Podcasts about value based care

In this episode of the Becker's Healthcare Podcast, Erika Spicer Mason is joined by Linda Bedwell of Powder River Surgery Center and Dana Jacoby of Vector Medical Group to discuss the evolving role of ambulatory surgery centers (ASCs) in value-based care. The conversation explores how physician alignment, data-driven strategies, and innovative care models are enabling ASCs to deliver longitudinal, patient-centered care—despite challenges like staffing shortages and low reimbursement rates. Tune in for insights on building sustainable, risk-aware strategies that move beyond fee-for-service and deliver measurable outcomes.This episode is sponsored by Vector Medical Group.

Dhrooti Vyas, Co-founder at a value-based care startup and expert in healthcare incubations at Primary VC, joins the podcast to share her perspective on what makes a healthcare startup truly impactful. She discusses foundational best practices for early-stage companies and emphasizes the importance of delivering real value to communities, specifically through her work with Crosswalk. Dhrooti also reflects on her personal experiences with the emergency department and how they revealed major issues in primary care—sparking efforts to connect EMS systems more directly with health insurance providers to close care gaps.

In this episode of the Becker's Healthcare Podcast, Erika Spicer Mason speaks with Brian Workinger and Lauree Handlon of The Craneware Group about how AI and data-driven insights are helping providers navigate increasingly complex payer contracting and reimbursement environments. The conversation covers predictive modeling, payer transparency, and preparing for shifts in Medicare Advantage participation, all within the broader context of value-based care. Tune in to hear how hospitals can leverage advanced analytics to drive smarter financial strategies and improve long-term sustainability.This episode is sponsored by Craneware.

Natalie Davis, CEO of United States of Care, joins us to talk about the challenges of discussing value-based care with patients and policymakers. Through extensive research with over 30,000 individuals, Davis shares that the term "value-based care" often evokes negative connotations of low-quality care. When presented with the benefits of value-based care without using the term itself, people were most interested in spending more time with their doctors and receiving personalized, quality care. Join us to learn more about effectively communicating with patients and policymakers about value-based care. Connect with us at acoshow@aledade.com or visit the Aledade Newsroom

Show Notes: Ami Parekh discusses the business model and services of Included Health, a company that provides personalized healthcare. Included Health partners with self-insured employers and health plans to improve the way working Americans and their families receive healthcare.  Included Health Services  About a third of Fortune, 100 companies, and 10 million Americans have access to Included Health's services. The company focuses on providing access answers and advocacy as people engage in the healthcare system. The company has nearly 3000 people, including 1000 clinicians across the country, including primary care doctors, specialists, nurse practitioners, and therapists. Additionally, hundreds of care advocates help patients understand the ins and outs of the healthcare system. Many patients come to Included Health because they can't get access to primary care and behavioral health, which can take one to two months across most of the country. The company aims to address this supply problem. Navigating the Healthcare System Ami talks about the role of Included Health in helping patients navigate the healthcare system, focusing on personalized and best-for-the-patient approach. She explains how it can help patients navigate their insurance and coverage options. She also covers the use of data and data science to match patients with the highest quality healthcare professionals for specific requirements, such as orthopedic surgeons or specialists. Ami emphasizes that Included Health are not plans or payers, but providers who work with a wide field of providers, and their job is to help patients achieve the best outcomes within the current healthcare system. Accessing Quality Data in Healthcare The conversation turns to the concept of quality data in healthcare, how it is crucial to consider the quality of care and the likelihood of repeat surgeries, and the issue of inappropriate prescribing behavior, such as the use of opiates and benzodiazepines, which can be addictive. Ami explains how Included Health accesses and uses data, and how collected sanctioned data can help determine if a provider is safe for family members to see. Ami emphasizes that data is never perfect, and in the worst case scenario, patients can consult with clinicians to find the right doctor. The data can help inform conversations about who to see, and Included Health offers support in finding publicly available data sources and the right practitioner. She highlights the need for better data and collaboration between healthcare providers and patients to improve patient outcomes and overall healthcare quality. Improving Healthcare Pricing and Cost Employers typically pay for Included Health as a layer on top of their health plan, as they want their employees to be healthy, productive, and engaged members of their workforce. They also want healthcare costs to remain low so that they can pay their employees a living wage and invest in other benefits. Healthcare is often the number two cost after supplies in America, and employers want their employees to be healthy, productive, and engaged. Included Health offers a way to give healthy days back to employees by reducing the number of days they are unable to be healthy due to mental or physical health reasons. This results in increased productivity, better work performance, and overall cost savings. There are two dimensions to using included health services: first-time care and saving time. First, employees get the right care the first time, which can lead to cost savings. Second, health plans are incentivized to offer support to their patient population, as they are paying for it. Third, Included Health helps find providers quickly, saving employees time and freeing them up to focus on the healing process and family. Furthermore, Included Health provides access to primary care doctors, which is crucial for long-term cost savings and better health. How Included Health Works Included Health has about 1500 clinicians available for virtual appointments, including behavioral health providers. The app allows users to schedule appointments within a week, ensuring choice and quick access to healthcare services. Technology has brought about broader trends in the industry, such as value-based care and making things easier to access. The cost of healthcare is increasing by seven to 10% year over year, making it unsustainable for the American population. Employers, who are often the purchasers of healthcare, are seeking better solutions to control healthcare costs. They are trying to do this through products and services, creating new networks, and focusing on wellness. The trend is driven by employers and the government, as well as insurance companies. Included Health fits into this trend by reducing total care costs and prioritizing the member experience. By being a one-stop shop for patients and members, employers can experiment with different services without disrupting the member experience. This allows them to work with the growing trend of cost-cutting and value-based care in the healthcare industry. Included Health's Clients and Pricing Structure  The pricing structure for the company is custom, client-by-client, and depends on the population being served. The company does not have a per-head pricing structure, but rather on a population level. Performance guarantees are part of the pricing model, which includes up-operation and delivery of savings.The company has started participating in shared savings models with CalPERS, which allows California employees and their dependents access to their services. Payers see the company as a provider for their members, and they believe that these models are helping them achieve better outcomes for patients. Included Health mostly focuses on larger enterprise and jumbo clients, with 33 of the Fortune 100 companies being clients. Smaller clients also receive good results from the company. The Role of AI in Healthcare Ami discusses the use of Telehealth in healthcare. She mentions her parents as an example of how they could do more virtually than they are today. Ami also discusses the role of AI in healthcare, stating that, by providing tools that can help healthcare workers it is a beneficial tool.  AI has been used in healthcare for therapy, diagnosis, and diagnosis, with 20% of conversations being healthcare-related. She is excited about the potential of AI in healthcare. Member-facing AI can answer basic health insurance questions and provide guidance on insurance deductibles and costs. Included Health ensures all of their AI services are supported by humans, whether on the clinical side or on the care team side, to ensure a human is available to the customer when needed.  Ami believes that AI will be a tool that supports the human workforce in healthcare, making their jobs easier and allowing them to do more for the members. Over the next year or two, AI will play a significant role in healthcare, with AI helping navigate systems, schedule calls, and provide better access to care for patients. Timestamps: 01:22 Included Health's Services and Impact 03:22: Navigating the Healthcare System  07:20: Challenges and Solutions in Healthcare Data  14:29: Employer and Health Plan Perspectives  21:33: Value-Based Care and Pricing Structure  27:21: Health Plan and TPA Relationships  32:41: Role of AI in Healthcare  Link:  https://includedhealth.com/   Unleashed is produced by Umbrex, which has a mission of connecting independent management consultants with one another, creating opportunities for members to meet, build relationships, and share lessons learned. Learn more at www.umbrex.com.

In today's episode of Value-Based Care Insights, host Daniel J. Marino sits down with Dr. Amit Jain, MD, MBA, Associate Professor of Orthopedic Surgery and Neurosurgery, Chief of Minimally Invasive Spine Surgery at Johns Hopkins, and Director of Value-Based Care for Johns Hopkins Health System. Together, they unpack how organizations can reduce costs while improving performance outcomes such as length of stay and readmission rates—ultimately advancing their value-based care strategy. Explore expert insights on aligning surgical services with cost-effective, high-quality care delivery.

On this episode of “Raise the Line” we welcome Dr. Sheldon Fields, a trailblazer in the nursing field and the president of the National Black Nurses Association. In a candid conversation, Dr. Fields shares his inspiring journey from the bedside to becoming a prominent figure in nursing, HIV/AIDS prevention and academia and also shares the challenges he faced as a Black man in a predominantly white and female field. "I fell in love with a profession that has not always loved me back," he tells host Kelsey Lafayette. Dr. Fields brings over thirty years of experience as an educator, researcher, clinician, administrator, consultant, health policy specialist, and entrepreneur to his current role at NBNA, and as the inaugural associate dean for equity and inclusion at the College of Nursing at Penn State University, where he also serves as a research professor. Listeners will find Dr. Fields' insights on navigating a career in healthcare particularly valuable, as he stresses the importance of resilience, continuing education, and mentorship. It's a compelling listen for anyone interested in the intersection of health, policy, and social justice.Mentioned in this episode:National Black Nurses Association If you like this podcast, please share it on your social channels. You can also subscribe to the series and check out all of our episodes at www.osmosis.org/raisethelinepodcast

Nurses aren't just at the bedside—they're in boardrooms, legislatures, and labs. In this episode, Ajay Mody and Asher Perzigian sit down with Dr. Allison Norful of Columbia University and Summer Davis of the Ohio Association of Advanced Practice Nurses to unpack how nurses are reshaping healthcare. From navigating towards full practice authority to driving policy and tackling mental health, this conversation reveals the untapped power of nursing leadership in a rapidly evolving system. Part of The Heart of Healthcare series—where the future of medicine gets personal.

No one is better equipped to support patients than providers. But do health systems have the power required to improve the healthcare system?  In this episode of Healthcare Insider, Premier Inc. President and CEO Mike Alkire explains why a provider-led model—not one led by payers or legacy tech vendors—is the only viable path forward. He outlines how hospitals can take back control and lead transformation by focusing on high-value partnerships, smarter use of data and AI-driven solutions. Listen to learn how health systems can: Shift power from payers to providers through strategic partnerships Leverage data and AI to reduce costs and improve outcomes Incentivize innovation to build a more sustainable system

Ep 127 - Dr. Jain- Improving Perioperative Services to Enhance Value-Based Care Exploring one of the most significant drivers of total cost of care: surgical and perioperative services. With surgical services accounting for up to 70% of a hospital's revenue, inefficiencies in the OR can have a profound impact on both financial and clinical outcomes. On this episode Dan sits down with Dr. Amit Jain, Associate Professor of Orthopedic Surgery and Neurosurgery and Chief of Minimally Invasive Spine Surgery at Johns Hopkins. Dr. Jain also serves as Director of Value-Based Care for Johns Hopkins Health System. Together, they unpack how organizations can reduce costs while improving performance outcomes such as length of stay and readmission rates—ultimately advancing their value-based care strategy. Tune in for expert insights on aligning surgical services with cost-effective, high-quality care delivery. To stream our Station live 24/7 visit www.HealthcareNOWRadio.com or ask your Smart Device to “….Play Healthcare NOW Radio”. Find all of our network podcasts on your favorite podcast platforms and be sure to subscribe and like us. Learn more at www.healthcarenowradio.com/listen

This episode of the Astonishing Healthcare podcast with Dr. Sunil Budhrani (Chief Innovation & Medical Officer) highlights the transformative potential of Judi Health™, the first Unified Claims Processing™ platform offering a combined medical and pharmacy benefit experience (with vision and dental soon to follow)! Why is unifying claim administration necessary to reach a value-based world? Well, everyone has been talking about VBC for years, and it's proved to be an elusive target. On Episode 7, Dr. Budhrani explained why pharmacy must be included in the equation along with providers, patients, and payers, and today we go a level deeper, explaining why "everything" - all the patient's data - must be in one system to be able to achieve better health outcomes at a lower cost. On AH054 - Judi Health™: Going Beyond Pharmacy and into Medical Claims, with AJ Loiacono and Dr. Sunil Budhrani, we revealed what we're doing and why.Today, Sunil discusses our experience thus far - 5 months into our unified claims experience - and the importance of flexibility in plan design to achieve a plan's goals. He also explains how Judi Health helps to empower providers and the provider-patient relationship via a "transparent architecture." What should the experience be like for patients? How about the plan sponsor/HR team side of the equation? Tune in to find out and hear why Judi Health represents an "opportunity to see - and achieve - what many people in healthcare say cannot exist" (hint: it's a win for all stakeholders). Related Content:Judi Health™ Earns Best Healthcare InsurTech Solution in the 9th Annual MedTech Breakthrough Awards ProgramCapital Rx Unveils Healthcare's First Unified Pharmacy and Medical Claims Processing PlatformAH058 - Building Judi®, the Healthcare Infrastructure of the Future, with Liya LomsadzeReplay - Build a Lasting Pharmacy Benefit Strategy with Never Move Again™Setting a New Standard for the Future of Pharmacy Benefit AdministrationFor more information about Capital Rx and this episode, please visit Capital Rx Insights.

Elligint Health provides a toolset outside of the electronic medical record to help organizations perform value-based care arrangements. In this episode, Chris Caramanico, CEO of Elligint Health, discusses how his organization is helping drive change in healthcare delivery. He shares insights into how their solution creates proactive workflows to affect patient outcomes, emphasizing the importance of data-driven decision-making and patient activation. Chris also shares that their platform provides analytics, care management tools, and communication solutions to improve patient outcomes and drive efficiency. Finally, he touches on emerging trends in healthcare technology, particularly the role of AI and interoperability, and how Elligint Health is addressing these needs. Tune in and learn how Elligint Health is transforming healthcare with its integrated approach to value-based care, analytics, and patient activation! Resources: Connect with and follow Chris Caramanico on LinkedIn. Learn more about Elligint Health on their LinkedIn and website.

Join hosts Asher Perzigian and Ajay Mody as they welcome Carolyn Jones, a renowned filmmaker and advocate for healthcare workers, to discuss the vital, yet often unrecognized, contributions of nurses. In this episode, Carolyn shares powerful stories from her film "American Delivery," highlighting the impact of the wholistic care nurses offer their patients. Carolyn, a brilliant storyteller, offers a unique perspective on the daily challenges and triumphs of these healthcare heroes, showcasing their technical expertise and unwavering compassion. Kicking off our Nurses Month mini series, The Heart of Healthcare, this episode is a timely reminder of the expertise and compassion that nurses bring to our communities each day. Tune in to explore the incredible work of these dedicated professionals and their crucial role in shaping the future of healthcare.

We're honored to continue our global tour of medical education today with Professor Katarzyna Taran, MD, PhD, a pioneering interdisciplinary researcher of tumor cell biology, an award winning educator noted for her focus on student engagement, and -- in a first for a Raise the Line guest -- a shooting sports certified coach and referee. As Professor Taran explains to host Michael Carrese, these seemingly disparate professional activities require the same underlying attributes: patience, the ability to overcome barriers, openness and adaptation. She believes those last qualities are especially important for today's medical students to acquire given the accelerated pace of change in healthcare. “They need to be equipped with the ability for critical thinking, to analyze and synthesize, and to search for unconventional solutions.” Professor Taran tries to impart these skills, in addition to the medical and scientific knowledge students must know, through a high level of engagement. “Teaching is relational, so try to be familiar with students' concerns. Talk to them, listen to them and you will become someone they trust.” In this wide-ranging and engaging conversation, Professor Taran also discusses her work as the head of the Laboratory of Isotopic Fractionation in Pathological Processes in Chair of Oncology, the use of neurodidactics in teaching, and the connection between the science of pathology and the future of humans in space. Mentioned in this episode:Medical University of Lodz If you like this podcast, please share it on your social channels. You can also subscribe to the series and check out all of our episodes at www.osmosis.org/raisethelinepodcast

As major healthcare payers, employers can drive value-based care, health equity, and innovative models to improve outcomes and cut costs. In this episode, Dan Mendelson, CEO of Morgan Health, discusses how employers, as significant healthcare payers, can play a pivotal role in demanding and implementing quality care models. He dives into the impact of primary care innovations, tackling health equity. Dan talks about the critical need for actionable data in transforming healthcare delivery. Dan also mentions how Morgan Health helps close the gaps by putting primary healthcare services close to their employees.  Tune in and uncover how employers can revolutionize healthcare delivery through value-based care, health equity initiatives, and innovative small business solutions!  Resources: Connect with and follow Dan Mendelson on LinkedIn. Follow Morgan Health on LinkedIn and visit their website.

Brian Drozdowicz, Senior VP and General Manager for Acute and Payer at PointClickCare, provides a platform using predictive analytics and AI for data sharing and collaboration across healthcare stakeholders. Interoperability has been an ongoing challenge due to the lack of standards and clear governance to support data sharing. The shift to value-based care drives the need for more access to patient data to improve patient outcomes, facilitate care transitions, and reduce readmissions and costs.   Brian explains, "PointClickCare has been a player in the market for quite some time. We're best known for the market-leading senior care EHR that we've had in market for 20-plus years. I run a business unit that sits by the side of that. We refer to that as the acute and payer business. And ultimately, this additional business and value proposition to the market operates the largest care collaboration network, sharing healthcare data across all the different stakeholders, hospitals, health plans, ambulatory clinics, community providers, and connecting is our core business. So we're ultimately in the business of sharing data and doing that safely, securely in a trusted way." "There are a lot of ways of driving adoption and sharing data at scale. I'd call out a couple of key areas in which we've seen a lot of progress in recent years. First is having well-established technology standards that safely and securely transmit that data. Number Two is having to share that data. So, otherwise, it's a bunch of data flowing back and forth just for the sake of data. And that doesn't solve anything with value-based care. Putting a set of guardrails in place requires providers and payers to work together with this data." #PointClickCare #HealthcareData #Interoperability #MedAI #DataSilos #ValueBasedCare #VBC  pointclickcare.com Download the transcript here

Brian Drozdowicz, Senior VP and General Manager for Acute and Payer at PointClickCare, provides a platform using predictive analytics and AI for data sharing and collaboration across healthcare stakeholders. Interoperability has been an ongoing challenge due to the lack of standards and clear governance to support data sharing. The shift to value-based care drives the need for more access to patient data to improve patient outcomes, facilitate care transitions, and reduce readmissions and costs.   Brian explains, "PointClickCare has been a player in the market for quite some time. We're best known for the market-leading senior care EHR that we've had in market for 20-plus years. I run a business unit that sits by the side of that. We refer to that as the acute and payer business. And ultimately, this additional business and value proposition to the market operates the largest care collaboration network, sharing healthcare data across all the different stakeholders, hospitals, health plans, ambulatory clinics, community providers, and connecting is our core business. So we're ultimately in the business of sharing data and doing that safely, securely in a trusted way." "There are a lot of ways of driving adoption and sharing data at scale. I'd call out a couple of key areas in which we've seen a lot of progress in recent years. First is having well-established technology standards that safely and securely transmit that data. Number Two is having to share that data. So, otherwise, it's a bunch of data flowing back and forth just for the sake of data. And that doesn't solve anything with value-based care. Putting a set of guardrails in place requires providers and payers to work together with this data." #PointClickCare #HealthcareData #Interoperability #MedAI #DataSilos #ValueBasedCare #VBC  pointclickcare.com Listen to the podcast here

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

We're discussing From Pain to Purpose: Transforming Trauma into Healing! Faisel and Dan are joined by Dr. Jeff Brenner: CEO at The Jewish Board.Our conversation revolves around the unexpected findings regarding coordinated care, the reality of medicalizing social issues, and the importance of timely empathy in mental and behavioral health.

Visionary healthcare leaders from The Permanente Medical Group, UC Davis Health, UNC Health, Summit Medical Group and Navina joined Eric Glazer to explore how artificial intelligence transforms clinical workflows and enables better value-based care. Discover how AI-driven chart prep, ambient scribe technology, and risk models streamline provider workflows, improve patient outcomes, and reduce clinician burnout. From overcoming implementation roadblocks to building cross-functional frameworks that promote trust and equity, this episode is packed with strategic insights and real-world success stories you can apply at your organization. Panelists Include: Brian Hoberman, MD, EVP & CIO, The Permanente Medical Group Reshma Gupta, MD, Chief of Population Health and Accountable Care, UC Davis Health Ram Rimel, Manager of Data Science Engineering, UNC Health Eric Penniman, D.O. Executive Medical Director, Summit Medical Group Dana McCalley, VP of Value-Based Care, Navina https://www.brightspotsinhealthcare.com/events/the-new-physician-playbook-ai-workflows-value-based-care-in-action/#url This episode is sponsored by Navina Navina is the clinician-first AI copilot for value-based care. Recently named Best in KLAS for clinician digital workflows, Navina turns fragmented patient data into actionable clinical insights right at the point of care. Natively integrated into the clinical workflow, their AI copilot helps improve risk adjustment, quality metrics, and population health – while significantly easing the administrative burden. Navina has earned the trust of more than 10,000 clinicians and care team members across 1,300 clinics, from some of the leading value-based care organizations in the country like Privia Health, Agilon Health, and Millennium Physician Group. About Bright Spots in Healthcare Bright Spots in Healthcare is produced by Bright Spots Ventures Bright Spots Ventures brings healthcare leaders together to share working solutions or "bright spots" to common challenges. We build valuable and meaningful relationships through our Bright Spots in Healthcare podcast, webinar series, leadership councils, customized peer events, and sales and go-to-market consulting. We believe that finding a bright spot and cloning it is the most effective strategy to improve healthcare in our lifetime. Visit our website at www.brightspotsinhealthcare.com

We like to think of Osmosis from Elsevier as a global community of millions of learners, connected by a desire to serve humanity and an inclination to use a diverse mix of educational resources to help them become excellent healthcare practitioners. On today's episode of Raise the Line, we're going to learn how Osmosis has created an opportunity for hundreds of those students from sixty countries to actually solidify those connections through the Osmosis Health Leadership Initiative (OHLI). Our guide to this effort is Osmosis Community Specialist Alfred Collins, who brings a keen interest in developing tech solutions to power the future of human communication to his work with OHLI.“Technology collapses barriers to communication and to understanding the nuances behind culture, behind global perspectives,” he tells host Lindsey Smith. One example he cites is how OHLI members learn about variations in the way different cultures approach collaboration, an important insight to gain as they head into team-based healthcare environments. OHLI members convene regularly over video sessions to hear from leaders in healthcare and learn about hosting successful on-campus events, among other enriching content.  They also have an opportunity to provide feedback on improving the Osmosis learning platform, and this year they're participating in a “hackathon” aimed at improving the future of healthcare. Tune in to find out more about what the OHLI program offers, how to apply, and how Alfred thinks virtual reality and AI technologies will impact the future of community building. Mentioned in this episode:Osmosis Health Leadership Initiative If you like this podcast, please share it on your social channels. You can also subscribe to the series and check out all of our episodes at www.osmosis.org/raisethelinepodcast

In this special edition of Quality Matters, we explore what three powerful conversations have taught us about one of health care's most pressing and perplexing questions: What do we know about the economics of care in America, and how can we make substantial, sustainable improvements? We look back at previous episodes of Quality Matters to reflect. We begin with health economist Sanjula Jain, who challenges conventional thinking around value-based care and urges a shift toward a more intuitive concept: “value for money.” With real-world examples (think hotels and Costco), she explains why the US health economy needs stability, and what it would take to rebuild trust and deliver real value to patients.Next, Brittany Cunningham, of Vanderbilt University Medical Center, shares how My Health Bundles help employers rein in costs while improving patient experience and provider satisfaction. Her team's approach flips the traditional payment model on its head—designing care first and payment second.And obstetrician Tiffany Inglis, of Elevance Health, takes us inside a groundbreaking program that pairs OB/GYNs with dedicated practice consultants. The result? Dramatic improvement in maternal health outcomes that could affect a staggering 12% of the nation's births.Each voice in this episode offers fresh, actionable insight. Together, they offer a roadmap toward a more sustainable—and humane—health care economy. Key Quote:“ Value for money is the ultimate consumer of the service is going to determine that value based off what they are paying. Value-based payment, it's different because value-based payment is ultimately a reimbursement scheme that doesn't change the total cost of care. Value-based payment is really a policy scheme focused on the provider level, which doesn't even affect the patient or consumer. It's one pool of dollars that is being reallocated. Providers are just reallocating those dollars and actually reducing the total cost of care. Who is benefiting doesn't actually translate down to the patient or the consumer.”Sanjula JainTime Stamps: (00:25) The Macroeconomics of Health Care(8:40) Value-Based Care in Action With Health Bundles14:30) The Economics of Prenatal Care

In this episode of Mavericks in Healthcare, hosts Ajay Mody and Asher Perzigian sit down with trailblazing leader Beth Dolan, Dean of the College of Health at Lehigh University. Beth isn't just rethinking healthcare education—she's turning it on its head. From championing interdisciplinary learning to weaving data science into the fabric of public health, Beth shares how Lehigh is preparing students to tackle today's most urgent health challenges. Discover how the College's bold initiatives—like its cutting-edge Population Health program and hands-on community-based research—are shaping a new kind of health professional. Plus, Beth opens up about the critical role of mental health in academia and what it really means to build a truly supportive student experience. If you're curious about the future of healthcare, education, and innovation, this conversation is a must-listen. Beth Dolan is on a mission—and she's inviting the next generation to lead the way.

Send us a textObesity is a pressing and complex challenge. GLP-1 meds are a game changer, but on their own, they may just bankrupt insurers without doing a whole lot to improve health. Can we build a better system for weight management that's clinically sound cost effective and scalable?In this episode of the HealthBiz Podcast, we're joined by Elina Onitskansky, Founder & CEO of Ilant Health. Elina explains why the current approach to obesity care is broken and how Ilant Health is making treatment more accessible by making it affordable, available, and accepted through value-based care.

This week on Faisel and Friends, we are discussing Expanding the Frontier: The Future of Primary Care. Faisel and Dan are talking with Tim Gronniger: Chief Executive Officer at Hopscotch Primary Care.Our conversation revolves around primary care in rural communities, the next generation of primary care practices, and pushing the boundaries of what primary care can be.

Jacob and Nikhil sit down with Dr. Rushika Fernandopulle. Rushika is the former CEO and Co-Founder of Iora Health, a primary care provider centered around value-based care and Medicare that One Medical acquired for $2.1 billion. They discuss why we're still in the second inning of value-based care, intersections of tech and healthcare, what it takes for VBC to succeed, and more. [0:00] Intro[0:29] Early Days of Value-Based Care[2:34] Challenges in Commercial Value-Based Care[5:20] Adapting Care Models for Different Populations[13:08] Medicaid and Long-Term Care Issues[16:30] Big Tech's Foray into Healthcare[20:37] Amazon's Healthcare Strategy[21:09] Challenges in Serving Low-Income Seniors[21:43] Innovative Solutions for Patient Transportation[22:16] The Economics of Healthcare Visits[23:22] Building a Custom EHR System[27:34] The Role of AI in Modern Healthcare[33:17] Future of Primary Care and Policy Implications Out-Of-Pocket: https://www.outofpocket.health/

The healthcare landscape is shifting—fast. As the industry moves away from Fee-For-Service (FFS) and toward Value-Based Care (VBC), practice groups must rethink how they deliver and get paid for care. But making the leap isn't just about changing contracts—it's about transforming the way care is coordinated, risks are managed, and success is measured. In this episode, our expert panel breaks down what it takes to thrive in a value-based world.

This podcast is brought to you by Outcomes Rocket, your exclusive healthcare marketing agency. Learn how to accelerate your growth by going to outcomesrocket.com Operationalizing value-based care is the core purpose of modern population health management, moving beyond simple definitions.  In this episode, Michael Hoxter, Chief Technology Officer at Lightbeam Health Solutions, shares key insights from HIMSS 2025, highlighting the growing role of AI and his company's 12-year journey from a small table to a major industry presence. He explains how Lightbeam leverages data warehousing, analytics, AI-driven patient segmentation, care management, and outreach to support value-based care, particularly in Medicare programs, where they have achieved significant savings. Michael distinguishes population health from chronic care management, emphasizing its broader responsibility for patient outcomes beyond clinical settings. He also discusses Lightbeam's shift from a product-only company to offering advisory and care management services shaped by client needs and industry feedback. Tune in and learn how data-driven insights transform patient care and the critical role of listening to clients in building a successful health tech company! Resources:  Connect with and follow Michael Hoxter on LinkedIn. Learn more about Lightbeam Health Solutions on their LinkedIn, Instagram, and website. Fast Track Your Business Growth: Outcomes Rocket is a full-service marketing agency focused on helping healthcare organizations like yours maximize your impact and accelerate growth. Learn more at outcomesrocket.com

Specialty medication spending is projected to rise sharply through 2026, intensifying pressure on health systems to control costs while improving patient outcomes. In this episode of Healthcare Insider, Cardinal Health's Mike Brown, vice president of managed services, and Naveen Mansukhani, director of specialty and ambulatory pharmacy solutions, break down the critical role specialty pharmacies play in managing spend, capturing revenue and retaining patients within the care continuum. They share real-world examples of how hospitals large and small are benefiting from tailored pharmacy models and discuss how to overcome common challenges such as labor shortages, compliance and ongoing accreditation requirements. Listen to learn how your organization can build a scalable, compliant specialty pharmacy strategy that supports value-based care and long-term success.

Today, we're excited to get to know Dr. Ali Khan, Chief Medical Officer of Aetna Medicare, overseeing healthcare services for over 4 million members. His career spans across some of the most impactful value-based care organizations, including Oak Street Health, CareMore, and Iora Health. He is also an adjunct lecturer at Northwestern University's Kellogg School of Management and serves on the clinical faculty of the Yale School of Medicine. Additionally, Dr. Khan is a director on the American Board of Internal Medicine. Also a trusted advisor on Pear's Health Industry Council.Before Aetna, Dr. Khan played a key role in Oak Street Health's rapid expansion, scaling it from 21 to 200+ clinics, culminating in its acquisition by CVS Health. Prior to that, he was instrumental in CareMore Health's growth and innovation in care delivery for vulnerable populations.He holds an MD-MPP from Virginia Commonwealth University and Harvard Kennedy School, completed his residency at Yale, and has taught at institutions like Northwestern Kellogg and Yale School of Medicine.As a leader in value-based care, he has firsthand experience in building, scaling, and optimizing healthcare startups—making his insights invaluable for founders, investors, and industry leaders navigating the complex world of healthcare innovation.

About Chris Caramanico:Chris Caramanico is a growth-oriented CEO, investor, and consultant with a proven track record of driving profitable growth in healthcare technology. With over 20 years of experience, Chris excels in both startups and large corporations, leading successful transformations and delivering results in complex environments. He is adept at anticipating market trends, developing innovative strategies, and building high-performance teams. Chris is a customer-focused strategist with expertise in value-based care and a passion for improving healthcare delivery through intelligence and intervention. Currently, he serves as CEO of Elligint Health, leveraging his expertise to reshape the healthcare landscape.Things You'll Learn:Elligint Health provides a toolset outside of the electronic medical record to help organizations perform value-based care arrangements.Their solution combines data analytics, care management, and communication tools to proactively identify and address patient needs.The platform aggregates data from various sources to create prospective work lists, enabling targeted interventions and improved patient outcomes.Elligint Health emphasizes patient activation, encouraging patients to take a proactive role in their care to improve health outcomes and address labor shortages.The organization is focused on interoperability and is prepared to meet CMS's rulings regarding prior authorization and data exchange.Resources:Connect with and follow Chris Caramanico on LinkedIn.Learn more about Elligint Health on their LinkedIn and website.

See omnystudio.com/listener for privacy information.

Send us a textIn this episode of the HealthBiz Podcast, host David Williams sits down with Terry Myerson, CEO and co-founder of Truveta, to explore how aggregated electronic medical record (EMR) data can drive groundbreaking insights in clinical research, drug development, and healthcare innovation. Terry shares his journey from mechanical engineering to tech entrepreneurship, his years at Microsoft, and how Truveta is using data to improve patient outcomes and save lives.

See omnystudio.com/listener for privacy information.

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

While many OTs work in a fee for service model, the reality is that we are undergoing a seismic shift towards value based care. In fact it's estimated that 238.8 million Americans receive healthcare in a value-based care model. These already large numbers are expected to grow significantly in the coming years.OTs has tremendous potential in value-based care models. But, the reality is we are missing the boat.  That's because becoming involved in a value based care model involves a contracting process that can feel complicated. There has been MUCH written to support doctors and other medical providers in the value-based care process, and they are outpacing us.  But, in today's episode we break this information down for OTs. Our favorite value-base care expert, Dana Stauss, PT, DPT  is going to walk private practice owner Carlin Reaume through: identify value-based care opportunities locally, crafting a proposal, and ultimately drafting a contract. Let's be honest. This feels dense. But, this is exactly what we need to be learning, and we are here to set you up for success!You can find more details on this course here:https://otpotential.com/ceu-podcast-courses/value-based-care-contracts Support the show Support the show

David Game remembers the days when the use of digital technology in education publishing amounted to putting a dictionary on a compact disc. Now, as the senior vice president of Product Management, Global Medical Education at Elsevier, he oversees a suite of learning materials that use artificial intelligence, virtual reality and 3-D modeling. “We've expanded into immersive technology with Apple Vision Pro that enables you to be inside the human body, to see and explore the human heart from the inside out and it is absolutely stunning,” says Game, whose long career in publishing includes experience in North America, the United Kingdom, Europe, China and India. As Game has witnessed first-hand, advancements in ed tech, including distance learning, have provided students with an array of options and modalities to choose from that accommodate different learning styles and life circumstances, and that puts a premium on being able to meet students where they are. “We want to make sure that students find learning from our materials engaging, efficient, and aligned with how they live their lives and do their work.” Join host Lindsey Smith for this fascinating episode of Raise the Line to learn how Elsevier is leveraging the innovations offered by Osmosis, Complete Anatomy and ClinicalKey Student to enrich the learning of medical students on their journey to becoming excellent clinicians.Mentioned in this Episode:Complete AnatomyClinicalKey StudentOsmosis If you like this podcast, please share it on your social channels. You can also subscribe to the series and check out all of our episodes at www.osmosis.org/raisethelinepodcast

Today's interview features Dr. Stephanie Huhn, founder of RoMo DPC as she shares her inspiring journey from traditional and "value based" primary care to Direct Primary Care (DPC) in rural Missouri. Dr. Huhn discusses her medical background, decision to pursue a DPC model, and how the transition has allowed her to offer personalized, patient-centered care without the constraints of traditional insurance. Throughout the conversation, she highlights the challenges and joys of working in a health professional shortage area and her dedication to improving healthcare access for her community. With her unique experiences in the Navy and academic settings, Dr. Huhn emphasizes the importance of following one's passions in medicine. She also shares successful community outreach strategies to educate patients about DPC, express her passion for patient care, and the rewarding aspects of the profession. For those interested in how rural healthcare can thrive under the DPC model, this episode offers valuable insights and practical advice. Join Dr. Huhn as she redefines healthcare delivery, ensuring patients experience the relief of having a physician in the family.FREE MARKET MEDICAL ASSOCIATION (FMMA) 4/9-11/25: Use code MYDPCSTORY for $800 off your FMMA Annual Conference registration! FREE Alternative to Up TO Date: OPEN EVIDENCESupport the showBe A My DPC Story PATREON MEMBER! SPONSOR THE PODMy DPC Story VOICEMAIL! DPC SWAG!FACEBOOK * INSTAGRAM * LinkedIn * TWITTER * TIKTOK * YouTube

We're discussing The Reality of Residency: Shaping Tomorrow's Family Physicians! Faisel and Dan are joined by Dr. Sarah Cole, Program Director at Mercy Family Medicine St. Louis.Our conversation revolves around workload in medical education, leadership involvement during residency, and expectations for family medicine Match 2025.

Send us a textJoin Dr. Paulie as he explores value-based care in education with Leila Farshchian MA, BCBA, leader of ABA Toolbox—an award-winning platform advancing science-driven, learner-centered interventions for individuals with autism and disabilities. The conversation explores how integrating behavior analytic principles with compassion and creativity can significantly enhance outcomes for students with special needs. Listen in as Layla shares her inspiring journey into behavior analysis, the critical role of values in education, and practical strategies to empower educators, students, and families alike.Key Takeaways:How CABAS merges science & teaching for individualized success The role of tech-driven solutions in special education & ABA Toolbox The power of collaboration in transforming therapy & learningThis engaging conversation is packed with practical insights for providers dedicated to collaboration, brining the learner to the center for enhanced treatment outcomes in education.To learn more about Leila and her mission, please visit us at: www.abatoolbox.comLeila Farshchian, MA, BCBA. https://www.linkedin.com/in/leila-farshchian-33974335 Contact: Leila@abatoolbox.com

In this episode, Jane Brown, Vice President of Medicaid Strategic Support and Oversight at Aetna, discusses the evolving Medicaid landscape. She shares insights on improving connectivity, driving value-based care, and empowering both providers and beneficiaries through data and technology.

Join hosts Ajay Mody and Asher Perzigian on Mavericks in Healthcare as they sit down with Alicia Graham, COO and co-founder of Claimable. Alicia shares the inspiration behind launching Claimable—a groundbreaking AI-powered platform that helps patients and providers challenge unjust healthcare denials in minutes. From her decade-long journey uniting clinical expertise, AI innovation, and patient advocacy, Alicia reveals how Claimable turns personal stories into powerful appeals, tackling crippling medical debt and amplifying shared patient experiences. Tune in to meet a true Maverick in Healthcare driving change for all.

Send us a textIs smarter decision support the key to unlocking value-based success?In this episode of the HealthBiz Podcast, Thaddeus Fulford-Jones, CEO of Radial, joins host David Williams to explore how Radial's AI-powered decision support software merges cutting-edge data science with clinical best practices to enhance patient outcomes, reduce costs, and optimize value-based provider operations.Thaddeus Fulford-Jones' book recommendation: Reservations for Nine by Dr. George Beauregard

Aledade CEO, Dr. Farzad Mostashari, and best-selling author Geoffrey Moore explore how the concepts in Moore's influential book, “Crossing the Chasm” can be applied to accelerate adoption of value-based care. In order to move to mainstream adoption, it's crucial to focus on the niche market of “pragmatists in pain” who have an urgent need that the current system isn't solving. Our co-host Sean Cavanaugh, chief policy officer at Aledade, points out that oftentimes in the traditional fee-for-service model, the pragmatists in pain are independent primary care clinicians. Moore and Dr. Mostashari also share insights and recommendations for the new administration from their recent article, including focusing on primary care, defining the competition and paving the way for simplifiers who can help clinicians navigate the complexities of value-based care. Using this framework, the Center for Medicare & Medicaid Services (CMS) could accelerate expansion of value-based care to the majority of the nation's primary care clinicians as well as their patients. Connect with us at acoshow@aledade.com or visit the Aledade Newsroom.

An interesting new study from the Geisinger health system in Pennsylvania examining if genomic screening in a large population increases the identification of disease risk prompted Raise the Line to re-release a previous episode about a textbook designed to help all medical providers understand the clinical applications of genomic testing. Genomics in the Clinic: A Practical Guide to Genetic Testing, Evaluation, and Counseling from Elsevier Science Direct dives into the use of this important tool in diagnosis and screening, indicating how individuals may respond to drug therapies, and more. “We really need to educate all healthcare providers about the practice of genetics because they're going to be involved directly or indirectly in genetic testing and conveying information about what the results mean to patients and their families,” explains co-author Dr. Ethylin Wang Jabs, enterprise chair of the Department of Clinical Genomics for Mayo Clinic. Jabs and her co-author, Dr. Antonie Kline, director of Clinical Genetics at the Harvey Institute for Human Genetics at Greater Baltimore Medical Center, chose a format that makes heavy use of case studies to help readers get a better grasp on this complicated field and they also include chapters on direct-to-consumer testing and the ethical and social implications in genomic medicine. “Any kind of potentially predictive testing can have ethical issues related to it, including insurance coverage, testing for family members, protections for minors, and more,” says Dr. Kline. Join host Caleb Furnas for an illuminating episode on an area of discussion in medicine that's growing in importance as the use of genetic testing rapidly increases. Mentioned in this episode: Genomics in the Clinic: A Practical Guide If you like this podcast, please share it on your social channels. You can also subscribe to the series and check out all of our episodes at www.osmosis.org/raisethelinepodcast

There is a lot happening in federal policy that may affect healthcare payment transformation and care delivery. But we've said it before: healthcare leaders can't afford to focus on fighting near-term fires at the expense of driving long-term success and sustainability. Amidst the uncertainty, it's more important than ever to push forward conversations about how we can structurally evolve our systems to align incentives to patient health. So, in this episode, we're talking about value-based care. Host Abby Burns invites Advisory Board expert Clare Wirth and Optum Advisory expert Erik Johnson to unpack the state of VBC in early 2025, and where they see it going next. They debate whether bundles can truly be considered “value-based care,” how specialty care will fit into the future VBC landscape, and which payer lines of business they have their eyes on. Links: VBC in 2025: What's now and what's next Inside Advocate Health's VBC approach that saved $136M How UNC Health made VBC sustainable in an academic health system The obstacles between health systems and VBC success Ep. 201: Value series: What does health system VBC adoption actually look like? Ep. 231: Big deal, little deal, or no deal? A 2024 health policy retrospective Value-based care landing page Enjoying this episode? Discover how Optum Advisory experts can help you design a VBC strategy to drive sustainable growth and profitability for your organization. Connect with one of our experts today. Advisory Board is a subsidiary of Optum. All Advisory Board research, expert perspectives, and recommendations remain independent. A transcript of this episode as well as more information and resources can be found on RadioAdvisory.advisory.com.

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

This week on Faisel and Friends, we are discussing Primary Care Scorecard: The Cost of Neglect. Faisel and Dan are talking with Dr. Yalda Jabbarpour, Director of the Robert Graham Center at American Academy of Family PhysiciansOur conversation explores the major strains on primary care in 2025, the focus on prevention as the national healthcare strategy, and the driving factors of workforce retention and depletion.Read the full Scorecard Report here: https://www.milbank.org/publications/the-health-of-us-primary-care-2025-scorecard-report-the-cost-of-neglect/

This podcast is brought to you by Outcomes Rocket, your exclusive healthcare marketing agency. Learn how to accelerate your growth by going to outcomesrocket.com The integration of AI and empathy is crucial to improving healthcare outcomes and affordability.  In this episode, Sanjay Doddamani, Founder and CEO, and Michael Gleeson, Co-founder and CTO, of Guidehealth, discuss how their company is tackling the healthcare productivity crisis by integrating AI into clinical workflows. They highlight the importance of expanding healthcare access without overburdening physicians while improving patient engagement and care quality. Guidehealth leverages AI to analyze previously inaccessible data, predict patient needs, and create personalized care plans for patients, families, and clinicians. They believe AI-driven advancements will enhance patient connections, streamline data access in EHRs, and open new opportunities for innovation in healthcare. Tune in and learn how AI and empathy are transforming healthcare delivery and improving patient outcomes! Resources:  Connect and follow Sanjay Doddamani on LinkedIn. Follow and connect with Michael Gleeson on LinkedIn. Learn more about Guidehealth on their LinkedIn and website. Fast Track Your Business Growth: Outcomes Rocket is a full service marketing agency focused on helping healthcare organizations like yours maximize your impact and accelerate growth. Learn more at outcomesrocket.com