opportunities? 34:30 What's Marshall Allen's opinion on having to pay credit card fees?   You can learn more by signing up for Marshall's newsletter at marshallallen.substack.com. You can also go to Allen Health Academy or to Marshall's site.   @marshallallen discusses operationalizing cash payments for #clinicalpractices on our #healthcarepodcast. #healthcare #podcast #pharma #healthcareleadership #healthcaretransformation #healthcareinnovation   Recent past interviews: Click a guest's name for their latest RHV episode! Stacey Richter (INBW39), Peter Hayes, Joey Dizenhouse, Benjamin Jolley, Emily Kagan Trenchard (Encore! EP392), Cora Opsahl (Encore! EP372), Jodilyn Owen, Ge Bai, Andreas Mang, Karen Root (Encore! EP381)  

This week's wheat/chaff separation process sifts the following from the rock and roll cornfield … … Tony Secunda, his gangsterish suits and the publicity stunt that backfired spectacularly. … our old Word magazine pal Rob Fitzpatrick talking about the Japanese composer Michiru Aoyama who's released an album a day since December 2021, each 20 minutes 20 seconds long. And the role of streaming in the ambient music boom. … the life of Denny Laine and the great “chamber pop” hit he wrote. ... why the Move's Flowers In The Rain has never earned the band a cent.   … how the death of John Lennon was the dawn of the ‘black border' magazine tribute. … Willie Nelson's way with a middle eight. … the last men standing in the Band On The Run album shoot.   … is there anyone still on the road older than “the French Bob Dylan” Hugues Aufray (94) and Marshall Allen 0f the Sun Ra Arkestra (99)? … and mentioned in dispatches - Harold Wilson, Frank Ifield, Ginger Baker's Air Force, ‘Ronnie & Clyde' and birthday guest Rob Collis and the best rock and roll movies.Subscribe to Word In Your Ear on Patreon for early - and ad-free! - access to all of our content: https://www.patreon.com/wordinyourear Get bonus content on Patreon Hosted on Acast. See acast.com/privacy for more information.

Marshall Allen is a journalist who investigates why we pay so much for healthcare here in America, while simultaneously we receive so little in return. He is the author of “Never Pay the First Bill: And Other Ways to Fight the Health Care System and Win” and he is also the founder of Allen Health Academy, which produces a curriculum of short on-demand videos to equip and empower employees to navigate the healthcare system. Marshall has been investigating the healthcare industry for 15 years, including over a decade at ProPublica. He also teaches investigative reporting at the Newmark Graduate School of Journalism at the City University of New York. We highly recommend that you listen to this episode if you're looking for practical ways to reduce how much you're spending on medical costs!   Want more How To Money in your life? Here are some additional ways to get ahead with your personal finances: Knowing your ‘money gear' is a crucial part of your personal finance journey. Start here.  Sign up for the weekly HTM newsletter. It's fun, free, & practical. Join a thriving community of fellow money in the HTM Facebook group. Find the best credit card for you with our new credit card tool! Massively reduce your cell phone bill each month by switching to a discount provider like Mint Mobile.   During this episode we enjoyed a Fade Away by Cruz Blanca Brewery - thanks to Dennis and our friends at the brewery for donating this one to the podcast! And please help us to spread the word by letting friends and family know about How to Money! Hit the share button, subscribe if you're not already a regular listener, and give us a quick review in Apple Podcasts or wherever you get your podcasts. Help us to change the conversation around personal finance and get more people doing smart things with their money!   Best friends out!See omnystudio.com/listener for privacy information.

Our latest episode of Kosher Money features Marshall Allen, author of the thought-provoking book, "Never Pay the First Bill: And Other Ways to Fight the Health Care System and Win."Allen challenges the status quo of healthcare billing and shares powerful insights on how individuals can effectively navigate and challenge medical expenses. With practical tips and alternative approaches, he empowers listeners to take control of their healthcare costs and fight back against a system that often seems overwhelming.You'll hear invaluable advice and actionable steps to help you navigate the healthcare system with confidence. Prepare to be inspired and equipped with the tools you need to fight for fair and reasonable medical expenses. I promise (or hope) this will change the way you approach your next hospital bill and empower you to win in the battle against exorbitant medical costs.HELPFUL LINKS:• Allen's Book on Amazon » https://amzn.to/3nXlQcm• His Free Newsletter » https://marshallallen.substack.com/• His Website » https://www.marshallallen.com/• Allen Health Academy » https://www.allenhealthacademy.com/✬ SPONSORS OF THIS EPISODE ✬► COLEL CHABAD: Please help Israel's neediest! Visit https://www.ColelChabad.org/KosherMoney to make a much-needed donation!► APPROVED FUNDING: Looking to purchase a home? Looking to get involved in real estate? Speak to Shmuel Shayowitz at https://approvedfunding.com/Shmuel/ to make sure you do it right.Our free call-in-to-listen feature is here:• USA: (712) 432-3489• UK: 0333-366-0154• ISRAEL: 079-579-5088Follow Kosher Money on social media:TikTok - https://www.tiktok.com/@koshermoneypodInstagram - https://www.instagram.com/koshermoneypodFor bonus content on our episodes, visit http://Mishpacha.com or pick up a new Mishpacha magazine weekly!Submit your questions to hi@LivingLchaim.com or WhatsApp us at 1-914-222-5513 - we love feedback, legit!Need financial guidance? Get help from our friends at https://LivingSmarterJewish.org/Subscribe to our YouTube channel for more awesome content! :)More shows here: https://www.livinglchaim.com/#FinancialEmpowerful #MedicalBills #KosherMoney #JewishPodcast Hosted on Acast. See acast.com/privacy for more information.