Afleveringen
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Recently on Relentless Health Value, we’ve been tinkering around with a few recurring themes—recurring through lines—that are just true about American healthcare these days.
In this episode of Relentless Health Value, host Stacey Richter speaks with Dr. Christine Hale about high cost claimants and the implications for healthcare plans in 2025 and beyond. They discuss the importance of trust in patient care, the financial incentives behind patient steering, and the critical role of timely and comprehensive data analysis.
Dr. Hale emphasizes the need for an integrated approach to medical and pharmacy claims data to avoid expensive consequences and improve patient outcomes. She also shares strategies for plan sponsors to effectively manage high cost claimants through evidence-based care, appropriate treatment settings, and creative problem-solving, while underlining the importance of patient engagement and satisfaction.
Don't miss next week's episode with Dr. Eric Bricker for a deeper dive into these topics.
=== LINKS ===
🔗 Show Notes with all mentioned links:
https://relentlesshealthvalue.com/episodes
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05:22 What is a high-cost claimant, and how is the definition changing?
07:42 Why buy-and-bill pharmaceuticals can be so costly for plan sponsors.
10:19 What are plan sponsors getting wrong about this situation?
11:28 What do you need as an employer to understand your plan data fully?
13:41 EP462 with Scott Conard, MD.
17:35 What are plan sponsors currently doing that they should not being doing?
19:54 Why starting small is important.
23:02 EP468 with Matt McQuide.
25:37 What are the steps employers should take to improve their high-cost claimant spend?
31:02 EP371 with Erik Davis and Autumn Yongchu.
33:46 EP467 with Stacey.
Recent past interviews:
Click a guest’s name for their latest RHV episode!
Nikki King, 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
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In this episode, host Stacey Richter revisits a conversation with Nikki King, CEO of Alliance Health Centers, discussing the critical issues facing rural hospitals and healthcare systems. They delve into the impacts of Medicaid cuts, the financial struggles of rural hospitals reliant on commercial insurance, and potential solutions like freestanding emergency rooms, telehealth, and the expanded roles of nurse practitioners.
The conversation also covers the complexities of maternity care and mental health services in rural areas, emphasizing the urgent need for systemic reforms to ensure equitable access to healthcare.
=== LINKS ===
🔗 Show Notes with all mentioned links:
https://cc-lnk.com/EP470✉️ Enjoy this podcast? Subscribe to the free weekly newsletter:
https://relentlesshealthvalue.com/join-the-relentless-tribe🫙 Support the podcast with a small donation to the Tip Jar:
https://relentlesshealthvalue.com/join-the-relentless-tribe📺 Subscribe to our YouTube channel https://www.youtube.com/@RelentlessHealthValue
🎤 Listen on Apple Podcasts https://podcasts.apple.com/us/podcast/feed/id892082003?ls=1
🎤 Listen on Spotify https://open.spotify.com/show/6UjgzI7bScDrWvZEk2f46b
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✭ X https://twitter.com/relentleshealth/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.”
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Zijn er afleveringen die ontbreken?
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In part 2 of episode 469, host Stacey Richter discusses the implications of Medicare site neutral payments and Health Savings Account (HSA) reforms with James Gelfand, president and CEO of the ERISA Industry Committee (ERIC).
The episode details how plan sponsors should adapt to Medicare's site neutral payment policies aimed at curbing hospital consolidation and inflated prices through facility fees and markups. Gelfand provides insights into how HSA reforms currently in Congress could expand the scope of preventive care covered before deductibles are met, benefitting both employers and employees.
The conversation also touches on the challenges high deductible health plans pose and the potential benefits of codifying recent IRS guidance to allow greater flexibility in pre-deductible coverage. The discussion underscores the importance of plan sponsors staying ahead of Medicare policies to avoid higher costs.
=== LINKS ===
🔗 Show Notes with all mentioned links:
https://relentlesshealthvalue.com/episodes✉️ Enjoy this podcast? Subscribe to the free weekly newsletter:
https://relentlesshealthvalue.com/join-the-relentless-tribe🫙 Support the podcast with a small donation to the Tip Jar:
https://relentlesshealthvalue.com/join-the-relentless-tribe🎤 Listen on Apple Podcasts https://podcasts.apple.com/us/podcast/feed/id892082003?ls=1
🎤 Listen on Spotify https://open.spotify.com/show/6UjgzI7bScDrWvZEk2f46b
📺 Subscribe to our YouTube channel https://www.youtube.com/@RelentlessHealthValue
=== CONNECT WITH THE RHV TEAM ===
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05:42 What does Medicare site-neutral payments mean?
08:59 How do markups play into the dynamics here?
09:52 Upcoming episode with Christine Hale, MD, MBA.
10:36 What does the “narrow” start for these changes mean?
11:42 What action steps should plan sponsors be taking?
13:01 What options do plan sponsors have in highly consolidated markets?
14:27 EP371 with Erik Davis and Autumn Yongchu.
14:53 EP448 (Part 1 and Part 2) with Shawn Gremminger.
15:46 Will this bill potentially make changes to HSA plans?
17:40 Why has the thinking behind healthcare usage changed since the inception of HSAs?
18:42 INBW41 with Stacey.
23:24 How are preventive care and first-dollar coverage connected within the context of HSAs?
25:48 Why would it be difficult to completely get rid of a high-deductible health plan and offer HSAs without them?
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In part 1 of this two part episode, Stacey Richter speaks with James Gelfand, President and CEO of the ERISA Industry Committee (ERIC), about the potential effects of proposed Medicaid cuts on plan sponsors and their members.
They explore ways plan sponsors can prepare for the changes, including Medicaid's four major areas of possible cuts: reducing waste, fraud, and abuse; implementing work requirements; reeling in provider taxes; and addressing the 'Cornhusker Kickback' from the ACA.
The conversation also delves into how state governments and hospitals might respond to these cuts and suggests actions for plan sponsors to mitigate potential impacts. The episode is part one of a two-part series, with the second episode covering Medicare site neutral payments and HSA reforms.
=== LINKS ===
🔗 Show Notes with all mentioned links:
https://relentlesshealthvalue.com/episodes✉️ Enjoy this podcast? Subscribe to the free weekly newsletter:
https://relentlesshealthvalue.com/join-the-relentless-tribe🫙 Support the podcast with a small donation to the Tip Jar:
https://relentlesshealthvalue.com/join-the-relentless-tribe🎤 Listen on Apple Podcasts https://podcasts.apple.com/us/podcast/feed/id892082003?ls=1
🎤 Listen on Spotify https://open.spotify.com/show/6UjgzI7bScDrWvZEk2f46b
📺 Subscribe to our YouTube channel https://www.youtube.com/@RelentlessHealthValue
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05:22 What’s happening with Medicaid cuts?
06:47 What are the four main things congress is actually looking at in cutting Medicaid?
09:12 What is the Cornhusker Kickback?
16:46 What should plan sponsors be doing right now to prepare for these potential Medicaid cuts?
20:04 What’s going to happen to hospitals with these proposed Medicaid cuts?
20:48 EP464 with Al Lewis.
23:41 How does hospital consolidation affect the potential future with these Medicaid cuts?
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In Episode 468, host Stacey Richter engages in a conversation with Matt McQuide, CEO of Synergy Healthcare. This episode delves into the critical assumptions surrounding member engagement within the healthcare industry.
Key points discussed include the role of employers in steering plan members, the importance of member engagement for navigating the healthcare marketplace, and Matt’s three major misconceptions about health plan membership.
Matt also presents real-life examples of how engagement significantly impacts health outcomes, emphasizing that relationships and trust are paramount. The episode concludes with practical strategies for employers to enhance engagement and manage employee health effectively.
=== LINKS ===
🔗 Show Notes with all mentioned links:
https://cc-lnk.com/EP468✉️ Enjoy this podcast? Subscribe to the free weekly newsletter:
https://relentlesshealthvalue.com/join-the-relentless-tribe🫙 Support the podcast with a small donation to the Tip Jar:
https://relentlesshealthvalue.com/join-the-relentless-tribe🎤 Listen on Apple Podcasts
https://podcasts.apple.com/us/podcast/feed/id892082003?ls=1🎤 Listen on Spotify
https://open.spotify.com/show/6UjgzI7bScDrWvZEk2f46b📺 Subscribe to our YouTube channel
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You can learn more at Synergy Healthcare and by following Matt on LinkedIn.
Matt McQuide is the founder and CEO of Synergy Healthcare, a role he has held since launching the company in 2012. Under his leadership, Synergy has made significant strides in improving member health, enhancing the health insurance experience and the financial integrity of health plans.
06:28 What are Matt’s three common assumptions that employers make about member engagement?
07:08 “Health is actually hard.”
08:19 Why is it important to meet people when their need for healthcare sparks their interest in their health?
11:29 “It didn’t take much … it just takes time.”
13:53 Why are relationships and trust more important today for employee health and member engagement?
16:04 Do people actually want optimal health?
17:44 Why is it important to meet people where they are today?
22:38 “Employers don’t want to fix healthcare.”
24:10 Why it’s important to remember that claims are real people.
24:38 Quote from Steve Schutzer, MD, about EP463 with Betsy Seals.
26:44 How do you solve the “middle way”?
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In this solo episode of 'Relentless Health Value,' host Stacey Richter dives into the intricate relationship between increased emergency room (ER) visits and the lack of access to effective primary care. Discussing insights from recent episodes featuring experts like Matt McQuide, Dr. Christine Hale, and others, Stacey explores how inadequate primary care leads to skyrocketing ER costs, which now account for 6% of total healthcare spending.
Key points include the systemic issues driving this trend, the incentives misalignments within hospitals and insurance carriers, and the importance of establishing trust and relationships in primary care. The episode also discusses perspectives from healthcare professionals and thought leaders on potential solutions to realign healthcare incentives and improve patient outcomes.
=== LINKS ===
🔗 Show Notes with all mentioned links:
https://cc-lnk.com/EP467✉️ Enjoy this podcast? Subscribe to the free weekly newsletter:
https://relentlesshealthvalue.com/join-the-relentless-tribe🫙 Support the podcast with a small donation to the Tip Jar:
https://relentlesshealthvalue.com/join-the-relentless-tribe🎤 Listen on Apple Podcasts
https://podcasts.apple.com/us/podcast/feed/id892082003?ls=1🎤 Listen on Spotify
https://open.spotify.com/show/6UjgzI7bScDrWvZEk2f46b📺 Subscribe to our YouTube channel
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02:16 Connecting the dots between the last six shows.
05:34 EP466 with Vivian Ho, PhD.
05:53 EP463 with Betsy Seals.
05:56 EP384 with Wendell Potter.
14:38 Where does the primary care through line connect to carriers?
17:13 Health Affairs study showing ER cost increases.
19:19 Kevin O’Leary’s Health Tech Nerds newsletter.
19:40 EP407 with Vivek Garg, MD, MBA.
20:47 How are hospital board directors affecting hospital price increases and why?
21:49 Upcoming episode with Matt McQuide.
Also mentioned in this episode are Matt McQuide; Christine Hale, MD, MBA; Kenny Cole, MD; Al Lewis; John Lee, MD; Rushika Fernandopulle, MD; Scott Conard, MD; Vivian Ho, PhD; Betsy Seals; Wendell Potter; Tim Denman; François de Brantes, MBA; Jeff Charles Goldsmith, PhD; Mick Connors, MD; Primary Care for All Americans; Rob Andrews; Alex Sommers, MD, ABEM, DipABLM; Ann Lewandowski; Steve Schutzer, MD; Sergei Polevikov, ABD, MBA, MS, MA 🇮🇱🇺🇦; Kevin O’Leary; Health Tech Nerds; Vivek Garg, MD, MBA; Suhas Gondi, MD, MBA; -
Healthcare costs keep rising, but what’s driving those increases? In this episode, Stacey Richter speaks with Dr. Vivian Ho, a health economist at Rice University and Baylor College of Medicine, to break down the real reasons behind skyrocketing commercial insurance premiums.
Are insurance premiums rising faster than wages—and why does it matter? What’s the biggest driver of premium increases? (Spoiler: It’s hospital prices.) Are hospital price hikes justified by rising costs—or is something else at play?Dr. Ho shares data-backed insights on hospital consolidation, executive incentives, and how health system pricing impacts self-insured employers and plan sponsors. If you’re a healthcare executive or a jumbo employer managing benefits, this episode is a must-listen.
=== LINKS ===
🔗 Show Notes with all mentioned links:
https://relentlesshealthvalue.com/episodes✉️ Enjoy this podcast? Subscribe to the free weekly newsletter:
https://relentlesshealthvalue.com/join-the-relentless-tribe🫙 Support the podcast with a small donation to the Tip Jar:
https://relentlesshealthvalue.com/join-the-relentless-tribe🎤 Listen on Apple Podcasts
https://podcasts.apple.com/us/podcast/feed/id892082003?ls=1🎤 Listen on Spotify
https://open.spotify.com/show/6UjgzI7bScDrWvZEk2f46b📺 Subscribe to our YouTube channel
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✭ X https://twitter.com/relentleshealth/05:12 Are insurance premiums going up?
05:59 What is the disparity between cost of insurance and wage increases?06:21 LinkedIn post by Byron Hugley.
06:25 Article by Michael Strain.
06:46 How much have insurance premiums gone up for employers versus employees?
09:06 Chart showing the cost to insure populations of employees and families.
10:17 What is causing hospital prices and insurance premiums to go up so exponentially?
12:53 Article by (and tribute to) Uwe Reinhardt.
13:49 EP450 with Marilyn Bartlett, CPA, CGMA, CMA, CFM.
15:28 Are razor-thin operating margins for hospitals causing these rising hospital prices?
16:56 Collaboration with Marilyn Bartlett and the NASHP Hospital Cost Tool.
19:47 What is the explanation that hospitals give for justifying these profits?23:16 How do these hospital cost increases actually happen?
27:06 Study by Zack Cooper, PhD.
27:50 Who typically makes up a hospital board, and why do these motivations incentivize hospital price increases?
30:12 EP418 with Mark Cuban and Ferrin Williams, PharmD, MBA.
33:17 Why is it vital that change start at the board level? -
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 ===
🔗 Show Notes with all mentioned links:
https://cc-lnk.com/EP465✉️ Enjoy this podcast? Subscribe to the free weekly newsletter:
https://relentlesshealthvalue.com/join-the-relentless-tribe🫙 Support the podcast with a small donation to the Tip Jar:
https://relentlesshealthvalue.com/join-the-relentless-tribe🎤 Listen on Apple Podcasts
https://podcasts.apple.com/us/podcast/feed/id892082003?ls=1🎤 Listen on Spotify https://open.spotify.com/show/6UjgzI7bScDrWvZEk2f46b
📺 Subscribe to our YouTube channel https://www.youtube.com/@RelentlessHealthValue
=== CONNECT WITH THE RHV TEAM ===
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✭ X https://twitter.com/relentleshealth/07:12 EP365 with Scott Haas.
07:17 EP397 with Paul Holmes.
07:19 EP439 with Luke Slindee, PharmD.
07:20 EP379 with AJ Loiacono.
07:44 What is the Aggregate Discount Guarantee?
13:49 Why do the divergent list prices and the perverse incentives prevent the Aggregate Discount Guarantee from really limiting cost spread?
17:55 Why is it important for plan sponsors to check these drug cost prices, and how can employers check them?
23:56 What drives cost lower, and why does it change everything?
25:09 How does RxSaveCard work?
25:44 EP461 with Chris Crawford.
30:01 Do you need a PBM’s permission to use RxSaveCard?
30:37 How does it look for employers/employees to use the RxSaveCard?
32:39 EP356 with Ge Bai, PhD, CPA.
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Emergency room costs now make up 6% of total healthcare plan spending—why? In this episode, host Stacey Richter welcomes Al Lewis to break down the data behind rising ER expenses, separating fact from fiction.
They discuss whether increased patient acuity or widespread upcoding is driving costs, the impact of the No Surprises Act, and why plan sponsors struggle to negotiate fair ER rates. Plus, Al shares actionable strategies for employers to push back against inflated charges.
If you want to understand the hidden forces behind escalating ER bills, this is a must-listen.
You can find the charts and links mentioned in the show notes in the link below.
=== LINKS ===
🔗 Show Notes with all mentioned links:
https://cc-lnk.com/EP464✉️ Enjoy this podcast? Subscribe to the free weekly newsletter:
https://relentlesshealthvalue.com/join-the-relentless-tribe🫙 Support the podcast with a small donation to the Tip Jar:
https://relentlesshealthvalue.com/join-the-relentless-tribe📺 Subscribe to our YouTube channel
https://www.youtube.com/@RelentlessHealthValue🎤 Listen on Apple Podcasts
https://podcasts.apple.com/us/podcast/feed/id892082003?ls=1🎤 Listen on Spotify
https://open.spotify.com/show/6UjgzI7bScDrWvZEk2f46b=== CONNECT WITH THE RHV TEAM ===
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00:00 Introduction
08:32 What is going on in ER visits, and how big of a deal is the total spend?
10:16 Why is the price of ER visits going up when it should be going down?
11:59 What is the major source of unexpected medical debt?
13:27 What is code creep, and why is it happening?
16:26 Why are plan sponsors unable to negotiate emergency room services?
19:22 EP415 with Rob Andrews.
25:53 Why is it important not to agree to consent when you go in to visit the ER?
27:47 EP386 with Al Lewis.
31:28 What steps can plan sponsors take to be proactive about limiting ER spending for their employees?
You can learn more at quizzify.com and by emailing [email protected]. You can also follow Al on LinkedIn.
Recent past interviews:
Click a guest’s name for their latest RHV episode!
Betsy Seals, Wendell Potter (Encore! EP384), Dr Scott Conard, Stacey Richter (INBW42), Chris Crawford, Dr Rushika Fernandopulle, Bill Sarraille, Stacey Richter (INBW41), Andreas Mang (Encore! EP419), Dr Komal Bajaj
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In this episode of Relentless Health Value, host Stacey Richter engages with Betsy Seals, CEO and co-founder of Rebellis Group, to analyze the future of key Medicare Advantage policies amidst a changing political landscape. They delve into four critical areas:
1. Medicare Advantage Stars Program: Examining potential changes due to recent lawsuits and the new administration’s stance on quality measures.
2. Risk Adjustment and Government Oversight: Discussing the focus on recouping improper payments and how oversight might evolve.
3. Use of Artificial Intelligence: Considering appropriate oversight for AI applications in prior authorization processes and ensuring they benefit patient care.
4. Agent and Broker Oversight: Exploring increased scrutiny over marketing practices and the dissemination of accurate information to beneficiaries.
Betsy emphasizes the importance for Medicare Advantage plans to prioritize patient value, maintain compliance, and proactively utilize data to navigate these evolving policies. This discussion provides valuable insights for stakeholders aiming to understand the future of Medicare Advantage.
=== LINKS ===
🔗 Show Notes with all mentioned links:
https://cc-lnk.com/EP463
✉️ Enjoy this podcast? Subscribe to the free weekly newsletter:
https://relentlesshealthvalue.com/join-the-relentless-tribe
🫙 Support the podcast with a small donation to the Tip Jar:
https://relentlesshealthvalue.com/join-the-relentless-tribe
🎤 Listen on Apple Podcasts https://podcasts.apple.com/us/podcast/feed/id892082003?ls=1
🎤 Listen on Spotify https://open.spotify.com/show/6UjgzI7bScDrWvZEk2f46b
📺 Subscribe to our YouTube channel https://www.youtube.com/@RelentlessHealthValue
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05:09 Will the Star Ratings program stay in this new administration?
08:08 How will the lawsuits against CMS policies play out with this new administration?
10:24 Why is it hard for Medicare Advantage plans to survive, let alone thrive?
16:22 How does AI directly impact beneficiary lives?
21:38 What’s going on now with the override payments?
27:08 How is non-collaboration going to impact Medicare beneficiaries moving forward?
31:45 Why is it important to become more technologically savvy in compliance?
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In this episode, Stacey Richter explores how the demands of shareholders influence the actions of publicly traded health insurance companies with guest Wendell Potter. Drawing from Milton Friedman’s assertion that a business’s primary responsibility is to its shareholders, we examine the implications of this philosophy in the healthcare sector. The discussion highlights concerns about fraud allegations among major insurers and the lack of open competition due to market consolidation.
We delve into the concept of the “medical loss ratio,” a key metric for investors, and how it pressures insurers to prioritize profits, often at the expense of patient care. Our guest, Wendell Potter, a former health insurance executive turned advocate for healthcare reform, provides insider insights into these dynamics. He discusses the challenges insurers face in controlling costs, the impact of rising premiums, and the broader consequences for patients and the healthcare system. This episode offers a critical look at the intersection of corporate interests and patient care, shedding light on the systemic issues that arise when profit motives drive healthcare decisions.
All mentioned links can be found in the show notes.
=== LINKS ===
🔗 Show Notes with all mentioned links:
https://cc-lnk.com/Encore384✉️ Enjoy this podcast? Subscribe to the free weekly newsletter:
https://relentlesshealthvalue.com/join-the-relentless-tribe🫙 Support the podcast with a small donation to the Tip Jar:
https://relentlesshealthvalue.com/join-the-relentless-tribe🎤 Listen on Apple Podcasts https://podcasts.apple.com/us/podcast/feed/id892082003?ls=1
🎤 Listen on Spotify https://open.spotify.com/show/6UjgzI7bScDrWvZEk2f46b
📺 Subscribe to our YouTube channel https://www.youtube.com/@RelentlessHealthValue
=== CONNECT WITH THE RHV TEAM ===
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08:31 What is the medical loss metric?
11:33 “The reality is, insurers have been jacking up premiums … for a long time.”
12:48 “It’s a short-term game.”
15:39 “You’re seeing that these companies are not doing a very good job … of controlling costs because they don’t have the incentive.”
20:19 EP366 with Kevin Schulman, MD.
22:45 How do payers ensure that they’re controlling utilization?
25:53 “It’s death by a thousand cuts.”
31:51 “Just like independent practice physicians are endangered, so are community pharmacists.”
33:17 Who runs our healthcare system?
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This podcast today is with Dr. Scott Conard, founder of Converging Health. You might remember him from the earlier episode (EP391). First of all, I enjoyed how it came to be. Brian Uhlig, an employee benefit consultant of some acclaim, came to me and offered to sponsor a show for someone else. Not himself. I gotta say, it’s stuff like this that warms my heart. It’s this village that we have here, this tribe of Relentless folks trying so hard to stand up for and help patients. So, thanks again to Brian Uhlig.
Right now, Dr. Conard is doing a bunch of work with Mike Adams from 7-Eleven, helping their plan members. A lot of this work is centered on and about a few pretty striking but very common insights that many plan sponsors will find in their own data. It turns out about 70%, give or take, of people who wind up costing the plan whatever the high-cost threshold is in any given plan year.
These higher-cost claimants didn’t fall out of the sky unexpectedly, 70% of them. They were actually high risk but low cost in prior years. So, the trick is to find these individuals and help them not fall into the high-risk and high-cost part of the graph. If the goal is how to best manage a population of members, a lot of that is, again, identifying high-risk patients who are currently in the low-cost zone, who, any given plan year, are gonna go out of that zone and get into the high-cost area.
So, if we’re thinking about best practices to avoid this, I’m gonna run through Dr. Conard’s list that we mostly run through in the show that follows.
Lastly, we touch a little bit in the show today on community-run primary care. This is a community paying for primary care for community members, just like they pay the fire department and the police department. There’s a town in Rhode Island doing this that Dr. Conard talks about today. In fact, Michael Fine, MD, is part of this effort in Rhode Island.
=== LINKS ===
🔗 Show Notes with all mentioned links and articles:
https://cc-lnk.com/EP462✉️ Enjoy this podcast? Subscribe to the free weekly newsletter:
https://relentlesshealthvalue.com/join-the-relentless-tribe🫙 Support the podcast with a small donation to the Tip Jar:
https://relentlesshealthvalue.com/join-the-relentless-tribe🎤 Listen on Apple Podcasts https://podcasts.apple.com/us/podcast/feed/id892082003?ls=1
🎤 Listen on Spotify https://open.spotify.com/show/6UjgzI7bScDrWvZEk2f46b
📺 Subscribe to our YouTube channel https://www.youtube.com/@RelentlessHealthValue
=== CONNECT WITH THE RHV TEAM ===
✭ LinkedIn https://www.linkedin.com/company/relentless-health-value/
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✭ X https://twitter.com/relentleshealth/07:10 How do we think about data wrongly, and how does that affect our healthcare spend in regard to population health?
09:43 What needs to be done with population health data once it’s collected.
14:48 Community in Rhode Island doing effective proactive care.
16:09 EP449 with Marty Makary, MD, MPH.
16:44 A real, successful case study.
24:08 How do we define high-cost patients?
24:14 What do we know about high-cost patients in regard to population health spend?
29:02 Why avoiding prevention in primary care only harms yourself in the future.
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In this inbetweenisode Stacey Richter dives into the complexities of benefit design in American healthcare. Highlighting insights from recent episodes with Bill Sarraille (EP459) and upcoming episode with Scott Conard, MD, Richter explores the impact of cost containment measures and the moral hazard of insurance, emphasizing the importance of creating balanced and efficient benefit plans that align with plan values and avoid unintended consequences.
She discusses the challenges and implications of high deductible health plans and copay maximizers/accumulators, urging plan sponsors to strive for pareto optimality and practical solutions. This episode is a call to carefully consider patient behavior, healthcare utilization, and the broader impacts of financial incentives in healthcare.
Going black and white or over-indexing to prevent outlier kind of stuff is probably not gonna end well. Not seeking a middle way can easily result in a solution that is possibly worse than the problem.
Moral hazard is actually a thing. There are lots of implications to patients not being able to distinguish high-value and low-value care. But if we know this, then, philosophically at least, how do we conceptualize a solve? What should we be doing? If we’re not doing black and white, what does the gray in the middle look like?
=== LINKS ===
🔗 Show Notes with all mentioned links:
https://cc-lnk.com/INBW42✉️ Enjoy this podcast? Subscribe to the free weekly newsletter:
https://relentlesshealthvalue.com/join-the-relentless-tribe🫙 Support the podcast with a small donation to the Tip Jar:
https://relentlesshealthvalue.com/join-the-relentless-tribe🎤 Follow on Apple Podcasts https://podcasts.apple.com/us/podcast/feed/id892082003?ls=1
🎤 Follow on Spotify https://open.spotify.com/show/6UjgzI7bScDrWvZEk2f46b
📺 Subscribe to our YouTube channel https://www.youtube.com/@RelentlessHealthValue
=== CONNECT WITH THE RHV TEAM ===
✭ LinkedIn https://www.linkedin.com/company/relentless-health-value/
✭ Threads https://www.threads.net/@relentlesshealthvalue/
✭ X https://twitter.com/relentleshealth/
✭ Bluesky https://bsky.app/profile/relentleshealth.bsky.social00:00 Introduction to the Rabbit Hole
04:05 Where did Stacey’s rabbit hole spiral start?
05:40 What is the moral hazard of insurance?
09:31 EP358 with Wayne Jenkins, MD.
12:49 Why isn’t moral hazard mitigated in insurance?
18:16 EP459 with Bill Sarraille.
20:51 “How do we conceptualize a solve?”
22:24 Why should we be striving for Pareto optimality?
25:20 What is the theory of second best?
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This episode with Chris Crawford, CEO of RxSaveCard, is not about the when, why, or how of GLP-1s for weight loss or best-practice prescribing. This episode very, very specifically is about the how and why of the pickle plan sponsors get themselves into often enough where if they impose formulary restrictions to limit the volume of meds that they are paying for, then unit prices go up, which is a thing for GLP-1s.
And this is critical just given how the costs associated with GLP-1s for weight loss contribute to some pretty significant increases in pharmacy trend for plan sponsors who choose to cover the GLP-1s for weight loss.
Chris Crawford and Stacey Richter discuss the challenges plan sponsors face with the rising costs of GLP-1 medications for weight loss. They explore how plan sponsors’ efforts to manage pharmacy trends often result in a tradeoff: lowering unit costs by increasing volume or vice versa. Chris also introduces a potential solution leveraging the growing cash marketplace, where employers can bypass traditional PBM contracts to achieve cost savings. Tune in for actionable insights into the perverse incentives in the pharmacy supply chain and innovative ways to navigate them. (Continued below the links)
=== LINKS ===
🔗 Show Notes with all mentioned links:
hhttps://cc-lnk.com/EP461✉️ Enjoy this podcast? Subscribe to the free weekly newsletter:
https://relentlesshealthvalue.com/join-the-relentless-tribe🫙 Support the podcast with a small donation to the Tip Jar:
https://relentlesshealthvalue.com/join-the-relentless-tribe🎤 Listen on Apple Podcasts https://podcasts.apple.com/us/podcast/feed/id892082003?ls=1
🎤 Listen on Spotify https://open.spotify.com/show/6UjgzI7bScDrWvZEk2f46b
📺 Subscribe to our YouTube channel https://www.youtube.com/@RelentlessHealthValue
=== CONNECT WITH THE RHV TEAM ===
✭ LinkedIn https://www.linkedin.com/company/relentless-health-value/
✭ Threads https://www.threads.net/@relentlesshealthvalue/
✭ X https://twitter.com/relentleshealth/
✭ Bluesky https://bsky.app/profile/relentleshealth.bsky.socialBottom line, there are some really impactful and not frequently delved into perverse incentives at play here. And we’re gonna talk about these today. And these are really key for anybody on or about the pharmacy supply chain in the U.S. to know about. This is very actionable insight.
So, again, there’s an unfortunate tradeoff, as it stands right now, for many plan sponsors. Lower your volume and raise the unit price or vice versa.
This episode is sponsored by RxSaveCard, and a big thanks for that. I really appreciate RxSaveCard for its financial support because this episode covers a really important topic that we probably would have covered anyway over here at Relentless Health Value.
And so, RxSaveCard standing up and offering their financial support to cover it was a really nice thing to do. And I thank them for their generosity.
07:57 What are the two pieces going on with GLP-1 PBM prices and rebates for employers?
10:00 Is the cash price for these name brand drugs currently less than the rebated PBM price?
11:49 Why does the rebate for GLP-1s disappear if employers try to put restrictions on who can receive access to these drugs?
15:07 Where does RxSaveCard come in to play here?
19:55 “We exist to save people money.”
20:45 EP456 with Brian Reid.
21:16 EP356 with Ge Bai, PhD, CPA.
21:37 EP439 with Luke Slindee, PharmD.
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In this Relentless Health Value episode, Dr. Rushika Fernandopulle discusses with Stacey Richter his four-prong theory of change for transforming the American healthcare system. Key topics include the necessity of new payment models, process innovation, employing a relational technology infrastructure, shifting the cultural mindset towards team-based care, and emphasizing the importance of long-term partnerships. The conversation underscores the urgent need to move away from the current status quo to ensure better health outcomes and affordable care for all Americans.
This is one of those episodes where we consider top-line strategic imperatives and key drivers. There was no better person to do this with than Rushika Fernandopulle, MD, who, in case you were unaware, was the founder of Iora Health, an advanced primary care group that was sold to One Medical and then to Amazon.
They discusses his four-prong theory and as Stacey says, "I can’t leave well enough alone, so I plucked one more prong from our conversation and stuck it on the end." For a summary of this 5 prong approach, visit the show notes page where we also list all of the links mentioned in the episode.
=== LINKS ===
🔗 Show Notes with all mentioned links:
https://cc-lnk.com/EP460✉️ Enjoy this podcast? Subscribe to the free weekly newsletter:
https://relentlesshealthvalue.com/join-the-relentless-tribe🫙 Support the podcast with a small donation to the Tip Jar:
https://relentlesshealthvalue.com/join-the-relentless-tribe🎤 Listen on Apple Podcasts https://podcasts.apple.com/us/podcast/feed/id892082003?ls=1
🎤 Listen on Spotify https://open.spotify.com/show/6UjgzI7bScDrWvZEk2f46b
📺 Subscribe to our YouTube channel https://www.youtube.com/@RelentlessHealthValue
=== CONNECT WITH THE RHV TEAM ===
✭ LinkedIn https://www.linkedin.com/company/relentless-health-value/
✭ Threads https://www.threads.net/@relentlesshealthvalue/
✭ X https://twitter.com/relentleshealth/
✭ Bluesky https://bsky.app/profile/relentleshealth.bsky.social06:39 How Dr. Rushika Fernandopulle found himself where he is now.
08:06 Dr. Fernandopulle’s conversation with Kenny Cole, MD.
10:33 Why is it important to have new payment models?
12:21 EP453 with Claire Brockbank.
14:50 EP455 with Beau Raymond, MD.
16:19 Why it makes sense to change as quickly as possible.
19:55 How to be proactive and not be reactive and achieve value-based reimbursement for good care.
21:41 Why team-based care is so important for change.
23:37 Why is it important to have a different set of technology tools?
24:38 EP391 with Scott Conard, MD.
25:24 Why changing the culture is important.
27:01 “Getting doctors to do things they don’t like is a waste of time.”
33:22 “Healthcare is local.”
35:31 EP364 with David Muhlestein, PhD, JD.
35:43 Study by Zack Cooper, PhD.
36:53 EP404 with Suhas Gondi, MD, MBA.
39:04 Why long-term partnerships are the only way to make things better.
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In Episode 459, host Stacey Richter speaks with healthcare attorney Bill Sarraille about co-pay maximizers and accumulators, mechanisms designed to extract maximum co-pay support dollars from pharmaceutical companies.
They discuss the financial implications for patients, plan sponsors, and pharmacy benefit managers (PBMs), emphasizing the legal and ethical issues and potential patient harm due to high out-of-pocket costs and surprise expenses.
Sarraille provides five key pieces of advice for plan sponsors and highlights the importance of transparency and proper utilization management to minimize patient access problems and legal risks. Listen or read the show notes on our site for the full list.
(continued below the links)
=== LINKS ===
🔗 Show Notes with all mentioned links:
https://cc-lnk.com/EP459✉️ Enjoy this podcast? Subscribe to the free weekly newsletter: https://relentlesshealthvalue.com/join-the-relentless-tribe
🫙 Support the podcast with a small donation to the Tip Jar: https://relentlesshealthvalue.com/join-the-relentless-tribe
===CONNECT WITH THE RHV TEAM ===
✭ LinkedIn https://www.linkedin.com/company/relentless-health-value/
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✭ X https://twitter.com/relentleshealth/
✭ Bluesky https://bsky.app/profile/relentleshealth.bsky.social
Co-pay maximizers and accumulators are programs designed to capture maximum co-pay assistance from phara. Maximizers spread pharma co-pay support evenly throughout the year, ensuring plan sponsors benefit while, in theory, patients face minimal costs. More on how that can go wrong in the episode.
Accumulators, however, design their plan to deplete pharma dollar support quickly, surprising patients with significant out-of-pocket expenses mid-year when they go visit the pharmacy.
These programs usually exclude pharma assistance dollars from deductibles, potentially causing financial hardship because when pharma is paying your co-pay, those payments don't count against your deductible.
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?
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In this Inbetweenisode titled 'End of Year Wrap Up and My Personal Charter Encore,' Stacey Richter extends heartfelt thanks to listeners and healthcare workers for their dedication.
She reflects on the challenges of maintaining personal integrity in a profit-driven healthcare system and introduces her personal charter. This charter, focused on ensuring net positive outcomes for patients, acknowledges that achieving transformational change in healthcare requires a collective effort.
Stacey discusses the complexities of balancing ethical decisions, financial constraints, and the broader impact on patient care, urging others to reflect on their own guiding principles.
Here's her manifesto which she is now calling her Personal Charter below which she breaks down in this podcast episode:
"If the thing results in a net positive for patients, then I will do it. The timeframe is short-term or medium-term. And the assumption is that it will take a village and I am not alone in my efforts to transform healthcare or do right by patients."
=== LINKS ===
🔗 Show Notes with all mentioned links: https://cc-lnk.com/INBW41
✉️ Enjoy this podcast? Subscribe to the free weekly newsletter:
https://relentlesshealthvalue.com/join-the-relentless-tribe🫙 Support the podcast with a small donation to the Tip Jar:
https://relentlesshealthvalue.com/join-the-relentless-tribe=== CONNECT WITH THE RHV TEAM ===
✭ LinkedIn https://www.linkedin.com/company/relentless-health-value/
✭ Threads https://www.threads.net/@relentlesshealthvalue/
✭ X https://twitter.com/relentleshealth/
✭ Bluesky https://bsky.app/profile/relentleshealth.bsky.social06:52 “It’s a zero-sum game.”
07:02 Is the amount of profit fair?
07:13 What is an inescapable fact of the healthcare industry?
07:30 What does the financialization of healthcare mean?
07:55 Why does the self-interest in healthcare matter?
09:54 “It’s basically up to us as individuals to do the right thing.”
13:39 What is the first part of Stacey’s personal charter?
13:54 How does Stacey calculate the net positive of an impact?
14:17 What are two major upsides/downsides that Stacey contemplates?
17:08 Why are incremental change and disruptive change not mutually exclusive?
21:16 “I always try to keep in mind that it will take a village.”
22:55 Why finger pointing is killing innovation in healthcare.
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Are you on the board of directors of a company? Or are you a shareholder of a publicly traded company? Or are you a CEO or a CFO or in-house counsel who reports to a board of directors or these shareholders? Well, this show is for you.
And it’s about how the healthcare industry has become financialized at the same time that providing health benefits has become the second-biggest line item after payroll for most companies. We talked about that in a recent encore with Mark Cuban (EP418) also, as well as the show with Cora Opsahl (EP452) and Claire Brockbank (EP453) from 32BJ.
In this encore episode of 'Relentless Health Value,' Stacey Richter interviews Andreas Mang from Blackstone about the financialization of health benefits for boards of directors and C-suites of self-insured employers.
They discuss the unseen financial layers in healthcare benefits and how companies can save significantly while improving employee satisfaction and health.
=== LINKS ===
🔗 Show Notes with all mentioned links: https://cc-lnk.com/EP458
✉️ Enjoy this podcast? Subscribe to the free weekly newsletter: https://relentlesshealthvalue.com/join-the-relentless-tribe
🫙 Support the podcast with a small donation to the Tip Jar: https://relentlesshealthvalue.com/join-the-relentless-tribe
=== CONNECT WITH THE RHV TEAM ===
✭ LinkedIn https://www.linkedin.com/company/relentless-health-value/
✭ Threads https://www.threads.net/@relentlesshealthvalue/
✭ X https://twitter.com/relentleshealth/
✭ Bluesky https://bsky.app/profile/relentleshealth.bsky.social04:55 Why Andreas starts every conversation with the question, “How’s your healthcare company?”
07:38 Why is it important, as a self-insured employer, to treat your business as a small healthcare company?
09:16 Why is it unnatural for companies to be providing health insurance?
10:47 What can be achieved when there is alignment between employers and insurers?
12:41 What things can a company do to reduce spend by 10%?
14:14 Why is it better to have CFO engagement in the benefits plan throughout the year?
16:25 Why does self-insurance save 5% to 9% for companies automatically?
18:14 “The funding isn’t a healthcare thing; it’s a CFO thing.”
18:27 Why is it vital to have a reliable, trustworthy broker?
25:12 When is the last time your company has RFP’d their health plan?
27:39 Why does changing a health plan feel scary but is necessary?
28:31 What is a dependent eligibility audit?
31:20 Why are employers better together?
34:34 How do employers truly get a flat-fee model with brokers?
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In Episode 458 of Relentless Health Value, host Stacey Richter speaks with Dr. Komal Bajaj about innovative strategies for addressing staffing shortages in the healthcare sector. They explore the importance of cultural alignment within organizations, emphasizing trust and shared values to retain staff.
Dr. Bajaj shares surprising findings from surveys indicating that healthcare workers are motivated by the goal of providing high-quality, planet-friendly care. The discussion highlights the interconnectedness of environmental sustainability and healthcare quality, presenting tangible ways to engage and empower healthcare workers while addressing both local community health and broader environmental concerns.
The episode underscores the strategic importance of aligning organizational goals with the aspirations of the workforce to foster trust and mitigate staffing shortages.
Stacey's guest today is Dr. Komal Bajaj. Dr. Bajaj is an ob-gyn who serves as the chief quality officer for a couple of hospitals in the Bronx, New York, that are part of the municipal health system of New York. She also now serves as medical director of sustainability for the municipal health system NYC Health + Hospitals.
=== LINKS ===
🔗 Show Notes with all mentioned links:
https://cc-lnk.com/EP458✉️ Enjoy this podcast? Subscribe to the free weekly newsletter: https://relentlesshealthvalue.com/join-the-relentless-tribe
🫙 Support the podcast with a small donation to the Tip Jar: https://relentlesshealthvalue.com/join-the-relentless-tribe
=== CONNECT WITH THE RHV TEAM ===
✭ LinkedIn https://www.linkedin.com/company/relentless-health-value/
✭ Threads https://www.threads.net/@relentlesshealthvalue/
✭ X https://twitter.com/relentleshealth/
✭ Bluesky https://bsky.app/profile/relentleshealth.bsky.social
08:20 How do we quantify the issue of staffing shortages?
11:18 Why do we need to look at the root cause of the shortages?
11:51 Deloitte survey on staffing shortages.
11:54 Why is trust one of the core problems when it comes to staffing shortages?
13:59 “Healthcare workers have choice.”
15:34 What are the strongest correlations that influence healthcare workers’ desire to stay?
18:17 What things give healthcare workers the most pause?
19:36 The U.S. Department of Health and Human Services Health Sector climate pledge.
20:20 The Commonwealth Fund survey on what health systems can do to address climate change.
22:29 What do we do about sustainable, climate-friendly healthcare being a driving factor in staffing?
27:28 How do you meet the desires of healthcare workers where they’re at?
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In this episode of 'Relentlessly Seeking Value,' host Stacey Richter is joined by healthcare entrepreneur Cynthia Fisher to discuss the crucial issue of medical spread pricing and the need for contract transparency.
Fisher explains how hidden fees and spread pricing by middlemen are leading to substantial overcharges for employers and patients in the U.S. healthcare system. The conversation delves into recent lawsuits that highlight these practices, the legislative strides made to enforce price transparency, and how transparency can potentially transform the industry.
Look, this is a thing now, medical spread. And similar to how PBM spreads adds up to millions, billions of dollars, medical spread is not change in the couch cushions. Did you see the lawsuit against Cigna? Cynthia Fisher mentions it in the conversation that follows. Spoiler alert, here’s the numbers: Self-insured employer paid $4 million for a claim.
There’s a slide on this Cynthia Fisher gave me, by the way, if you want to see all this written out. So, the employer pays $4 million. The provider was paid—drumroll, please—$876,000. I’m pausing so that sinks in: $4 million paid by the employer; $876,000 of that makes it across the trench to the provider.
To view the meme we created for how carriers are learning to do spread pricing from the PBMs, visit our show notes page below. (continued after the links below)
=== LINKS ===
🔗 Show Notes with all mentioned links:
https://cc-lnk.com/EP457✉️ Enjoy this podcast? Subscribe to the free weekly newsletter:
https://relentlesshealthvalue.com/join-the-relentless-tribe🫙 Support the podcast with a small donation to the Tip Jar:
https://relentlesshealthvalue.com/join-the-relentless-tribe=== CONNECT WITH THE RHV TEAM ===
✭ LinkedIn https://www.linkedin.com/company/relentless-health-value/
✭ Threads https://www.threads.net/@relentlesshealthvalue/
✭ X https://twitter.com/relentleshealth/
✭ Bluesky https://bsky.app/profile/relentleshealth.bsky.socialFisher emphasizes the importance of employers and unions demanding accountability, using existing laws to unveil true pricing, and advocates for a revolution in healthcare to ensure fair, equitable, and transparent billing. Insights are also shared from industry experts who were previous guests including Chris Deacon, Justin Leader, and Andreas Mang. You can find the links in the show notes on our site.
09:03 What is the goal of PatientRightsAdvocate.org?
10:28 Is American competitiveness being affected by healthcare spend?
13:47 Why is transparency a root cause to healthcare costs?
15:11 What’s going on across the country to empower transparency in healthcare?
19:31 “I think people are fed up.”
21:22 The Cigna lawsuit in California.
26:36 How do employers navigate contracts against anti-steering?
28:54 EP419 with Andreas Mang.
29:33 EP452 with Cora Opsahl and EP453 with Claire Brockbank.
29:45 EP433 with Justin Leader.
You can learn more at PatientRightsAdvocate.org.
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