Afleveringen
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This show from last year was one of the most popular episodes of the past year. And it’s also extremely relevant right now, given all of the PBM (pharmacy benefit manager) goings-on, as well as ongoing litigation like the J&J lawsuit, etc. Listen to the show with Julie Selesnick (EP428) for more on that one.
For a full transcript of this episode, click here.
If you enjoy this podcast, be sure to subscribe to the free weekly newsletter to be a member of the Relentless Tribe.
Also, Brian Reid (EP456) in the episode from a couple of weeks ago. And he talks about how Mark Cuban’s way of communicating and framing some of the issues with the big PBMs and just all of the perverse incentives in the drug supply chain. He says this way of communicating is “the chef’s kiss.”
So, besides the insights here that follow being relevant in and of themselves, there’s also some lessons just in how those issues are teed up and communicated that we all can learn from.
CEOs and CFOs … hey, this show is for you. Let’s start here:
What do all of these numbers have in common: $140,000, $3 million, $35 million, and $3 billion?
These are all actual examples of how much employers, unions, and some public entities saved on healthcare benefits for themselves and their employees. The roadmap to saving 25% on pharmacy spend and/or 15% on total cost of care in ways that improve employee health and satisfaction always begins when one thing happens. There’s one vital first step.
That first step is CEOs and/or CFOs or their equivalents roll up their sleeves and get involved in healthcare benefits. Why can’t much happen without you, CEOs and CFOs?
Here’s the IRL: In 2023, the healthcare industry has been financialized. There is a whole financial layer in between your company and its healthcare benefits.
And unless the C-suite is involved here and bringing their financial acumen and organizational willpower to the equation, your company and your employees are currently paying hundreds of thousands, maybe millions, of dollars too much and doing so within a business model that deeply exacerbates inequities. There are people out there who are very strategically taking wild advantage of a situation where CEOs/CFOs fear anything to do with healthcare in the title and don’t do their normal level of due diligence. You think it’s an accident that this whole space got so “complicated”? HR needs your help.
Bottom line, if you are a CEO or CFO and you do not know everything that Mark Cuban and Ferrin Williams talk about on the pod today … wow, are you getting shellacked. Mark Cuban uses a different word. Healthcare benefits are, after all, for most companies the second biggest line-item expense after payroll.
But don’t despair here, because all of this information is really and truly actionable. Others out there are cutting zeros off of their spend and actually doing it in ways that are a total win for employees as well.
My guest today, Mark Cuban, is a CEO, after all; and when he looked into it, it took him T-minus ten minutes to figure out just the order of magnitude that his “trusted” benefits consultants and PBM and ASOs (administrative services only) and others were extracting from his business. He pushed back. So can you.
But just another reason to dig into that financial layer wrapping around your employee health benefits right now, you might get sued by your employees. Below is an ad currently being circulated on LinkedIn by class action attorneys recruiting employee plan members to sue their employers for ERISA (Employee Retirement Income Security Act of 1974) violations. It’s the same attorneys, by the way, from those 401(k) class action lawsuits. I’ve talked to a few CEOs and CFOs who are scrambling to get ahead of that. You might want to consider doing so as well.
Now, for my HR professional listeners, considering that some of what Mark Cuban says in the pod that follows is indeed a little spicy, let me just recognize that the struggle is real.
There are multiple competing priorities out there in the real world, for sure. And bottom line, because of those multiple competing priorities out there in the real world, it’s really vital that everybody work together up and down the organization in alignment. Lauren Vela talks a lot about these realities here in episode 406.
This is a longer show than normal, but it’s also like a show and a half. Mark Cuban talks not only about his work with Mark Cuban Cost Plus Drugs, which is a company that buys drugs direct from manufacturers and sells them for cost plus 15%, a dispensing fee, and shipping. It’s kind of crazy how so often that price is cheaper, sometimes considerably cheaper, than the price that plan members would have paid using their insurance—and the price that the plan is currently paying the PBM.
Most Relentless Health Value Tribe members (ie, regular listeners of this show) will already know that, but what is also fascinating that Mark talks about is what he’s doing with his own businesses and the Mavericks on other fronts, like dealing with hospital prices. In this show, we also talk the language of indie pharmacies, fee-only benefits consultants, TPAs (third-party administrators), PBMs, and providers doing direct contracting. There are, in fact, entities out there trying to do the right thing; and Mark acknowledges that.
Ferrin Williams, PharmD, MBA, who is also my guest today, is chief pharmacy officer at Scripta and an expert in pharmacy benefits. She adds some great points and some context to this conversation. Scripta is partnering with Mark Cuban Cost Plus Drugs. Scripta has a neat Med Mapper tool and also services to help employees find the lowest costs for their prescriptions. If you are a self-insured employer, for sure, check out Scripta.
Here are links to other shows that you should listen to now if you are inspired to take action. I would recommend the shows with Paul Holmes (EP397); Dan Mendelson (EP385); Andreas Mang (EP419); Rob Andrews (EP415); Cora Opsahl (EP372); Lauren Vela (EP406); Peter Hayes (EP346); Gloria Sachdev, PharmD, and Chris Skisak, PhD (EP390); and Mike Thompson (EP389). Also Mark Cuban mentions in this show the beverage distributor L&F Distributors.
Thanks to Ge Bai, Andreas Mang, Lauren Vela, Andrew Gordon, Andrew Williams, Cora Opsahl, Kevin Lyons, Pat Counihan, David Dierk, Connor Dierk, John Herrick, Helen Pfister, Kristin Begley, AJ Loiacono, and Joey Dizenhouse for your help preparing for this interview.
Also mentioned in this episode are Mark Cuban Cost Plus Drug Company; Scripta Insights; Julie Selesnick; Brian Reid; Paul Holmes; Dan Mendelson; Rob Andrews; Peter Hayes; Gloria Sachdev, PharmD; Chris Skisak, PhD; Mike Thompson; and Scott Conard, MD.
You can learn more at Mark Cuban Cost Plus Drug Company and Scripta Insights.
You can also connect with Scripta and Ferrin on LinkedIn.
Mark Cuban has been a natural businessman since the age of 12. Selling garbage bags door to door, the seed was planted early on for what would eventually become long-term success. After graduating from Indiana University—where he briefly owned the most popular bar in town—Mark moved to Dallas. After a dispute with an employer who wanted him to clean instead of closing an important sale, Mark created MicroSolutions, a computer consulting service. He went on to later sell MicroSolutions in 1990 to CompuServe.
In 1995, Mark and longtime friend Todd Wagner came up with an internet-based solution to not being able to listen to Hoosiers basketball games out in Texas. That solution was Broadcast.com—streaming audio over the internet. In just four short years, Broadcast.com (then Audionet) would be sold to Yahoo!
Since his acquisition of the Dallas Mavericks in 2000, Mark has overseen the Mavs competing in the NBA Finals for the first time in franchise history in 2006—and becoming NBA World Champions in 2011.
Mark first appeared as a “Shark” on the ABC show Shark Tank in 2011, becoming the first ever to live Tweet a TV show. He has been a star on the hit show ever since and is an investor in an ever-growing portfolio of small businesses.
Mark is the best-selling author of How to Win at the Sport of Business. He holds multiple patents, including a virtual reality solution for vestibular-induced dizziness and a method for counting objects on the ground from a drone. He is the executive producer of movies that have been nominated for seven Academy Awards: Good Night and Good Luck and Enron: The Smartest Guys in the Room.
Mark established Sharesleuth, a research and investigation Web site to uncover fraud in financial markets, and endowed the Electronic Frontier Foundation’s Mark Cuban Chair to Eliminate Stupid Patents, an effort to fight patent trolls.
Mark gives back to the communities that promoted his success through the Mark Cuban Foundation. The Foundation’s AI Bootcamps Initiative hosts free Introduction to AI Bootcamps for low-income high schoolers, starting in Dallas. Mark also saved and annually funds the Dallas Saint Patrick’s Day Parade, the largest parade in Dallas and a city institution.
In January 2022, he started Mark Cuban Cost Plus Drug Company as an effort to disrupt the drug industry and to help end ridiculous drug prices because every American should have access to safe, affordable medicines.
Ferrin Williams, PharmD, MBA, is chief pharmacy officer of Scripta. With 15+ years’ experience in the pharmacy industry, Ferrin brings a unique perspective to Scripta that spans the retail pharmacy, pharmacy benefit manager (PBM), and broker/consulting sectors. Her expertise ranges from pharmacy operations and services to innovative clinical programs, pharmacy audit, alternative payer funding, and specialty drugs.
As chief pharmacy officer, Ferrin leads the company’s clinical strategies organization responsible for devising innovative cost-containment strategies for prescription drugs, ensuring Scripta clients, members, and their providers are provided with best-in-class clinical insights and tools.
Ferrin earned her bachelor’s, Doctor of Pharmacy, and MBA degrees from the University of Oklahoma.
06:29 What was Mark Cuban’s own journey as a self-insured employer with Cost Plus Drug Company?
07:44 What did Mark find when he decided to go through and look through his company’s benefit program?
09:12 “When you think it through, you start to realize that money is being spent primarily by your sickest employees.” —Mark
10:02 How do you get CEOs and CFOs of self-insured employers to realize that their sickest employees are the ones subsidizing their checks?
13:00 What is the role of insurance in healthcare?
14:30 “If you can’t convince them, confuse them and hide it.” —Mark
15:24 The reality behind getting a rebate check.
16:21 Why are rebates going away, and why isn’t that changing PBM earnings?
19:05 How do you get CEOs and CFOs to dig into their benefits plan?
20:59 Does morally abhorrent move the needle?
21:33 “What we’re trying to do is just simplify the [healthcare] industry.” —Mark
24:19 What’s been changing in consumer behavior?
25:04 “Transparency is a huge part of building that trust.” —Ferrin
25:19 Why CEOs and CFOs really have the power to change healthcare.
32:29 What are Cost Plus Drugs’ plans to expand?
39:21 Where is the future of the prescription drug market going?
42:09 What will happen to the prescription drug market in 10 to 20 years?
48:40 The wake-up call self-insured employers should be acknowledging now.
52:02 Where is the real change in the healthcare industry going to come from?
You can learn more at Mark Cuban Cost Plus Drug Company and Scripta Insights.
You can also connect with Scripta and Ferrin on LinkedIn.
@mcuban and Ferrin Williams provide advice for #CEOs and #CFOs of #selfinsuredemployers on our #healthcarepodcast. #healthcare #podcast #digitalhealth #valuebasedcare #healthcareoutcomes
Recent past interviews:
Click a guest’s name for their latest RHV episode!
Rob Andrews (Encore! EP415), Brian Reid, Dr Beau Raymond, Brendan Keeler, Claire Brockbank, Cora Opsahl, Dan Nardi, Dr Spencer Dorn (EP451), Marilyn Bartlett, Dr Marty Makary
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In this episode, Stacey Richter speaks with Rob Andrews, CEO of the Health Transformation Alliance (HTA) and former Congressman, about the strategic steps jumbo employers can take to achieve improved health outcomes while reducing cost. They delve into the importance of using data to discern effective practices, negotiate contracts, and hold intermediaries accountable.
To Read The Show Notes With All Mentioned Links, Visit the Episode Page.
If you enjoy this podcast, be sure to subscribe to the free weekly newsletter to be a member of the Relentless Tribe.
The discussion highlights maternal health as a critical area of focus, with successful interventions shown to reduce NICU admissions and overall healthcare costs. Andrews emphasizes the role of self-insured employers in driving systemic changes that align financial incentives with health outcomes.
This encore is very relevant after the shows with Cora Opsahl (EP452), Claire Brockbank (EP453), and Marilyn Bartlett (EP450). Getting better health for the 160 million Americans covered by commercial insurance is all about rates, rights, and power.
07:34 How did Rob get to his current role?
09:08 The problem of maternal health and mortality rate, and how self-insured employers wind up directly and indirectly paying for this.
10:27 Why economic consequences move the needle, and why sometimes they don’t.
12:26 Why the best way to address costs isn’t to re-shift costs but to address them directly.
13:22 Why compensation that isn’t dependent on outcomes is a problem.
16:23 “Strategy’s not what people say; it’s what they do.”
18:21 How do you operationalize saving money with better outcomes?
26:26 How do employers turn conflict into collaboration?
28:20 What is the win-win-win structure among employers, payers, and providers in Rob’s eyes?
30:53 To whom should the task of risk adjustment fall?
34:43 “Better contracts do improve outcomes.”
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Zijn er afleveringen die ontbreken?
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In this comprehensive episode host Stacey Richter sits down with Brian Reid to discuss pivotal aspects for the pharmaceutical industry. Key topics include understanding product value from the perspectives of plan sponsors, patients, and society, and the significance of benefit design in improving patient affordability.
For the show notes with all links mentinoed, visit the episode page.
If you enjoy this podcast, be sure to subscribe to the free weekly newsletter to be a member of the Relentless Tribe.
The discussion delves into the complexities of drug pricing, the roles of Pharmacy Benefit Managers (PBMs) and brokers, and the impact of healthcare consolidation on costs. Reid emphasizes the importance of transparent communication among stakeholders, the detrimental effects of cost containment strategies, and the necessity of considering policy and reputational impacts.
Throughout the conversation, examples such as the Hepatitis C drug illustrate the broader implications on drug access and affordability. Listeners are provided with critical insights into how pharmaceutical companies can better engage with ultimate purchasers to ensure patients receive necessary, cost-effective medications while navigating a changing healthcare landscape.
For the show notes with all links mentinoed, visit the episode page.
08:29 Why is it important to understand the term “value” in respect to medicine?
10:07 Why is it important to consider all the players affected by the idea of this “value”?
11:06 Who are the ultimate purchasers in Pharma?
12:23 Findings of the Kaiser Employer Health Benefits Survey.
14:52 Why does it matter that we consider what value looks like to all players affected by Pharma?
16:46 EP300 with Bruce Rector, MD.
18:38 EP448 (Part 1) with Shawn Gremminger.
20:04 What does Pharma need to do to showcase their value when PBMs are often “locked in” at the moment?
23:11 Why Brian is celebrating companies that put their prices in their press releases.
32:31 Why does Pharma have an obligation to explain their value?
33:16 EP426 with Nina Lathia, RPh, MSc, PhD.
33:39 Why is it important for Pharma to keep an eye on hospital monopoly behavior?
35:55 EP370 with Erik Davis and Autumn Yongchu.
37:44 Why Pharma needs to capitalize on alignment.
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In this conversation, Stacey Richter engages with healthcare leader Dr. Beau Raymond from Ochsner Health Network to explore the blueprint for better patient care through enlightened leadership, data-driven strategies, and localized health initiatives.
The discussion covers shifting from 'sick care' to preventative healthcare, integrating technology and data tools like glucometers for health coaching, and addressing health equity through accurate data and regional strategies.
To Read the Show Notes with Mentioned Links and a Full Transcript, Visit the Episode Page.
If you enjoy this podcast, be sure to subscribe to the free weekly newsletter to be a member of the Relentless Tribe.
The conversation explains the importance of stakeholder engagement, setting clear goals, financial incentives aligned with patient care, and continuous improvement through feedback loops. Practical steps such as weekly huddles for primary care teams and the role of digital health in managing chronic conditions like diabetes and hypertension are also highlighted to improve healthcare outcomes and operational excellence.
A rate critical to attain better care for patients, I’m gonna say, is enlightened leadership—maybe dyad leadership—at a clinical organization. I am saying this because without enlightened leaders, it’d be harder to build from the blueprint that Beau Raymond, MD, talks about today on the show.
10:44 Why is it important to be flexible while keeping your goals in sight?
11:48 Dr. Eboni Price-Haywood’s article on disparities in COVID.
12:29 How is equity a data point to achieving overall care improvement?
15:01 “If you can’t measure it … accurately, you’re not going to be able to do anything differently.”
20:52 What strategies have been successful in using data to improve healthcare outcomes?
23:17 Why did Ochsner Health avoid looking at the individual physician standpoint in regard to an equity standpoint?
30:40 Why engaging patients in their healthcare actually improved patient visits and did not necessarily reduce patient visits.
34:49 “It’s really about engaging with the patient.”
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In this episode, host Stacey Richter and guest Brendan Keeler dive deep into the significant legal clash between Epic and Particle over electronic health record (EHR) data access and market competition.
To Read the Show Notes with Mentioned Links and a Full Transcript, Visit the Episode Page.
This episode examines the broader repercussions on healthcare data exchange, including antitrust concerns, data liquidity, and the ethical considerations around secondary use of treatment data. The discussion brings to light how the outcome of such lawsuits could influence data transparency, interoperability, and the rules governing data sharing among plan sponsors, employers, and healthcare providers.
Notable points include the shift to a judicial era impacting health tech companies and the potential for regulatory and judicial actions to improve data access and efficiency within healthcare networks. The episode emphasizes the critical need for clear pathways, accountability, and structured regulations to enhance patient care and reduce fraud in the healthcare data ecosystem.
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07:21 Who can gain access to EHR data?
10:31 Are there limits to how EHR data can be used secondarily?
11:36 Can EHR data be shared secondarily?
15:47 Part one and part two of Brendan’s comprehensive account of the Epic/Particle dustup.
15:57 What was the dispute that started Epic v Particle?
18:21 What are the two viewpoints in this dispute with Epic’s actions?
26:16 What progress has been seen since this lawsuit began?
28:00 Who else will be impacted by the likely rule cementing from this lawsuit?
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In this episode, host Stacey Richter delves into the complexities of the Third Party Administrator (TPA) Request for Proposal (RFP) process with guest Claire Brockbank from 32BJUnion.
The discussion highlights the critical role of contracts in managing health plans effectively and the potential pitfalls of accepting contracts crafted by TPAs without thorough review. Drawing from Claire's experience, they explore tactics like starting with your own contract paper in RFP processes to gain negotiation leverage, and the benefits of employer coalitions in navigating health care complexities.
To Read the full article which includes mentioned links visit the episode page.
If you enjoy this podcast, be sure to subscribe to the free weekly newsletter to become a member of the Relentless Tribe.
Real-world examples underscore the financial impacts of poorly negotiated contracts and highlight successful strategies for health plan sponsors to optimize costs and services. The episode aims to empower employers with tools and insights to negotiate effectively and ensure their health plan contracts align with their strategic goals, ultimately paving the way for better population health management and cost-effective care delivery.
As but one example—and Cora Opshal spoke about this last week and Claire talked about this today—it’s about how allowing upside-down payments, for example, that are in a lot of ASO contracts, this allowing of upside-down payments. I mean, it turns out that 32BJ spent around $10 million paying more than the bill was for one year. If somebody signs that contract as handed to them by the carrier, then the plan is now contractually obligating themselves to pay more than the price the clinical practice was charging. So, doc sends bill for $100, and the carrier pays that practice $200 on behalf of the plan sponsor.
So now the plan sponsor is paying $200 for a $100 bill. Is this conflict of interest? Is it imprudent? Is it not reasonable? Said another way, is that a bit of a fiduciary breach on the plan sponsor?
So it's understandable why the team at 32BJ pushed back and pushed back hard. We all can see why the leading edge of plan sponsors and more and more C-suites are hotfooting it into conference rooms to plan their RFP process and doing it in the way that Claire Brockbank talks about today.
For an open-source contract and some other free tools, please do head over to the 32BJ Insights Web site.
05:36 How does the initial contract writing affect how events in your healthcare plan will go?
06:56 What happens if a plan sponsor or employer doesn’t do the contracting right?
10:42 How much could be saved by doing contracting right?
11:01 EP433 with Justin Leader.
12:22 How do you start an RFP process with your own contract?
14:06 What Claire Brockbank recommends doing to do a TPA RFP process in a way that’s best for you.
19:46 What factors do carriers need to get an ASO or TPA to respond to using your contract?
21:11 Open-source contract available from 32BJ.
21:57 Why it’s important to really probe brokers, despite loyalty to your broker/consultant.
24:30 Who are the reliable agents and experts when carriers are looking to start this process?
26:24 EP428 with Julie Selesnick.
27:56 What’s the silver lining to this effort?
29:17 Why is it important to make it clear why you’re doing what you’re doing for your lawyers and any other support team you need?
31:39 What does “good” look like in this process?
34:15 Why is it important to continue to hold your ASO accountable?
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In this episode I interview Cora Opsahl from the 32BJ Health Fund to examine the intricate dynamics between fiduciary duties and the entrenched status quo in healthcare. The discussion focuses on the challenges employers face when dealing with anti-competitive contracts and their responsibility to ensure plan expenses are reasonable. Cora Opsahl, my guest today, is the director of the 32BJ Health Fund, serving over 200,000 folks. Their ability to kick NewYork-Presbyterian, a big, consolidated, very expensive hospital, out of their network in 2018 enabled them to offer maternity benefits for $40 in total out-of-pocket for members. And also, employees got their biggest raise ever; employers got a premium holiday and a 3% rate increase for a bunch of years after that; and yeah … this is where we start the conversation today. Furthermore, you will find links to a template health savings calculator for plan sponsors and also a template contract (again for plan sponsors) that 32BJ has made available, in our show notes.
To Read the Full Show Notes with the Mentioned Links Visit the Episode Page.
If you enjoy this podcast, be sure to subscribe to the free weekly newsletter to be a member of the Relentless Tribe.
06:16 Why is it imperative for employers to do something differently when it comes to being plan sponsors?
09:22 How analyzing claims data allowed 32BJ Health Fund to reshape their benefit design.
12:09 What anticompetitive rights did 32BJ run into that limited 32BJ Health Fund from managing their benefit design?
14:12 How do these anticompetitive rights have quality implications as well as cost implications?
18:43 How did 32BJ Health Fund remove NewYork-Presbyterian from their network, and how much did it save 32BJ Health Fund per year?
19:46 What did the healthcare savings allow the unions and employers to do?
20:46 Study by Zack Cooper, PhD.
21:26 Why rising healthcare costs has pushed 32BJ Health Fund to move beyond benefit design to manage healthcare spend.
24:15 Why 32BJ Health Fund wants to control the contracting process.
26:00 EP419 with Andreas Mang.
27:18 What are 32BJ Health Fund’s four non-negotiables?
33:17 Wall Street Journal article on health insurance contract.
35:30 Upcoming episode with Claire Brockbank.
36:14 What is the challenge that exists in our current healthcare environment?
37:43 Cora’s advice on how to get high-quality healthcare at an affordable price.
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In this Spotlight Episode host Stacey Richter discusses the management of oncology side effects with Dan Nardi, CEO of Reimagine Care. Highlighting the challenges cancer patients face, especially following chemotherapy which often leads to nausea and readmissions, the conversation delves into how Reimagine Care facilitates at-home integrative cancer care. Their services focus on proactive and reactive support via AI-driven tools like 'Remy' to assist patients outside of clinical environments. This approach aims to reduce emergency visits and improve patient outcomes while easing the workload on healthcare providers. The discussion underscores the role of patient reported outcomes and the integration of technology with human care to improve the quality of oncology treatment pathways.
To Read the Full Article Notes with Mentioned Links, Visit Our Episode Page .
If you enjoy this podcast, be sure to subscribe to the free weekly newsletter to be a member of the Relentless Tribe.
Note from Stacey Richter: Pulling off a show like this one is not cheap, and my Aventria business partner Dave Dierk and I are happy to fund the vast majority of it. But yeah, breath of fresh air, and thanks much to the team over at Reimagine Care for their sponsorship. My one disclaimer is that I have not personally vetted the solution, but there is a white paper available where you will also find some insights from Reimagine Care’s work with Memorial Hermann Health System.
03:38 Why is it really important to keep track of oncology patients and their side effects?
04:27 Why is cancer treatment such a complex care journey?
05:57 Are there outcome and financial issues that compound when an oncology patient is left to navigate their care journey on their own?
08:53 What is difficult in navigating cancer treatment care pathways, and what does Reimagine Care tackle within that?
09:55 EP157 with Ethan Basch, MD.
10:17 How does Reimagine Care proactively check in with oncology patients to help them navigate their care pathways?
12:41 How does Reimagine Care measure their performance, and how did their work affect patient outcomes?
13:28 The Reimagine Care white paper.
14:57 How do providers feel about Reimagine Care services?
17:37 Where can technology really make a difference in cancer care?
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In Episode 451 of Relentless Health Value, host Stacey Richter converses with Dr. Spencer Dorn about the implications of AI in healthcare, referencing lessons learned from EHR implementations.
They discuss Kranzberg's first law of technology, which advises against labeling a technology as inherently good, bad, or neutral, emphasizing instead the importance of its application, configuration, and the human decisions surrounding its use. Dorn and Richter explore both the potential benefits and drawbacks of AI, drawing parallels with past experiences in healthcare digitization.
To read the full article with links mentioned or to sign up to the newsletter, visit our episode page.
The first takeaway from this short show focused on artificial intelligence is gonna be the same, really, as it was in episode 446 about EHRs. Do not ascribe any given technology a label of, as good, bad, or even neutral. That is Kranzberg’s First Law of Technology; and it applies here, too.
Second major takeaway—and again, this is the same as in that earlier show about EHRs, but today we’re talking about AI—if you’re thinking about the ultimate impact of the people and the processes that have some technology in their midst (technology, again, such as AI, artificial intelligence), the ultimate impact will not be a black-and-white binary.
We talk about some of these nuanced not binaries in the 10 minutes that follow, but for more, I’ve put some links in the show notes on our epsiode page for some newsletters et cetera to check out.
05:23 What could happen with AI in healthcare if we aren’t thinking about how we’re deploying it?
05:58 How could the lessons from digitizing healthcare help us with employing AI?
08:25 How could artificial intelligence make things better and simultaneously worse?
10:55 Why is it important to look beyond the hype and pessimism and make a clear-eyed assessment?
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In Episode 450 I speak with Marilyn Bartlett, a renowned CPA in the healthcare field, about her remarkable achievement of transforming the state of Montana’s employee health plan from $9 million in debt to a surplus of $112 million within three years.
You can read the full show notes with mentioned links on the epsiode page.
If you enjoy this podcast, be sure to subscribe to the free weekly newsletter to be a member of the Relentless Tribe.
Marilyn discusses the steps she took, including identifying financial inefficiencies, targeting high-cost areas, and implementing data-driven strategies to produce quick wins and sustainable results. The conversation delves into the importance of having the right team, communicating effectively with stakeholders, and staying focused amidst challenges. Listeners will gain valuable insights into strategic change management and actionable advice for improving healthcare plans.
Yeah, I made a meme for the show with Marilyn Bartlett. My very first meme ever. In this meme, I picture that Olympic silver medalist shooter from Turkey who showed up in a T-shirt and his hand in his pocket versus the others with all their fancy equipment that, turns out, may or may not be necessary, regardless of who might swear up and down that complexity requires even more complexity and plenty of expensive gear to shoot straight.
Point being, it’s amazing what a dedicated CPA with a spreadsheet and their eye on the target can accomplish in the real world when they just do their thing and follow the dollar.
And with that, Marilyn Bartlett has entered the chat. Marilyn Bartlett isn’t called the “Queen of Healthcare” for no good reason, and nobody is joking when they say this. She was probably the first person (or one of the first, at a minimum) to truly identify the amount of money getting sucked out of the wallets of taxpayers and employers and plan members and into the pockets of the healthcare and insurance and consulting industries. She is a through and through numbers person but also deeply cares. She is truly a senior stateswoman in our field.
To read the full article with mentioned links or the transcript, visit our epsiode page.
06:45 What gave Marilyn the confidence to fix Montana’s state health plan?
08:11 Why Marilyn knew she would have enough power to make the changes needed in Montana’s state health plan.
09:11 What Marilyn achieved in her time as the administrator of the Montana State Employee Health Plan.
10:38 What were the “quick wins” Marilyn was able to achieve when she first took over as administrator?
17:33 Stay tuned for an upcoming episode that covers RFP in detail.
17:50 How Marilyn structured her plan for the Montana State Employee Health Plan.
21:21 What’s the key to setting yourself up for success when doing what Marilyn was able to achieve?
25:02 Why putting together your own team is so important.
29:07 What happened when Marilyn left the Montana State Employee Health Plan?
31:08 Have the costs of the plan gone up since Marilyn’s time working on it?
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So, I had a chance to read Dr. Marty Makary’s new book, which is called Blind Spots; and here’s why I wanted to get him to come back on Relentless Health Value and talk to you, people of the healthcare industry. It’s because of something that he said on page 127 and which I’ve been mulling over for probably years, actually.
To Read The Full Article Including Links Mentioned, click here.
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It’s this idea of what is appropriate care and how good are we at ensuring that patients/members get said appropriate care. Lots of people are of the same minds because appropriate care has come up in the show with Ben Schwartz, MD, MBA (EP434); John Lee, MD (EP438); Spencer Dorn, MD, MPH, MHA (EP446); Tom Lee, MD (EP445).
I mean, an estimated 21% of all medical care is potentially unnecessary. And unnecessary is, of course, one category of things that are not appropriate. This is according to a national survey of physicians: 25% of diagnostic tests, 22% of all medications, and 11% of all procedures are unnecessary/inappropriate. This is billions of wasted dollars doing stuff that shouldn’t be done, and it’s not appropriate care.
But think about this: How many visions for how to fix healthcare and how to reduce waste depend upon a broad-stroke assumption that we will materially ensure that patients are getting best-practice (ie, appropriate) care? That we cut down on over-medicalization and surgeries on the back end and add appropriate preventative stuff and optimal medical therapy to the front end?
Dr. Makary and I delve into the challenges of ensuring patients receive appropriate care, touching on medical dogma, financial, business, and legal incentives, and the importance of measuring practice patterns. Dr. Makary provides practical advice for clinical leaders, payers, and plan sponsors on promoting transparency, improving health literacy, and steering members towards higher performing providers.
To Read The Full Article Including Links Mentioned, click here.
07:32 What is appropriate care?
10:19 Why what we think might be appropriate care might not be appropriate care.
10:34 Why is medical dogma damaging to appropriate care?
12:45 Why we need less absolutism in medical practice.
13:37 How is groupthink prevalent in medicine?
14:02 Why do we resist new ideas?
17:43 How do providers figure out what to believe and what not to believe?
20:59 “If you leave it to the medical profession to fix itself … so far, it’s not going well.”
22:33 How does supporting health literacy affect appropriate care?
30:23 “People need to find their care based on quality and price.”
34:28 What proportion of medical care is deemed unnecessary right now?
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Maybe you’ve already caught Part 1 of my conversation with Shawn Gremminger, and if so, you're ahead of the game. But if not, no worries—here's the deal: I decided to split this deep dive into the 340B program with Shawn into two parts. So, feel free to jump into one or both—it’s totally up to you.
To Read The Full Article Including Links Mentioned, click here.
If you enjoy this podcast, be sure to subscribe to the free weekly newsletter to be a member of the Relentless Tribe.
These episodes don’t have to be listened to in order, so you’re good to start here with Part 2. Let’s get into it!"
Right now, we are going to talk about how 340B impacts employers and commercial plans and other plan sponsors. So, if all you want to hear about is the why—as in, Why do employers care about what amounts to a program that is or was supposed to be for low-income Americans and Medicaid?—you are in the right place.
As just one example of the why should employers care if you are teetering on the edge of proceeding, did you know that if an employee or a member of a commercial plan gets a drug at a contract pharmacy participating in 340B, the employer does not get the rebate? The employer is gonna pay the list price for that med.
Wait, what? Yeah, details follow because Shawn Gremminger is gonna get into this and many other reasons why employers or anyone in the commercial market (or taxpayers, really) should care about this, as some may call it, Medicaid program. The fact is, 340B is currently so gargantuan that it creates market distortions that bleed into the prices and possibly the quality of healthcare for everybody, all Americans. And that could really matter to employer or Taft-Hartley plan sponsors.
After you listen to this show, if you want to drill in a little deeper on the “what the what” and the history of 340B, head back and take in Part 1 of this episode 448. Shawn Gremminger gives the skinny on how the program morphed over the years into a $53 billion juggernaut and is credited (or blamed) for all kinds of healthcare market consolidation and many other weird and unusual consequences that make me admire some of the folks who are truly gold medal winners in the sport of financial engineering.
If you want a summary of the points Shawn makes for why employers should care, it is your lucky day, because here you go. Here’s the four distortions in the market that Shawn talks about which impact employers:
To continue reading, please view our show notes/full article.
09:11 Why do employers care about 340B, which is a Medicaid program?
11:30 Why do I care as an employer, even if I’m not Pharma?
12:44 Why is 340B causing employers to pay significantly more for healthcare?
14:36 Study by Zack Cooper, PhD.
15:06 Why are there distorted pricing models at 340B hospitals?
21:22 Why do employers need to stop playing the blame game?
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So, after some pondering, I decided to release this conversation with Shawn Gremminger about 340B in two parts. So, listen to one, listen to both, pick your poison. Shawn Gremminger came up with three really important takeaways relative to 340B, which is a feat unto itself, considering how sprawling this conversation can be. So, if you came here for some concise and actionable takeaways, you have come to the right place.
To Read The Full Article Including Links Mentioned, click here.
If you enjoy this podcast, be sure to subscribe to the free weekly newsletter to be a member of the Relentless Tribe.
This first part you are listening to right now zeros in on Shawn’s first takeaway: whether or not the original intent, or the presumed original intent, of the 340B program has actually been met.
Many do not realize that 340B began life as a caterpillar. It originally, actually, was conceived as a lowly bureaucratic fix. But over the past 15 years, it has gone into a chrysalis and emerged into a 500-pound gorilla that sits in the corner of a lot of rooms, actually—probably more than many people realize. All of that being said, when you’re done listening to this first part of the convo, you should be able to competently assess whether or not 340B does, in fact, adequately help underserved communities get better healthcare—because 340B is supposed to help safety-net healthcare providers stretch scarce resources.
The second part of the show, which is a separate episode called Part 2, is how all of this impacts employers and commercial plans. And there’s two more takeaways there.
So, if you already have the gist of how we got from the beginnings of 340B to where we are in 2024 already and all you want to hear about is why do employers care about what amounts to a low-income program or was purported to be a low-income program, feel free to zip over to the second show and cut to that chase.
If you’re still with me for this Part 1—and I hope you are, because … wow, it’s a wild and tangled journey—here’s an outline of where this first part of the discussion is headed. So, for the sake of posterity and having this introduction transcribed in your inbox (be sure to sign up for the free newsletter), here you go. Here’s the outline.
Visit the full article to read more.
05:25 Shawn’s three takeaways from the 340B program.
06:04 What is the intent of the 340B program?
08:22 Read the full 32-page report of the Energy and Commerce Committee.
09:17 Why does Medicaid have to get the best price?
13:26 Why was there a shift in how the 340B program looked starting in the mid-2000s?
15:11 Why do more than half of acute care hospitals now qualify for 340B?
18:18 How has hospital consolidation affected 340B?
20:37 What is the misalignment between how a hospital qualifies for 340B and how it benefits said hospitals?
24:11 How is a 340B designed for hospitals to make a profit?
28:45 Why isn’t there a real patient definition in 340B?
31:46 Why is 340B still popular among policymakers?
33:05 Are 340B dollars being used in underserved communities?
33:57 EP394 with Vikas Saini, MD, and Judith Garber, MPP.
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In this Summer Short Episode of Relentlessly Seeking Value, host Stacey Richter discusses the hidden costs and inefficiencies of value-based care with Elizabeth Mitchell, President and CEO of the Purchaser Business Group on Health (PBGH).
To read the full article and show notes which include mentioned links, visit the episode page.
If you enjoy this podcast, be sure to subscribe to the free weekly newsletter to be a member of the Relentless Tribe.
They uncover how value-based care, often touted as the ideal system, can be manipulated by middlemen to extract more money from plan sponsors without delivering real value to patients.
Through a critical conversation involving examples and insights from various experts, they explore the disconnect between financial incentives and actual care quality in American healthcare.
Elizabeth argues for for-real alternative payment models that are transparent to the employer plan sponsors. She wants prospective payments or bundled payments, and she wants them with warranties that are measurable. She wants members to get integrated whole-person care in a measurable way, which most health plans (ie, middlemen) either cannot or will not administer.
Elizabeth says to achieve actual care that is of value, cooperation between employers, employees, and primary care providers is crucial (ie, direct contracts). She also says that this whole effort is really, really urgently needed given the affordability crisis affecting many Americans. There’s been just one article after another lately about how many billions and billions of dollars are getting siphoned off the top into the pockets of the middlemen and their shareholders.
These are dollars partially paid for by employees and plan members. We have 48% of Americans with commercial insurance delaying or forgoing care due to cost. If you’re a self-insured employer and you’re hearing this, don’t be thinking it doesn’t impact you because your employees are highly compensated.
As Deborah Williams wrote the other day, she wrote, “Co-pays have gotten high enough that even higher-income patients can’t afford them.” And she was referencing a study to that end.
To read the full article and show notes which include mentioned links, visit the episode page.
If you enjoy this podcast, be sure to subscribe to the free weekly newsletter to be a member of the Relentless Tribe.
So, yeah … with that, here is your Summer Short with Elizabeth Mitchell.
10:36 What are members and providers actually asking for in terms of value-based care?
10:56 Why won’t most health plans administer alternative payment models?
12:17 “We do not have value in the US healthcare system.”
12:57 Why you can’t do effective primary care on a fee-for-service model.
13:30 Why have we fragmented care out?
14:39 “No one makes money in a fee-for-service system if people are healthy.”
17:27 “If we think it is not at a crisis point, we are kidding ourselves.”
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My conversation today is with Will Shrank, MD. Dr. Shrank led the evaluation group at CMMI (Center for Medicare and Medicaid Innovation). He has spent time in the private sector, first at CVS Health and UPMC (University of Pittsburgh Medical Center) as chief medical officer of the health plan in Pittsburgh, and then as the chief medical officer for Humana. Now he is a venture partner at Andreessen Horowitz and doing some consulting for CMMI.
To read the full article and show notes which include mentioned links, visit the episode page.
If you enjoy this podcast, be sure to subscribe to the free weekly newsletter to be a member of the Relentless Tribe.
We start out this conversation talking about waste in healthcare. In fact, Dr. Shrank was on a team who did a study about waste in the US healthcare system. (The article is, unfortunately, paywalled.) In that study, it says estimates suggest we have upwards of a trillion dollars of waste a year.
This waste can be categorized into administrative and clinical failures. Dr. Shrank emphasizes the need for aligning incentives with higher quality care, paying for patient outcomes, and highlights the potential rising power of PCPs. The discussion covers the progress made towards value-based care, the challenges faced by the current fee-for-service model, and the future landscape of primary care and healthcare delivery.
In sum, we have a waste problem in this country. Aligning incentives might be one way to curb that waste.
06:54 Can we cut healthcare waste while improving patient care?
07:33 What does “healthcare waste” consist of?
07:46 What are the six categories of “healthcare waste”?
10:23 EP363 with David Scheinker, PhD.
10:37 How much money does Dr. Shrank estimate is wasted each year in healthcare?
13:09 Where is that healthcare waste going, and why does it happen?
20:07 Uncaring by Robert Pearl, MD.
21:18 “We’ve built a backbone of extraordinary waste on a fee-for-service chassis.”
22:16 EP409 with Larry Bauer, MSW, MEd.
24:24 EP359 with Dan O’Neill.
26:02 Dr. Shrank’s warning to providers out there.
30:03 Summer Shorts 2 with Scott Conard, MD.
31:41 Why there might be a generational shift among younger providers looking to work with different models.
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This encore episode is with Amy Scanlan, MD. It was, in fact, one of our most popular episodes of the past year. It is still just as relevant today in a slightly different way. It’s interesting how things which were said maybe a year ago have shades of meaning which become evident as time goes on. So, I liked this show a lot in the second listen with the advantage of time passing.
To read the show notes with mentioned links and a transcript, head over to our site.
If you enjoy this podcast, be sure to subscribe to the free weekly newsletter to be a member of the Relentless Tribe.
Complicating fact of current life, it’s becoming increasingly obvious that in order to stand up a practice that can take advantage of value-based care payments—payments where primary care docs mainly at this time can get paid more and likely more fairly to care for patients well—you need a lot of infrastructure. You need data, you need tech, you need a team. Translation: You need money, maybe a lot of money, to invest in all of this.
These are the external realities that hit anyone trying to do right by patients from every direction. But on the other hand (or maybe different fingers on the same hand), as Dr. Amy Scanlan says in this healthcare podcast, physicians are the backbone of this system. Dr. Scanlan talks in the interview today about the opportunity, and maybe the responsibility, that physicians have here for patients; but also the Eric Reinhart article comes up again about rampant physician moral injury (unpaywalled link with my compliments).
Right now might be a great time to read something from Denver Sallee, MD. He wrote to me, and he wrote, “Like many physicians, I did not have much understanding of the business side of medicine, as I mistakenly thought as long as I helped take great care of patients that I was doing my job. More recently, it became apparent to me that by ceding the management of medicine to nonclinical administrators and to companies interested primarily in value extraction for the benefit of shareholders that I needed more education in order to truly help patients.”
Today as aforementioned, I’m talking with Amy Scanlan, MD, who is chief medical officer of the clinically integrated network (CIN) that is the joint venture between Intermountain Health and UCHealth in Colorado.
We talk about what it’s like to be in the kind of messy middle of transformation to integrate care in a clinically integrated network, trying to figure out how to help physician practices and the CIN itself navigate the external environment in a way that empowers different kinds of practices at different points in their transformation journey that empowers physicians to be in charge, and considering clinical and financial outcomes (ie, the business of healthcare).
Dr. Scanlan brings up four main factors to consider when plotting strategy from here to there. Listen to the episode or read the show notes to learn about the four factors.
06:35 How is Dr. Scanlan thinking about the transformation process and the shift to value?
09:16 “It is really trying to think about, how do we help practices get there?”
11:48 “The hard part is the in-between spaces.”
13:21 EP407 with Vivek Garg, MD, MBA.
14:12 “Team-based care done badly is really just a series of handoffs.”
15:52 “We have to get to that point where the culture of collaboration is more pervasive.”
19:58 “How do we as healthcare providers step in and solve this problem?”
20:06 Why do providers have a responsibility to step in and try to fix the healthcare system?
20:22 Article (unpaywalled) by Eric Reinhart, MD, PhD.
21:51 Why do physicians need to be accountable for the cost of care as well as outcomes?
23:38 Why does physician burnout give Dr. Scanlan hope?
24:26 What is the solution to changing fee-for-service incentives?
25:43 What are some of the challenges facing changing incentives?
27:16 Why is data so important?
28:54 EP393 with David Muhlestein, PhD, JD.
30:13 “It’s important to understand that we are in the middle of this change.”
31:18 Dr. Scanlan’s advice for those trying to stand up a CIN.
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In Episode 447, Stacey Richter interviews Ashleigh Gunter, president of Translucent Healthcare Consulting, to discuss the indispensable role of change management in healthcare transformation. They emphasize that creating an effective change strategy involves great leadership, a clear case for change, influential change champions, over-communication, and continuous measurement and celebration of successes.
The conversation highlights the importance of understanding and aligning with the 'why' that drives healthcare professionals and the necessity of a multi-faceted approach beyond just implementing technological solutions like EHR systems.
Visit the Episode Page to read the show notes with mentioned links.
If you enjoy this podcast, be sure to subscribe to the free weekly newsletter to be a member of the Relentless Tribe.
I saw a bar chart by Phil Ballentine the other day in Nikhil Krishnan’s Out-Of-Pocket newsletter that showed, in the USA, in 2024, there are 18,982 live instances of Epic. Each one of those 18,982 live instances are all different: different workflows, separate data, different ways to do the same thing. So, even if having an “Epic strategy” actually was a complete master plan to change behavior in clinic, healthcare has no “nationwide, everywhere it’s all the same, so figure out your thing once and you’re good to go” thing going on.
There are 18,982 differences of opinion out there, but here’s the actual and big kahuna real reason why I’m leery. An Epic strategy is not equivalent to a change management strategy. That’s the real point that I want to make.
It’s necessary, very necessary even, but not sufficient. You want to make the way as easy as possible once the “why” goes down and the case for change is made, but even if it’s one click and not your usual 14 to 60 clicks, there’s no “why” there. There’s no automatic case for change that slithers out of anybody’s API like a spontaneous miracle.
I said this last week, too. Lots of things are really pretty easy. Lots of things are in Epic. Yet no one uses them. I mean, let’s talk about actually reading most of the best-practice alerts that pop up. How about consistent use of SmartSets in the majority of those 18,982 instances?
Anyway, I couldn’t be more pleased to have learned a thing or two from Ashleigh Gunter about change management and how to do this whole thing right. This conversation happened actually a while ago. It’s re-edited for 2024—call it a supercut—specifically considering change management at hospitals or physician organizations.
Ashleigh Gunther is president of Translucent Healthcare Consulting. She is also an expert in change management and how to align employees and staff so that an organization can move forward together.
One quick spoiler before we proceed: According to Ashleigh, there’s five steps to effective change management that will ensure success:
1. Having great leadership
2. Creating a case for change. This includes the whole “why” thing.
3. Finding champions—engaging people who have to change so that they can contribute and be supportive
4. Overcommunicating
5. Measuring how things are going and also celebrating small triumphs
If you continue to be interested in this topic, do go back and listen to the show with Karen Root (EP381) on shepherding innovation through a large company.
Before we kick in to the show today, let me remind you, if you haven’t done so and you appreciate the show, could I ask you to please leave a rating and review on Apple Podcasts or Spotify? We haven’t had any of them this month, and it is important for the show to get found and for me and the team to stay motivated over here. While you're there, be sure to Follow the show.
09:22 How does change management go wrong in healthcare?
09:56 “Communication [of change] in and of itself isn’t change management.”
10:53 How does change management work on the provider organization side?
15:33 “You want to ensure you are educating the operational folks.”
16:35 What is change management?
17:36 What does great leadership look like in change management?
18:55 “Leadership sets the tone.”
19:04 What makes change management so hard?
19:31 “What’s the company reason to make this change happen?”
20:51 What are change champions, and why do you need to create them when changing your benefit plan?
21:57 Crossing the Chasm by Geoffrey A. Moore.
23:21 Why is it important to overcommunicate change?
26:47 Why is it important to measure your successes and communicate those after a change?
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In Episode 446, "Hey, Let's Not Talk About EHRs," host Stacey Richter engages Dr. Spencer Dorn, vice chair and professor of medicine at the University of North Carolina, in a comprehensive discussion about the implications of healthcare technology, specifically electronic health records (EHRs).
Visit the Episode Page to read the show notes with mentioned links.
If you enjoy this podcast, be sure to subscribe to the free weekly newsletter to be a member of the Relentless Tribe.
The conversation emphasizes the necessity of understanding technology as a tool that neither possesses inherent goodness nor badness but delivers results based on its implementation and usage.
They discuss the paradoxical nature of technology in healthcare, highlighting how EHR systems can simultaneously empower and overwhelm healthcare practitioners.
Dr. Dorn and Stacey delve into the effects of digital technology on patient-doctor and clinician-clinician relationships, stressing the importance of proper deployment, operational excellence, and continuous improvement to optimize healthcare outcomes. In essence, the episode sheds light on the necessity of viewing technology as a means to an end rather than an end in itself.
06:15 Breaking down Kranzberg’s Laws of Technology.
08:16 How do EHRs go right?
12:49 “EHRs empower us with information, yet they also overwhelm us with information.”
16:00 How do EHRs bring healthcare workers closer together?
19:35 The Digital Doctor by Robert Wachter.
21:33 “The whole point of healthcare is to help people live healthier, happier lives.”
22:41 How the same EHR deployed in different places can be more or less efficient.
25:51 Why the problem is not necessarily the EHR but actually operational.
28:51 How technology has also changed our expectations on timing and value.
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I wanted to talk with Dr. Lee because so many RHV (Relentless Health Value) listeners are trying to figure out how to sustain primary care as a stand-alone entity when the most obvious and most common way to make enough money in primary care is to drive and maximize the dollars from downstream volume of high-priced service lines, which, if you think about it, undermines the entire point of primary care.
To read the full article, show notes as well as the links mentioned visit our episode page. While there, consider signing up for our free weekly newsletter.
In Episode 445 of Relentless Health Value, Stacey Richter interviews Dr. Tom Lee, founder of One Medical and Galileo, about the sustainability of standalone primary care practices in 2024. Dr. Lee also was a founder at Epocrates
They discuss the paradox of primary care, the economic challenges of running an independent practice, and the importance of enlightened leadership with a value-focused mindset.
Dr. Lee emphasizes innovative service operations, cutting hidden waste, and balancing human-centered care with efficient processes. The conversation explores various facets of primary care, including access, longitudinal patient care, and the role of technology.
Tune in to understand how primary care can thrive amidst economic and systemic challenges.
07:02 What is the paradox of primary care?
09:19 Why is it hard to run an independent primary care practice?
10:01 What are the barriers to running an independent primary care practice?
10:41 Can you have fee for service and value?
12:25 “Value is more about a mindset.”
13:22 What hidden waste is there in a primary care practice?
15:11 What do you need to have a value-focused mindset?
17:14 Why does access precede quality?
18:20 Why have retail clinics failed in being longitudinal primary care destinations?
20:29 What is a longitudinal primary care destination and why does it matter?
23:48 What are the nuances of a service business that make them challenging for managers?
24:35 How do you find the balance between fee for service and value?
31:17 EP438 with John Lee, MD.
32:14 How can you invest in quality without a value-based contract?
34:19 How do you address the trade-off between fee-for-service finances and investing in value-based care?
35:36 Where is the “productive middle”?
36:27 Dr. Tom Lee’s message to payers.
39:55 Dr. Tom Lee’s message for policymakers.
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In this encore episode of 'Relentlessly Seeking Value,' host Stacey Richter revisits a critically important conversation with ERISA attorney Paul Holmes about the complexities and hidden pitfalls in Pharmacy Benefit Manager (PBM) contracts.
Aimed at CFOs and employer plan sponsors, Holmes highlights how poorly reviewed PBM contracts can lead to companies paying 30-40% over market for pharmacy benefits, discusses the potential legal exposures under the Consolidated Appropriations Act (CAA), and suggests the essential need for independent reviews.
Holmes also delves into issues with Employee Benefit Consultants (EBCs) taking indirect compensation from PBMs and offers actionable advice for employers on how to mitigate these risks.
To read the full article, show notes as well as the links mentioned visit our episode page. While there, consider signing up for our free weekly newsletter.
07:41 What are Paul’s usual observations when a PBM contract crosses his desk?
08:34 “If you just sign … one of their model contracts …, you’re probably gonna pay 30% to 40% above market on your drug spend.”
12:11 What is a PBM lawyer? And why is it important to find an ERISA PBM lawyer?
17:12 EP379 with AJ Loiacono.
17:40 Who is on the hook for the cost of the PBM contracts?
21:05 What’s the problem with most ERISA lawyers today?
22:56 Lawsuit about PBM contract.
27:43 What’s Paul’s advice for benefits consultants?
31:40 How much might a plan sponsor be paying their consultant versus what a consultant might be making from a PBM?
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