Podcast appearances and mentions of Paul Holmes

Ali was one of NZ's most high profile broadcasters and journalists for more than two decades and worked for One News, Breakfast, Fair Go, Seven Sharp, Radio Live, Close up and many more.In this episode we talk about her rise to the top of NZ Media and all of the twists and turns along the way, getting made redundant five times and how she kept bouncing back, why her relationships became front page news of every media outlet, working with Paul Holmes, Mike Hosking, Paul Henry and Willie Jackson, leading the charge on NZ's MeToo movement - and what she's doing now.We also talk in detail about her new book No Words for This, where she talks for the first time about the monster that haunted her childhood. As young girls, Ali and her sister were sexually abused by their father on multiple occasions, and it's revealed in the book that he also repeatedly raped his grandson. It's a shocking, and confronting story that is told with the hope of helping others.Ali's story is complex and powerful and she does such a great job of articulating it. And she is brilliant company, warm fun and engaging.And a content warning: This episode deals with sexual abuse and may not be suitable for all listeners. Hosted on Acast. See acast.com/privacy for more information.

In a candid conversation with Paul Holmes, chief impact officer Michael Gonda discussed the past year at McDonald's from inflation to the election, from E.coli and DEI.

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

Building on Zeno Group's recent report on “Allies & Advocates,” which provides a new blueprint for civil society engagement in an increasingly polarized world, Paul Holmes sat down with Sarah Ogden, chief client officer for Zeno in London, and Georg Schmitt, former head of stakeholder engagement for the World Economic Forum and now a member of Zeno's reputation advisory board, to discuss the report's recommendations.   Looking at corporate engagement with civil society issues on a continuum that starts with mere compliance, progresses through support and advocacy, and culminated in activism, the report found that both consumers and executives feel the “sweet spot” is in the middle: with companies supporting and advocating for social causes. The discussion focused on a strategic approach that can help companies decide when and how to engage.

In the first of a series of interviews with the leaders of agencies around the world, Paul Holmes sat down with Richard Edelman, CEO of Edelman. In a conversation that covered the firm's history, the reasons it has remained committed to its independence, its Trust Barometer research, and the challenges Richard sees ahead as the competitive landscape evolves. Future editions of this podcast will feature a wide variety of leaders, from giant multinational agencies to small specialist boutiques, from all of the world's regions as we seek to capture what drives success in a dynamic, fast-changing, hyper-competitive PR business. Read highlights from the episode here: https://www.provokemedia.com/long-reads/article/richard-edelman-i-like-to-run-the-pirate-ship

We are on the cusp of a fundamental shift in the role that journalism plays in our lives. Terms like “Fake News” exist to downplay scandal, social media has unchained hate and negativity and allowed those with the most money to have biggest voice and to punch down on anyone who speaks out against them. Public Relations stands at the vanguard of democracy right now, defending free speech, diversity, climate change and exposing hypocrisy and cruelty. As Chairman of PRovoke Media, Paul Holmes is the figurehead for the world's public relations business. If you need to know what's what in the increasingly influential world of public relations, anywhere in the world, then you'd better speak to Paul. Show notes: Paul Holmes' LinkedIn page: https://www.linkedin.com/in/paul-holmes-4255475/ Provoke Media: https://www.provokemedia.com The Ivan Fernandes LinkedIn article: https://www.linkedin.com/posts/ivanfernandes1_strategy-wpp-accenture-activity-7276729033378136064-3gVp? Learn more about your ad choices. Visit megaphone.fm/adchoices

Research from UK agency Brands2Life found business-to-business marketers struggling to balance the immediate payoff of lead generation with the long-term imperative of building brand equity. PRovoke Media's Paul Holmes sat down with Emily Thomas of B2L and Coopervision senior global brand director Chris Carter to discuss how marketers can strike the right balance.

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

Moira Gilchrist, chief communications officer at Philip Morris International, joins Paul Holmes to discuss the “Fifth Estate,” and the changing face of activism.

My guest and conversation partner for this episode is Anna Pereira. Anna grew up in New Jersey. She tells us about growing up in a home where she was discouraged by her father from going to college. She tells us that while her mom typically exceeded to the wishes of her dad, Mom did insist that Anna should be able to go to college if she wished. And so Anna did, but only stuck it out for three semesters.   Anna then joined the workforce holding a variety of jobs and becoming successful at most of them.   In 2009 she met and married her husband. That story is one I leave for Anna to tell, but suffice it to say Anna's story is an inspirational and fascinating one you should hear from her. Anna's husband is a sports expert as you will learn. A few years after marrying Anna and her husband moved to Portugal for a job and have been spreading their time between New Jersey and Portugal ever since. In fact, not just travels to Portugal but also to other countries around the world.   The Wellness Universe concept was created by Anna to help bring wellness to leaders and others. Through The Wellness Universe, and now Wellness Universe Corporate Anna has reached thousands of people. Her programs are in large part membership-based endeavors that help promote well being and a more positive outlook on life.   Our conversation is not only informative and inspirational, but it also is quite animated in a positive way that I believe will keep you engaged. Please enjoy your time with Anna and reach out to her afterward at www.thewellnessuniverse.com. I think you will see why Anna believes she is truly changing the world.       About the Guest:   Anna Pereira is the CEO of The Wellness Universe, and Wellness Universe Corporate, creator of wellness events, projects, community, programs, author of 4 best selling books, and founder of Wellness for All, donation based wellness programming and leads a woman-owned business, where they believe happy, healthy, healed humans lead to peace globally. She's an inspirational leader, mentor, and connector for business owners who help humans to live and lead their best life. Anna has worked with thousands of wellness business owners bringing their transformational resources to those seeking wellbeing and now taking those people to help transform organizations through the lens of company culture and well-being. Her contribution and impact are well documented through those she has worked with, evident in over 150 written recommendations in her Linkedin profile.  Anna resides between Portugal and her birthplace, New Jersey, USA, with her husband, sports expert, Hugo Varela. The couple has adopted pets (one dog and two cats) and cares for strays and their African Gray is a quite conversationalist speaking two languages. Her relationship with her loved ones and others is top priority. Anna finds balance in being creative, in nature, and at the beach.  She's dedicated to serving her calling and leaving her legacy as a ‘conduit for change' by bringing more health, happiness, and wellbeing to the world with a collaborative spirit and intentional action.   Ways to connect with Anna:   https://www.linkedin.com/in/annapereira1/  https://www.thewellnessuniverse.com/world-changers/annapereira https://www.facebook.com/CirclesOfInspiration IG - @annapereiraofficial Books - https://www.amazon.com/dp/B08VFFJPN9       About the Host:   Michael Hingson is a New York Times best-selling author, international lecturer, and Chief Vision Officer for accessiBe. Michael, blind since birth, survived the 9/11 attacks with the help of his guide dog Roselle. This story is the subject of his best-selling book, Thunder Dog.   Michael gives over 100 presentations around the world each year speaking to influential groups such as Exxon Mobile, AT&T, Federal Express, Scripps College, Rutgers University, Children's Hospital, and the American Red Cross just to name a few. He is Ambassador for the National Braille Literacy Campaign for the National Federation of the Blind and also serves as Ambassador for the American Humane Association's 2012 Hero Dog Awards.   https://michaelhingson.com https://www.facebook.com/michael.hingson.author.speaker/ https://twitter.com/mhingson https://www.youtube.com/user/mhingson https://www.linkedin.com/in/michaelhingson/   accessiBe Links https://accessibe.com/ https://www.youtube.com/c/accessiBe https://www.linkedin.com/company/accessibe/mycompany/   https://www.facebook.com/accessibe/       Thanks for listening!   Thanks so much for listening to our podcast! If you enjoyed this episode and think that others could benefit from listening, please share it using the social media buttons on this page. Do you have some feedback or questions about this episode? Leave a comment in the section below!   Subscribe to the podcast   If you would like to get automatic updates of new podcast episodes, you can subscribe to the podcast on Apple Podcasts or Stitcher. You can subscribe in your favorite podcast app. You can also support our podcast through our tip jar https://tips.pinecast.com/jar/unstoppable-mindset .   Leave us an Apple Podcasts review   Ratings and reviews from our listeners are extremely valuable to us and greatly appreciated. They help our podcast rank higher on Apple Podcasts, which exposes our show to more awesome listeners like you. If you have a minute, please leave an honest review on Apple Podcasts.       Transcription Notes:   Michael Hingson ** 00:00 Access Cast and accessiBe Initiative presents Unstoppable Mindset. The podcast where inclusion, diversity and the unexpected meet. Hi, I'm Michael Hingson, Chief Vision Officer for accessiBe and the author of the number one New York Times bestselling book, Thunder dog, the story of a blind man, his guide dog and the triumph of trust. Thanks for joining me on my podcast as we explore our own blinding fears of inclusion unacceptance and our resistance to change. We will discover the idea that no matter the situation, or the people we encounter, our own fears, and prejudices often are our strongest barriers to moving forward. The unstoppable mindset podcast is sponsored by accessiBe, that's a c c e s s i capital B e. Visit www.accessibe.com to learn how you can make your website accessible for persons with disabilities. And to help make the internet fully inclusive by the year 2025. Glad you dropped by we're happy to meet you and to have you here with us.   Michael Hingson ** 01:21 Well, hi everyone, and welcome to another edition of unstoppable mindset. Today we get to chat with Anna Pereira. And Anna is the founder of the wellness universe, the wellness universe and other things that we're going to talk about. She's written several books, and she has been a very active and engaging person. We've had fun catching up even before we started doing this podcast, because Anna spends her time between Portugal and her home in New Jersey, and where she lived in New Jersey was like just a few miles from where I and my wife Karen lived in Westfield New Jersey for six years, so we hadn't talked about that before. Shame on us, but now we have, and we got caught up. Anna, welcome to unstoppable mindset. We're glad you're here. Oh   Anna Pereira ** 02:14 Michael, thank you so much. I am delighted to be here. Thank you for having me. Well,   Michael Hingson ** 02:18 I'm really glad that we're getting a chance to do this. So tell us a little bit about kind of the early Anna growing up and all that stuff. Might as well start with that,   02:31 such a big question. Well,   Michael Hingson ** 02:33 if we take the hour to talk about that, then we know that there were some interesting events.   Anna Pereira ** 02:39 All right. Well, great. Well, you know, it's so funny, like you said, we were talking about growing up in in very close proximity to each other, probably around those same years, and had no idea that here we are, later again and and it was our wonderful friend Sharon Carn, that actually put us together here. Yeah. So I grew up in New Jersey, and I had a pretty, pretty average childhood, except for the fact that I feel, and I think that with a lot of first generation immigrants, people that came in from a very strict background, my my culture, my background is Portuguese. My parents raised me in a pretty strict household, but I was not a very compliant individual, growing up with a very free spirit and very creative spirit. So with that, I was always very independent. Wanted to do my own thing, and at the same time, there wasn't, like, a lot of, I want to say nurturing or good parenting from the from the angle of, there wasn't a lot of I love using the house, or there wasn't a lot of encouraging me to pursue a more of an academic route in life. When I expressed that I wanted to further my education, I was met with the minds with my father's fear mindset around money, saying, you know, no, you're not going to college. We can't afford it. Instead of saying, let's explore options here, let's get our child who is interested in furthering her, you know, her, her education, the resources that she needs in order for her to pursue her dreams. So everything was kind of met with that. So where was your mom and all that? My mom was there, and she was just basically subserving to my father. Okay, the and it's a great segue to the the conclusion of that my mom was the one who said, no, no, we're going to go enroll you in college. That's what I was wondering. Yes, thank you. So I went to the wonderful UCC over here in in Cranford. So. I went to for a few years of Union County College, and it still wasn't for me. So I never really finished with any degree, as with many union, I'm sorry, county college students and I joined the workforce. But growing up was a mixed bag. I was very artistic, and I was very well championed and respected, and my peers and even teachers and people around me really knew me for my artistic talent. They and I was very much celebrated and encouraged in that area, but there was a lot of areas that I felt were lacking. I was bullied when I was growing up, and again, the lack of nurturing, and if something happened, well, it had to be my fault. And if it was my fault, then there was the shame and the blame and all that put there. So in growing up with all of these stigmas and traumas, only as I became an adult, did I understand what what I went through and how to become more aware of the situations and circumstances which kind of led me to where I am today. But all through that time, it was interesting, because I don't know where the inspiration came from to have adult conversations as a teen with my teachers, my guidance counselor, which with other adults, and they would ask me for my advice or my perspective on things that I I don't know where I came up with things, but that was kind of like the the seeding of where I am now,   Michael Hingson ** 06:46 interesting. You know, one of the things that that comes to mind when you when you say that last bit, is that I've learned, if nothing else in the world, our subconscious minds, our heart, if you will, observes everything that goes on around us, and oftentimes, will tell us things if we learn to listen. So in a sense, I'm not really surprised that maybe you were able to carry on adult conversations because they picked up on that, but clearly you had been observant enough to be able to gather the knowledge to be able to go off and deal with some of those things, and it's so often that people don't do that today. My favorite example of that is playing Trivial Pursuit. When somebody asks a question and you immediately think of an answer, and then you go, Oh, no, that can't be the right answer. It came too quick, and then you give some other answer, but the original answer was the right answer. And we just don't follow our instincts and our heart nearly as much as we probably ought to.   Anna Pereira ** 07:44 I love that you use the word instinct, Michael, I like to use the word intuition.   Michael Hingson ** 07:49 Same concept, yeah, for what I'm talking about here. Yes, it's there, and we just, we don't use it. We, we seem to be taught by others that that's not the way to do things, and it's a problem.   Anna Pereira ** 08:08 I'm laughing so hard right now, authentically, laughing at what you're saying honestly, and people are now. And then you learn. You go through life, and then you learn like I should have listened to my gut. I should have listened to what I was being told, you know? And if we, if we do, listen more into that, and we lean into that space, which is what, literally, I'm all about right now, and the people I surround myself, it's like listening to that, tuning into your heart, tuning into your gut, and quieting the mind, because the mind is really great after you've come to some sort of decision to help you balance that decision. But if you go to your strictly to your mind, well, that just that just gets all up in the way.   Michael Hingson ** 08:54 Of course, it's really going to part of your mind, because the other part of your mind is really your gut that we don't tend to listen to nearly as much as we should agree. How long ago did you leave college? When did you leave?   Anna Pereira ** 09:06 Oh, my goodness, it was, it was quick. It was basically, I went to county college. So I went for like, three semesters or something. I was probably around, like, 19 or 20.   Michael Hingson ** 09:18 Okay, well, I was wondering how, like, how long, so, how long have you been in the workforce? Then,   Anna Pereira ** 09:23 oh, I've been in the workforce since I was 12 years old, if you want to talk about workforce, okay, no, I got it. I got a part time job after school, and then I was working three jobs when I was 19, so I can get my own apartment. So I joined the workforce like early on, and had always worked, and even when I was in college, I was working two jobs along with being in college. So it just kind of my ethic. And honestly, again, from the immigrant perspective, you work hard, you stay out of trouble, and then. You know you'll have an okay life. And so   Michael Hingson ** 10:03 often, even on this podcast, I hear people who talk about being immigrants directly, or first generation with parents who were immigrants, who say that very same thing and who follow that work ethic, and it serves them so well.   Anna Pereira ** 10:22 There's, there's lots of great things to take away from that. I will say, like when I'm dedicated, I'm committed. You know, there's a lot to be said for a lot of the benefits, as they have seen, have benefited them. But I also see how it creates a lot of shortcomings in your life, and I'm trying to reverse some of that, those patterns and that thinking and those beliefs, those false beliefs, as I've gotten older, because that they really don't serve. Not, not every single thing from that point of view, serves   Michael Hingson ** 11:02 no but it lays a foundation. And then the question is, how you work with and how you evolve? Yes, yeah, which, which really makes a lot of sense. But so you had, what kind of jobs did you have after you left college? Then,   Anna Pereira ** 11:17 oh goodness, well, I've done everything from retail to undercover security, to office, to head of a $15 million division for a pet products company. I've had my own businesses. I've had my own clothing lines, I've had jewelry collections. I I've been an entrepreneur, and I still am, and so it's kind of a hodgepodge, and I've taken away from every single experience, a very big learning experience, from the people that I worked with to the jobs that I've held to you know, even when I talk now, I know, for example, when I design product for a pet products company, I know that there's a certain footprint that a department store or a spec or a store, you have to stay within that footprint when you're designing the packaging, because if you design the packaging outside of that footprint, they're not going to bring the product in it. The profit margin is not there to that makes sense to occupy that footprint, right? So there's, there's so many things that I've learned along the way that I bring into my now. But, yeah, I've hold, I've held, like, various, various job. Telemarketer, like, you name it, almost, I've done it. I've done it. Michael, well,   Michael Hingson ** 12:34 let's, let's get real. You live in New Jersey. Bada, bing, bada, boom. Did you ever work with Tony Soprano? Just checking.   Anna Pereira ** 12:42 I did not, you know, just yesterday, where we headed out to Connecticut, and one of the one of the rest stops are named James Gandolfini, rest stops.   12:50 Oh,   Anna Pereira ** 12:51 I was like, That's so nice, yeah. Well,   Michael Hingson ** 12:52 what? I actually have a funny story when we were building our house. Well, we built our house, and the builder was a gentleman and his sons, Joe scalzidonna, and his partner was the financier for the for the group, and his name was Joe Pinto. And they Joe, especially Pinto, I guess, made his money ready. Here it comes in the garbage business. And it means all that that implies. But, you know, they were very nice to us. All of them were, were really great to us and helped us a lot. They they were very concerned about making sure everything that could be done to make the house accessible for Karen was done. And did some some really great things, and had some really creative contributions over the things that we included in the design. So it was wonderful to work with all of them. But, you know, it's an interesting it's, I like New Jersey. We had a lot of fun there. We would go into New York many weekends and go to the theater or just walk around, and so it was a lot of fun. But Karen was a native Californian and always wanted to get back to California. So after September 11, we did move back here, but it's always good to keep in touch.   Anna Pereira ** 14:14 Yeah, I do love it here. I couldn't give up my home when I married my husband back in 2009 um, it was we were here. But then my husband had to leave and go out of the country, back to Portugal to for an opportunity that he had, that he couldn't, that he couldn't refuse,   Michael Hingson ** 14:33 couldn't refuse one of those, huh?   Anna Pereira ** 14:37 But in a good way. And you know, then there was the, this is where it led to me living between two two countries. But I literally, there was no way I could go in my home in New Jersey. I'm sorry. I am a Jersey girl at heart.   Michael Hingson ** 14:49 There you go. Do you guys ever commute back to Portugal now?   Anna Pereira ** 14:53 Oh, yeah, we live between the two and also our global citizens. Like I just got back from San Paolo on I. Friday morning? Yeah, we, I've traveled this so this year, so far, we've been to San Paolo three times, Rio to London to Dubai to Oh, Argentina is   Michael Hingson ** 15:14 all of that for work?   Anna Pereira ** 15:16 Yes, well, both, because both of us are both business owners, entrepreneurs, networking is a big part of our success. So it's work related, not you know more, more with networking and showing up for different things. I came actually here from Portugal to attend an event as a as a facilitator of a master class for wellness. So I was actually in Portugal when I got called back here to come back to New Jersey, so and so. There is no rhyme or reason or where we go, or what when we go, unless it is provoked by a business opportunity or meeting.   Michael Hingson ** 15:58 What kind of work does he do? So   Anna Pereira ** 16:01 my husband is a very interesting person. He is actually a specialist in the sports world. He had played, yeah, he had played professional football in Portugal, which we call soccer. We call soccer Yes. And from that, it kind of ushered him into this amazing career. He used to be a professional goalie. He went from that to sports agent to advisor to sports team owners restructuring teams, to overseeing the whole workings of teams and helping helping an owner to being part of a fund and being owner of teams, as well as intermediate intermediating different deals and negotiations between partners and just all kinds of things he is. He is a sports expert. He's actually been asked last week to be part of a book that has nothing to do with sports. It's about, I think it's a mathematician or an economist that is a professor over at the college in Portugal has asked him to contribute to the book based on his expertise of sports management. So he's kind of like I want to say, and you and I will understand the terminology. He's a businessman in the sports world so   Michael Hingson ** 17:26 well, that's pretty cool. So does he own a team? Yes.   Anna Pereira ** 17:30 So we are in and out of ownership, depending on when you speak with us. Their their group buys and sells teams. They go in, they restructure, they make sure that the team becomes, you know, better than they were, and they create a great investment out of the the team that they're invested in based on, you know, recruiting great, great talent, selling those, selling the players for transfers much more than what they paid, things like that. So right now, we're in between, but something is coming very soon, and I'll let you know when that happens. When it happens. Keeps   Michael Hingson ** 18:06 you busy. Has he ever thought of or ever explored? This is an off the wall question. But what the heck creating any kind of level of accessibility in soccer, either for like people in wheelchairs or people who are blind, because there are people. I don't know about soccer, but I know that, for example, there are blind people who are well, there are blind golfers. I know a couple of blind people who is children in high school actually played baseball, and they have a clever way to do it. And it was and it was competitive. They were parts of regular teams, and of course, there's, you know, other things like basketball. But I'm just wondering, has he ever considered that, or has that ever come up? I   Anna Pereira ** 18:49 love that you brought this up. First of all, Michael, because this was actually just part of a larger conversation of the conference that I came back for. So my husband's wheelhouse is not in that area. However, you can imagine the amount of detail that goes into the inner workings or structure of an organization for the employees and the structure of a sports organization, down to the individual athletes and then to all of the experiences for everyone who's engaged, every stakeholder, every fan, and so I don't know how much he's ever been involved in those particular conversations before, but I will tell you what was so interesting last week, the organization Sega Sports integrity, global alliance is the organization that is addressing this. And last week we had the master class, sorry, a week and a half ago, there was the master class that I was part of, and the next day were panels, and one of the panels really addressed diversity and inclusion. And the the whole event was, was. Focused on female leadership in sport to bring in more women into the leadership. Their goal is to have 30% of the leadership to be women in sport, professional sport, all of it. So they their big focus, because their founder was part of the soccer world, Emmanuel, but they focus on all the other areas of sport, and so they had offensive champion on the panel. They had someone representing golf, someone there representing chess. They had someone representing all of these different areas, basketball, volleyball, from all these different areas of sport and the the Special Olympics and the Olympics were discussed, and there was a speaker there in a wheelchair, and we, they actually addressed this at this conference specifically. So it is a big conversation. It is a big topic. But to answer your question specifically about my my husband, my husband, I don't know how much he's been into that conversation, specifically.   Michael Hingson ** 21:06 Well, it's interesting. I remember this year when the LA Marathon was run, the first winner was the person from well, the wheelchair category. And I learned last year or the year before, in talking to somebody on the podcast that in reality, oftentimes people in chairs will actually complete a marathon course significantly faster than regular runners because they they get those chairs moving. But of course, it does mean that they have the athletic prowess to do it. And equating competitiveness is, of course, a different story. I suppose that ought to be explored. But the fact of the matter is that oftentimes, wheelchairs will will go through the whole 26.3 miles, or whatever, faster than a person just running with their legs. Now, at the same time, I know a woman who is blind who was an international rower. So rowing is not something that requires any real mate, well, any adaptations to work. But she could never be on an Olympic team. She could only be on a Special Olympic team because she was blind, even though what she did and what rowers did certainly could be done whether you're blind or sighted. So you know my my opinion is what we really should do is require that all sports be played totally in the dark, without any lights, and then we'll see who wins.   Anna Pereira ** 22:49 That is, that's an interesting approach. That's an interesting approach.   Michael Hingson ** 22:52 I worked for a company once, and when my wife also worked for the company, and she was in charge of Doc document control for the company. And one of the things I said is, if you really want to have true document control, because some of the people in the company, including the President, would oftentimes go in and steal the gold copy or the master copy of something, and send it out, rather than making a duplicate, which is a no no. But they did it anyway. And I said, well, then to have doc control, just put everything in Braille and then see what they do. But, you know, good doc control. But so it was just an interesting question, and it is a topic that is more and more part of the discussion, the whole issue of having some level of access for people who are who have other disabilities. And I say that because my opinion is, of course, that every person has a disability. Yours is your light dependent. You know, if the lights go out, you're in a world of hurt, although I'm not. And you know, Thomas Edison and the invention of the electric light bulb mainly fixed that it covers up the disability, but it's still there, but it's but it is true that we are at least discussing it more than we used to. And if we take that discussion further and make something happen with it, that will be a good thing, but it is a an interesting thing that we we end up having to face from time to time.   Anna Pereira ** 24:23 Well, I'll tell you what the individual that I was just speaking about that was part of that panel would probably be interesting for you to have a conversation with. If this is something that you're passionate, have a conversation with Michael. Her name is Karen Korb, K, A, R, I N, K, O, R, B and she she was the one that was speaking on that panel, specifically, and and she was in a wheelchair, so that is really something that she would love to dive into. I'd   Michael Hingson ** 24:50 love to chat with her. If you have a way to help us get an introduction, that would be cool. We'd love to have her on the podcast.   Anna Pereira ** 24:56 Absolutely, she's a divine in. Visual. And   Michael Hingson ** 25:01 of course, as I as I tell people often on this podcast, anyone who has an idea for a guest, we're always looking for, for more people to have so love to meet folks. It's fun.   25:12 Absolutely well, so   Michael Hingson ** 25:14 you wrote a book, 25 tools for happiness, one of four, I believe. And you talk in there about the fact that you manifested your husband. That's an interesting topic. Tell me about that, if you would.   Anna Pereira ** 25:27 Yes. Oh, Michael, this is one of my favorite stories. Thank you. Thank you. Thank you for the opportunity. Any chance, any chance I get. To number one, talk about my husband. Number two, encourage hope in someone who is of, you know, a middle age and still single. Is, is just, it's just a joy for me so and just, I just wanted to correct that. I didn't write the book. I authored book because I had, and this is why I want to, I want to really make note of this. I had 24 other 25 amazing authors contribute to this book. The diversity of stories in that that particular book is really, really, really amazing. So, God, where do I start? And it happened here, in the hat, in the home in union, New Jersey. And a lot of going back to what we were talking about earlier, about what structured my belief system about myself from my childhood and growing up, and how it manifested through my life, and the type of self love, self awareness, belief system I had from growing up really impacted my general happiness. So one of the things that at this point in my life, I just really wanted to settle down with someone that that I was going to build a life with. And in that introduction to the 25 tool this, it's the wellness universe guide to complete self care. 25 tools for happiness. Book my introduction specifically shares my secret sauce of how my life has literally turned into well, I mean, nobody has a fairy tale. Even a fairy tale has its challenges, right? But of as much of a fairy tale as possible, humanly possible on this earth, one day for no reason at all, and I this is why I believe that we all are connected to the Divine and have this channel, this guidance. I wish I just I was at the second floor of my house. I was at the top of my stairs, and it just hit me like because I had just gone through some really traumatizing experiences with somebody that I was getting involved in business with, and she was it just, was just terrible, terrible experience, one of the worst in my life taught me a lot of things. And for some reason, just that day, I was like, and I was raised Catholic. I don't really go to church. I don't like, I don't believe in strict religious rules, but I believe in my spirituality and who exists on the other side watching over me. I think that they are so I was at the top of my stairs, and I was like, Dear God, universe. You know Mary, Jesus, you know Joseph, Saint Rita, whoever's watching over me, I'm like, please just let me, allow me to release judgment of myself, judgment on others, and what I believed others are going to judge me on. And please just bring me someone that's going to allow me to live my happiness and make beautiful babies with and that's what I asked for. And all of a sudden, just by voicing that out, I release so much off of myself, but hearing myself say those words allowed me to have hope and believe in this and hang on to it and cling on to it. And I did. And nine months later, on october 26 I went out on my first date with with my now husband, but I didn't know it at a time. So october 26 was our first date. And on December 23 2009 we were married, and we've now been married 14 years. If, if I met, my math is correct and and that is, I believe, how I manifested, you know, my husband, because of making sure I voiced it, I committed to that I owned it. And then i i Every day, I reminded myself of what I really wanted, and because for me, happiness, it's not it's not what you're experiencing now, you don't really even know what happiness is until you're experiencing so I can't say I want this for the rest of my life, because you don't know if that's exactly what you will want tomorrow, it can make you very miserable tomorrow. Or whatever's making you happy today, like I might not want to go on a roller coaster tomorrow. You know what I mean, and I liked it when I was 14 or 15, so leaving it open to please just allow me to live my happiness was a very strong statement and resonated with me because I was aware enough to know that there was so much undiscovered territory in the world that I would not know what happiness was until I was there and and now here I am living around the world, experiencing all of these new experiences globally, traveling everywhere that I would have never known existed if I had boxed myself into one scenario or one expectation, or what I thought I would be happy, happiness for me, at least at that time, having the wherewithal to say, just allow me to live my happiness and make beautiful babies with and then beautiful babies was just more of a metaphor of Like, bring me someone who's attractive, who I'll be attracted to, who's and that we can create things together that would be beautiful. And I believe that we're doing that through his work, through my work, and through what we're doing on this earth, and our relationships with our friends and family. I think we're creating beautiful things.   Michael Hingson ** 31:18 So do you have children? No, we   Anna Pereira ** 31:21 have not had children and when the window is closed, but we do, we do talk about adoption when things get a little bit more settled, things are a little crazy with all the travel and the work. But no, we ended up not have being able to have children, not because of, you know, physiological reasons, but because of just timing and travel and time passed. I was 36 when, when we met. So,   Michael Hingson ** 31:48 yeah, well, and so, you know the for us when I met Karen, it was in January of 1982 and so I was basically 32 and she was almost 33 and we I always thought there had to be somebody who would be right for me, and I would know it when we met and when I met Karen, and it was a friend who introduced us, we started talking, and when we hit it off. So it was just great conversations. Great great interacting together. And over six months, we we talked some, and then, well, actually, seven months, and then at the end of July of 1982 we were in a car in Santa Ana, and I asked her to marry me, and she said yes, and we have said ever since we were old enough and mature enough to know what we wanted in a person who we would spend the rest of our life with and as I said, it is we. We were together 40 years, and I'm sure that she's still up there monitoring me, so I will behave but, but you know, it, it was just something that took it was the right thing to do, and she was definitely the right person. We had conversations about children and decided she was in a chair and didn't want to really go through a lot of the physical things, because she said if she had to be pregnant, she'd probably be bedridden for a lot of it, and she didn't want to do that. So we made the decision together that we would spoil nieces and nephews, because the advantage of that is that we could kick him out at the end of the day and shoot him home and do and did. So it worked out pretty well. But I know exactly what you're saying, and you know it when the right person comes along, if you really look at it and think about it, and again, it's like most things, all too often, we don't think about the right kinds of things, or we don't think about stuff enough, and that can be a challenge. Or in our case, it wasn't because we thought about it enough and it worked.   Anna Pereira ** 34:15 I love that. Thank you for sharing that.   Michael Hingson ** 34:18 So it is that's cool. And you know, you you guys will will figure out what you're going to do. And adopting. There's a podcast episode that we did with someone now, almost two years ago, and he and his wife adopted two daughters from China when they were over 40, because she wanted to adopt a child from China. And there were stories behind it, but they adopted, and now the children are, I think, like 22 and 25 or 23 and 25 or so, and he's written a book about their adopted. Option journey. But again, the the issue is that you never know where life's going to take you. And they never thought about adopting a Chinese girl, or he didn't his wife did for for various reasons, but they both became part of the journey, and it was, and it still is, a great adventure for them.   Anna Pereira ** 35:21 That's wonderful. So gives us hope.   Michael Hingson ** 35:24 Yeah, a lot of a lot of kids need adopting too. Yeah, so you went to Portugal and for the first time, and by the way, have you learned Portuguese? Let   Anna Pereira ** 35:40 me just put it this way, my Portuguese is as good as my singing. You don't want me to hear you want to hear me do either unless I am. It's absolutely necessary so,   Michael Hingson ** 35:55 and I assuming people in Portugal have probably affirmed that in some way, so I won't dig any deeper. Yes, but you, while you were there or somehow involving Portugal, you decided to form this thing called the wellness universe. Tell us about that.   Anna Pereira ** 36:15 Oh, thanks. Yeah. So I was over in Portugal, and I really didn't have much to do. I started a jewelry collection and a Facebook page to kind of get, you know, get the word out about the jewelry collection, but much more my my approach was to just share who I was and inspirational messages, because that's kind of what lent to the jewelry collection. They were called circles of inspiration, and they had, you know, words of inspiration and colors that attracted certain things to you. And so my facebook page actually really became the outlet for my inspirational memes and quotes and things like that, just where I shared and I grew a great community organically. You know, I started in 2011 and I kind of quickly grew to about 300,000 Facebook followers. And from there, I was very much networked with a lot of inspirational people, whether they were life coaches or spiritual coaches or counselors or speakers or authors or therapists, they all had something to do with being inspiring or motivating in some way shape or form a group of my followers And so we were networking and sharing each other's inspirational posts, you know, the memes, things like that. And then I was sitting at my kitchen table again, when you're hit with these moments of inspiration, when you go quiet and you listen, you know, it's amazing what messages you receive. And I was sitting on my kitchen table in Portugal in 2013 September 2013 and something told me, you know, there needs to be a place where people who are changing the world need to come as a community, and you're the one to build it. And I was like, Okay, not too big of an ask. I'm like, All right, so I kind of held to myself for a couple of months, and then I went out to one of my friends, Teresa. She ran this, this page called on the road to me, I believe it was, and I told her first, and I got her input, because she was very wise and she was a good friend, and she's like, Oh my gosh, it sounds like such a great idea. And I said, okay, so Well, since that was the cat was let out of the bag, I'm gonna move forward with this. I went to my husband, I said, Look at this, what I'm thinking of doing. Are you behind me on this? Because basically, when I moved to Portugal, he was like, you don't have to work. You don't have to do anything. You just, you know, you just hang out and you do what you want to do. And I was like, Okay, well, I can't not work. I mean, I have an entrepreneurial spirit. I cannot not work. So aside from the the the jewelry collection, which was slow, I mean, the the it was a slow business, so the inspirational side of me really took over. And this building, the wellness universe, was the next project on my agenda. And through 2014 we started growing a Facebook group of practitioners and people who and hobbyist as well. And then in 2015 we launched the first version of the platform, and it was, you know, self funded, membership supported. And so from 2015 january 2015 we've been growing the wellness universe every year. And now it's a basically, it's a directory of practitioners, wellness practitioners, and people who are making the work. A better place. So anyone go and find them through the wellness universe.com but we also have amazing classes and courses. The practitioners who are part of membership are able to host their classes and courses on our platform, the lounge, the wellness universe lounge. But also we work in partnership with those that we know, love and trust to help them also amplify their message through a program, what we call wellness for all and wellness for all programs on the platform are all free to join in donations supported by people who are seeking those courses and classes. And we have a blog, and like you mentioned, we have the books, the four books that we've published with over 65 people that we've created into best selling authors, because some of them have repeated through some of the books. So that's why it's not 100 authors, 25 chapters per book with 25 different authors. And now we've launched wellness universe corporate, and so we are actually delivering wellness solutions through a company culture lens of analyzing, going in and assessing an organization on what their needs are and their culture, through their culture, and then bringing in wellness components to shore up those gaps, while we have the buy in from the leadership, letting everyone know, hey, based on, you know, the assessment the organization, this is what you need, and we're bringing this in. So that's kind of like the very condensed version of the wellness universe, and wellness universe corporate division. And I'm really, really honored and blessed to have worked with some of the most transformational people in the world, like our friend Sharon, and bringing wellness to to places that it may have not been before, and bringing the conversation to stages and and rooms and boardrooms and classrooms and retreats and things like that that may not have experienced it before, which is really, that really, I find is the most fun when I when I bring something to someone and they never heard of it before, like EFT or muscle testing or, you know, you know, you know, you know, trauma informed, you know, sessions, stress management sessions, you Know, Like, what like that really has been so rewarding when people at the end of the day are like, you know, I learned from you last week, or what I read or whatever, or the person that you brought to me or to my organization, and it truly has transformed my life. I found, I found. I just got a story the other day from a woman who read our books, and from reading the stress relief book, she's like, you know, after reading this book, I had, I found the self love to go and get a surgery on my foot that I've been putting off because I feel I was worth the investment of the surgery to relieve myself of this pain. But then I did it after reading your book, and I was like, I literally was in tears. And of course, Michael, as you know, as an author, how often do we actually hear those stories that are so rewarding from the people you know? How do you feel about that? By the way, let me ask you questions. I know that. I know that you're interviewing me, but   Michael Hingson ** 43:20 how it's a conversation. It's fair.   Anna Pereira ** 43:23 Thank you. How great is it when somebody comes back to you and says, Your story has changed my life?   Michael Hingson ** 43:33 Well, let me tell you one of my stories. So the answer is great, of course, but I also know that I can't let that kind of thing go to my head. But let me tell you one of my favorite stories. I've talked about it a couple times here. In 2003 I was asked to go to New Zealand, so as basically a year, and it was about 1516, months, no, 14 months after September 11, and 16 months, I guess. And anyway, I was asked to go and help to raise some funds for the Royal New Zealand foundation of the blind by speaking. And they paid me to come over. And before I had had come over in, actually, early 2002 a gentleman from New Zealand called he said his name was Paul Holmes, and he wanted to interview me. Well, he came, what I learned was to to do an equivalent sort of thing. He is, what you would say would be the Larry King of New Zealand, so very famous and all that. Well, anyway, he came and we chatted and all that. And he said, If you ever get to New Zealand, I want to interview you first before you go anywhere else and talk to anybody else. And I said, Okay, had no idea that anything was going to happen about going to New Zealand. But then the next year. Early in 2003 I was invited, and we set up the trip to go over in early May. So needless to say, being a loyal kind of guy, I emailed Paul Holmes and said, hey, guess what, we're coming over. So we got there on a Wednesday, and he had arranged for the interview to be done that night, New Zealand time at seven o'clock. So we went and did the interview, and the Royal New Zealand Foundation had me traveling all over New Zealand for basically 16 or 17 days. We did 21 different stops, both by flying and by car and all that, in 16 or 17 days. But anyway, so we did the interview and a week and a half later. So it was the second Sunday I was in New Zealand. Now we were on the South Island. We had landed originally on the North Island. Now we're on the South Island. And I was speaking to a group of blind people, and I they wanted to know all about the World Trade Center and all that. And I told them, and then one of them said, we have to tell you a story. And his story went on something like this yesterday. That would have been a Saturday. We took a river rafting trip, and the foundation set it up. These are all clients from the foundation, and said they set it up, and the guy who was in charge of the trip took us out, and we all had a great time. It was wonderful. But at the end, he said, I have to be honest with you guys, I was about to cancel this trip. And I said, why? Or No, I didn't say, I mean, they said, why? And he said, well, because he said I didn't think that blind people could do this. He said I was just all afraid that the next thing that was going to happen by the end of the trip is at least one person was going to fall overboard and drown. But he said, I happened to be watching the telly the other night, and I saw Paul Holmes interview this blind bloke from the United States who was in the World Trade Center. And he said, if he could get out of the World Trade Center, the least I could do was have an open mind about you guys going on this trip. And he said, it has been the best trip I have ever had. Wow. So, you know, I, of course, there was a lot of pride. I love the story, and I know I've taken a fair amount of time to tell the story, but the point is, you never know what seeds you're going to plant. And the bottom line is that my goal in speaking has always been if I can help even one person learn something and inspire one person. I've already done my job. And more important, I've decided a long time ago, if I could help people move on from September 11, and I've done my job, but what a what a great story. And yeah, it has inspired me a lot, and it's one of the stories that continues to propel me forward, knowing that if I can help people and get them to understand about being blind a little bit more and and accepting of people who are different than they then, then it's working out really well. Michael,   Anna Pereira ** 48:22 I am so glad that you shared that story with me, and that is really that speaks the truth and the power of showing up and sharing who you are and impacting someone where they impact the many. Wow. Can you imagine if that guide had called off that trip and didn't give the opportunity, sure people, I'm sure, I'm sure, probably many was their first time. I don't even think river rafting. Oh my gosh, that's great. Thank you for sharing that.   Michael Hingson ** 48:55 It was great. I haven't either. I've been on boats, I've been on cruises, but I haven't gone river rafting, so it's something to do someday. Yeah, well, let me ask you this. You know you talked earlier, especially about your husband and in relationships and networking and so on, networking is certainly a very important thing. So relationships are really essential to having success. Tell me what you think about the whole idea and the intersection of having a relationship and building relationships, especially authentic relationships and success.   Anna Pereira ** 49:37 Michael, I've been talking a lot about this lately. To be honest with you. We were even talking about this last night, the new company that we're forming, we're actually putting together a very strategic team on the back side, and some of those people are new in my world. And one of the people happened to be this gentleman that was introduced to me by my partner. And. Founder of the wellness universe Corp. And his name is Jack, and I've met him online, virtually, you know, on Zoom calls, over several calls, I'm very confident, very comfortable with him. And I really, I really admire him and the work he's done in his life and what he's achieved. So he's already proven that he has been able to create successful businesses, manage successful businesses, exit successful businesses, and things of this nature. So none of that was was was why I wanted to meet with him, but I found out that he was because he lives kind of in the middle of the middle of the country, lives in Milwaukee, so he was coming out to New York and to Connecticut, actually, to for his current company that he's at, to be a part of a conference. And so with that, I'm like, Oh, you're coming out here, Hugo and I are going to be home. I want to come out. I want to meet with you. And what's interesting is he disclosed to me last night that I'm not going to use the words he says, But he said, like when I asked him to meet up in person, you know, he gets off the call with me, and he turns his wave. He's like, you know, what is Anna? Want to bleep and beat me for? And it was so funny to hear him say that last night, because for me, it's about making that authentic connection and meeting someone in person, if I have the opportunity to which I do and investing, knowing that you're investing in a bigger, a bigger project, building a company together, you know, it's, it's not transactional, it's about, it's about a bigger thing and and so I couldn't understand why he felt that when he when he said this To me last night. But then he said, I understand now, like, and I get it like, I get that. I get who you are, and I see who you are, and I see that you just wanted to just meet up, just to see who you know who I am, and for me to see who you are. I said, That's it, Jack. Because his immediate response, as you know, a man who's white in the business world. He felt that probably I was Troy. I wanted to kind of, quote, unquote, interview him in person after all of these months of working with him, you know, remotely, with alongside with him, on through us, building this new team together. But for me, it was all about beginning the foundation to nurturing a relationship that we've had many meetings, many strategy sessions, many of the do, do do phone calls and the what's what phone calls. But I wanted to sit down with this gentleman and have a break bread with him, see what he's about, him to see what I'm about, what my husband's about, and I truly believe, and I say this over and over and over again, and quite unfortunately, because of my position as the founder of the wellness universe, people see the wellness universe as a bright, shiny object. They see me as somebody in a place of power that I can just give stuff out or help them, give them a hand up, but it's it's not always that. It's still the same thing. Relationships need to be nurtured. I need to get to know someone if they're going to represent the brand of the wellness universe and work with us through wellness universe corporate, for example, or they're going to be a member, I have to see who they are in action that's helping me to nurture the relationship so I can work with them and bring opportunity to them, as well as you saw, Michael, as soon as I am completely networking relationship minded, I am all about giving opportunity and sharing the spotlight and giving the microphone over to people who are talented, just as you said before. It reminded me of Karen Korb, you know, I would love to introduce you to her, for her to be a guest because of a specific topic that was struck up while we were having conversation. This is just who I am. I do believe that networking has a bad name. And if you believe in the networking, like from the early days, and it's just about exchanging business cards, which of course, nobody even has anymore, but I mean, you know what I mean, I have one too, by the way. But if you just think it's about showing up and shaking as many hands as possible, and then, like just vomiting all over somebody what you do and how great you are at it, you're never going to get far in business these days, it's about building, nurturing those relationships and sharing and listening to what someone needs and sharing with them whether you're a resource for that need or not, and chances are 99% of the time, you're really not. But by giving them something that they need, they're going to remember you, and you've just created yourself as a value in their life. So by creating yourself as a value in their. Life, you're still nurturing the relationship. It may not have created a business transaction in the moment, but guess what? You're starting to nurture a relationship that will lead to business growth, that will lead to personal growth. I like to approach things that like you said before, if you don't, it was, well, you didn't say this, but it was part of the conversation, in a way, I think was before we started. You know, if I don't like the person, why would I want to do business with them? And I look at every, every person that I come into contact with, like, do I like this human? Am I trying to show up as my best self for them to like me as a human? And then we'll see where the chips fall around that, yeah, and that. That's kind of my whole philosophy around networking and building relationships.   Michael Hingson ** 55:44 Well, you know, one of the things that I encounter a lot when I'm talking to people about coming on the podcast is, well, I don't, I don't see why I would be an interesting guest. Why do you want me to have Why do you want to have me as a guest on the podcast? I don't have anything in the way of a famous story or anything to tell. And I, I love to tell people, Look, everyone has stories to tell. And the fact is that if you're willing to come on and talk about things and and as you know, I really want to cover the topics that you as a as a person, coming on as a guest, want to talk about, but we do have a conversation, and I do like to encourage everyone to come and tell stories, because I've yet to find people who don't have a story to tell, and I believe everyone does. Everyone's adventures in life is a little bit different than everyone else's, which makes the telling of the story worthwhile.   Anna Pereira ** 56:47 Agreed? Oh, agreed.   Michael Hingson ** 56:51 So with the wellness universe, Corp and so on. Tell me a little bit more, if you would, about wellness and how that plays into company culture,   Anna Pereira ** 57:05 absolutely well. I want to thank you for that. I mean, a few years ago, somebody else was because I was in the throes of my initial co founder, exiting the company and pivoting in some great way, and I didn't know really what was going to be. And at the same time, someone approached me, they wanted to create, you know, corporate wellness solution with me, and that started and fizzled out. And then I brought on somebody else that was going to do that with me. And then that started up and fizzled out. So over the past several years, I've been looking for the proper strategic partner that created a holistic approach to the well being of an organization so we can really create impact. Because all of these years, I've been building the community. I quite honestly, have had 1000s of members come through the wellness universe. Right now, we have a little over 100 and something, enrolled members, active members, people who have a membership and pay a membership and have a public platform through the wellness universe that we work with. But there's been 1000s that have come through. And I really wanted to find a way to work with the people I know trust and love, because they have something, something so great to offer the world. And it wasn't just about creating a wellness app or just the wellness component. There had to be something else that we can sink our teeth into. And also allowed an organization to really get behind because what happens is they bring in a wellness app because it's nice to have, and I'm doing air quotes right now, it's nice to have a wellness app, and then the truth behind it is, for a wellness app, the success rate is to have, you know, 4% is the highest engagement on with a wellness app, and that's their success rate. So nobody really uses that. They the wellness apps, and nor do I find it like a sustainable or something that's part of the person to go to through, through their you know, through their work. But if you go into an organization and you do an assessment around what's going on in the company, and you have that buy in from leadership, because they can see exactly where the breakdowns are and where the successes are. And then you bring in the solutions to reinforce the successes and also shore up where they have the challenges, and then you bring in wellness as a component for for the retention of the employee, for the happiness and health of the employees as individuals, then you have an ecosystem that creates success for the entire organization. And. Coming back down to the individual. So it's really important to find this way to holistically serve and it's a delicate balance, because sometimes it's going to create disruption and the changes that need to be implemented, but you have to have buy in from the leadership, and you have to show them this is exactly why you need it, and that's why the company culture, and addressing that through the assessment that we have is really essential to bringing in the different solutions we have, from the corporate trainings and things like that, to the wellness experience, the wellness experiences and stress management type of classes and courses and things. So for me, it was an evolution and a learning curve over the last four years. I think it took for me to find the proper partner, Alex Bowdoin and people first is her company, and that's where she comes from as a HR consultant, expert, and coming together with the wellness universe, and knowing what I know in the people experience, along with the evaluating the practitioners for what they do and how they serve to give a great experience to a wellness seeker, and then merging the two worlds together with the technology and the platforms and the solutions that we bring so then, that way, it's a really in depth, and I want to say all encompassing solution for an organization, for everyone to walk away, go home and feel good at the end of the day, and come back to work more and be more productive and happy in what they do, and know that they are, that they're supported by their organization, for an organization to be proud to bring these solutions to their employees, knowing that they're bringing something that they actually will use,   Michael Hingson ** 1:01:55 and that's really all anyone can ask For. They will do that and make it work. And think about it, they'll be more successful by any standard in the world. I would think   1:02:10 we would hope Yes. So if people want   Michael Hingson ** 1:02:12 to reach out to you and learn more about wellness universe and maybe contact you and become a part of it, how do they do that? Sure, so   Anna Pereira ** 1:02:21 my email is so simple. It's Anna a n, n, a at the Wellness universe, typical spellings, the wellness universe.com, they can reach out to me there, or they can go right to the wellness universe, which is the wellness universe.com, and connect with me there, or on any of my social platforms. I spend a lot of time on LinkedIn. I'm very excited to be a top voice in leadership on the platform, and they can connect on LinkedIn as well by searching. Anna Pereira, you'll see me come up. But I think those are probably the best ways to connect with me. There's, you know, there's Facebook and Instagram and things like that, but if you really want to reach me, I check these platforms, my email, and I check my LinkedIn and my wellness universe. Well,   Michael Hingson ** 1:03:12 there you go. Well, I hope people will reach out. This has been fun. It's been exciting, and what a great conversation. I'm glad that we did it and we finally got connected. And thanks, Sharon. Thanks, Sharon, for me, and I hope all of you have enjoyed this as well. So love to hear from you. Love to hear your thoughts. Please feel free to email me. I'm easy to reach. It's Michael M, I, C, H, A, E, L, H, I at accessibe, A, C, C, E, S, S, I, B, e.com, or you can go to our podcast page, www, dot Michael hingson.com/podcast, and Michael Hinkson is m, I, C, H, A, E, L, H, I, N, G, s, o, n, so as I said earlier, love it. If you have any ideas for guests, we really appreciate and value any introductions that you can make. And Anna, we didn't mention it and much, but that's okay. I do. I'm really ramping up speaking again. So if anybody knows of anyone that needs a speaker, love to explore that and and we'll always be glad to talk to people about coming and speaking. If you would please give us a five star rating wherever you're listening to us today, we really value your ratings and your thoughts, and of course, I want to hear your opinion, so please let us know. So thank you once again, everyone for listening. And Anna, specifically for you, thanks again for being here and for being on the podcast. Thank   Anna Pereira ** 1:04:34 you, Michael. I really appreciate the time with you.   Michael Hingson ** 1:04:41 You have been listening to the Unstoppable Mindset podcast. Thanks for dropping by. I hope that you'll join us again next week, and in future weeks for upcoming episodes. To subscribe to our podcast and to learn about upcoming episodes, please visit www dot Michael hingson.com slash podcast. Michael Hingson is spelled m i c h a e l h i n g s o n. While you're on the site., please use the form there to recommend people who we ought to interview in upcoming editions of the show. And also, we ask you and urge you to invite your friends to join us in the future. If you know of any one or any organization needing a speaker for an event, please email me at speaker at Michael hingson.com. I appreciate it very much. To learn more about the concept of blinded by fear, please visit www dot Michael hingson.com forward slash blinded by fear and while you're there, feel free to pick up a copy of my free eBook entitled blinded by fear. The unstoppable mindset podcast is provided by access cast an initiative of accessiBe and is sponsored by accessiBe. Please visit www.accessibe.com . AccessiBe is spelled a c c e s s i b e. There you can learn all about how you can make your website inclusive for all persons with disabilities and how you can help make the internet fully inclusive by 2025. Thanks again for Listening. Please come back and visit us again next week.

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

In the wake of our PRovokeGlobal Summit, Paul Holmes got together with Drew Warren and Rachel Caggiano from Ogilvy to discuss the dominant themes of the event, from the future of purpose in a politicized environment to the impact of AI on newsrooms and PR agencies—as well as Ogilvy's big night at the Global SABRE Awards, where it was crowned Global Creative Agency of the Year

This Sunday was week one in our new series 'the higher road'. Paul Holmes opened up the series talking to us about integrity and how important it is for us to be people who are the same no matter the environment or the situation we find ourselves in. We're called to a higher road.

In this episode of the PRovoke Media podcast, Avoq strategic planning leader Dianne Riddle Mikeska takes a wide-ranging look at how the comms industry, with a particular focus on public affairs, is leveraging data in its decision-making process. The far-reaching conversation with PRovoke Media founder Paul Holmes covers topics from the key role tools and technology play in strategic planning to the importance of maintaining people — by way of polling, focus groups and the like — as a central part of the process.

Please join us Right Now,  September 23, 2024  at 11:00AM PST as  Actress, Singer, Writer, Producer Rose Weaver,  Producer, Director Michael Massey and Percussion Drums Gary Paul Holmes  join host Ron Brewington on "The Actor's Choice."

PRovoke Media founder Paul Holmes sat down with principals from 2024 Agencies of the Year Chandler Chicco, Day One and The Sway Effect to find out what they did last year — in terms of employee culture, agency marketing, and client relationships — to create success in a challenging environment.

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)  

Paul Holmes is joined by Alison Dasilva and Penny Kozakos from Zeno Group to discuss what stakeholders expect from corporations when it comes to controversial issues—and how new research can help companies address those expectations smartly in an era of increasing political polarization.

Paul Holmes brought the second instalment of our series 'PAYING ATTENTION' looking at the importance of spiritual disciplines in the midst of our modern & busy lives. A challenging yet encouraging message!

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. 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  

In this edition of the PRovoke Media podcast, Paul Holmes is joined by GCI Health global CEO Kristin Cahill and Europe and Middle East president Kath Harrison, along with Aimee Christian, VP and global head of corporate communications and engagement at Jazz Pharmaceuticals, to talk about the success factors for modern global healthcare campaigns. The discussion includes how to translate campaigns from one country to another, drawing a thread through global strategy to local implementation while taking cultural and language differences into account and maintaining consistency of the corporate brand. The guests also talk about engaging internal stakeholders, patients, advocacy groups and healthcare providers across markets, and the importance of finding ‘universal human truths' that resonate beyond local nuance.

Paul Holmes aka Black Bourbon Maverick joins the team for the final episode of Season 10 & 'Nem. They talk bottles, the Black Bourbon Run, the Industry, and catch up with one of their day one supporters. Paul was generous enough with a Sample Pack for the team and they work their way through it with guidance from the man himself. This is one you don't want to miss. Stay Black and Keep it Brown. | They will see you in Season 11 | Instagram: @dablackandbrownpodcast @my_government_name_is @agbk06 @delvinj33 @black.bourbon.maverick Twitter: @dablackandbrown YouTube: https://youtube.com/@blackandbrownpodcast2036 Merch: www.dablackandbrown.com --- Support this podcast: https://podcasters.spotify.com/pod/show/dablackandbrownpodcast/support

Marsha Vanwynsberghe grew up in Ontario Canada and still lives there today. I met her a few months ago when I was invited to be a guest on her podcast, Own Your Choices Own Your Life. My team at Amplifyou, located in British Columbia, arranged my appearance and then, as is only fair, I asked them to help get Marsha to join me on Unstoppable Mindset. We had a fabulous conversation discussing everything from why more people don't share their own stories to how we, Marsha and I, learned to tell our own stories and how we help others to grow as they discover more about themselves.   Marsha worked for a company for some 26 years while, as she discovered, learned a lot about coaching. She also faced her own life challenges as she will tell us. In 2020 the company employing her closed its doors. By that time Marsha realized how much coaching of others she already was doing. She started her own coaching program. As I said, she also has been operating her own podcasts which I urge you to find, of course after listening to Unstoppable Mindset.   Marsha shows us the value of learning about facing our own inner selves and learning to tell our own stories. She discusses how many of her clients, through discussing their own experiences, have become more confident and how they have learned to be better persons in their own skins.     About the Guest:   Marsha Vanwynsberghe — Storytelling NLP Trainer, Speaker, Publisher & Author, 2xs Podcaster   Marsha is the 6-time Bestselling Author of “When She Stopped Asking Why”.  She shares her lessons as a parent who dealt with teen substance abuse that tore her family unit apart. Marsha has been published 7xs, most recently with her co-platform, Every Body Holds A Story, and she is on a mission to continue to help women and men to speak, share and publish their stories.  Through her tools, OUTSPOKEN NLP certification, programs, coaching, and podcast, Marsha teaches the power of Radical Responsibility and Owning Your Choices in your own life.  She empowers people how to heal and own their stories, be conscious leaders and build platform businesses that create massive impact.     Ways to connect with Marsha:   Website: https://www.marshavanw.com/ Instagram: https://www.instagram.com/marshavanw/ Facebook:https://www.facebook.com/marsha.vanwynsberghe Linkedin: NLP Trainer, Storytelling Trainer, Speaker, Podcaster, Author - Marsha Vanwynsberghe Coaching | LinkedIn Podcast Link: Own Your Choices Own Your Life https://apple.co/3h2Jcti YouTube: https://bit.ly/3Dmk75q TikTok: https://www.tiktok.com/@marshavanw     About the Host: Michael Hingson is a New York Times best-selling author, international lecturer, and Chief Vision Officer for accessiBe. Michael, blind since birth, survived the 9/11 attacks with the help of his guide dog Roselle. This story is the subject of his best-selling book, Thunder Dog.   Michael gives over 100 presentations around the world each year speaking to influential groups such as Exxon Mobile, AT&T, Federal Express, Scripps College, Rutgers University, Children's Hospital, and the American Red Cross just to name a few. He is Ambassador for the National Braille Literacy Campaign for the National Federation of the Blind and also serves as Ambassador for the American Humane Association's 2012 Hero Dog Awards.   https://michaelhingson.com https://www.facebook.com/michael.hingson.author.speaker/ https://twitter.com/mhingson https://www.youtube.com/user/mhingson https://www.linkedin.com/in/michaelhingson/   accessiBe Links https://accessibe.com/ https://www.youtube.com/c/accessiBe https://www.linkedin.com/company/accessibe/mycompany/ https://www.facebook.com/accessibe/       Thanks for listening! Thanks so much for listening to our podcast! If you enjoyed this episode and think that others could benefit from listening, please share it using the social media buttons on this page. Do you have some feedback or questions about this episode? Leave a comment in the section below!   Subscribe to the podcast If you would like to get automatic updates of new podcast episodes, you can subscribe to the podcast on Apple Podcasts or Stitcher. You can also subscribe in your favorite podcast app.   Leave us an Apple Podcasts review Ratings and reviews from our listeners are extremely valuable to us and greatly appreciated. They help our podcast rank higher on Apple Podcasts, which exposes our show to more awesome listeners like you. If you have a minute, please leave an honest review on Apple Podcasts.     Transcription Notes Michael Hingson ** 00:00 Access Cast and accessiBe Initiative presents Unstoppable Mindset. The podcast where inclusion, diversity and the unexpected meet. Hi, I'm Michael Hingson, Chief Vision Officer for accessiBe and the author of the number one New York Times bestselling book, Thunder dog, the story of a blind man, his guide dog and the triumph of trust. Thanks for joining me on my podcast as we explore our own blinding fears of inclusion unacceptance and our resistance to change. We will discover the idea that no matter the situation, or the people we encounter, our own fears, and prejudices often are our strongest barriers to moving forward. The unstoppable mindset podcast is sponsored by accessiBe, that's a c c e s s i  capital B e. Visit www.accessibe.com to learn how you can make your website accessible for persons with disabilities. And to help make the internet fully inclusive by the year 2025. Glad you dropped by we're happy to meet you and to have you here with us.   Michael Hingson ** 01:21 Hi all and welcome to unstoppable mindset where inclusion diversity in the unexpected meet and who knows what else? Oh, that's the unexpected part. Sorry. Anyway, we're really glad you're here. And today, we get to have the opportunity to chat with a person who is a storytelling NLP trainer, a best selling author, a speaker, and a 2x s podcaster, among other things. And on top of that, she's very open about telling stories, which is great. I love people who want to tell stories. I've been in sales for a long time, and I learned that the best salespeople know how to tell good, true stories. That's another story, but we won't worry about it right now. But anyway, I'd like you all to meet Marsha Vanwynsberghe. My screen reader pronounced van winchburgh. But she was impressed by that it was pretty close. But it's van Weinsberg. And Marcia, welcome to unstoppable mindset.   Marsha Vanwynsberghe ** 02:17 Thank you so much for having me, Michael, I'm thrilled to be here. Well, it's   Michael Hingson ** 02:21 an honor to have you and I was on marshes podcast on your choice on your life. And that was a lot of fun. And I told her that the price for me being on was that she had to come on unstoppable mindset. And she was willing. So here we are,   Marsha Vanwynsberghe ** 02:36 well, I jumped at the invitation I just jumped   Michael Hingson ** 02:40 Well, it's fun, and it's great to share. And it's it's great to get to know people and and get to know them even more when we get to do it the other way. And hopefully we'll do more things together as well. And love that. I would absolutely love that. Well tell us a little bit about kind of the early Marsha growing up and all that sort of stuff. It's always a great place to start.   Marsha Vanwynsberghe ** 02:59 It is the early Marsha. So I was born in 1970. And I say that because um, you know, in that time and era, kids were to be seen and not heard. Yeah, I was very, I was very outspoken as a child. And I have pretty strong personality. And a I use my voice a lot. And back then we used to tell or we used to hear that, again, be seen and not heard. And I often think back to you know if if young girls, we can tell them that those are leadership skills and not bossy skills. It's there's a lot of things that I learned as a child, but I mean, I grew up with a family who we moved a few times. And my dad he started a business that continued to grow. So I really grew up around entrepreneurship, and finding and carving your own way and building resiliency. You know, working from a young age I was my first jobs were at 1213. So I grew up in that era of like, work hard. That mindset.   Michael Hingson ** 04:12 Where did you Where were you born and where did you come from?   Marsha Vanwynsberghe ** 04:15 I was born in Chatham, Ontario. Yep. And then we moved up near a it's kind of farm area but near Woodstock Tillsonburg area for people who might know, in Ontario and I've lived it. I've been in Ontario my whole life. But that's where I was. I was born in the city and then I was moved to a farm which I really did not like my parents for that at the time. I didn't know it, but honestly the best move we ever did, but then I've lived within that vicinity for since then.   Michael Hingson ** 04:49 Didn't you want a pony? I   Marsha Vanwynsberghe ** 04:51 did not. I did not. I worked in tobacco as a kid. I was not. I was definitely I had farm jobs I was I was a hard worker.   Michael Hingson ** 05:04 Well, I suppose the benefit is that you learned to be a hard worker. And that's a good thing, although tobacco but of course that was then this is now. So it's a whole lot different environment. So very   Marsha Vanwynsberghe ** 05:17 different environment now, like that was definitely what we did then, for jobs. But I also at the same time it put me through school, that's how I paid for school, and I was able to, you know, go with that time. But yeah, it's a very different era, that is not something that you see very much of anymore, thank goodness, it's still there. But as we'll see it very much.   Michael Hingson ** 05:38 I love to collect and listen to old radio shows from the 30s 40s and 50s. And so on one of the shows, I really like a lot is dragnet. And the reason I mentioned that is that dragnet for a while in the 50s, was sponsored by Fatima cigarettes. And it was fascinating listening to the commercials, statistics, prove Fatima cigarettes are better for you, and more like than any other cigarette, and of course, that's all they would ever say, Where are the statistics? But you know, that was advertising back then, too.   Marsha Vanwynsberghe ** 06:13 It was advertising. It makes me nervous when you hear things like that, like the things that we thought were okay, not even okay, but that they were good for us. Yeah, we're not obviously not.   Michael Hingson ** 06:25 I think at the same time today, some people would say, well, we should get rid of all that stuff. We shouldn't allow that. It's just not true. And the reality is, my belief is no, we shouldn't it's part of our history. And we need to recognize from whence we came.   Marsha Vanwynsberghe ** 06:39 I think that's how we learn lessons. And we move forward. I mean, it's not perfect. There's still definitely a lot of issues, even health wise that I see now. But no, I agree with you. I don't think I think that is part of history. I think that is part of of history and what we walked through, and I mean, hopefully we continue to learn and do better, right and do better and make different choices, etc. But that's definitely what marketing was, then.   Michael Hingson ** 07:08 Yeah, and it still is somewhat today, there's more than anything fear in marketing, Oh, me, sure you buy our car warranty service before your check engine light goes on, and just so many different things, we, we still have a lot of things to address at some point, although that isn't really necessarily being dishonest, but we still use fear a lot. And politicians use fear so much to completely distort the reality of what we ought to be doing, which is to analyze what they say, for ourselves, rather than just living in fear. And oh, someone said, this is true. So it must be so I   Marsha Vanwynsberghe ** 07:48 love that you said that. I really do. Because I feel like in some sense. We're losing the I don't want to say it's the ability because it's not the ability, but we're losing the practice of like distorted thinking and asking questions. And it's just, it's not to disagree, but I think that we should be asking questions and, and asking for, you know, doing some of our own research and looking and, and not just not just taking the advice without asking any questions. Yeah. And that's   Michael Hingson ** 08:23 the real issue. And, and just the whole art of conversation seems to have gone by the, by the wayside in so many ways, especially with, and I'm not going to get too political, but a lot of the politicians all around, is it's all about trust me Do as I say not as I do. And we're encouraged not to ask questions, which is so unfortunate.   Marsha Vanwynsberghe ** 08:47 It's scary. Actually. I think it's actually scary. Because I think that I think anytime that I am encouraged or questioned not to ask questions. If I go back to my nature, as I talked when I was younger, then that's the first thing I do. Yes. Very first thing I do. I'm like, huh, that doesn't feel right. That's   Michael Hingson ** 09:07 and, you know, we, we let we let some people just steer us so much one of my favorite gripes of late is weather people out here in California. In May and June, we had a lot of marine layers and a lot of clouds and so on. So people were always complaining, the weather prognosticators were complaining about May gray and June gloom. Will it ever end? Yet? The reality is it kept the temperatures down. Now we're getting away from all of that. And we're up at like 95 or 96 Fahrenheit today. We were yesterday as well. And oh, what's happening? Now we're starting to see wildfires and we're hearing about why we have wildfires. And we're going to be in the fire season. And isn't that horrible? Well, you wished You wished it all on us? Because you didn't like may grand June gloom. I mean, we can't please anybody anymore.   Marsha Vanwynsberghe ** 10:05 No. And it's interesting because I always like, I think, to look to go back to gratitude in some way, shape or form, as a Canadian who literally only has like three to four months a year that are nice, where it's warm. I mean, I couldn't even imagine being upset about made like, yeah, it's just perspective, right? It's a perspective, I look for the things to be grateful for.   Michael Hingson ** 10:29 Yeah. And you know, what, the May grand June Gloom did keep things cool. Hardly any fires. I heard on the news this morning. There were four, although relatively small, and they were caught quickly, because we're getting better at dealing with it here. Small wildfires that helicopters and tankers dealt with very quickly. But nevertheless, now we're seeing it. And it's so unfortunate, we can't, we can never be satisfied.   Marsha Vanwynsberghe ** 10:59 No, and I actually we don't have a lot of experience that within Ontario, where I live like other parts of Canada do. But this year, we definitely got the effects of the what we were surrounded by wildfires and the like, not literally, but the smoke came in. And we probably had about two weeks where, you know, it was yellow skies, it was hard to breathe. It had moments where it was really challenging. So it really did give a perspective of you know, I had people here who were saying like, this is just absolutely horrible. And like, it's not great, but I mean, we could be in the fire, like, yeah, not like it's still I can still go outside. It's still safe. It's not ideal, but I guess my brain, I'm looking at it going. I mean, I'm not in the fire. So it could be much worse.   Michael Hingson ** 11:46 Do we know where the fires came from? And we had them on both   Marsha Vanwynsberghe ** 11:50 sides. We had them on our east coast. So in Nova Scotia had, and then Calgary has a really bad beginning of May. So they kind of came from both ways.   Michael Hingson ** 12:03 Do we know what caused them yet?   Marsha Vanwynsberghe ** 12:05 Nope. Nothing I've heard.   Michael Hingson ** 12:09 That's unfortunate. But, you know, the other side of it is was it was it really warm? Was that also part of it? Well,   Marsha Vanwynsberghe ** 12:15 I watched the interview, it was interesting, because I did watch with a lot of friends who were firefighters and I watched an interview with a firefighter who said that we had very like our snow was we had a very heavy winter, and the snow was gone early April. And then we had a lot of rain the beginning of April. And then it got really hot for about two weeks, and then it got dry, super dry. And it was just the perfect condition. They said it's absolutely a perfect condition for it to happen. So I think that's I don't remember a year like this that we sub assuming that was part of it.   Michael Hingson ** 12:51 See down here with all of the marine layers and so on, and the fact that I don't know whether it's all gone, but as of the beginning of July, there was still snow on the ground in some parts of California, like the, the mountain areas and so on. And we didn't have hot, dry May, or mostly all we had no hot dry June. So now we're starting to see it. And I can understand that. And that would and I was always wondering, well, why did Canada get the fires that it did that sent the smoke everywhere? But it makes sense with what you're describing? Yeah, very similar   Marsha Vanwynsberghe ** 13:29 to what you said, like we ended up it was very, very hot in the US, not it not normal at all. And then we had no rain until almost the end of May, early June. So it was very, it was very strange spring for us. Now we had lots of rain since then. But it's okay. It's like actually cleared up there to be honest. So I take it again, it's perspective.   Michael Hingson ** 13:51 It is. It's all about perspective, which makes a lot of sense. Well, so getting back to you and all that. So you went to college.   Marsha Vanwynsberghe ** 14:01 I went to university here and I actually took I became a registered Kinesiologist. So I worked and post physical rehab for about 28 years. And over the last couple of years before I was done in that career, which ended very abruptly during 2020 and never came back until like probably eight or nine months later. And by that I knew the business had pretty much dissolved itself. And so I did that for I spent about 20 years and I did love it. I like the problem solving, like the thinking and the helping people. I had some people we were learning how to walk again, like that week post recovering from surgery. And then really as that time wore on, and my life was walking through some different challenges. Then I started to work into a space of like what Learning how to share stories and navigate a really difficult time. And so when the pandemic came, I actually just pivoted, went right into coaching online and supporting people online. And I felt like it had been like a complete out of nowhere. But it hadn't. I mean, out of the 20 years in working with physical rehab, I did a lot of coaching, I had to do an awful lot of coaching and supporting with people. So it was very similar.   Michael Hingson ** 15:30 So when did he start involving yourself in the whole concept of NLP and bringing that into what you did. So   Marsha Vanwynsberghe ** 15:37 I actually did things very backwards. I, if I'll take it back to a little bit, about 1012 years ago, we started to experience teen substance abuse, I found my world get really, really small, and I lost my voice didn't know how to use it. And I really started to do a lot of work to learn how to, you know, reframe my thoughts and catch my what I was thinking and the words that I was saying, for probably three years, I was doing the beginning pieces of NLP without ever knowing that was NLP, I had no idea. And in 2020, it crossed my path. And I looked at it and when that's interesting, there was something about it that was intriguing to me, is learning to understand the power of my thoughts and how I my brain works and how to get it to my thoughts to actually support me and what I am creating. And what I want to do. The other piece that really intrigued me with NLP was that the way it was taught for me was that there was a lot of ways to support myself in healing. And I say that because I really didn't understand how we hold on to so much. I mean, trauma stress in our tissues in our body, and we push that down and we carry it for years, the LP tools helped me to really start to learn how to release that. And that helped me to work through some of the healing. So had I learned that earlier, I think that it would have actually really supported me earlier. But we all know that the teacher comes when we're ready, and I probably wouldn't have been ready, and I probably wouldn't have seen it, and I wouldn't have understood it. So it all happened in the timing that it was meant to happen.   Michael Hingson ** 17:24 He told me a little bit about what NLP is what it stands for, and all of that, especially for those who who may not be very knowledgeable about it.   Marsha Vanwynsberghe ** 17:33 Absolutely. It is called neuro linguistic programming. It's really the so neuro how we bring in our information, we all bring it into a number of our different senses. The linguistic is like the language, the words that we speak, the programs that we speak, how we be are able to take in that information and like delete, distort, generalize, put it together. And then the programs is really how we all function. Most of us, this is how it works. Our conscious mind is only responsible for like 5% of our thoughts, our beliefs, our decisions. And we set our goal with our conscious mind. Our subconscious mind is like the wheel that's never stopping. It's running on autopilot, nonstop. And most of us, we go into this space, this learning space, personal development space, helping others, we try and set goals for ourselves. And we do it with 5% of our capacity. But we're never addressing the stories, the limiting beliefs, the things that we have, that we're holding on to that keep blocking us. And then what happens is, is that you set a goal, you work like crazy to get to it. And you might just find fall shy of it. Or if you do achieve it, but you don't believe that you're worthy of receiving it. You'll self sabotage, you'll lose it you will keep on this cycle of always trying to strive and achieve more. And as you do that, it's just it, we put ourselves on that hamster wheel nonstop. And really, it's not the goal. That's the problem. It's Do we believe in ourselves to achieve the goal that is really what we want to work towards. And with so many of us who again, we've carried these stories in our bodies for so long. You can't just work harder to make something happen. It's sometimes you have to go backwards and figure out what it is that has been holding you back so that you can actually move towards your goals in a more aligned and effortless manner.   Michael Hingson ** 19:46 One of the things that I find often and I've worked to get away from this but is that we don't tend to do much introspection, especially on a daily basis. We don't take Take time at the end of the day to look at what happened. Not and I don't like to use the word fail, because I think it's all about learning experiences. But what didn't go as well as it could? How do I make it better next time? What went really well? And what can I do to even improve that, and really pondering and thinking about what happened in the course of the day, and we don't, we don't do that we don't talk to ourselves, we don't talk with ourselves. And we really just figure Oh, I don't have time I got too much other stuff to do. So listening to you describe NLP really does in part go back to you've got to be your own best teacher and really learn how to do these things. I   Marsha Vanwynsberghe ** 20:40 couldn't agree with you more I really couldn't. I think this is the big thing is that we're on a journey of always learning to lead ourselves. That's what I believe. I think that we're learning always learning to lead ourselves. And one of the number one premise of NLP is to live out cause in your life. And that is, we can either live at cause or live in effect. When we live in effect. We are in a space in a mindset of victim mindset, anger, blame, resentment, all of those emotions. I lived there for a really long time. I think all of us at one point in their life have lived there. But when we stay there, we don't. We don't create change. When we live at cause we come to a space of saying like, how can that introspection you're talking about? How can I, you know, look at what went well, today? What's not going well? And one of the first things I'll do, I have moments sometimes where I'm like, well, Marsha, I'm really not really proud of how you're behaving right now, or what is going on with you acting this way. And it almost always comes down to if I'm completely honest, I have a moment of introspection, and I'm like, Okay, wow, you're not doing the things that you need to take care of you. You are not putting the boundaries in place, you're not getting the rest. Okay, so now how can we put that plan in place, and it's like a calibration that comes back to regularly being in that space of taking responsibility for myself, so that I can best lead myself, never about perfection. But there is I'm in a constant conversation with myself all day long. And when things are going right, when I could maybe do something differently, when I'm working to, you know, maybe celebrate something that I'm doing that is a challenge. I think that that piece of self awareness and introspection, is I don't want to call it a lost art. But it's not something that we're making time for on a continuum.   Michael Hingson ** 22:42 Yeah, we're not at all. I love to, to joke and tell people, you know, when we talk about talking to ourselves, and so on and say, Well, do you get answers? When the reality is, of course, that the more we do, the more we do it, the more we will get answers. And the one I'm going to worry is when I don't get an answer. Yes,   Marsha Vanwynsberghe ** 23:03 yes, I'm with you. I am with you on that.   Michael Hingson ** 23:08 Because we are Yeah, well, we really need to learn to communicate with our heart with ourselves and, and understand, as I have learned to tell people, I used to say I'm my own worst critic. And I've learned that's a horrible thing to say, it's really I'm my own best teacher, because I'm the only one who can really teach me other people can advise and give me information, but I'm the one that has to learn it. And I'm the one that has to teach it to me.   Marsha Vanwynsberghe ** 23:36 I love that you've said that. Because I think that that's a really powerful reframe. And I think that's noticing that comes from a lot of the NLP training is learning how to reframe thoughts. But that's a really powerful reframe, because I have called myself my own worst critic for most of my life. I have and and it's interesting because, you know, there's, there's, there is an advantage, they do want to share one thing quickly, because in the area that I work in, where I help people with vulnerable stories, how to share, show them set, like show up, be seen user voice, one of the biggest things people are constantly afraid of, I would say one of the number one fears is what will people think of me? It's It's amazing. It is the number one fear, what will people think of me? And I often ask people like, well, what are some of the thoughts that you have about yourself? What do you say about yourself? Because I think when we really break it down, there's no one who's criticizing us nearly as bad as what we're doing to ourselves. And so when you start to see that, it's like, Wait, why am I giving all of this energy to what everyone else is saying? When really, I spend 24/7 with myself and my thoughts and what I'm saying to myself is never going to help me move forward. So that's the first piece of it. The second piece is that I think, again, my opinion but ever Every relationship that we build outside of ourselves comes from us first. So I can't be a really nice, I genuinely believe this, I can't go out and be a very nice human to everyone else and be an absolute piece of garbage to myself, because that is it's not authentic, that's not authentic at all. And so I think that if you want to create change in your life, even externally, with relationships, friends, whatever that is, it really does start with learning how to be a better human to yourself.   Michael Hingson ** 25:34 Yeah, and you've got to learn to like yourself, and if you don't, then find out why. And it's okay to find out why. And the reality is own ultimately, people can make observations to you, but only you can really tell you why the two of you aren't getting along.   Marsha Vanwynsberghe ** 25:54 Because I'm my best teacher, I love it. You said that I just, that's a beautiful reframe week, and we can be our best teacher and I am with you in the sense that I actually don't, I rarely use the word failure, because I don't like the connotation with it. Because I think everything is teaching us something. And we get to look at that is that well, that taught me something. Now, if I choose to make the same choice over and over and over, and I'm angry with everyone else in my life, there comes a point where I have to recognize that I'm the common denominator. So what can I do differently? How can I choose differently? How can I surround myself with different people? And then I'm learning the lessons that I'm here to learn. But I really think that we're on a constant cycle of learning.   Michael Hingson ** 26:43 I love Albert Einstein's definition of insanity, which is that people who do the same thing the same way every time and expect a different result, certainly are not all there. No.   Marsha Vanwynsberghe ** 26:57 And I mean, I listen, I've caught myself, there have been many times in my life where I've caught myself, and I'm frustrated with something or something that's happening. And it will be like, Wait, this is the exact same response that happens every single time. Yeah. And that's when it's like, no, so why would I possibly expect something different? Like why would i That doesn't make any sense. And I can catch it and work on that reframe. But again, this goes back to having this dialogue with myself with ourselves on a daily basis.   Michael Hingson ** 27:28 What we tend to not understand or don't want to understand is that there really are basic laws that we live by and should live by. And if you are within those laws or not, but if you're doing something and you do it the same way, every time, you're gonna get the same result. And you have to decide whether you want that result.   Marsha Vanwynsberghe ** 27:50 And if you don't, then something different is required of you, in order to create a different result. We do live I know people don't like that. But we do live the same lessons over and over until we learn the lesson, like do the same experiences over and over until we learn the lessons. And   Michael Hingson ** 28:08 unfortunately, it happens time and time again, generation and generation again. And somehow we've got to do a better job of really learning that you've got to do things different if you want a different result when we were talking earlier about the whole issue of growing up and, and learning and recognizing what we learn and all that and like banning books, you know, we're getting away from understanding history. And so what are we doing? We're banning books, we're getting rid of the lessons or the places where we could get great lessons for poor excuses for banning the books in the first place. Yes,   Marsha Vanwynsberghe ** 28:51 I have a hard time understanding all of that not not to get like not getting political. I just have a really hard time understanding that we're just going to we did make mistakes in past 100% We made and we're still making them today. But banning things and ignoring it like it never happened, then we're not pulling lessons from that we're not learning something from that. I don't think that anything it I don't think it's beneficial to pretend that things didn't happen. I think we some very valuable lessons from some very big mistakes in history.   Michael Hingson ** 29:26 Well, people have said that Dr. Seuss was a racist. And so we shouldn't be banning his books. Is that good justification for banning all the good things and all the positive stuff that kids get out of the books? Or does that open up a great opportunity to have a discussion and teach people the subtleties of maybe where racism did come through and some of the things that he wrote, but for the most part, people acknowledge that he did a great job or even To Kill a Mockingbird is is a real crazy one to talk about banning because it's All about discussing how people were treated inappropriately. I think   Marsha Vanwynsberghe ** 30:05 we have to continue having those conversations if we're going to change behavior and and learn how to treat   Michael Hingson ** 30:12 people differently, should all of Bill Cosby's humor go away, simply because, as it turned out later in life, we found that he had feet of clay in some ways. And the reality is, I think they're two different things, the humor, and the the wonderful joy and laughter He brought to people as a stand up comic, and even in TV and so on, can't be erased. And if you do, you're missing so much. You   Marsha Vanwynsberghe ** 30:39 are and I think this is a this is a really interesting conversation, because I do not know the quote, but if we're only I'm not justifying, what if we are judged by our worst days, then like, nobody is going to nobody is is free, in a sense. And I think that we need to be accountable for our mistakes, especially when we are doing things like this. I definitely agree with you on this. But there has to come a point that, I mean, if I hold on to the energy of that feeling of holding the worst days of every person in my life against them, I'm not going to have anyone in my life. Because I mean, and what a terrible thing to focus on is only the worst things that people have done.   Michael Hingson ** 31:31 And the reality is that there's so much positive energy that that we can attract, if we choose to be more positive than negative, and recognizing that we don't need to be negative, it doesn't add value to us. It   Marsha Vanwynsberghe ** 31:46 doesn't and that's and that's such a such an expression, such an understanding, it doesn't add value to us, many people and people will say, and we will have why. How do I show up when everyone around me is just negative like that, like, I don't know how to do it? Well, sometimes boundaries have to come in place. And sometimes you decide where you put your time and your energy. And you have to know that, you know, there are times where I will say no to certain things, because that's just not where I choose to put my energy. And I think this is really important. I'm not saying that because I'm judging somebody else. And I don't like how they're how they speak or how they show up. I'm doing that because that's what's best for me. That's, I feel like that's choosing ourselves, we get to choose who we spend that time and energy with. It's not about pointing fingers and making it about other people, we just get to decide where we put it. And I really think that there's a there's a difference between two. Yeah,   Michael Hingson ** 32:45 yeah. And it's always a matter of choice as to which way you want to go. And like I've said to people, on many occasions, sometimes things happen to us that we don't have. And actually a lot of times probably things happen to us that we don't have any control over happening. But we always have control over how we choose to deal with what happens.   Marsha Vanwynsberghe ** 33:07 Yes, and that is actually I'm probably going to butcher the quote, but it was years ago. For me one of the big turning points was when I heard Stephen Covey's quote, and it was that you are not a product of your circumstances, you are a product of your decisions. Yep, that that was a light switch for me moment where I went, Oh, okay, that no, that actually makes sense. Because I was living in a situation that I don't remember asking for, I didn't want it's not what I wanted to deal with. But I did have a choice in how I responded. And that really started to reframe my thoughts that I could choose how I show up, I could choose how I responded. And when you can start to take back even a sliver of choice in your life, it really will start to shift your energy and how you show up. If you actually I think the other piece of this is that when we stay in that angry victim mindset, and feel like this is just all unfair. And it's happening. No change happens there. And when we can start to become a product of our decisions, we can actually start to create change. And that's the it's a really powerful message for and I know it's not easy. I know it's not easy. I just know that it's soul choice.   Michael Hingson ** 34:23 Yeah. It's always a choice.   Marsha Vanwynsberghe ** 34:27 Well, you thought of energy that's wasted when it's not   Michael Hingson ** 34:31 Oh, so much. Yeah. I love the quote I heard and I don't know about the truth of it, but I choose to think it makes sense that it takes 17 muscles in your face to frown But only three to smile.   Marsha Vanwynsberghe ** 34:44 Isn't that something, isn't it? Yeah, it's in and that's a that's a choice. Sometimes when I go for a walk and I'm gonna walk my dog a lot or I'm in the store. I tried really hard to make eye contact and smile at people and it's an Have you seen how that's just not always? That might be seen as weird? But I actually have to do it?   Michael Hingson ** 35:07 Yeah, well, and it makes such a difference. You smile, people smile at you. And it goes so far toward helping, I think people feel better.   Marsha Vanwynsberghe ** 35:19 Yes. And you can be meeting people on sometimes their worst day. And sometimes that smile, that just gesture can make such a difference, and it can make an impact in both of your lives. Yeah, absolutely.   Michael Hingson ** 35:31 And you may not even know the impact ever, or until later. But still, it makes a big difference. So many times we plant seeds that we don't necessarily know how they'll grow. And we may not even learn how they grow. But nevertheless, it's always good to to work on planting good seeds and and not bad ones. Now   Marsha Vanwynsberghe ** 35:54 100% And it made me think of I really like it. This is such a short and simple book. But I really like the is it Mitch album, the five people you meet? And I like that because the reframe there is that the people that you have the biggest impact on you might not even realize it. Yeah, like, there might they're not the they might not be the closest people to you. It could be somebody that you crossed paths on their worst day. And that created a ripple in their lives. And I just I've always loved that concept.   Michael Hingson ** 36:27 Well, and you may not even ever No, no, how much of an impact you had one of my favorite stories, and I've told it a couple of times here, but I'll tell it again, is that in 2003, I went to New Zealand and I had been introduced and interviewed in 2001 by a gentleman who was always known as the Larry King of New Zealand. His name was Paul Holmes. And he came to interview us in the States at our home in New Jersey. And he said, If you ever get to New Zealand, let me know I want to interview you first. And so it turns out that there was an opportunity to go and do work in New Zealand for three weeks. And I emailed Paul and let him know we were coming. And we got there on a Wednesday morning and I got a chance to nap because it was a long flight. But we got there and napped. And then I was on his show that night at seven. And what happened was that a week later, a weekend a few days later was the second Saturday I was in New Zealand. Apparently, the show interviewing me reran. And the next day, and I wasn't connected with this at all. But a group of blind people took a river raft, and they had a guide. And they all went and they had a great time. And at the end, the guide said, I have to tell you a story. He said I was going to cancel this trip yesterday, because I didn't think fine people could do this and that you would have any fun at all. And I probably have to be jumping in the water and saving all of you. They said last night, I saw the Pol Home Show. And there was this bloke from the States I love it. This bloke from the states who was on who was in the World Trade Center on September 11. And he got out and I figured if he could get out and he could be here and talk about that, I should be able to have fun with all of you guys. And I have to tell you, this was the best trip I have ever had a chance to guide. Hi.   Marsha Vanwynsberghe ** 38:25 Thank you for sharing that I have not heard that one. I love that story. That's beautiful.   Michael Hingson ** 38:30 You just never know. And it will have always felt if I can make a difference in my life or one person's life, then I've done my job. And anything else beyond that is great. And I've chosen to speak because my belief is that if I can help people move on from September 11, and learn about blindness and guide dogs and so on, then it's a good thing. And that's what I've been working on for the last almost 22 years now. And having a lot of fun doing it.   Marsha Vanwynsberghe ** 38:59 Yeah, I think that was one of the things that drew me to your story and knowing that I wanted to share it is because exactly that you are you're making a difference with your story. And it is just it's really opening up conversations and showing people how they can move forward and how they can make a difference. And I just I absolutely love that.   Michael Hingson ** 39:22 Well tell me a little bit about you getting into doing a lot of storytelling. You said that you during your your career, which I assume ended mostly because of the pandemic, the company. Yeah. But you learn a lot about telling stories, which I always think is a great way to handle any situation and it helps people grow to have a greater understanding. But then you started coaching full time. And now you tell stories. So what does it mean to own your own story?   Marsha Vanwynsberghe ** 39:51 Well, I think I love this question. And I I just I think when it comes down to it. You either own your story Don't you to keep it super simple. If you are, we've all walked through an experience, we've all walked through challenges. But that doesn't have to identify us, right? It's part of us. But it doesn't have to be our identity. And I think that's the piece is that when you own the story, it doesn't own you. But when it does own you, it controls you. And I mean that in a sense that there is a tremendous amount of people who are hiding in what I would call a shame story, and are hiding it, hoping and praying that no one ever knows that they've struggled, that they're struggling, that there's a challenge happening. I think that has been even more amplified with social media. Because I think that for a long time, there was this this image that of, you know, perfectionism, and wow, look at how great everyone is doing, when that's just, it's just a snapshot of a person's day. And so when you don't own the story, it owns you. And for the longest time, I really tried to hide that part of myself, because I just didn't know how to deal with it. I didn't know how to deal with the criticism, and the judgments, and all of the words and and I'm still trying to, at the time was trying to navigate a really difficult time. And so when that those words started to land on me, like on your choices on your life and owning your story, and what did that look like? It was amazing that I came to a point of saying, Yes, I was a parent who dealt with teen substance abuse, it changed me at the core. And I learned how to share my story which allowed me to heal, which allowed me to build better relationships with my kids to really do something really good with the most difficult experience of my life. And part of that became sharing stories. How Hermie how do you share a difficult story? Like how do you share a story, especially when there's other people involved? How do you share a story when there's other people involved? And I think that is something that is misunderstood a lot. But here's the thing is, is that when we don't, when I first started to share my story, I was blown away by how many people would stop me and say, Oh, my gosh, that's my story. I've never told a soul. I've held on to it for 3040 years and listening to people. Be that victim to shame and shame. Shame, love secrecy. Right? So the more people shut it down, the more shame grows. So by helping people to share a story, then all of a sudden, they were able to feel free from that story. And it started to open up this this idea of how can we start to share more of us. And that's how we find our connections and how we build our connections. So storytelling wise, if I can share, I watched this today, I actually ran a masterclass today. Pardon me, I've been talking all day. But I ran a master class today. And I asked if there was anybody who wanted to come on live and practice how to share and frame a story. And one of the moms who jumped on I saw her jump, and I'm like, This is awesome. I'm so excited. Because I've had a number of conversations with her and both of her boys experience. They both had a genetic condition. They spent 18 years in the hospital, almost 95 in the hospital. So I could imagine what that family went through. They lost their one son, the other son survived. And she started to share. And she was very afraid she was scared to share it. She got quite emotional. But as she did it, people were commenting and pouring so much love and support into her that I actually made her pause and I said I need you to read these comments, like read these comments. And she just sat there and went, I had no idea. And I'm like, this is the point about our stories. Our stories show that we are so much more connected than we think that we are we are so much more alike than we think that we are. And I think that learning how to share our stories, normalizes our connections. And we don't have to walk the same story as somebody else in order to be connected to them. Because we're all connected by emotions, experiences, lessons, etc. So that's really where it started. And when I started to find my own freedom from my story, I actually started to heal, but listening to everyone else, give me feedback and tell me that that was their story. It just gave me fuel to keep going and I felt very compelled that this was my purpose in life was to start to change stigma and start to open up conversations about difficult topics. Yeah.   Michael Hingson ** 45:06 Well, and it's how do I say it is an exciting thing to be able to do and to recognize and then to help bring about, and whether you know, what it was we talked about before whether you know, what really happens and, and how you affect people or not isn't the issue, but at least you're the conduit, and you know that. I   Marsha Vanwynsberghe ** 45:26 like being the conduit, I'm actually I like, I actually like it. And it helped me to shift in looking that, you know, through the most difficult experience I've walked through, I was able to give it purpose. And because I could give it purpose that helped me to heal. And it helped me feel like, maybe that's what I'm supposed to be doing. And accounts are sent that to me. And it was etched in me, when I said no matter where I go, nobody's talking about difficult things in life. And she said, maybe that's good. You're supposed to, maybe you're supposed to talk and I'm like, You want me to just talk about this, like, What will people think what will they say? And I can tell you all of the stories I made up in my head about how bad it would be and how scary it would be none of them happened, survived. And I mean, you speak you understand, like, it's two big groups, we tell ourselves stories. But it was incredible experience. And I continue to do that to this day. And podcasting is part of it. And what it's done is brought connections into my life that I never would have had. And I know I've normalized a lot of topics that people don't want to talk about. But I do think the interesting thing is, is that, tying it back to the very beginning of my story and intro that I shared here, I grew up in an era when you didn't talk about difficult things, like you literally just put your smile on and pretended everything was fine. And so when I decided that I wanted to start sharing, I would love to say I was met with so much love and support. And that was not the truth. It took time because it was it was uncomfortable for people in my life. But I kept saying just trust me that I will be always sharing and leaving everyone in integrity. It's the utmost highest intention. And it didn't take long for others to see why I wanted to do it. And I'm so grateful that I did. Yeah. Well,   Michael Hingson ** 47:22 you talked about having teen substance abuse in your family. And that had to be a hard thing. But learning to talk about it is also part of what probably was good therapy for you.   Marsha Vanwynsberghe ** 47:33 It was the best therapy I've done all I have done so much different support. And I would say it was one of the best things that I ever did for myself healing wise and therapy wise.   Michael Hingson ** 47:45 Ironically, picking on the media, as we often do for me, subjecting myself to literally hundreds of interviews after September 11. From from media people who asked anything from the most intelligent thought provoking questions to the dumbest questions in the world. Even so, it made me talk about September 11. And it made me do it in ways I would never have imagined. So for me, that was some of the best therapy I think I've ever had. And I and I think everybody in the media for it, ironically enough, after knowing that we we still have to pick on them anyway.   Marsha Vanwynsberghe ** 48:23 Yeah, and I'm sure that like, I've had many people ask me questions, and I'm like, I am not answering that. Like, I'm just not there's no purpose behind that. I'm not saying that. People will ask I also think that people ask because they don't know, or they're looking for a sweet, they don't know. It's interesting, because I think I actually I'm gonna say this, I think that I would rather somebody asked me a question that's not appropriate, then give me that glance and judge and not ask, because sometimes people don't ask out of fear. And I've actually had a couple of really interesting opportunities when I where I've been able to use that conversation as a little bit of nice education. Because I think the other thing is, is that with my with our story, we didn't look like what most people thought, like who had this issue, which, to me, was all the more reason to start to talk about it. Because there's, there's hundreds of 1000s of me, it's not that I was the only one. And I mean, the only reason that most of us feel alone when it comes to these topics is because we're not talking and we're not alone. None of us are. And so I really think those are those are the pieces but I love how you share that. And I do think that by talking, I really wanted to help others out. And I was also helping myself. I didn't know that at the time. One of the best things I could have ever done, because   Michael Hingson ** 49:58 it helped you as much as anything How did you discover that you could only own your own choices?   Marsha Vanwynsberghe ** 50:05 The hard way. I think the hard way, I spent a lot of time trying to fix, manage control, micromanage everything around me trying to make it better trying to save them trying to, you know, fight a system, I was just in this constant fight mode. And really what was happening there is nothing external to me was changing. And everything internal to me was changing, but not for the better. I was in a space where I was probably my worst health, I wasn't sleeping hardly at all, I didn't have hardly energy, I didn't have a lot of positive joy or good outlook in my life. And through a lot of work, and reading and support, I started to recognize that I wasn't owning any of my own choices. I was literally blaming everyone for that, and not taking any responsibility for myself. And ironically, when I started to do that, it got really easy to say, Wait, is that my choice? Nope, that was not mine, either. Nope, that one's not mine, either. And I literally would go through the list. And it was like, Oh, my gosh, I'm spending like, I was spending like, 97% of my day, doing everything that wasn't my choice, and then having nothing left for me. And then being angry at everyone else, because I had nothing left for me in order to do that. So owning owning my choices became a model for me. And when it came to wanting to start the podcast, on your choices on your life, that was I mean, people say that's too long of a title, you shouldn't do that. And I'm like those words saved me. And that's, that's literally they've become the pillar cornerstone for me. And they saved me so that it became very easy to use them.   Michael Hingson ** 51:45 I never would have thought of calling your choices on your life being too long of a name. It   Marsha Vanwynsberghe ** 51:52 was I had so many people. I mean, this is the thing when you ever want to do anything new, be very careful how many pins you ask for? Yes, get a lot.   Michael Hingson ** 52:04 Or feel free to get all the opinions and then you just have to synthesize them together and decide where you're gonna go. Exactly,   Marsha Vanwynsberghe ** 52:10 exactly. When I when I wrote my solo book in 2017. It's called when she stopped asking why. And I waited for a while for that title just hadn't come to me yet. And when it did, I went to my publisher. I'm like, I've got the name. It's once you stopped asking why. And the publisher said, Oh, no, that's just way too long. That's way too long, no one's going to understand it. And I said, I actually think more people are going to get it than anything. Because it's, you know, when we ask that when you ask the question, why it only is appropriate if you're moving towards something like if you're focusing on the why the bigger picture, and that mission. But if you're asking why as a victim, and why is this happening to me, that will never change the story. And for me, that's when the story change is I would catch myself and ask why. And it's like, no, wait, why does it matter? The what matters, what is the verb, what is an action, that is something I can control. And that's what I would just shift it to. So again, back to what you're saying, you've got to follow your gut on some of these things, and listen to what feels right for you.   Michael Hingson ** 53:14 We forget all too often to follow our gut and our instincts. And they're always telling us the right answer.   Marsha Vanwynsberghe ** 53:21 They are they're speaking to us, we just might not be listening. I   Michael Hingson ** 53:25 learned that playing Trivial Pursuit learned it the hard way, you know, you got to listen to what your brain tells you. Because you're sitting there going, when a question comes up, and you get an answer. No, that can't be right. And you give another answer. And it turns out, you were supposed to answer what the original answer.   Marsha Vanwynsberghe ** 53:40 The first one how many times in Toronto procedures that happen a lot all the   Michael Hingson ** 53:43 time. A lot. So I work at it and and then and now people say when I play it, how can you get so many of these right? You know, and I just keep telling, telling them? I'm just listening to my gut? That's awesome. It is it's fun. Well, you know, when you are working with people, are you expecting to make a change? Or do you do you feel that's what you have to do? Or you're just really trying to help and let them make their own choices and decide whether they want to change or not be   Marsha Vanwynsberghe ** 54:16 the opposite? Yes, I again, back to conduit. I like to be the person. So this person who came on to the masterclass today, for example, I probably have four or five conversations with her. And this has just been something she's working towards, like these are difficult, vulnerable stories that people are showing up and trying to find a way to share. Because the intention is is that they want to do something good in the world with it. They want to help somebody else. They a lot of times like we're perfectly designed to help the younger version of who we work. And so they want to do something, but it will be in her own time and it will be in their own time. And she even said today she's like thank you for like just nudging me, but never We're pushing and I'm like, it's, I can't make you do anything. And if so, like, that's not where real change comes from. So I like to be a person who can help them to, a lot of times I can see what someone has available, but before they can see it, but I can't make them do it. That's it's never my job to make them do it, it's it's my job to show them what's possible. Yeah.   Michael Hingson ** 55:27 And you can't make the change happen. All you can do is at most set by example, as Gandhi said, Be the change you want to see in the world, but you have to do what you have to do, and be who you have to be. And hopefully, people will recognize the example. Yes, that's,   Marsha Vanwynsberghe ** 55:47 and that's why I think I really on a regular basis Share, Like I just share so openly, because I, I am never going to be the person who shows up online and saying everything is rainbows and butterflies, and it's a piece of cake. I'm not going to go on to complain, but I know how to be real. And it's like, you know, sometimes we're walking through really difficult times. And it requires me to focus even more on my own mindset and how I show up. But I will never show up and pretend that it's a piece of cake. And it's never a problem, because that's not relatable, that doesn't help anybody. I would rather show people how to navigate through something, and if it speaks to them, and it helps them to say I actually want to do something with my story, too. I would love to know how to help someone else out, then I hope it inspires them to do that.   Michael Hingson ** 56:39 And what do you say when they say that?   Marsha Vanwynsberghe ** 56:41 I asked them, usually the first thing I ask them is what's the vulnerable story that you're holding on to that you wish you could share more openly with others. And for example, somebody will say, you know, I experienced this, I have dealt with addiction, I have dealt with this. And I helped them to come to a framework with their story where they're able to have perspective, and they're able to pull the lessons and the learnings and the experiences from what they walked through. Because that's what they share. Right? That's what you share, you don't share the details of the story. It's you share the experience of what you walked through and how you helped, like how you got yourself through. And that's what you share. So I really helped them to kind of dissect and look at like, what, what did these experiences teach you? Who are you now because of it? And what do you want to do in your life? Because of this? Yeah, that's   Michael Hingson ** 57:43 what I was gonna get to is then what comes next? And it's what do you want to do with your life? Exactly.   Marsha Vanwynsberghe ** 57:48 And for some people, it's like their entire mission now. And I just love it. To me, it's very, it's a ripple effect. And I'm grateful to see it firsthand is to watch people step into and share vulnerable stories. And when I see people do that, like, I just, I just cheer them on, because I know how scary that is. And I know how hard that is. But I also know that story is going to reach others. I actually interviewed a musician who had dealt with addiction for a number of years, most people didn't know it. And he's, you know, he was sharing online, he was building quite a following. He was singing people loved his music, at cetera. And it he said, you know, it was funny, it was building a following, until I decided to quit drinking. And then I started to share my story as somebody who was was working through addiction, then all of a sudden, he goes my following. And my support and my community grew tenfold. Because I let them see me, I gave them something to root for. And I just I think that is such a beautiful piece that as humans, we want to be able to support others. But that's going to require that we let others see themselves through our experiences. Like they have to be able to recognize that Wait, she knows what if she knows what I'm going through? Because I could I could hear it and her message. And then we start to build these connections.   Michael Hingson ** 59:20 It isn't telling the story. It's telling the story in a personal and open way. So that people as you say, See you it's not just I'm going to tell the story and everything's gonna be great and people are gonna love me. Doesn't matter if you're not genuine.   Marsha Vanwynsberghe ** 59:40 No, it's the the authenticity, the genuineness. realness is so much more important. And even even here as an example for anybody who's listening. Like I didn't share much of my story. And I didn't have to. You don't have to share the details. It's not the details that is going to connect you with other people. It's that experience and what you choose to do with it. And I see such a bigger movement now of people who are recognizing that they've walked through something really difficult, and they want to do something good with it in the world. And I think that's how we start to change the conversation around these kinds of topics.   Michael Hingson ** 1:00:20 When you start to tell your story, if you get somebody who really pushes back and criticizes you, how do you handle that? What do you do? And how do you rebound and go on? Well,   Marsha Vanwynsberghe ** 1:00:30 in the beginning, it took me a while to rebound, I'm not gonna lie, like in the beginning, it was hard, because, you know, critics, nobody wants to be criticized. And but it didn't take long, I had some really good mentors, and I did a lot of work. It didn't take long to recognize that when you're going to talk about difficult things in life, you're gonna ruffle some feathers, you're gonna you're gonna push buttons, it's gonna happen. And people will always react to you based on whatever lens they're wearing. If they're wearing a lens of like victim anger, resentment, you don't get me you don't understand, I can't change that. I can't fix that. Like, I can just be me I can be I can. And I used to be the change, I literally wear that word on my bracelet like that is those are my go to words, I get to choose how I can be the change that I wish to see. And so that's always a reminder for me. But when I see that criticism now, this is how and I advise and share is this just my opinion on it, is when I see it, if it doesn't feel good for me, I will delete it lockup, if it is something that is constructive, that maybe a person is asking for some questions on, then I will I will try and answer because maybe this person is just a space of curiosity going wait, how do you move through something that's difficult. So I don't just take it at face value and judge it. But if it doesn't feel good, I still get criticism to this day, I will block delete, I will move things. I can really protect my energy put boundaries in place when it comes to putting myself out there. And I there are times that I have to remind myself, you know, sometimes I'll share something that's quite vulnerable. And I'll get 1015 Incredible comments back and I'll get one negative one. Do I choose to put all my energy into the one negative one? Or do I focus on the other 10 to 14 that were incredible. I think we get to choose what we focus on. And so the day that I start to focus on the only the negative comments, that person is, I can't I can't make them change. And maybe that's not their journey. And and that's not up to me. So when that happened, I just honestly I check in with myself again, go back to self like reflection and intention. And I look at it and say Did I say anything that was inappropriate? Did I do something I will go internally and look not being critical, but I will look to make sure I didn't do anything that wasn't. And then I just look at it and say I can't change that person sometimes even said thank you for your opinion. And sometimes I just block and delete, because I know that. I mean, at least once a week I get a message from a completely new person. I take those messages, I screenshot I save them

PRovokeGlobal Podcast Sponsor, Unlock Health joins Paul Holmes ahead of this year's Global Summit to talk disruption in the PR space and making impact. Unlock Health is a single source growth partner for healthcare providers with services that span the full range of marketing solutions from audience engagement and consulting, to technology solutions that connect the full eco-system for their partners. Join us 6-7 November for this year's PRovokeGlobal in Washington, D.C. 

On this episode of Between Two Beers we're rewinding the clock back to April of 2022 when we sat down with Jack Tame.   Jack is journalism's Swiss Army Knife – a guy that does it all. He's been a Breakfast host, a 6pm news reader, he hosts one of NZ's biggest radio shows on Newstalk ZB, is a columnist for the NZ Herald, has moderated live election debates, now hosts TVNZ's Q and A and has seen more, and experienced more of the world – than any 36-year-old we know.   In this episode we talk about how he was given Paul Holmes' radio job on ZB at the age of 25 with no radio experience, *That* interview with Winston Peters where Jack was called James – about 10 times, the time he was recording live TV while fearing for his fathers life, dancing with Beyonce, covering Trump, why he left Breakfast TV, the things you don't know about MIke Hosking and so much more.   This was one of our favourite episodes and one we wanted to share with new listeners of the podcast. Jack is, in my opinion, the best political interviewer in the country and his razor sharp mind and quick wit made this one a lot of fun.   Listen on iheart or wherever you get your podcasts from, or watch the vid on our Youtube channel.   A huge thanks to those supporting the show on patreon, if you want to chip in for the cost of a cup of coffee a month, go to betweentwobeers.com   This episode was brought to you from the Export Beer Garden studio. Enjoy. See omnystudio.com/listener for privacy information.

BCW joins the podcast to discuss their recently announced partnership with Limbik, a top information defense technology company rooted in cognitive artificial intelligence (AI), which will provide clients with advanced identification and mitigation solutions in today's post-factual environment. Paul Holmes hosts guests BCW Chief Innovation Officer Chad Latz, and Limbik's Co-Founder and CEO Zach Schwitzky, along with Chief Revenue Officer Caroline Tarpey in this episode. 

Paul Holmes looked at the story of Gideon and how it can encourage us to embrace who we are, make a start and to trust God with the result. A challenging message for those who want to grow.

Joining Iain Dale on Cross Question this evening are former Australian Foreign Affairs Minister Alexander Downer, Labour's Shadow Employment Minister Alison McGovern, Conservative Party vice-chair Paul Holmes and the UK director of Human Rights Watch Yasmine Ahmed.

Shadow Chancellor Rachel Reeves takes your calls, Cross Question and is Israel's military operation on the West Bank morally defensible?Joining Iain Dale on Cross Question this evening are former Australian Foreign Affairs Minister Alexander Downer, Labour's Shadow Employment Minister Alison McGovern, Conservative Party vice-chair Paul Holmes and the UK director of Human Rights Watch Yasmine Ahmed.

MMC Executive Creative Director James Ferber joins Paul Holmes beachside in Cannes to discuss the power of creativity in PR. Ferber proposes that unlike commercials and magazine spreads in advertising, the canvas of PR is the real world which commands an entirely different mindset, and is arguably more challenging. 

Paul Holmes kicks off the Influence 100 podcast series focused on critical challenges facing corporate communications leaders sponsored by FGS Global. in this episode he is joined by FGS Global's Co-Lead of Global Strategy and Reputation Practice, Liz Micci, and Medtronic's Chief Communications Officer Torod Neptune to discuss the various challenges specifically facing CCOs. 

I'm gonna run through the five reasons Lauren Vela talks about in this healthcare podcast for the “why” with the inertia in benefits departments of self-insured employers. But before I do, let me report that, in sum, they add up to … in many cases, benefits folks sit between a rock and a hard place. You really can't poke fingers at benefits teams who don't have the bandwidth, the resources, the expertise, or the organizational power to, in essence, run a small insurance company in-house and also do the rest of their jobs. This is especially true when benefits teams get no help or air cover from the CFO or CEO of their companies. So, the bosses are, in effect, telling benefits teams to manage the second-biggest company expense—this uncontrolled thing growing at multiples of the rates of inflation. They say, “Go get a handle on that but also don't make any noise, don't disrupt anything.” And meanwhile, I don't know, is the CFO under the impression that all he/she needs to do is pop by once or twice a year, issue some nastygrams about renewal rates to people who have no training in any of the financial and probably other skills required to manage this huge spend? And/or, on the other hand, the CHRO doesn't report to the CFO—so, same result, opposite problem. Here's the five pillars for the “why” with the inertia that I explore pretty deeply with Lauren Vela on the show today: 1. Transforming the healthcare industry is not actually in the job description of benefits professionals. 2. Outsourcing to consultants. Benefits departments a lot of times don't have the resources or adequate staffing to get deep into the complexities of healthcare, which means that lots gets outsourced to consultants. If you have listened to the episode with Paul Holmes (EP397) or AJ Loiacono (EP379), the problem here is that many traditional EBCs (employee benefit consultants) and brokers have a very vested interest to maintain the status quo. Currently, some are able to skim commissions of up to 30% of pharmacy spend, of employer healthcare spend, into their own pockets. These consultants have zero interest in upending absolutely anything. Employer inertia is paying for their vacation home, after all. 3. Nobody gets fired for hiring the same ASO (administrative services only) or TPA (third-party administrator) or PBM (pharmacy benefit manager) or whomever as their predecessor hired or they've been using for years. But they might get fired for doing something new that doesn't go so well. There might be no patience for even the shortest of learning curves or the smallest amount of disruption. There's also the aspect of a benefits team being capable of selling a transformational idea up the organizational ladder. Does the benefit department really know what the goals of the C-suite are? And if they aren't crystal clear on C-suite goals and aren't the best presenters in the world, it's gonna be a no-go on the new idea and then, yeah … inertia. 4. There's no obvious solution, no magic bullet, or easy answers. It might be hard to even figure out what to do that might have the positive impact a benefits team might be looking for. And then we get into the “is the juice worth the squeeze” discussions. 5. There is a status quo bias. Inertia is human nature. But at the same time, employers are wasting up to 30% or more of their healthcare benefits spend. That's a lot of money. These dollars are getting siphoned right off the top and going into someone's pockets in ways that do not help employees get better health. Dollars that could have been used to give tens of thousands of dollars in raises. Dollars wasted by the employer. But also, the employee gets ensnared in this financial lack of oversight because employees have deductibles and coinsurance. So, it's everybody sagging under the current model of some EBCs and payers and providers and PBM executives getting rich and hardworking Americans paying for it. So, let's cut to the chase. What are two solves? There's many more, but here's two. And Lauren Vela and I sort of ran out of time before we could adequately explore more, but these two will get anyone who wants to started: 1. C-suites. Yeah … you. Get involved. Provide adequate air cover for your benefits teams to move in new directions and also resource and staff your benefits teams with the kind of stuff and skills that they desperately need right now. Attracting and retaining employees has a whole new reality and opportunity, and a benefits team staffed for the market environment 10 years ago but not for the market today is a growing competitive and financial disadvantage. 2. There is a playbook for how to go about this. Listen to the show with Lee Lewis (EP244) for his, but step one of almost everybody's playbook is to find the right consultants working at the right consultant organizations. These right consultants and companies are the ones who are not taking indirect money under the table from an employer without that employer's knowledge. And if you're sitting right there thinking, “Oh no, that's not me,” unless you've very deliberately changed consultants so that it isn't, don't kill the messenger here. Again, listen to the shows with AJ Loiacono (EP379) or Paul Holmes (EP397). Ignorance is not bliss in this case like many others. Also, Eric Bricker, MD, just did a video on EBCs and broker types. So, do these solves mean spending more on a department that is already a cost center? Yeah, good question … wrong question, as the conversation with Lauren Vela today really gets into. The actual question is: Can you afford not to spend more on a department so that you aren't getting wildly taken advantage of in the current market environment. If you spend one dollar and save more than one dollar and also get employees better health, that does not seem to be a bad deal. As I've mentioned several times, today I am speaking with Lauren Vela. Lauren is a very experienced consultant working with coalitions, groups of employers, physician organizations, and also in the PBM space.   You can learn more about Lauren's work by connecting with her on LinkedIn.   Lauren Vela is a passionate advocate for a more rational and sustainable healthcare system and recognizes the influence had by employers and other commercial purchasers through their oversight of employer-sponsored insurance plans. As an independent consultant, she partners with entities that are committed to changing the ineffective status quo. Previously, Lauren was the director of health care transformation with Walmart, where she partnered with the Walmart Benefits team to identify solutions concerning low-value care, site of care, and vendor evaluation. Prior to her tenure at Walmart, Lauren led market strategy and member initiatives for the Purchaser Business Group on Health, where she cumulatively spent two decades working within various healthcare sectors, including health information technology, provider organizations, and pharmacy benefit management. Lauren also served, for seven years, as the executive director of the Silicon Valley Employers Forum, a trade association of high-tech employers collaborating on innovative delivery of both domestic and international benefits.   07:16 What does inertia actually mean in the healthcare benefit space? 08:02 “Fixing healthcare is not really the benefit manager's job.” 08:22 How could a benefit manager's job actually do the opposite of making healthcare better? 10:56 EP358 with Wayne Jenkins, MD. 11:56 “Americans are in pain.” 13:31 Why do benefits managers partner with consultants, and why is that bad? 14:17 “Benefit departments are cost centers; they're not revenue centers.” 15:30 “Every single company is in the healthcare business.” 16:40 EP397 with Paul Holmes. 18:12 Why relationships with consultants can make it very difficult for benefits departments to change. 22:46 Is the juice worth the squeeze? 23:12 “There's not one silver bullet that fixes healthcare.” 27:42 What is status quo bias? 28:56 Why employers may not be able to stay with their legacy vendors and also change for the better. 30:56 EP244 with Lee Lewis.   You can learn more about Lauren's work by connecting with her on LinkedIn.   @laurenvela1 discusses #benefitdepartments and #selfinsuredemployers on our #healthcarepodcast. #healthcare #podcast #digitalhealth #hcmkg #healthcarepricing #pricetransparency #healthcarefinance   Recent past interviews: Click a guest's name for their latest RHV episode! Dale Folwell (Encore! EP249), Eric Gallagher, Dr Suhas Gondi, Dr Rachel Reid, Dr Amy Scanlan, Peter J. Neumann, Stacey Richter (EP400), Dawn Cornelis (Encore! EP285), Stacey Richter (EP399), Dr Jacob Asher  

So, let's talk about North Carolina. What a weird outlier of the direction of other states getting active on their healthcare spend. I'm talking about Texas, Indiana, Wisconsin ... I'm naming so-called red states because the legislature in North Carolina is a Republican majority. Gotta say, normally I'm down for a little weird. I find it mostly charming. But with the information I have at present about what's going on in North Carolina, I don't love this for you. And when I say “you,” I pretty much mean any family who happens to live in North Carolina or any businesses in North Carolina trying to afford their employee health benefits right now. This whole shebang and the reason I'm covering this on Relentless Health Value is that it is also extremely relevant to anybody else in this country as a case study or a cautionary tale, depending on your point of view. So look, there's two pieces of legislation running through North Carolina's Senate and House right now, but both of these pieces of legislation—one that Blue Cross Blue Shield (BCBS) is angling for and the other one that UNC, a big hospital chain in North Carolina is all hachi machi to get passed—both of these have precedents. Both of these things were done elsewhere, and the results were not great, to put it mildly. BCBS wants to be able to open up a holding company that is able to take BCBS policyholder payments and invest them in for-profit ventures—BCBS being a nonprofit and all. Here's a quote Chris Deacon mentioned on LinkedIn from an article on this topic: “A 2019 examination of the aftermath of 11 conversions of BCBS affiliates showed that fully insured premiums increased roughly 13 percent … suggesting a post-conversion exercise of market power. Significantly, rivals of these large converting insurers also raised their prices following the conversions.” And here's a link to a Health Solutions podcast with Cristy Gupton, Chris Deacon, and North Carolina Commissioner Mike Causey. So, that's one of the pieces of legislation on the docket. Then, on the hospital side of the equation, we also have a proposed bill that could give UNC Health Care a green light to expand and buy more physician practices and hospitals without as much oversight. Proponents of the bill say that this will better enable UNC to take over struggling rural hospitals in danger of closing. Considering that UNC has already taken over rural hospitals in danger of closing, not exactly sure how or why basically removing federal and state antitrust scrutiny is helpful here. I went around looking for evidence that if you reduce antitrust scrutiny and enable more unfettered consolidation and expansion that population health outcomes improve. I could not find any. I did find lots of great talking points, but all of them seemed a little light on the evidence. There is, however, an insane amount of evidence at this point that shows unfettered hospital chain consolidation harms local communities from a financial standpoint without improving the quality or outcomes of patient populations, especially when hospital chains, in conjunction with third-party payers, are not willing to share their pricing, even with their largest customer. But I'm getting ahead of myself, because this is exactly what I'm talking about in this 2019 interview with Dale Folwell, the state treasurer of North Carolina. And it is a doozie of a frustrating story, just to cut to the chase. Look, you might be able to hear I definitely have an opinion formed on this topic, and I don't want to sway yours until you look into all of this yourself. But I loved what Jeff Leston wrote the other day. He wrote, “The North Carolina Legislature proves that they report to the healthcare industry in the State, not the people who actually elected them.” Okay … teeing up the interview today, this whole thing started when the North Carolina State Employees Health Plan (SEHP) crafted a proposal to pay network hospitals based on a transparent pricing schedule. Considering that SEHP purchases benefits for 720,000 people in North Carolina at a cost to taxpayers of billions of dollars, this seems reasonable. When you're the fiduciary of thousands of dollars, let alone add six more zeros, it would seem to be nonnegotiable to actually see the numbers and not write a check to a black box. Nonetheless, a few of North Carolina's largest hospital chains disagreed. They wanted to bill whatever they wanted to bill shrouded in a cloak of secrecy. In this healthcare podcast, as I mentioned earlier, I am speaking with North Carolina State Treasurer Dale Folwell. This is a rebroadcast from an interview in 2019 but still, somewhat sadly, completely relevant.   You can learn more at nctreasurer.com. You can also connect with Treasurer Folwell on Twitter at @DaleFolwell or on Facebook at Dale Folwell.     Dale R. Folwell, CPA, was sworn in as State Treasurer of North Carolina in January 2017. As the keeper of the public purse, Treasurer Folwell is responsible for a $100 billion state pension fund that provides retirement benefits for more than 900,000 teachers, law enforcement officers, and other public workers. Under Treasurer Folwell's leadership, the pension plan was rated among the top five highest funded in the country and won accolades for proactive management and funding discipline. In 2018, the state's coveted AAA bond rating was reaffirmed by every major rating agency, making North Carolina one of only 13 states in the country to hold that distinction. Treasurer Folwell also oversees the State Health Plan, which provides medical and pharmaceutical benefits to more than 720,000 current and retired public employees and is the largest purchaser of healthcare in North Carolina. Folwell was first elected to public office as a member of the Winston-Salem/Forsyth County Board of Education. He brought his problem-solving skills to the North Carolina General Assembly in 2004, where he served four terms in the House of Representatives, including one term as Speaker Pro Tempore. Treasurer Folwell began his career as a blue-collar worker and became a Certified Public Accountant and investment advisor after earning bachelor's and master's degrees in accounting from UNC-Greensboro.   05:59 The North Carolina state spend on healthcare. 07:21 “In medical terms, why has this become acute?” 08:00 One week of work for starting North Carolina troopers and teachers out of every four is going to family healthcare costs. 09:14 The problem of health insurance vs healthcare. 09:59 “If they can do this to the largest customers in this state … imagine what they can do to them.” 10:20 “This is about the industry whose whole business model is based on secrecy.” 11:47 “We've already focused on the why, and now we're [focusing] on the how.” 12:46 “We're trying to attack a problem.” 15:46 What the Clear Pricing Project aims to do. 18:08 “We're not trying to be disruptive; we're trying to fix a problem.” 19:55 Why the Clear Pricing Project went the self-insured route and how that's worked for them. 24:14 Who's behind the institutions fighting transparent pricing in North Carolina. 25:15 Instances where the Clear Pricing Project could actually stand to help rural hospitals make more money. 27:29 Dale's advice for other states trying to do this. 28:49 Dale's message to healthcare providers out there who want to see this change to price transparency.   You can learn more at nctreasurer.com. You can also connect with Treasurer Folwell on Twitter at @DaleFolwell or on Facebook at Dale Folwell.   @DaleFolwell discusses #financialtoxicity in #healthcare on our #healthcarepodcast. #podcast #digitalhealth #hcmkg #healthcarepricing #pricetransparency #healthcarefinance   Recent past interviews: Click a guest's name for their latest RHV episode! Eric Gallagher, Dr Suhas Gondi, Dr Rachel Reid, Dr Amy Scanlan, Peter J. Neumann, Stacey Richter (EP400), Dawn Cornelis (Encore! EP285), Stacey Richter (EP399), Dr Jacob Asher, Paul Holmes  

Paul Holmes, Founder and Chair of PRovoke Media, explains why companies should not only lead with their values but obtain a greater business purpose. Paul discusses current events such as the Disney lawsuit and Bud Light's recent ad campaign. Paul also reflects on the growth of the PR industry. Read Paul's article here: https://www.provokemedia.com/long-reads/article/the-pr-industry-needs-to-defend-business-against-anti-%27woke%27-ideologues

Let's cut to the chase. You've gotten to the point where you have a gang of physicians/clinicians/physician practices who have expressed a desire to work together. What do you need to know right now? Eric Gallagher, CEO of the Ochsner Health Network, is my guest in this healthcare podcast; and I largely asked him the same question that I had asked Amy Scanlan, MD, from the UCHealth/Intermountain clinically integrated network in Colorado in episode 402 a couple of weeks ago. The question I asked both Eric and Dr. Scanlan is: What are you doing to help align physician practices into an integrated model? How are you going about that? Now, let me remind you, Ochsner Health Network is practically long in the tooth when it comes to clinically integrated networks; and it also exists in an environment that is unique, as are most local markets. But Ochsner's local market is mostly Louisiana, which has an older population and a huge Medicare Advantage penetration. That is quite a different local market from what's going on in Colorado, which is the location of Dr. Scanlan's joint. As we all know, different stages of any journey require different solution sets; and different local markets certainly require different solution sets. But what was so interesting to me was to notice that despite the market differences and the where-are-we-in-the-transformation-journey differences, how many of the things that you'll hear about in this episode are in the same spirit as the stuff that we talked about in that earlier show with Dr. Scanlan. Eric Gallagher lists three things that he says are essential in the transformation journey: 1. Making sure that physicians, care teams, and those working directly with patients are part of the transformation process, both from a practice standpoint but then also from a financial standpoint. This makes so much sense when I state it explicitly here, but so frequently, it doesn't happen. So frequently there's a value-based care team that tinkers around in a silo and then an announcement comes over the loudspeaker one day that henceforth we shall add some more clicks … but trust us, it's important for some reason we aren't going to bother to tell you about … you'd be bored by it or you wouldn't understand it. Even if this was not the intention (and it probably wasn't), the result is going to be the bad taste in your mouth that I just left you with. Eric Gallagher's #1 here, that everybody be part of the transformation, might be the umbrella really over the first thing that Dr. Scanlan talked about in that earlier episode, which was to make sure to give practices the tools that they need to succeed—not what you think they need but what you've discerned they actually need because you've listened to them. It's a bidirectional exchange here with everybody working together. Eric adds some new ground to that. He says that to make sure that everybody can productively contribute to this transformation process (and probably know what tools they may need), it's vital that everybody understands the “why” behind what the organization needs to do, meaning educating physicians and other clinicians in the business of medicine and the financial reasons for the “why” with the whatever. Insulating docs from the real world here helps no one, and it's not really viable actually in the world that we live in today … … which is a callback to the point that Denver Sallee, MD, made also in episode 402, which, in a nutshell, was that he thinks that unless docs, as a gang, start learning a lot more about the business of medicine, that we'll continue to see this value extraction and financial toxicity and moral injury–inducing environments that we see right now. Dr. Sallee wrote, “I needed more education in order to truly help patients.” So, let me posit that this “everybody works together and gets educated together” step can help the practice and help patients in a myriad of ways, both at the practice level and at the patient level and also probably at a national level. 2. A recognition that practice transformation requires process transformation and thinking about things very differently. Now, all of a sudden, we are getting paid to coordinate care. We must work as a team because there are people on staff who can influence social determinants of health, for example. We have a vested interest to create a community board advocating for food banks and sidewalks and air pollution controls so all the kids who play soccer don't wind up with asthma. Ochsner actually set up a school because they realized educated communities are healthier communities. Dr. Scanlan's clinically integrated network? They're much earlier in the journey. They're at the point where they're working hard to get participating practices the tools that they need to succeed and help doctors and other clinicians help patients through what Dr. Scanlan calls the “in-between spaces”—the times between appointments. But all of this really rolls up to the point that Eric Gallagher is making about everybody working together and recognizing that practice transformation requires process transformation. 3. The culture change that's necessary among physicians and other clinicians (pretty much everybody), and Dr. Amy Scanlan leaned into this one, too—hard. Both brought up the same nemesis: inertia. And the requirement to change culture can't be underestimated, and the change management that's required here cannot be phoned in. Culture eats strategy for breakfast, lunch, and dinner, as they say. My two macro-level takeaways after talking with Eric Gallagher today and Dr. Amy Scanlan earlier are that, even though the local market and the nuances of any given particular practice have such a huge impact on what's going to work at an operational and tactical level, if we stay up in the strategic zone, there's some best practices and points to ponder which are likely possible to universalize. Now, emphasis on the “stay up in the strategic zone.” I was just talking to another person today with yet one more story amounting to “it didn't work because it never was going to work,” wherein, in this case, apparently a very large payer is running around attempting to do a pilot in an attempt to learn exactly and specifically how to operationalize something, and then their plan is to roll out this one model nationwide. So, something works in one local market at one practice, and we're just gonna assume if it worked there, it's gonna work everywhere. And, yeah … good luck with that. After you listen to this show, listen to episode 402 with Amy Scanlan, MD, as I have mentioned multiple times. Episode 343 and episode 316 with David Carmouche, MD, would be good to check out. Also episode 393 with David Muhlestein, PhD, JD, and episode 394 with Vikas Saini, MD, and Judith Garber, MPP.   You can learn more at Ochsner Health Network.     Eric Gallagher, chief executive officer for Ochsner Health Network (OHN), is responsible for directing network and population health strategy and operations, including oversight of performance management operations, population health and care management programs, value-based analytics, OHN network development and administration, strategic program management, and marketing and communications. Prior to joining Ochsner in 2016, Eric held leadership positions in healthcare strategy and execution—including roles at Accenture, Tulane University Health System, and Vanderbilt University and Medical Center. A New Orleans native, Eric earned a bachelor's degree in human and organizational development from Vanderbilt University and an MBA from Tulane University.   08:14 What does everyone need to be on the same page about when it comes to clinical integration? 13:42 “For physicians, we really have to overcome this threat to physician autonomy.” 16:52 “Health inequity is really just societal inequity.” 19:24 What is the principal agent problem? 20:00 “There are things health systems can do that are probably outside of their traditional field of responsibility.” 20:09 Why did Ochsner Health Network start a couple of schools? 20:42 What can empower a care team in a value-based care model? 21:53 Why is it important to transform into a team-based model? 23:24 “In the DNA of our organization, resiliency runs strong.” 26:01 Why is building an effective care model easier than building trust with patients? 26:14 What is Eric's advice to physicians trying to integrate right now? 28:50 How do you get everyone on the same side of aligning for integration?   You can learn more at Ochsner Health Network.   Eric Gallagher of @OchsnerHealth discusses #clinicalintegration for #physicians on our #healthcarepodcast. #healthcare #podcast   Recent past interviews: Click a guest's name for their latest RHV episode! Dr Suhas Gondi, Dr Rachel Reid, Dr Amy Scanlan, Peter J. Neumann, Stacey Richter (EP400), Dawn Cornelis (Encore! EP285), Stacey Richter (EP399), Dr Jacob Asher, Paul Holmes, Anna Hyde  

So much of this episode (and this podcast as a whole, really) is about one consistent theme: How do we reset or redesign our healthcare industry, including hospital chains—mostly talking about the big consolidated ones that have a lot of money here—but how do we redesign these leviathans to be more consistent with our values as a country and the values of the doctors and other clinicians and others who work in these places and who went into the healthcare profession for a reason that had, you know, something to do with patients? And I mean something to do with patients that doesn't involve dressing up for Halloween as a giant cardboard dollar sign, like some finance department guy did at one large nonprofit hospital in the spirit of shaking money out of poor patients (see article here). Or listen to previous episodes about hospitals raising prices way higher than the rates of inflation. Not to belabor this because we've already talked about it so very often, but you also have the whole thing with big, well-funded, nonprofit hospital chains going on cost-cutting extravaganzas and, at least in one case, basically creating their own staffing crisis. Do these activities have a familiar ring to them? Do they strike you as a page out of a playbook you may have seen elsewhere? I don't know about you, but they remind me of things that private equity or financial folks run around doing. I mean, the classic stepwise for how to maximize the financial value of an “asset” from a financial industry standpoint is to cut costs and raise prices. Piling on this “kind of sounds like a B-school group project” thesis, what about the thing with a bunch of these big, consolidated hospital systems with rich endowments crying crocodile tears about how much money they lost last year? Except … in a whole bunch of cases, the money they lost—some of which came from the COVID CARES relief act funds they got, by the way—but this money was lost when their risky stock market investments tanked. Those are their losses. Stock market losses. From speculative investments. Are you kidding me? But hospitals are charities, right? They are nonprofits. They aren't owned by private equity. They aren't owned by an investment bank or a team of financiers, so you wouldn't expect them to be acting like they are owned by Wall Street. But … oh, wait … how weird. You know who is on the boards of some of these very well-known nonprofit hospitals? If you don't, I'm not surprised, because in too many cases, if you ask me, you have to dig around in tax filings and other bureaucratic paperwork to unearth the names of these members who have quite a large amount of power (it turns out) over what goes on in the hospital. But you know who is on these boards? Yeah … almost half of board members tend to have a financial background. Almost none of them are nurses. And what about doctors? Are physicians on these boards? Well, almost one-third of hospital boards did not have a single physician member. So, there's that. Here's a quote from a STAT news article written by my guest in this healthcare podcast, Suhas Gondi, MD, MBA, and also Sanjay Kishore, MD, about a study that the two of them coauthored about who is on hospital boards. Here's the quote: Our findings are cause for concern. If hospital executives are largely held accountable by finance professionals and corporate leaders, instead of by clinicians and patients, might they focus more on revenue and expenses than the needs of their communities or staff? While some argue that margin facilitates mission, the measure of a nonprofit organization is how these priorities are balanced by leaders who ultimately answer to their board. So, I get there's balance. You have to be financially sustainable. But I also get that, apparently, tigers don't change their pinstripes. The pin-striped suit remains even when the finance tigers become the board members of a charitable organization that's supposed to be serving the surrounding community paying its freight in the form of its tax exemptions. This is what this conversation is about today: Who is on these hospital boards? How much power do these hospital boards have? And what might be done to switch it up some so that we can get hospitals that are reflective of our values as a nation and what we want for ourselves and our families? Today, as aforementioned, I'm speaking with Suhas Gondi, MD, MBA, who, along with his coauthor Sanjay Kishore, MD, wrote a paper on this exact topic. Check out some great Tweets and comments. Following are some suggestions that Dr. Gondi makes in this podcast interview that follows to help us get a little less misaligned. Here's one mandate and three suggested models for current hospital boards, which (let's get real) are currently comprised a lot of times of a group of people making decisions in closed boardrooms that impact a whole lot of people. First of all, there should be transparency about who is on the board and what they are doing in those closed rooms—what decisions they are making. Second of all, the IRS could surely mandate that for anybody looking to get tax-exempt status, certain requirements are in order for the boards of said organizations. Then here's three suggested models to consider: 1. At other kinds of charities and even healthcare organizations with clear missions, like Federally Qualified Health Centers (FQHCs), the composition of the boards is mandated; and for FQHCs, 50% of the board has to be patients who are patients at the FQHC, for example. And, yeah with this. Hospitals are tax-exempt entities. That means that others in the community are paying more in taxes so that this hospital isn't paying taxes. This hospital, therefore, is in debt to the community. Having a board that is reflective of the community could be one way to ensure that this hospital has an accountability to that community and can serve its needs adequately. 2. NASDAQ requires that two members of every board have some “under-represented” diversity, so that could be a thing. You could add to that professional background diversity. I was looking at a Web site the other day featuring a team photo with the caption something like “Here's our diverse team,” and the entire photo was of, I'm going to say, literally 30+ white men. The caption clarified that they all had different experiences … in the pharmacy benefit administration space. So, nothing against white men, but … yeah, it might be a good idea to align as a community on a broad definition of diversity and what “reflective of the community” means. 3. Accountable capitalism. This was originally suggested by Senator Elizabeth Warren, who argued that 40% of boards should be elected by workers. So, not the majority of the board but enough of the board that it becomes accountable to frontline workers and others.   You can learn more by connecting with Dr. Gondi on Twitter and LinkedIn.     Suhas Gondi, MD, MBA, is a resident physician in internal medicine and primary care at Brigham and Women's Hospital. As an EMT in his hometown in Virginia, he saw how structural barriers impact access to healthcare for vulnerable patients. He dedicated himself to studying medicine and policy together with the goal of building a healthcare system that delivers better outcomes and prioritizes equity. His academic work focuses on incentives in our healthcare system and how they shape the behavior of providers and payers. His work on healthcare payment and delivery system reform has been published in the New England Journal of Medicine, JAMA, and The Lancet and has been cited by the Medicare Payment Advisory Commission. His advocacy and writing have been featured by CNN, NPR, New Yorker, and USA Today. He graduated from Harvard Medical School and Harvard Business School and previously served on the White House Health Equity Leaders Roundtable.   05:26 What's a hospital board, and how much power do they have over goings-on? 06:51 How big is a hospital board typically? 07:45 How powerful is a hospital board actually? 09:12 What percentage of these board members have roles within the finance industry? 10:04 What percentage of these hospital board members are health professionals? 10:47 How do these hospital boards work? 12:44 Have hospital boards always been made up of financial board members, or is this a recent thing? 18:12 “The private equity model … fundamentally changes the incentives of the organization.” 23:21 Are hospital boards a potential place to create change within the healthcare industry? 25:16 “It's about who has power.” 30:55 What's the hope with diversifying hospital boards?   You can learn more by connecting with Dr. Gondi on Twitter and LinkedIn.   @suhas_gondi discusses on our #healthcarepodcast who is on #hospitalboards. #healthcare #podcast Recent past interviews: Click a guest's name for their latest RHV episode! Dr Rachel Reid, Dr Amy Scanlan, Peter J. Neumann, Stacey Richter (EP400), Dawn Cornelis (Encore! EP285), Stacey Richter (EP399), Dr Jacob Asher, Paul Holmes, Anna Hyde, Dea Belazi (Encore! EP293)

When PR agency founders move on, they face several choices about the fate of their business. In this episode, Paul Holmes interviews second-generation leaders from three PROI partner agencies that remained independent after their founders stepped down and the implications for everyone involved. 

This is a conversation about physician compensation, which is often oddly misaligned from the way that the whole physician or provider organization is getting paid. Now, first thing to point out: There are lots of different kinds of physicians doing all kinds of different things. As with most everything in healthcare, lumping everybody together and making general proclamations about what is best is a really cruddy idea. With that disclaimer, if you think about the main models of physician compensation, there are two; and this is oversimplified, but let's call one fee for service (FFS), which is really getting paid for generating RVUs (relative value units)—in short, getting paid for volume. The more you do (especially the more expensive things you do), the more you get paid. And then we have getting some kind of capitation payment. A capitated payment is some kind of per member per month-ish flat payment to ideally keep patients healthy, and you will make the most money if you can figure out how to have the least volume of expensive stuff. As an individual doc getting a salary to care for a patient panel of a certain size, let's just consider commensurate with that. These incentive models obviously have a big impact on any given doctor's ability to get paid to do things that they think they should be doing. For example, the current fee-for-service RVU fee schedule frequently rewards those doing the stuff a lot of specialists do much more than those doing primarily cognitive work, including those doing work for patients who aren't sitting in the exam room at the time—like a PCP arranging for a patient to go to hospice or answering patient portal questions. In my opinion, the goal here should be to pay docs and others fairly for providing high-value care. These payments also should actually be proven to actually incent that high-value care. Here's the obvious problem: Neither of these two things, either the quantifiable definition of high-value care and/or the best way to pay for it, has any kind of canon. There are no rules which are considered to be particularly authoritative and definitive here, really. So, what is the downside of not aligning physician compensation models to what good looks like, meaning to the kind of care that patients really need in that particular community? A couple of downsides for you: One is moral injury. Not the only reason, but a reason for moral injury is getting paid in misalignment with what is best for patients. That sucks. You want to help your patients as best you can, and then you can't earn a living and/or you get in trouble with the boss if you do what you think is right. This can cause real mental anguish for especially PCPs but also others who see the need to do anything that doesn't have a billing code. Here's another downside to not worrying about physician compensation, and it's for plan sponsors (employers, maybe) who are trying to get integrated care or a medical home for their employees. I was talking to Katy Talento about this. She was telling me that in ASO (administrative services only) contracts, there are often line items for value-based care and for capitated payments. So, good news? Well, let's follow the dollar here, because we wind up with a disconnect that doesn't help patients but certainly can earn a nice little kitty for those who can get away with it. Here's where that dollar goes: This VBC (value-based care) or capitated payment kitty may go to a health system that the ASO says is to be a medical home for employees or plan members. But the PCPs mainly who are treating members in those medical homes are getting paid, it often turns out, fee for service with maybe some quality kickers. So, the plan is paying a value-based care payment, but the PCPs are getting paid FFS. Is anyone shocked when the members report that they don't actually feel like they are getting integrated care, that they are getting rushed in and out because maximizing throughput becomes a thing when you're getting paid for volume? Dan O'Neill also talks about this at length in episode 359, because IPAs (independent physician associations) are doing kinda the same thing. Getting so-called value-based care contracts with MA (Medicare Advantage) plans or CMS or employer groups, I'd imagine, and then paying all the individual practices or the solo practitioners fee for service and scooping up the excess payments themselves, most docs manage to provide high-enough-quality care that the contract holder can scoop up the profit off the capitation without actually having to share the capitation to achieve this high-enough-quality care. In this healthcare podcast, I am digging into all of this physician compensation ballyhoo with Rachel Reid, MD, MS. She was an author on a study at the Center of Excellence on Health System Performance at RAND. This study specifically set out to look at how health systems and provider organizations (POs) affiliated with those health systems incentivize and compensate the physicians who work there. Short version: Yeah, it's confirmed. Most docs are paid using the classic RVU productivity measures representing a big chunk of their compensation, even PCPs. There's frequently some kickers or extra payments to achieve some kind of quality metric, but this is the icing, not the cake. The cake is still very fee for service-y. This is true regardless of how the physician organizations, the provider organizations themselves are getting paid by payers. I asked Dr. Rachel Reid a bunch of questions about this, but one of them was (this seems weird, a weird misalignment), Why is this happening? And Dr. Reid listed out five reasons beyond the macro existential question of what is value and do we even know how to change human behavior to get it. 1. The payment is not big enough from the payer for the physician organization to go through all the time and trouble and risk frankly of changing the whole comp model. 2. The value-based payment arrangements that do exist at the organizational level often have a fee-for-service chassis with an icing of quality payments or some kind of value payment on top of it. So, maybe there's actually more alignment than we might think. 3. It's hard to try to change comp models—it's a thing. And there is risk in messing it up. 4. Inertia. The ever-present inertia. 5. We know what we want to move from, but what exactly are we moving to? And this “What do we want to move to?” is going to change for PCPs and for every single different specialty and could even vary by patient population. I then also asked Dr. Reid what could be done by plan sponsors, for example, to pay docs in alignment with the goals of the contract; and she said, write physician comp expectations into the contract. Something to think about. We dig into all of this today. Shows that you should, for sure, listen to for additional insights include the one with Dan O'Neill (EP359) as aforementioned. Also the show with Brian Klepper, PhD (AEE16), where we dig into how the RUC is behind some of these FFS rates. Also episode 391 with Scott Conard, MD. My guest today is Rachel Reid, MD, MS. She is a physician policy researcher at RAND Corporation and a primary care physician at Brigham and Women's Hospital.   You can learn more about Dr. Reid, her publications, and the work she has done on the RAND Web site.     Rachel Reid, MD, MS, is a physician policy researcher at the RAND Corporation. Also a practicing primary care physician, her research focuses on measuring cost, quality, and value in healthcare. She has particular interest in the primary care delivery system, physician payment and compensation, and delivery and payment system reform. Dr. Reid has been engaged in the RAND Center of Excellence on Health System Performance, assessing health systems' compensation and incentives for physicians, leading work related to assessing low-value healthcare delivery, and measuring primary care spending. She is the principal investigator on an NIH-funded grant assessing novel Medicare billing codes for transitional care provided after hospital discharge. Prior to joining RAND, Dr. Reid worked in the Research and Rapid Cycle Evaluation Group at the Centers for Medicare & Medicaid Services' Innovation Center. Her clinical work has included ambulatory primary care and hospital-based internal medicine. She is an associate physician at Brigham and Women's Hospital and an instructor in medicine at Harvard Medical School. Dr. Reid received her AB in biochemical sciences from Harvard University and her MD and MS in clinical research from the University of Pittsburgh School of Medicine.   07:13 What did Dr. Reid's recent study show about how doctors are currently being paid and incentivized? 08:11 Why Dr. Reid decided to do the study in the first place. 09:49 What are the main foundations of what doctors are paid on? 10:31 Why is value-based compensation still just the “icing” on the cake? 13:08 What is the biggest value add for doctors, and does it vary between specialties? 14:32 Why wouldn't a physician organization change their comp models? 19:55 Are we at a moment of evolution? 20:20 “Tying dollars to measured quality gaps doesn't necessarily produce results.” 20:42 EP295 with Rebecca Etz, PhD. 22:04 “I don't think there's a current gold standard for how to pay doctors.” 25:37 Job one: What are we trying to incent? 31:28 From the payer or insurer perspective, what's the leverage they have to change doctor compensation?   You can learn more about Dr. Reid, her publications, and the work she has done on the RAND Web site.   Rachel Reid, MD, MS, of @RANDCorporation discusses on our #healthcarepodcast how doctors get paid. #healthcare #podcast   Recent past interviews: Click a guest's name for their latest RHV episode! Dr Amy Scanlan, Peter J. Neumann, Stacey Richter (EP400), Dawn Cornelis (Encore! EP285), Stacey Richter (EP399), Dr Jacob Asher, Paul Holmes, Anna Hyde, Dea Belazi (Encore! EP293), Brennan Bilberry

So, let me just cut to the chase here with very little preamble, and all of this is a setup to the interview that follows, although it is not really what the interview that follows is all about. A mentor of mine used to say, you can't legislate the heart. Let me also suggest you can't give someone in finance financial incentives and then expect them to not prioritize financial incentives. It stands to reason that if the healthcare industry is found to be quite attractive to those who are money focused, then do I need to say this? The money focused amongst us will, of course, do the whatever to the extent that they can make money. They aren't gonna be throwing their backs into quality or cost effectiveness or taking care of patients. They are throwing their backs into making money. Is anyone shocked? Now, don't get me wrong; I'm not a Pollyanna. And in this country, in order to run a healthcare business, you have to make money; otherwise, you'll go out of business. So, do well by doing good and all of that. But how much money is too much money? This is an important line to figure out because that's where you are doing well but you've stopped doing good—you've tipped into financial toxicity. You are taking more than the good you are doing, and the net positive becomes a net negative. But complicating fact of current life, it's becoming increasingly obvious that in order to stand up a practice that can take advantage of value-based care payments—payments where primary care docs mainly at this time can get paid more and likely more fairly to care for patients well—you need a lot of infrastructure. You need data, you need tech, you need a team. Translation: You need money, maybe a lot of money, to invest in all of this. And let me ask you this: Who has a lot of money in this country? Here's the point of everything I just said: These are the external realities that hit anyone trying to do right by patients from every direction. But on the other hand (or maybe different fingers on the same hand), as Amy Scanlan, MD, says in this healthcare podcast, physicians are the backbone of this system. Dr. Scanlan talks in the interview today about the opportunity, and maybe the responsibility, that physicians have here for patients; but also the Eric Reinhart article comes up again about rampant physician moral injury (unpaywalled link with my compliments). Right now might be a great time to read something from Denver Sallee, MD. He wrote to me the other day. He wrote, “Like many physicians, I did not have much understanding of the business side of medicine, as I mistakenly thought as long as I helped take great care of patients that I was doing my job. More recently, it became apparent to me that by ceding the management of medicine to nonclinical administrators and to companies interested primarily in value extraction for the benefit of shareholders that I needed more education in order to truly help patients.” Today as aforementioned, I'm talking with Amy Scanlan, MD, who is chief medical officer of the clinically integrated network (CIN) that is the new joint venture between Intermountain Health and UCHealth in Colorado. We talk about what it's like to be in the kind of messy middle of transformation to integrated care in a clinically integrated network, trying to figure out how to help physician practices and the CIN itself navigate the external environment in a way that empowers different kinds of practices at different points in their transformation journey that empowers physicians to be in charge, and considering clinical and financial outcomes (ie, the business of healthcare). Dr. Scanlan brings up four main factors to consider when plotting strategy from here to there: 1. Give practices the tools that they need to succeed—not what you think they need but what you've discerned they actually need because you've listened to them. 2. Many times, these tools will consist of some combination of data, tech, and also offering the team behind the scenes to help doctors and other clinicians help patients through what Dr. Scanlan calls the “in-between spaces”—the times between appointments. 3. Medical culture really has to change, and in two ways: doctors learning how to be part of and/or leading functional teams and building functional teams. Because there are teams, and then there are teams. Well-functioning teams can produce great results. Nonfunctioning teams, however, are, as Dr. Scanlan puts it, just a series of handoffs. And don't forget, handoffs are the most dangerous times for patients. The DNA of team-based care—real team-based care—for better or worse, are the relationships between team members, between physicians who work together, between doctors and patients, between clinicians and clinicians. So, fostering relationships, creating opportunities to collaborate and talk, is not to be underestimated. How do you re-create the doctors' lounge in 2023? 4. Getting out from underneath the long shadow of fee-for-service incentives, specifically the paradigm that only patients who get mindshare are the ones in the exam room. Value-based care, integrated care is as much contemplating the patients who don't show up as the ones who do. This is a really big mind shift, much bigger than many realize.   You can learn more by reaching out to Dr. Scanlan on LinkedIn.     Amy Scanlan, MD, serves as chief medical officer for the new joint venture CIN between UCHealth and Intermountain Health—a physician-led, clinically integrated network of more than 700 primary care providers from UCHealth, Intermountain Health Peaks Region, the University of Colorado School of Medicine, and multiple independent practices along the Front Range. Dr. Scanlan trained as a family practice physician and has continued to practice for the past 25 years. She has worked as a physician-owner in a small independent practice and has held multiple leadership positions as part of large health systems. She has served on numerous health system committees spanning quality, innovation, recruitment, and credentialing. She is very familiar with value-based care models, having been part of an accountable care organization (ACO) practice for the past 15 years, as well as participating on an ACO Practice Performance and Standards Committee and serving on a local ACO board. She received a bachelor's degree with honors from Wesleyan University in Connecticut. She obtained her medical degree from Case Western Reserve University in Cleveland, where she received the Kiwala Award for Research in Family Medicine. Her residency was completed at St. Anthony's Family Medicine Residency program in Denver. She is currently board certified by the American Board of Family Medicine and NCQA (National Committee for Quality Assurance) certified in diabetes.   06:33 How is Dr. Scanlan thinking about the transformation process and the shift to value? 09:14 “It is really trying to think about, how do we help practices get there?” 11:46 “The hard part is the in-between spaces.” 14:10 “Team-based care done badly is really just a series of handoffs.” 15:50 “We have to get to that point where the culture of collaboration is more pervasive.” 19:57 “How do we as healthcare providers step in and solve this problem?” 20:04 Why do providers have a responsibility to step in and try to fix the healthcare system? 20:20 Article (unpaywalled) by Eric Reinhart, MD, PhD. 21:50 Why do physicians need to be accountable for the cost of care as well as outcomes? 23:37 Why does physician burnout give Dr. Scanlan hope? 24:25 What is the solution to changing fee-for-service incentives? 25:42 What are some of the challenges facing changing incentives? 27:14 Why is data so important? 28:53 EP393 with David Muhlestein, PhD, JD. 30:11 “It's important to understand that we are in the middle of this change.” 31:16 Dr. Scanlan's advice for those trying to stand up a CIN.   You can learn more by reaching out to Dr. Scanlan on LinkedIn.   Amy Scanlan, MD, of @uchealth discusses real-world #clinicalintegration on our #healthcarepodcast. #healthcare #podcast   Recent past interviews: Click a guest's name for their latest RHV episode! Peter J. Neumann, Stacey Richter (EP400), Dawn Cornelis (Encore! EP285), Stacey Richter (EP399), Dr Jacob Asher, Paul Holmes, Anna Hyde, Dea Belazi (Encore! EP293), Brennan Bilberry, Dr Vikas Saini and Judith Garber  

Somebody wrote on Twitter the other day that he was gonna give a talk on the use of evidence in drug policy, and Barrett Montgomery replied, “That'll be a short talk then!” So, let's talk about the IRA (Inflation Reduction Act) for a moment, specifically the “CMS can negotiate for drugs for Medicare patients” part of the IRA. There's one topic I don't hear discussed what I would consider maybe often enough. Will these negotiations result in pricing that is evidence based? Will good drugs that companies developed using less taxpayer money for R&D, drugs that positively impact the patient lives or have spillover benefits for society or save downstream medical costs, drugs that have solid comparative evidence data, drugs that are a meaningful therapeutic advancement over competitors ... will these drugs be priced in line with that value? Everything I just mentioned, by the way, are things that CMS is supposed to take into account during its negotiations. So, that's what this show is all about. To have this conversation, I invited Dr. Peter Neumann on the podcast because Dr. Neumann (along with his two coauthors, Joshua Cohen and Daniel Ollendorf) just wrote a book about pharmaceutical pricing entitled The Right Price. I convinced Dr. Neumann to come on the show and talk about what the likely impact the IRA will have on these right drug prices. And short version, Dr. Neumann told me that “presumably drugs that offer more therapeutic advances will do better under these negotiations.” Here's a really, really top-line summary of the negotiation provisions that are in the IRA: CMS will negotiate prices on the highest gross spend top 10 Part D drugs in 2026, 15 Part D drugs in 2027, and 15 drugs from Medicare Part B and D for 2028. Small molecule drugs become negotiation contenders after 9 years, and biologics after 13 years. Once a generic or biosimilar comes out (ie, the patent is well and truly expired), then this negotiation provision is no longer in play. Now, CMS is given some discretion over how it's going to do things, and they will issue guidance and figure out how to implement the law over the next couple of years. As with so many things (and Chris Deacon talked about this recently on LinkedIn), it's how that law is operationalized that actually determines if it achieves this “right price” goal and/or—and Dr. Neumann, my guest in this healthcare podcast, makes this point really clearly, too—maybe the point of the law is as much about cost containment, frankly, as it is about achieving value-based “right” prices. And cost containment and value-based pricing are not the same thing. I'm gonna do a show on this coming up. So, what are the likely effects of the IRA pharma price negotiation provisions? And not talking about the whole IRA here and the cadre of other stuff like patient out-of-pocket caps and inflation caps. This show is complicated enough just talking about the negotiation portion and just talking about its potential to achieve pricing based on “value.” Here's a summary of likely impact of Medicare drugs being negotiated, some of which we talk about in this episode. There's “seven-ish” main implications: 1. “Some Medicare patients will benefit substantially from negotiations …, as a reduction in the drug's price will result in lower coinsurance and liability during the deductible phase.” Okay … this makes sense. 2. “Overall, negotiations are projected by the CBO [Congressional Budget Office] to reduce premiums, resulting in lower costs for all Medicare beneficiaries.” References: CBO estimates drug savings for reconciliation. Committee for a responsible federal budget. Accessed April 11, 2023. https://www.crfb.org/blogs/cbo-estimates-drug-savings-reconciliation  Congressional Budget Office. Estimated budgetary effects of Public Law 117-169, to provide for reconciliation pursuant to Title II of S. Con. Res. 14. Published 2022. Accessed April 11, 2023. https://www.cbo.gov/system/files/2022-09/PL117-169_9-7-22.pdf Okay … so, this #2 here is kind of thought provoking, especially when it's unclear at this time whether the negotiated price will refer to the list price, the AWP (average wholesale price), or the rebated price (ie, the price after rebates are applied). There are many, many implications if the negotiated price is before or after rebates, just given how “addicted” plans are to rebates and use the rebates, and cost shifting to patients, in a convoluted and super-inefficient way to try to keep premiums down. Listen to the show with Chris Sloan (EP216) for more on this. 3. There's more incentive to go after biologics than small molecule drugs—obvious, due to the 9-year versus 13-year thing. There's additionally some incentive for rare-disease and orphan drugs, most of which are biologics, in other parts of the IRA. 4. More interest in drugs for non-Medicare markets (ie, drugs for diseases of younger populations, perhaps) 5. Possibly less pharma innovation, fewer drug launches Oh, boy, with this one. Listen to the show with Mark Miller, PhD (EP380), for many, many nuances here. But let me give you a few things to think through, and I'd start with four words: We are chasing Goldilocks. There are two ends of the spectrum, and neither are good. On one end, Pharma charges way too much and the system gets bankrupted while pharma shareholders get rich. On the other side of the spectrum, there's not enough returns for any investors to invest in new drug development. It's all about moderation—finding the sweet spot in the middle—something the healthcare industry has a super hard time with. Bottom line, we want to incent meaningful innovation, drugs that actually work. If we pay a ton of money for drugs that don't work particularly well, then what's the incentive to find good drugs? As per my earlier point, if this legislation does as was intended, then good drugs should get rewarded and less comparatively effective drugs should be less rewarded. Let's cross our fingers, shall we? 6. Will Pharma raise its launch prices because the negotiations center on discounts? A higher price times the discount means a higher discounted price, after all. This one could be exacerbated by the part of the IRA that mandates inflation caps. There is some evidence that higher launch prices are already happening. 7. Manufacturers wait to launch until they have all their indications ready to go. If you didn't understand this, we explain in more detail during the interview. 8. There are incentives for Pharma to jack up commercial prices. Because they're making less money in Medicare, they try to make more money in the commercial market. But as Dr. Neumann says, you'd think that if Pharma could do that, they already would have done it. Or let me say that a different way: You'd think that if Pharma could have raised their commercial prices more than they already have been raising their commercial prices, they would have already done it. So, I think whether cost shifting actually increases here is a sizable question mark. 9. There's also less incentive for Pharma to innovate me-too kinds of drugs. If a drug in the same class for the same disease is being negotiated, then a new drug coming out in that same category might sort of have to charge a price similar to the negotiated price of the other drug. Dr. Peter Neumann, my guest in this episode, has a background in health economics and currently directs a research center that's focused on health economic issues. His group does a lot of work trying to understand the cost effectiveness of drugs and other health interventions. Other shows you should, for sure, listen to here are the ones with Mark Miller, PhD (EP380); Anna Kaltenboeck (EP303); Bruce Rector, MD (EP300); Scott Haas (EP365); and Chris Sloan (EP216). These shows offer context and adjacencies that are extremely relevant right now if you're gonna understand the potential impact of the IRA. Here's a quote from the book The Right Price (written by Dr. Peter Neumann and his coauthors, Joshua Cohen and Daniel Ollendorf) that I thought summed up some of the issues here very nicely: If there existed a Rorschach test for drug prices, it might conjure one of two images. Some people might perceive prices as a compass directing companies to invest in products that people value most. Aligning prices with value is akin to a “true north” orientation of the compass's arrow. Failure to link prices with value sends misleading signals to drug producers. Others might regard drug prices as a wall preventing patients from accessing the drugs they need. For them, the barrier should be as low as possible. But aligning prices with value might have little effect in lowering the wall. How then to accomplish that goal?   You can learn more at cevr.tuftsmedicalcenter.org or by reading The Right Price.   Peter J. Neumann, ScD, is director of the Center for the Evaluation of Value and Risk in Health (CEVR) at the Institute for Clinical Research and Health Policy Studies at Tufts Medical Center and professor of medicine at Tufts University School of Medicine. He is the founder and director of the Cost-Effectiveness Analysis Registry, a comprehensive database of cost-effectiveness analyses in healthcare. Dr. Neumann has written widely on the role of clinical and economic evidence in pharmaceutical decision-making and on regulatory and reimbursement issues in healthcare. He served as co-chair of the 2nd Panel on Cost-Effectiveness in Health and Medicine. He is the author or coauthor of over 300 papers in the medical literature and the author or coauthor of three books: Using Cost-Effectiveness Analysis to Improve Health Care (Oxford University Press, 2005); Cost-Effectiveness in Health and Medicine, 2nd edition (Oxford University Press, 2017); and The Right Price: A Value-Based Prescription for Drug Costs (Oxford University Press, 2021). Dr. Neumann has served as president of the International Society for Pharmacoeconomics and Outcomes Research (ISPOR). He is a member of the editorial advisory board of Health Affairs and the panel of health advisors at the Congressional Budget Office. He has also held several policy positions in Washington, DC, including special assistant to the administrator at the Health Care Financing Administration. He received his doctorate in health policy and management from Harvard University.   09:33 Is it imperative that drugs whose patents are expiring have their prices negotiated? 10:50 “We need innovation; we want to encourage innovation.” 11:01 Does this new law strike a balance between innovation and price regulation? 11:21 How are we assessing cost effectiveness and innovation in the drug space? 12:29 What's the problem with the current drug markets? 13:14 Why can't you rely on the drug market for the cost effectiveness of a drug? 14:13 Why very expensive drugs do not equate to poor value. 15:06 What are the likely outcomes of the IRA? 18:33 How does pharmacy budget factor into high-value drugs? 19:26 “Value-based pricing doesn't mean necessarily lower spending overall.” 22:59 What are the types of drugs that will be excluded from the IRA? 23:22 Who will the law create problems for? 24:44 What have pharmacy benefit managers (PBMs) been doing to move forward with the new law? 26:04 What are plan sponsors doing right now? 28:32 What are the most important value metrics according to Dr. Neumann?   You can learn more at cevr.tuftsmedicalcenter.org or by reading The Right Price.   @PeterNeumann11 discusses #drugprice #negotiations on our #healthcarepodcast. #healthcare #podcast   Recent past interviews: Click a guest's name for their latest RHV episode! Stacey Richter (EP400), Dawn Cornelis (Encore! EP285), Stacey Richter (EP399), Dr Jacob Asher, Paul Holmes, Anna Hyde, Dea Belazi (Encore! EP293), Brennan Bilberry, Dr Vikas Saini and Judith Garber, David Muhlestein  

I hope you listened to episode 399, which was Part 1 of this two-part exploration of my manifesto, meaning my aims and my path or framework to achieve those aims. Regarding the first part of my manifesto, episode 399 from two weeks ago, here's the tl;dl (too long, didn't listen) version; but please go back and listen to that show (Part 1) because it's about you—and it's a compliment and a thank you, and you deserve both. Just to quickly recap, Part 1 of my manifesto is that I started this show because I want to, and wanted to, provide information to those in the healthcare industry trying to do the right thing by patients, to get you the insights that you might need to pull that off, to create a Coalition of the Willing, as I've heard it called. When we get reviews like the one from Megan Aldridge, a self-proclaimed Relentless Health Value binge listener, I feel very gratified because it makes me feel like I'm chipping away at this mission and in a non-boring way. Thank you, Megan. Along these lines, there was also a recent review from Mallory Sonagere, who says she listens to learn new things and to be a little sharper at how she approaches her day job. And just one more I'll mention: I loved the review from Mark Nixon calling Relentless Health Value the best healthcare podcast out there. Every review like this I take as validation that maybe I can count some measure of success toward achieving the mission to empower others on their journeys to make it better for patients or to transform the healthcare industry. But this whole endeavor to create a manifesto is also borne out of me struggling personally to figure out what “having personal integrity” in this business actually means when it comes to deciding what to do and what not to do, when it comes to deciding who or what to try to help or support or who or what to step away from either passively or actively. I mean, how this podcast gets funded is my business partner and I pay for it with money from our consulting business and from some tech products that we have on offer. Who do we choose to take on as clients, and what are we willing to do for them or help them with? These are questions that literally keep me up at night. And this is what this episode, Part 2, is all about. It's about my struggle and how I attempt to navigate my own path forward. And holy shnikeys, it's tough to find a path, especially when you have the sort of perspective that I've wound up with over these past however many years. It can feel like no matter what I do, there's negatives as it relates to the Quadruple Aim. You raise one of the quadrants, and something else for somebody else certainly has the potential to be negatively impacted. We cannot forget here in the short term, but, for sure, often in the longer term as well, it's a zero-sum game. Every dollar someone takes in profit under the banner of improving health or even saving money is a dollar that someone else paid for. Is the amount of profit fair? Where'd that money come from? Is there COI (conflict of interest), and if so, what's the impact? I think hard about things like this. An inescapable fact is that there has been a financialization of the healthcare industry, and that includes everybody who also gets sucked into the healthcare industry whether they want to be or not (ie, patients/members and plan sponsors and, oftentimes, physicians and other clinicians, too). But the financialization of healthcare means that most everybody at the healthcare industry party has a self-interest to either make money or save money. And sometimes the saving money means saving money for themselves, not necessarily anything that is ever gonna accrue to patients or members. Now let's say I'm trying to determine if I want to take on a new client or decide if I personally want to promote or do something or other. This self-interest that abounds all around matters here because it means it is often very tough to find some kind of “pure” initiative to hitch your wagon to. The crushing reality that we all face is you gotta earn a living. The other reality is that often the person that benefits from the thing you want to do (ie, the patient) is not gonna pay for it. And frequently, physician organizations won't either. If everybody was lining up to pay to get something fixed, the problem would not be a problem, after all. But the only way your moral compass is the only moral compass in play is if you're doing whatever you're doing for free, really, or by yourself—and thus you are not encumbered by anybody else or any self-interest beyond your own … and your own motives are the only motives that you can control. I hear all the time initiatives and coalitions and advocacy organizations and even research funded by grants … these things also get bashed as suspect because who'd that money come from and whose “side” are the funders on. Nikhil Krishnan wrote on LinkedIn the other day (and I'm gonna do a little bit of editing, but yeah). He wrote: “Patients have low trust in healthcare because they think every stakeholder is incentivized not in their best interest. Many patients think the hospitals want to keep them sick, the [carriers and plan sponsors] don't want to pay their claims, the drug companies want to keep them on their meds, etc. And we can't pretend like that … isn't true.” Every party, every stakeholder has some measure of self-interest. They have to; otherwise, they'd be out of business. It's all a matter of degrees. No big group, no entire category gets to stand on the high ground here when you think like a patient. There's great hospitals and great people who work at hospitals, and then there's people doing things that cause a strikingly large percentage of patients to fear going to the hospital for clinical and/or financial reasons. Pick any other stakeholder and I'd tell you the same thing. Any other stakeholder. It's basically up to us as individuals to do the right thing. In every sector of the healthcare industry, there's good eggs and there's bad eggs and there's eggs in the middle just doing their day jobs as instructed. Personally, I want to be a good egg, and that's what my manifesto is all about. Let me dig into this a bit further for just a sec and then I'll continue with my personal manifesto for how I find my own path of integrity through all of this confusion. Here's another anecdote. Stuff like this I make myself crazy thinking about: I was listening to a podcast, and one of the guests said, “I wanted to get my MPH [Master of Public Health] because I felt a personal calling to be altruistic.” Then, 120 seconds later, he says something like, “So then, when it came time to pick my internship, I hunted around to find the one that paid the most money—and that's how I wound up working for an HMO in the '90s.” Consider how that strikes you. How do you feel about that guy right now, who, by the way, has gone on to support some very interesting and probably impactful initiatives? There's this commonly used phrase, “Let's do well by doing good.” So, back to that HMO intern. Let's just say we all agree that these HMOs were not unconflicted organizations. We all know they had a reputation for putting profits over members, and a reason they went out of business was because they denied care. They refused to pay claims for patients who had AIDS. And it turns out that the friends and families of people with AIDS are incredibly well organized and sued the crap out of the HMOs, which may have expedited their demise. You know what the intern was doing at the HMO? He was helping them with data analytics, and his personal goal was to use that data to improve patient outcomes. So, okay … here's the thought experiment: Do we want this HMO taking money that they're gonna take anyway and then not adding the value that they potentially could add with their data because they don't have any smart, dedicated, highly compensated interns working there to keep the ship pointed in a decent direction? I mean, I guess if I know I'm gonna spend a dollar as a member of that plan, I'd prefer to get as much as possible for my dollar that is already being spent. Maybe from that perspective, this guy is doing well by doing good. You see how this gets messy when you take a theoretical statement and then apply everyone's real-world prejudices and predilections to it. Here's a last point to ponder, and this is another thought experiment … so, just heads up and then I'll get to the point here: Say you are asked to help with a program run by a Medicare Advantage (MA) plan to provide those in need of transportation a ride to their annual wellness exam. Do you help? Those who listen to this show will fully understand there's a lot of self-interest involved in getting patients to the annual wellness exam because … risk adjustment. Also, star ratings. Listen to the show with Betsy Seals (EP375 and EP387) if you need the full story here. Short version is, MA plans can't upcode, either fairly or aggressively (if they are so inclined), if the patients don't show up for their annual physical. So, there's a lot of money for them at stake. But, then again, are physicals important for patients? Do they improve patient care and health? If we think yes, then again, is this doing well by doing good to help patients get to their appointments? After literally years of asking myself questions like this—and most of them were not thought experiments—I came up with my manifesto. And there are three parts to it, and I will go through each of them. But here's my manifesto in full: If the thing results in a net positive for patients, then I will do it. The timeframe is short-term or medium-term. And the assumption is that it will take a village and I am not alone in my efforts to transform healthcare or do right by patients. Here's how I think about the first part of my manifesto: If the thing results in a net positive for patients, then I'll do it. And keep in mind, I could talk about this for seven hours; so everything I'm saying is oversimplified to some degree and has as many nuances as there are stars in the sky. So, to calculate the net-positive impact, I think through what good the thing could do and weigh that against the negatives. And there are always negatives because, most of the time, the work that I do anyway has to get paid for by somebody and that somebody has some self-interest. Self-interest means that they are attaining something that furthers their business goals. Let me list two major upside/downside contemplations: 1. How much good does the thing actually do for patients? I think about this. What's the value here? Is it a little? Is it a lot? Will this thing be a distraction for clinicians, because time is often the most precious currency? If we're talking about some kind of navigation or utilization management, what's the reason someone wants to do this? Is the reason clinically and, for reals, evidence driven? Or are we predominantly doing this to enrich shareholders or save plan sponsors money in ways that are not a win-win for patients in the clinic right now trying to get cancer treatments for their kid? I try to think like a patient and be as impartial as possible. 2. Money. Where's the money for this thing coming from, and who wins in this particular initiative (ie, is it a win-win and patients win something worthwhile)? Now, the company doing the funding has got to win, too; otherwise, they wouldn't fund the thing. That's where it gets subjective, and, as aforementioned, do I care if the company in question wins if the patient wins, too? Or is this company so damn evil at its core that I am willing to sacrifice the opportunity to do a good thing for patients in order to not have anything to do with said possible funding entity. Or am I cutting off my nose to spite my face because this is a really important thing for patients and this particular company is the only one that's gonna fund it? Because tragedy of the commons or whatever else. Again, this gets dicey really fast. Let me poorly paraphrase a little exchange I saw on LinkedIn the other day that had me completely preoccupied during my work-from-home midday walk around the block for at least three days. Somebody wrote (maybe that Master of Public Health intern), “Given how intractable it feels to me to try to reduce healthcare spend, I think I'm going to try to help patients get more value out of the dollars that are currently being spent by them or on their behalf.” Do you think that's a worthy goal? Well, not everyone does. Somebody in T-minus 8 seconds responded, “That's a toxic way of thinking. Everyone who is not actively working to reduce healthcare spend by putting patients in cash-pay models is part of the problem.” This is a good segue into the second part of my manifesto. The first part is: If the thing results in a net positive for patients, then I'll do it. Here's the second part: The timeframe is short-term or medium-term. And here's what I mean by that. My main focus is helping patients right now. This is what this has to do with the aforementioned exchange on LinkedIn wherein someone was trying to figure out how to get more out of the dollars we're currently spending and someone else said that's toxic, because we should rip it all down and build a better model. There's incremental change, and then there's disruptive change. These two things are not mutually exclusive. Apparently, Mr. This Is Toxic doesn't agree with me, but as I said in the last episode, there's that Buckminster Fuller quote: “You never change things by fighting the existing reality. To change something, build a new model that makes the existing model obsolete.” And sure, I like to aspire to that as much as the next person. But does aspiring to a big hairy goal mean completely forgoing any incremental ways that patients can be helped immediately, like right now? If you ask me—and you're listening to this, so you de facto asked me—incremental change will probably actually support and beget disruptive change. So, incremental versus disruption is not a battle royale. These things are not diametrically opposed. They're probably actually aligned. I could go on a tangent here to explain why, but I'm not going to … except to say tipping points. But forget about that for a sec. Here's the more basic question: If all parties are interested in transforming healthcare, legit, how does someone trying to do it incrementally, or improve value for patients right now, in any way negatively impact someone trying to be disruptive and/or trying to change financial models? Keep all this in mind and now let me get back to my manifesto. I'm worried about patients, and I'm worried about them largely right now, short term to medium term. So, if I have the opportunity to help a patient—and I think about my two grandmothers (God rest their souls) here, but both of them would have died in the healthcare system multiple times in avoidable ways had my family not been there advocating for them—if I have the opportunity to help a patient, I will do so as long as I believe that the impact is a net positive in the shorter term. Disruption is a longer-term operation. Some have said it's a generational change. When I see stuff like Toxicity Guy wrote on LinkedIn, I really try to understand what his point is, as I always try to understand what people's points are. Could he be arguing that no one should work to improve care right now or try to maximize what we get for the bucks that we've already been shelling out? And, if so, for what reason … so that what happens? So that resentment about poor-quality care builds up to a boiling point such that everybody shuns the status quo and moves to a new care model and financial models faster? Is that the aim of Toxicity Guy? To force a let-them-eat-cake moment for the purposes of triggering a faster revolution? I've probably thought about this guy's motives and his potential impact harder than he has. In my manifesto, in my worldview, I don't let grandmas suffer right now so that someone else has a better narrative, even if I am in full support of what that person is trying to do and the mission that they are on, which, by the way, is a longer-term one. This gets me to the third part of my manifesto: The assumption is that transforming the healthcare industry will take a village and I am not alone. When I state this outright, it's gonna seem self-evident; but sometimes it's hard to not push blame here like Toxicity Guy, so I say this sort of in his defense. Here's the point of contemplation: There's maybe four big parts of the healthcare industry at a minimum. We have those trying to fix SDoH (social determinants [or drivers] of health). We have those trying to fix medical morbidity (ie, are patients on evidence-based pathways and taking meds appropriately, limiting polypharmacy side effects/cascades). Once a patient is in the healthcare system, what happens then? Then we have those working hard to improve behavioral/mental health. And lastly, everything going on with what I'm gonna call FDoH (financial determinants of health)—patients making decisions or having decisions made for them due to financial implications for them or for somebody else. Lots of stuff rolls up under these categories, but even just listing out these four things, we got a hell of a lot of work to do to improve the lot of patients and taxpayers and make it easier to do business in this country. I always try to keep in mind that it will take a village. Just because someone is working on getting patients housing or eating better does not imply that they don't care about employers struggling to curb claims billing waste, fraud, and abuse—and vice versa. It's just not everybody can do everything. For me personally, I tend to focus my attention on helping as many patients as possible get on what would be for them the optimal treatment plan or best care pathway. That does not mean I'm anti-someone working on getting more competition in the payer space. Nor does it mean I'm against trying to curb the price of overpriced (as per ICER [Institute for Clinical and Economic Review]) pharmaceutical products or legislate to rein in hospitals doing stuff that, in my book, they should not be doing. I am all for getting all of these things done. I just do not have the bandwidth or the depth of expertise to do everything myself. I would suspect that no one does. As my grandma used to say (and anyone who attended a slumber party seance in eighth grade might know), many hands make light work. You get 15 girls each holding out but two fingers, and you can lift up your friend, no problem. When I keep in mind that it takes a village, it helps me curtail the tendency to become paralyzed in my quest to help patients because I can see a potential problem it might create somewhere else in the industry or somewhere else down the line. I have to trust that one of my fellow villagers is holding down that end of the fort. Here's a quote from J. Michael Connors, MD, that he wrote in his newsletter: “When you point one finger, three are pointing back at you … It's like everything you learned in kindergarten seems to be so applicable to our approach to healthcare. Sadly, the game of finger pointing and pushing blame on others is killing real innovation in healthcare.” This is so real, which is why inherent in my manifesto here is my efforts to remember we are all on the same team (all the good eggs, anyway). That it takes a village, that there will be some things that some people are doing that I maybe don't fully agree with. There might be groups who don't accomplish much. There are certain people doing well (ie, doing self-interested things) but, at the same time, creating a better place for patients. As long as, in general, we are all following the same North Star, we'll achieve much more spending our time focused on our own missions and not worrying about what other people are doing. And when I say “not worrying about what other people are doing,” I mean people in the “good egg” village. I do not mean I intend to stop calling out conflicted and net-negative self-interested behavior, because this is what some people in the village should hopefully have their eyes on and get busy working against. The village here, it's a Venn diagram. At the point where other people's circles intersect with my mission or what I think would be better for patients, these are the people I can work with and collaborate with. These are the people that I'd take their business or I'd try to help them if I can. My manifesto is to determine when something is a positive for patients and then to find others who will win as a result of that thing happening. Then I can study why this is a win for those others, which is always going to be some self-interested why. And then I can think through what the negatives are if their self-interest comes to fruition. Is it still a net positive? If yes, proceed. Look, this making it better for patients, this transforming healthcare, it is hard, dispiriting work. It's a long slog. I'd like to suggest we encourage each other. Can we be the wind beneath each other's wings when we find a kindred spirit? Can we focus on the points of intersection and spend our energy deepening what's going on there? So again, here's my manifesto: If the thing results in a net positive for patients, then I'll do it. The timeframe I'm concerned about … short-term, medium-term. The assumption is that it will take a village to transform healthcare and I am not alone. I feel kind of exhausted having finished that. But let me ask you this: What is your manifesto? If you have one or if you have thoughts on this, go to our Web site and click on the orange button to leave a voice message. My hope is to do an upcoming show sharing what you think.   For more information, go to aventriahealth.com.   Each week on Relentless Health Value, Stacey uses her voice and thought leadership to provide insights for healthcare industry decision makers trying to do the right thing. Each show features expert guests who break down the twists and tricks in the medical field to help improve outcomes and lower costs across the care continuum. Relentless Health Value is a top 100 podcast on iTunes in the medicine category and reaches tens of thousands of engaged listeners across the healthcare industry. In addition to hosting Relentless Health Value, Stacey is co-president of QC-Health, a benefit corporation finding cost-effective ways to improve the health of Americans. She is also co-president of Aventria Health Group, a consultancy working with clients who endeavor to form collaborations with payers, providers, Pharma, employer organizations, or patient advocacy groups.   03:16 “It's a zero-sum game.” 03:26 Is the amount of profit fair? 03:37 What is an inescapable fact of the healthcare industry? 03:54 What does the financialization of healthcare mean? 04:19 Why does the self-interest in healthcare matter? 06:18 “It's basically up to us as individuals to do the right thing.” 10:03 What is the first part of Stacey's manifesto? 10:18 How does Stacey calculate the net positive of an impact? 10:41 What are two major upsides/downsides that Stacey contemplates? 13:31 Why are incremental change and disruptive change not mutually exclusive? 17:40 “I always try to keep in mind that it will take a village.” 19:19 Why finger pointing is killing innovation in healthcare.   For more information, go to aventriahealth.com.   Our host, Stacey Richter, discusses our #healthcarepodcast and where she sees the path moving forward. #healthcare #podcast   Recent past interviews: Click a guest's name for their latest RHV episode! Dawn Cornelis (Encore! EP285), Stacey Richter (EP399), Dr Jacob Asher, Paul Holmes, Anna Hyde, Dea Belazi (Encore! EP293), Brennan Bilberry, Dr Vikas Saini and Judith Garber, David Muhlestein, Nikhil Krishnan (Encore! EP355)  

Well, this episode became extremely relevant again after that Cigna case bubbled up in the news. Here's the “too long, didn't read” version: Attorneys filed a class action lawsuit against Cigna, alleging that the carrier is overcharging for lab services or did overcharge for lab services. The plaintiff is an individual member of a Cigna plan. The complaint tells a pretty wild story. On the Explanation of Benefits (EOB) that this member received for lab services, the amount billed was over $17,000. My understanding is, this member went to Labcorp to get those lab services. Cigna claimed it had negotiated a discount of over $14,000 for those lab services, meaning the remaining balance was something like $2700. OK … good news, I guess. Instead of the lab services costing $17,000, they cost $2700 to the plan and member. Except Cigna said to this member that they were only gonna pay $471 on the member's behalf. This left the member with the responsibility to fork out over $2000 in deductible and coinsurance payments. I'm rounding the numbers here for brevity. So, in sum, member's told she owes $2000+ out of pocket for charges that were allegedly originally over $17,000. Now, a couple things: The cash price for an uninsured customer at Labcorp for the same services was $449, according to the complaint. Also, weirdly, on the Explanation of Benefits, Cigna allegedly said that the lab services provider was not Labcorp. It was “Health Diagnostic Lab” (or everything I just said in all caps with some letters missing) instead of the actual provider Labcorp. Then the plot thickens … The lawsuit alleges that this “HLTH DIAG LAB” is a pseudonym for Cigna Healthcare of Arizona and that this Cigna affiliate used their pseudonym to create a fake invoice. This is also a quote from the complaint. Bottom line, and this is the real point I wanna make here, the actual out of pocket to the payer was something less than $500, $600, you would think. But it appears that the plan was hoping to get almost 5x that out of the plan member. And had this plan member met her deductible that year, I would speculate that this 5x would have come out of the pocket of the plan sponsor. Either way, 5x margin? That's some pretty sweet returns. Look, the point I'm making here isn't about this particular case. It's about the totality of the thing. This case just got a whole bunch of attention because, as Julie Selesnick put it on LinkedIn recently, “This case … hits all the high notes—overcharging, keeping the spread, fraudulent billing.” But think about this for a second. You think this was an isolated incident? That someone in Arizona had a brainstorm to juice their quarterly earnings and set up a whole company to jack up one person's lab payments? I don't know. What do you think? As Lee Lewis mentioned on LinkedIn, while this case has a lot going on, a member getting charged $2500 for what should cost $450 or whatever … he wrote, “I've seen worse.” I say all this to say: Plan sponsors? Hi there. Are you getting your claims data, and are you having it audited for stuff like this? And by whom are you having your claims data audited for stuff like this? And that's not a rhetorical question. I mean, here we have a well-respected payer opening up (allegedly) a reseller of lab services sending allegedly fake invoices. That's one way to vertically integrate, I guess. Here's another way you can vertically integrate that maybe we all should be aware of: companies that provide audit services that many plan sponsors use to check if claims have been paid properly. Those same auditing companies, these same companies oftentimes have another book of business besides their auditing claims for plan sponsors work. They also work with provider organizations doing revenue optimization. Right. They help providers maximize their revenue, revenue that is coming from … claims they send plan sponsors. Sometimes when I talk about this stuff, I feel like I'm in a cartoon—like that meme with all the Spider-Men pointing at each other and nobody knows who is actually Spider-Man because everybody is dressed up in the same costume pointing and saying the other guy is the one causing the problems here. As Dawn Cornelis says in this episode today, approximately 30% of healthcare spending (ie, healthcare payments) are some combination of fraud, waste, and/or abuse. It's a $1-billion-a-day problem. In this episode, we dig into the three main issues that Dawn tends to find when looking at the claims that were going to hit the checkbook of a plan sponsor as per their payer or TPA (third-party administrator): 1. Claims that were not paid correctly: Turns out, 5% to 10% of claims just aren't paid right. There's a whole motley crew of errors that can transpire, but bottom line, the bill was for $10 and somehow the plan sponsor was gonna pay $15. Or they double paid. 2. Things that, if we knew about them, we could do better in the interest of the member: Jeff Hogan put this really well on LinkedIn the other day. He wrote, “Today's purchaser fiduciary needs great analytics to prioritize the needs of their members … including wasteful and abusive vendors, site of care, cost/quality variation in health systems.” Do labs that the plan is being charged $2500 instead of $450 go here or in the next problematic category? I'm not sure. 3. Claims that are just wrong: They should never have been sent in the first place. We also talk about kind of a different issue entirely: the hidden fees that are buried in some of these payer contracts, which felt like a reprise, frankly, of the conversation I had with Paul Holmes a few weeks ago in episode 397 talking about PBM (pharmacy benefit manager) contracts and all the hidden fees and, ultimately, probably costly provisions buried in them that plan sponsors are on the hook for—a lot of times very unknowingly.   You can learn more at claiminformatics.com or by emailing Dawn at d.cornelis@claiminformatics.com.     Dawn Cornelis is a professional in healthcare cost containment with 30+ years of dedication to combatting improper payments, fraud, waste, and abuse. She has led the industry in developing healthcare transparency technology platforms and services. As a result of her efforts, hundreds of millions of dollars of improper payments were delivered through pre- and post-payment technology programs. She is an expert in the field of healthcare claims data, with an emphasis in audit and recovery, and has navigated the payment systems of all of the national healthcare carriers. Furthermore, she approaches each project with integrity and attention to detail while cultivating long-term client relationships. In 1993, Dawn cofounded the first audit and recovery firm and served for 17 years as the chief operating officer of Claim Recovery Services while representing some of the best Fortune 100 companies. In 2017, Dawn cofounded ClaimInformatics, a healthcare technology company that offers a SaaS-based solution product to support health plans in the marketplace that addresses the new transparency regulations. She developed and trademarked multiple technologies and has a United States Patent Pending named CONTINUITY OF CARE (Publication #20150127370). Dawn currently serves as a member of the Self-Insurance Institute of America's price transparency committee, which focuses on legislation and education for self-funded entities. Over the course of her career, Dawn's efforts have supported national and local organizations spanning financial, healthcare, union, and government sectors. With her years of healthcare knowledge, Dawn is a proven expert, consistently delivering excellence.   06:57 The story in the data. 07:33 Who's submitting these claims? 08:04 The three problems with the data. 10:54 The varying factor between carrier systems to stop fraud, waste, and abuse. 11:32 Why carriers don't push for better systems to stop inappropriate dollars. 13:28 The difference between fraud, waste, and abuse. 14:46 “When it becomes the norm, that's what's very bothering.” 15:10 The barriers or hurdles in the marketplace. 17:38 What we don't know about but could do better at when looking at the data. 19:10 “It's not so much the health system and what they are charging. It's about … what the contracted rate is agreed to. That's what drives our costs.” 20:04 “Data's fixed for itself.” 22:49 Identifying and eliminating fraud. 22:54 The lack of enforcement behind preventing illegal billing. 26:01 How providers ensure they aren't inadvertently harming employers and patients through billing.   You can learn more at claiminformatics.com or by emailing Dawn at d.cornelis@claiminformatics.com.   Check out our encore #healthcarepodcast with Dawn Cornelis of @claiminformati1 as she discusses saving billions through healthcare billing. #healthcare #podcast #digitalhealth #healthtech #healthcarebilling   Recent past interviews: Click a guest's name for their latest RHV episode! Stacey Richter (EP399), Dr Jacob Asher, Paul Holmes, Anna Hyde, Dea Belazi (Encore! EP293), Brennan Bilberry, Dr Vikas Saini and Judith Garber, David Muhlestein, Nikhil Krishnan (Encore! EP355), Emily Kagan Trenchard

This week and in episode 400 of Relentless Health Value, at the encouragement of the Relentless Health Value team, I'm gonna do two shows entitled “My Manifesto,” Part 1 and Part 2. In other words, why did I start Relentless Health Value and what's the goal around here? I started contemplating this mission to define the mission thinking about how healthcare will ultimately be transformed and my role (if any) in all of this—or, more accurately, your role as a listener of this show and, often enough, someone who has the ability to take action. You there, listening right now, you are the alchemist who will transform the words that you hear here into something tangible. And that is how this show makes a difference. It is through the Relentless Health Value Tribe, and you, whether you realize it or not, are a very special person. But before I continue along this complimentary vein, let me back up for just one sec and talk about how I realized how special you are to begin with. It's a funny thing because I get asked all the time who listens to this show, sometimes with a “Who listens to this show?” vibe. I mean, we talk about complicated topics; and when I say we talk about complicated topics, I mean we hurl ourselves right in the middle of them. Acronyms and 400-level perplexities abound. I used to say who listens to this show when asked—and this is absolutely true—I used to say that more than 40% of you are senior-level executives with decision-making authority, which might mean you are a doctor or a nurse or other clinician and a leader of some kind, either formally or informally. You could work at a provider organization, a payer, a digital health company (big or small). Maybe you make policy, you're a researcher, private equity … You're an EBC (employee benefit consultant) or work in benefits at an employer. Maybe you do something in the population health space. You could be a legislator looking for insight. A journalist. Right? We get around. But while the audience of this programme is big (very big by some standards), I run across healthcare industry peeps often enough in decision-making roles who listened to half a show one time and decided it wasn't for them. It took me a long time to put my finger on who listens and who does not, and this was also the moment that I started thinking about our listeners as a tribe. The people who listen 99% of the time are listening to figure out how to do the right thing for patients or members. They want to know how what they do fits into the larger picture, this larger healthcare ecosystem. And they want to know this for actionable reasons. I mean, frankly, this is a lot of the reason why I started this show to begin with: because I found myself in a similar situation (still am, truth be told). I started to understand that doing something in healthcare is like a game of pachinko. The action, which might feel like it logically should result in X good thing for patients, bounces around in this black box that is the healthcare ecosystem and may pop out the other side in ways that are the opposite of what was originally intended. I want to have positive impact, right? All of us do, or you wouldn't be listening right now. And that is the common thread that holds us all together—besides, of course, being smart, capable, curious, and incredibly charming individuals. And I say all this with evidence: Every single person I have met who listens to this show on the regular meets all of these criteria. You are great people, and it is a distinct honor and a privilege to spend time with you every week. I am proud, really proud of what this group of individuals has accomplished. We have moved needles, and we have pushed agendas. Now, I know you people. You are going to be doing one of two things right now. Twenty percent of you are gonna be smiling and thinking about the program you started or the work that you did and the accolades that followed. Or maybe you're just simply aware of what you've done because you have data, or patients or members or family members thanked you and you saw that look in their eyes and you knew how much what you did meant for them. Or you work for a company that is laser focused on some kind of disruption, and it's small enough that you can clearly see your impact. But there's a lot of you (the majority of you, frankly) I get on the phone with, and you're less sure if you've actually had any impact. You are frustrated—and a little depressed maybe—because you see all this madness and ways patients are harmed all around you. You see maybe decisions that you realize have a deleterious (ie, bad) impact on patients or members. You are now eyes on, and now you feel largely powerless. I will tell you the same thing that I tell every member of the Relentless Health Value Tribe who says this. I don't doubt it might be more difficult to see the impact you are having if you work for a larger company or if you work for one of these incumbents, especially when you have a recognition that there might be other departments or other individuals doing things that you may not be fully aligned with. But do not doubt that you have impact and that that impact is meaningful. I was talking to Larry Bauer, and he told me with a lot of conviction (and he's one that would know) that you, Relentless Health Value listeners, you are the innovators. You are the ones who spot problems, and you tinker around with available resources and you figure out how to make it just even a little bit better for patients or members. Think about it this way and just hang with me through this: CEOs do not actually drive what happens in their organizations. The big bosses set up the incentive structures and are the tip of the spear (or whatever that metaphor is) for sure. But an organization's behavior is decided by 10,000 probably tiny little decisions each and every day … 100,000 decisions by the employees of that organization. It's the sum of all those micro choices, those micro moments, that determine the impact that that organization has on those it serves. I saw a meme the other day: “When people travel to the past, they worry about radically changing the present by doing something small. Few people think that they can radically change the future by doing something small in the present.”     Who your boss is doesn't matter is my point. If you are touching things in the middle of that pachinko game, you have power. Right? We are all decision makers here, and we are not synonymous with the companies that we work for. We are not the Borg. Would it be nicer and faster if there wasn't an ongoing financialization of the healthcare industry? If boards of hospitals and private equity and C-suites all would put their “mission before margin” hats on for a change? Yeah, that would be ideal. Would it be nice if the disrupters among us had more market penetration? Sure … the good ones, absolutely. And probably the best path forward is to get ourselves over to a company that's building a new model to make the current one obsolete, to quote Buckminster Fuller. But it's not like it's an either/or. In addition to having a long-term vision, maybe we can do something in the meantime here. I'd rather that some patients and members get treated some amount of better right now as well as envisioning a new model to make the current one obsolete. We each might be pressing forward, I don't know, 0.01% at a time; but let's just consider that 0.01% in this country is 35,000 people plus their families and ~$300 million when it comes to healthcare in the US. Multiply that impact by everybody listening right now—there are thousands of you. So please do not dismiss the impact that you have, no matter who you work for: thinking critically, considering the larger picture, recognizing the impact that your organization has in big ways and in small ways and then making big and small choices and decisions that are aligned with your values and your integrity. Sometimes people will talk to me about what they want their legacy to be, and this is kinda it. So, how to deepen that possible impact that any of us might have? It is always the highlight of my day when I hear that one of you has found somebody else in the RHV Tribe and the two of you (or three of you or four of you) have struck a deal to do something. You've collaborated in some way. The larger organizations everybody might work for … maybe they're on board or half on board, but again, we are not our companies. I love it when I hear that a physician organization hooked up with somebody at a payer and figured out how to do a pilot or collaborate on something, not going through the official Contact Us forms or whatever but by finding somebody on the same mission in that other organization and then everybody working up the chain in their own organizations from the inside. So many different individuals who work for so many different parts of the healthcare ecosystem listen, and there are lots of synergies to explore, especially if we stop thinking at the organizational level and start thinking about what we individually want to achieve. It's possible to help each other, to find the overlapping bit of the Venn diagram where interests align and something can get done. And I'll talk about that more in Part 2. Here's from Malcolm Gladwell's The Tipping Point. He wrote: “If you want to bring a fundamental change … you need to create a community … where … new beliefs can be practiced and expressed and nurtured.” This, maybe in sum, is the ultimate goal of Relentless Health Value: to provide that loose-knit community so that those in the Relentless Health Value Tribe who want to can find like-minded people across the industry to work with, the ones who are also just as well informed and understand how this ecosystem knits together—meaning you can more easily work with them to find points of mutual interest that are net positive for patients. There was a point in my podcast career where I thought having a really broad audience of listeners from all across the industry was kind of a problem because it makes it really hard to answer the question, “Who listens to your show?” But now I realize it's a huge accelerant to our potential impact. As I was recording this, I realized I probably should do one thing here; and that is at some juncture, I will probably make an RHV Tribe directory or something. So, go over to our Web site and sign up for the weekly email, which you can do on the Web site, because whenever I get around to doing that, I will start with everybody on the mailing list (because I have your email address). I'll send out a notice or something and ask if you'd like to be part of that directory. This is Part 1 of my manifesto. Next week (hopefully, if I can get my act together) or, if not, the week after that, I will bring you Part 2. In the meantime, thank you from the bottom of my heart for being who you are and doing what you do. It is going to be Relentless Health Value listeners who turn this oil tanker of a healthcare industry around. I guarantee it.   For more information, go to aventriahealth.com.     Each week on Relentless Health Value, Stacey uses her voice and thought leadership to provide insights for healthcare industry decision makers trying to do the right thing. Each show features expert guests who break down the twists and tricks in the medical field to help improve outcomes and lower costs across the care continuum. Relentless Health Value is a top 100 podcast on iTunes in the medicine category and reaches tens of thousands of engaged listeners across the healthcare industry. In addition to hosting Relentless Health Value, Stacey is co-president of QC-Health, a benefit corporation finding cost-effective ways to improve the health of Americans. She is also co-president of Aventria Health Group, a consultancy working with clients who endeavor to form collaborations with payers, providers, Pharma, employer organizations, or patient advocacy groups.   00:47 What is your role as the listener of this show? 01:27 How did Stacey realize how special our listeners are? 01:56 Who are our listeners? 03:15 Why did Stacey start the Relentless Health Value podcast? 04:10 What have the listeners of the Relentless Health Value podcast and its guests accomplished? 05:13 What is Stacey's advice to listeners that feel powerless? 06:22 “It's the sum of all those micro choices … that determine the impact that that organization has on those it serves.” 09:22 “There are lots of synergies to explore.” 10:51 Sign up for our weekly email here.   For more information, go to aventriahealth.com.   Our host, Stacey Richter, discusses why she started our #healthcarepodcast. #healthcare #podcast   Recent past interviews: Click a guest's name for their latest RHV episode! Dr Jacob Asher, Paul Holmes, Anna Hyde, Dea Belazi (Encore! EP293), Brennan Bilberry, Dr Vikas Saini and Judith Garber, David Muhlestein, Nikhil Krishnan (Encore! EP355), Emily Kagan Trenchard, Dr Scott Conard  

Yeah, so while the commercial payer marketplace is completely boring, the reasons it's boring are not. Let me walk you through this conversation I have in this healthcare podcast with Jacob Asher, MD. First, we establish that the relative number of each carrier's commercial members in California don't seem to change year over year … and this has been true for years. When you rank order carriers by member count, the song remains the same. It's Groundhog Day. Here's a link to the 2022 CHCF (California Health Care Foundation) enrollment almanac, which shows for the large group market, Kaiser has captured and retained just over half of enrollees. Anthem comes in next with 14%, Blue Shield gets 9%, and then bringing up the rear we have UHC, Aetna, Cigna, Centene, and all others in descending order splitting the remaining 21%. Hmmm … intriguing, the whole idea that these relative member counts remain so consistent. Then Dr. Asher and I dissect what is anybody actually doing to cut into the Kaiser market share or try to grab share from the two blues plans, if anything. Dr. Jacob Asher was a great guy to have this conversation with. He was a practicing head and neck surgeon with Kaiser Permanente, and then he also served on the Permanente Medical Group Board of Directors. Then he changed careers and became a full-time health plan chief medical officer for, first, Anthem, then Blue Cross, then Cigna, then UHC (UnitedHealthcare). Now he's “retired” and reflecting back on unsolved and unaddressed issues within healthcare. And we've covered one here: Why is the commercial payer market as boring as it appears to be in California? Now, after I had this conversation with Dr. Asher, I called up Wendell Potter, who everybody already knows (EP384), and Lauren Vela, who everybody also probably already knows, but she has spent her career at various employer coalitions and now works at a big employer transforming their health benefits (and she lives in California). I learned a few things that really helped me frame my thoughts on some of the issues that surfaced in the conversation that I had with Dr. Asher and that you'll hear today. So, let's get to it. Why doesn't the relative market share of the big payers change year over year in California in the commercial space. May I present six reasons: 1. Everybody I talked to—Dr. Asher, Wendell Potter, Lauren Vela—first thing right out of the gate that practically everybody mentioned is employer inertia. Trying to get an employer to switch carriers is like trying to pull Excalibur from its stone. And right, not so surprising, it's disruptive and obnoxious for employees and also benefit teams if carriers are switching all the time. 2. EBCs (employee benefit consultants). They have deals with carriers and others, and they also have a lot of power over employers. Listen to the show with AJ Loiacono (EP379) and Paul Holmes (EP397) for more on this. 3. As Wendell Potter put it, “The commercial market is [as a whole] stagnant. No real growth nationally. And in many states, the real money for carriers is not in the self-funded market; so they don't care much about aggressively competing for market share.” Given that chart that just came out the other day showing the insane relative gross margins that carriers are making on Medicare Advantage patients, which is over double other lines of business … yeah, totally. 4. Just keep this in mind before we barrel into reason #4 here for a stagnant and maybe not exactly competitive market. Kaiser excluded, all of the rest of the California payers have what amounts to largely the same provider network. I'm exaggerating slightly here, but largely the same hospitals, the same consolidated integrated delivery networks. And one thing that's pretty clear (not just in California but across the country): Plans who bring the most members get the best prices from these hospitals and other provider organizations. Also, as Dr. Asher mentions in the show today, he never saw an employer buy on quality. Most were far more concerned about discounts. So, right … we have some circular reasoning here or circular logic. The big plans get the best prices, and then, because they have the best prices, they maintain their market share. But wait … there's more to this one, and it's not just big gets you lower prices. Remember from episode 395 with Brennan Bilberry? He talked about the concept of the Most Favored Nation (MFN) anticompetitive clauses in hospital contracts. This concept is also super relevant here for payers as well if you think about it. This MFN Most Favored Nation anticompetitive clause, this is where a big hospital and “big carrier” have a chat … in a back room. The hospital agrees to not give any other carrier a lower price than the “big carrier.” These MFN clauses are, of course, terrible for competition and plan sponsors and any patient with cost sharing. A lot of states have started to ban, restrict, and limit these clauses. The DOJ brought a case in Michigan about this, and here's a great federal government summary of the problem: “The department and the state of Michigan alleged … that the MFN clauses in [Blue Cross Blue Shield of Michigan's (BCBSM's)] contracts with Michigan hospitals decreased competition among health plans. Some … clauses required hospitals to charge competitors more than the hospitals charged BCBSM, often by a specified percentage. Moreover, BCBSM often agreed to raise the prices that it paid hospitals, in part to obtain [the] MFN clauses.” Oh, hey … I'll let you raise your price so I can have a Most Favored Nation clause, just as long as I get a lower price, which is higher than it was originally. And this was actually back in 2013. I have no insight at all or knowledge, or I am not suggesting in any way that what was going on in Michigan is going on in California. However, this anticompetitive practice is common enough. If you're interested in how common, count the lawsuits. 5. Employers are unaware a lot of times of how they are being charged more than what might be appropriate. And they are largely unaware of options other than Blue Cross, United, Cigna, Aetna … the big payers. 6. As Dr. Asher talks about and which I never really thought about, Kaiser doesn't have Medicaid patients. [Correction: Kaiser does have some Medicaid members—just less than others.] And because their network and hospitals to a large extent are closed, they also don't have uninsured patients to a large extent. So, no charity care to speak of and, therefore (at least as it is posited), they can be cheaper because they don't have to cost offset. So, their price advantage has a structure element here that could make it even more untouchable. So, there's your six reasons. You can start to see basically all of these things solidify into the same thing. It's less about trying to get new business and more about locking in the existing business. It's not really a secret that this market is rock hard. Plans realize that. They realize that the cost of keeping an enrollee is cheaper than acquiring a new enrollee. So, carriers focus sales and marketing efforts on holding on to their existing customers, especially the coveted jumbo accounts. Interestingly (and I was talking about this with Lauren Vela), the more clinical programs a carrier has deployed for an employer, the more the carrier is locked in there. So, the more the clinical value proposition resonates, the more clinical stuff that gets integrated. Changing plans becomes even more disruptive, and employers are even more likely to remain where they are. So, there's more to clinical programs than payers catching themselves a little PMPM (per member per month) something something upcharge recurring revenue or trying to get new business. It's also locking in customer retention. Is any of this specific to California? Some of it is—like a lot of the Kaiser stuff—but most, not. Meaning a lot of the country doesn't exactly have a functioning commercial small group or large group marketplace either. To a certain extent, it's no wonder big employers don't change plans that often. Why would they bother, given probably fairly incremental differences between these big payer carriers? I realize I'm scrambling out on a limb here and making assumptions, but to achieve more than incremental improvements, a BUCA (Blue Cross, United, Cigna, Aetna) would need to invest all kinds of resources into being that shining star. And why would they do that when nobody can take down Kaiser? And for all the reasons that we just talked about, it's a hard row to hoe to grab new clients. There's a lot of ramifications to this, but this show can't be seven hours long.    You can learn more by connecting with Dr. Asher on LinkedIn.   Jacob Asher, MD, completed a residency in otolaryngology–head and neck surgery at the University of California, San Francisco, after receiving degrees from Brown University and the Boston University School of Medicine. Dr. Asher then practiced as an ENT (ear, nose, and throat) surgeon with Kaiser Permanente in Northern California and also served on the board of directors of The Permanente Medical Group, where he focused on physician compensation reform, member satisfaction initiatives, and retirement benefits. After transitioning to full-time health plan management, Dr. Asher served as a California commercial market medical director between 2008 and 2022 for Anthem Blue Cross, Cigna, and UnitedHealthcare. In those roles, he supported membership growth and retention in both fully insured and self-funded product lines and promoted value-based reimbursement, including capitation. He has led utilization management teams, collaborated with internal and external population healthcare advocates, and worked to develop clinical initiatives that sought to achieve the Triple Aim. In his role as the clinical face of the health plan to the local market, he worked with network colleagues on accountable care organization partnerships and hospital and physician contract renewals with integrated pay for performance, supported Obamacare exchange participation, engaged in quality improvement collaboratives, and supported regulatory compliance efforts. Currently, Dr. Asher is serving as a mentor for the Stanford Master in Medical Informatics program while exploring innovative solutions to healthcare delivery.   10:00 What is the competitive picture of California's health plans? 11:28 What was everyone doing in order to get market share? 15:07 EP387 with Betsy Seals. 15:22 EP379 with AJ Loiacono and EP397 with Paul Holmes. 15:26 Why is it difficult to take market share? 16:16 Who was Dr. Asher pitching to and why? 18:49 Did employers ever buy plans for quality? 22:43 What does this look like from the payer perspective? 27:01 What improvements have there been to engagement in health plans? 29:07 Have plans gotten better at communicating with employers? 30:38 Why is it hard to compare the Kaiser world to the non-Kaiser world? 33:00 EP390 with Gloria Sachdev, PharmD, and Chris Skisak, PhD.   You can learn more by connecting with Dr. Asher on LinkedIn.   @JacobAsher18 discusses California's #commercialpayer marketplace on our #healthcarepodcast. #healthcare #podcast Recent past interviews: Click a guest's name for their latest RHV episode! Paul Holmes, Anna Hyde, Dea Belazi (Encore! EP293), Brennan Bilberry, Dr Vikas Saini and Judith Garber, David Muhlestein, Nikhil Krishnan (Encore! EP355), Emily Kagan Trenchard, Dr Scott Conard, Gloria Sachdev and Chris Skisak  

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. Stop buying the gold paper clips. 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, after all. 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. That's a metric load of our cold hard cash that got dumped out back and burned. 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) at the beginning of 2022. 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. Oh, hey … one last thing and new topic. Here's a cool goings-on: Right now, the March Healthcare Classic is in full swing. Each spring, Josh Berlin's rule of three team collaborates with other experts to predict which major trend will find itself at the top of the healthcare agenda over the next 12 months. This year, their selection committee includes Anisha Sood; Danny Brywczynski; David Carmouche, MD; Shaheed Koury, MD; and Stephanie Mercado. Check it out and weigh in yourself should you choose to do so.   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 recently, after 31 years with Nixon Peabody LLP and Ungaretti & Harris LLP. Paul has extensive and unique experience in representing large employers and Taft-Hartley welfare funds in their selection, contracting, auditing, and litigation with large pharmacy benefit managers (PBMs). Paul has logged over 8000 hours during the past four to five years, advising large employers and Taft-Hartley welfare funds managing their prescription drug benefit plans. This work includes active oversight of the request for proposal (RFP) process for selecting a PBM, the negotiation of final PBM contracts (including pricing, rebates, and audit rights), and regular audits of PBM compliance with their contracts. 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.   06:06 What are Paul's usual observations when a PBM contract crosses his desk? 06:57 “If you just sign … one of their model contracts …, you're probably gonna pay 30% to 40% above market on your drug spend.” 10:35 What is a PBM lawyer? And why is it important to find an ERISA PBM lawyer? 15:37 EP379 with AJ Loiacono. 16:05 Who is on the hook for the cost of the PBM contracts? 20:36 What's the problem with most ERISA lawyers today? 22:28 Lawsuit about PBM contract. 27:15 What's Paul's advice for benefits consultants? 31:11 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   Recent past interviews: Click a guest's name for their latest RHV episode! Anna Hyde, Dea Belazi (Encore! EP293), Brennan Bilberry, Dr Vikas Saini and Judith Garber, David Muhlestein, Nikhil Krishnan (Encore! EP355), Emily Kagan Trenchard, Dr Scott Conard, Gloria Sachdev and Chris Skisak, Mike Thompson  

It may have taken longer than other regions for Asia-Pacific to adopt health care as a standard among PR and Comms practices, but the region is swiftly setting some global trends. Finn Partners' Fern Lazar joins Paul Holmes on this episode of the PRovoke Media Podcast to discuss the health ecosystem within the Asian markets. 

PRovokeGlobal 2022 capped off a year spent discussing the many industry trends that have emerged and re-emerged. Over the course of the year which culminated with the 2022 Summit, we've covered topics such as internal stakeholders, purpose, data and disinformation. In this PRovoke Media Podcast episode, Paul Holmes chats with Stephan Miller, Kivvit's Chief Brand Strategist to unpack themes from the recent Summit and what they mean for the industry this year.

This Episode we interview Paul Holmes, Nikhil Bagri, Joe Smith about their take on being a Gym Owner. Welcome to the Gym Lords Podcast, where we talk with successful gym owners to hear what they're doing that is working RIGHT NOW, and to hear lessons and failures they've learned along the way. We would love to share your story! If you'd like to be featured on the podcast, fill out the form on the link below. https://gymlaunchsecrets.com/podcast

I'm delighted to speak with Dr Matthew Scott, Prof Paul Holmes and Dr David Wright in this episode.   Matt is a Postdoctoral Research Fellow at the University of British Columbia in the School of Kinesiology. Matt investigates the effect of dyad practice - training with a partner - on motor learning. His interests are in combined (and independent) action observation and motor imagery, motor learning and motor control. Paul is Deputy Pro-Vice Chancellor in the Faculty of Health and Education at Manchester Metropolitan University and a Research Professor of Motor Cognition. Paul's research interests include motor cognition in human performance and movement rehabilitation where he has published widely on both subjects focusing on motor imagery and action observation mechanisms. Paul has worked as a sport psychologist in high performance sport for over 25 years. David is a Senior Lecturer in Psychology in the Department of Exercise and Sport Science at Manchester Metropolitan University. His area of interest is in neurophysiological processes involved in various aspects of sport psychology. David's research focuses on motor imagery using brain stimulation techniques. Matt, Paul, David and I discuss a fascinating paper they have published alongside Dr Dave Smith and led by Matt which reviews PETTLEP imagery. The PETTLEP model was first published by Paul and Professor Dave Collins 20 years ago as a framework to improve the delivery and outcome of motor imagery (MI) interventions. Drawing on research from neuroscience, cognitive-behavioural psychology, and sport psychology the model served as a set of guidelines for sport psychologists to consider when developing MI interventions and tailoring them to individual athlete needs. PETTLEP is an acronym for seven practical elements that sport psychologists could consider when developing MI interventions with athletes (Physical, Environment, Task, Timing, Learning, Emotion, and Perspective). In the 20 years since its publication, the PETTLEP model has become one of the most dominant models for structuring MI interventions in sport.  Please see a link to the paper here https://www.sciencedirect.com/science/article/pii/S2667239122000260?via%3Dihub