Relentless Health Value™
543 episodes - English - Latest episode: 20 days ago - ★★★★★ - 203 ratingsAmerican Healthcare Entrepreneurs and Execs you might want to know. Talking.
Relentless Health Value is a weekly interview podcast hosted by Stacey Richter, a healthcare entrepreneur celebrating fifteen years in the business side of healthcare.
This show is for leaders in pharma, devices, payers, providers, patient advocacy and healthcare business. It's for health industry innovators, entrepreneurs or wantrepreneurs or intrapreneurs.
Relentless Healthcare Value is the show for you if you want to connect with others trying to manage the triple play: to provide healthcare value while being personally and professionally fulfilled.
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Episodes
EP374: How to Grade a Health Plan and a Few Validated Success Stories, With Dave Chase, Cofounder of Health Rosetta
July 21, 2022 11:30 - 35 minutes - 48.8 MBSo, let’s put the last, I don’t know, 300 episodes of Relentless Health Value into perspective here. The USA wastes about $1.5 trillion a year on some combination of paying way too much for low-value care, fraud, and waste—$1.5 trillion down the drain. As my guest, Dave Chase, says in this healthcare podcast, if this was a country, what we waste would be the 11th biggest GDP in the world. We could call it Healthcare-istan. Meanwhile, outcomes aren’t anything to brag about on the world stag...
EP373: How to Kick a Big Hospital Out of Your Network, With Cora Opsahl
July 14, 2022 11:30 - 28 minutes - 39.2 MBIn this healthcare podcast, I am speaking with Cora Opsahl, who directs the 32BJ Health Fund. This is the second conversation I’m having with Cora (last one was EP372), but these two conversations are not really linear—so listen in whatever order you want to. Important to know about Cora’s background, in previous roles, she has worked deep in the inner sanctums of the healthcare industry. So, she came to 32BJ armed with a BS meter that’s finely tuned, which is, as I said last week, an un...
EP372: Step One for Employers and Unions—Get Your Data, With Cora Opsahl
July 07, 2022 11:30 - 33 minutes - 46.4 MBIn this healthcare podcast, I am speaking with Cora Opsahl, who directs the 32BJ Health Fund. Important to know about Cora’s background is this: In previous roles, she’s worked deep in the inner workings of the healthcare industry. So, she came to 32BJ armed with a BS meter that is finely tuned, which is, unfortunately, an essential skill for anyone trying to help the patients and members relying on them to successfully navigate the healthcare industry. So sorry to have to say that, but ...
Encore! EP308: How Financial Toxicity Wreaks Havoc on Value-Based Payment Success, With Mark Fendrick, MD
June 30, 2022 11:30 - 35 minutes - 48.4 MBI wanted to remind everyone about this show from last year because it’s becoming increasingly relevant. We have this weird thing going on where everybody seems to be talking about physician incentives and payments and financial implications but so often disregards patient incentives and payments and financial implications. Consider that we’re at a place in the time-space continuum where it is inarguable that financial toxicity has become clinical toxicity. Patients are increasingly in huge...
EP371: Buy and Bill vs Pharmacy Bagging—Which Is Better for a Plan Sponsor and Patients? With Erik Davis and Autumn Yongchu
June 23, 2022 11:30 - 32 minutes - 45 MBSo, this is a 400-level episode in specialty pharmacy options for plan sponsors, meaning here are your prerequisites: You gotta know what buy and bill is, and you gotta know what pharmacy bagging is, meaning white bagging, for example. If you do not, I would listen to Encore! EP282 with Aaron Mitchell, MD, MPH, where we go deep on buy and bill. And then listen to EP369 for the skinny on pharmacy bagging. If you already know what buy and bill is and you already know what white bagging is, the...
EP370: How Do Some Health Systems Manage to Charge 6x the Cost of a Specialty Pharmacy Med to Infuse It? With Erik Davis and Autumn Yongchu
June 16, 2022 11:30 - 31 minutes - 43.6 MBI have been on a mission to figure out why some health systems, particularly in the oncology space but not limited to the oncology space, could manage to mark up the price of infused specialty pharmacy drugs up to 6x. Some employers and patients are paying six times the cost of a specialty pharmacy drug in markup for some already incredibly expensive specialty pharmacy drug at some oncology centers. Read more about this in a study by Roy Xiao, MD, and colleagues. Let’s not forget now or ev...
EP369: What’s Up With Specialty Pharmacy Bagging? With Keith Hartman, RPh
June 09, 2022 11:30 - 33 minutes - 45.9 MBLast week’s show was an encore episode with Dr. Aaron Mitchell (Encore! EP282), and we talked about buy and bill. To continue our exploration of specialty pharmacy intrigue, let’s talk about so-called “bagging.” I wanted to get an overview of all of the different kinds of specialty pharmacy bagging. Bagging is a big deal. If you have anything to do with trying to control pharmacy costs or the clinical outcomes of specialty pharmacy patients, you too are going to want to understand what’s goi...
Encore! EP282: Do You Know How Much Cancer Centers Get Paid to Put Patients on Drugs? With Aaron Mitchell, MD, MPH
June 02, 2022 11:30 - 33 minutes - 45.8 MBAfter that recent episode with Scott Haas (EP365), where we talked about the real deal with PBM contracting, I kicked into high gear trying to untangle this whole apocalyptic honky-tonk we call benefits for prescription drugs. Notice I did not say prescription drug benefits because that would imply that pharmaceuticals are only charged for under the umbrella of pharmacy benefits. Ha ha, that would be just too easy. No, some pharma drugs are charged as part of patients’ medical benefits. An a...
INBW34: The Absence of Collaboration Between Healthcare Stakeholders: What It Means
May 26, 2022 11:30 - 19 minutes - 26.4 MBIn INBW32, I talked about telehealth. In this episode, I’m talking about collaboration between healthcare stakeholders or the lack thereof. My grandfather suffered from heart failure. This was many years ago now. But when I say suffered, I mean it. As many of you know, when heart failure is uncontrolled, it is painful to go through or even watch a loved one go through. There was that one time when I accompanied my grandfather (and my grandma was there, too) on a trip to the emergency roo...
EP368: How to Successfully Roll Out New Benefit Designs to Employees and New Care Delivery Models at a Provider Organization, With Ashleigh Gunter
May 19, 2022 11:30 - 30 minutes - 42.3 MBPeople are averse to change. It’s a thing. It’s a thing that affects even those of us who consider ourselves highly educated and/or very smart. Nobody likes disruption or, even worse, the prospect of disruption and the uncertainty that goes along with that. Nobody likes to feel like the rug just got pulled out from under them or that they’ve lost control of something, especially something important like their health benefits or how they care for patients. Changes to health insurance and he...
EP367: Why Would a Hospital Direct Contract With an Employer Looking to Pay Less? With Doug Hetherington
May 12, 2022 11:30 - 33 minutes - 46.3 MBLots of talk about direct contracting going on these days. Many of you will be familiar with the term, but in short, direct contracting means when a self-insured employer directly contracts with a provider organization with no payer in the middle of that arrangement. And when I say “employer,” I mean the employer and all their peeps—their TPAs, repricers, other vendors, and consultants. Most of this talk, though, seems to come from the point of view of the employer. It’s super easy to quan...
EP366: An In-Depth Dissection of Our Dysfunctional Healthcare Benefits Market, With Kevin Schulman, MD
May 05, 2022 11:30 - 32 minutes - 45.2 MBFirst of all, this is a 400-level discussion. If you think you already know all about our dysfunctional healthcare benefits market, then this show is for you. Before we begin, I just want to say something. I’m gonna refer back to David Muhlestein’s episode (EP364), where he talks about the first step toward healthcare transformation. It is, let’s just say, for incumbent health systems and payers, people who work there, to step back and in the harsh light of day really contemplate their bus...
EP365: The Real Deal With PBM Contracts and Drug Rebates, With Scott Haas
April 28, 2022 11:30 - 33 minutes - 45.4 MBOne of my mentors often said price is irrelevant. He said he would sell anything for any price as long as he could define the terms of the deal. During this conversation today with Scott Haas about PBMs, that quote was playing in my head like an earworm. I’m henceforth gonna struggle with the term rebate to define dollars that the PBM gets back from Pharma, because, according to my guest in this healthcare podcast Scott Haas, it turns out “rebates” comprise only about 40% of those back-end...
EP364: A Way to Think About Transforming the Healthcare Industry, With David Muhlestein, PhD, JD
April 21, 2022 11:30 - 36 minutes - 49.4 MBIn this healthcare podcast, we’re gonna zoom out and look at the entire healthcare industry. I am very confident that you know a lot about the healthcare industry and its basic stats. It’s huge. The healthcare industry is approaching the $4 trillion mark, and it employs more people than any other industry in 47 states. Think about that momentarily. More people work in healthcare than in any other industry in every state except for Wisconsin, Indiana, and Nevada. We could get into (but we w...
EP363: How to Cut the Healthcare Administrative Burden in Half, With David Scheinker, PhD
April 14, 2022 11:30 - 32 minutes - 44.5 MBAdministrative costs in the United States have a bad rap. You don’t have to look too far to find an article about how there’s now, like, 10 administrators for every 1 physician in this country. Or 3 to 4 billing people for every physician. Or find someone complaining about arduous prior auth processes and how long specialists sit on phones trying to get a prior auth approved while having a frustrating “peer consult” with a “peer” whose career has nothing to do with that specialty and, in fac...
EP362: A CFO Talks About a Hybrid Business Model, With Ali Ucar
April 07, 2022 11:30 - 32 minutes - 45.1 MBLet’s talk about provider organizations and telehealth. It’s just too common a refrain amongst provider organizations who say some combination of: Our patients and/or clinicians don’t like telehealth. Telehealth is too expensive for us to do ... unless maybe we should charge facility fees for telehealth visits. Telehealth is risky to invest in because as soon as payers start paying less than 65% of in-person visits, we’re gonna drop it anyway. These things are said despite the overwhel...
EP361: The Gap in Closing Care Gaps, With Carly Eckert, MD
March 31, 2022 11:30 - 32 minutes - 44.4 MBDavid Contorno the other day posted the life expectancy chart comparing the US to comparable countries. Spoiler alert: It’s horrifying. You see Japan; you see Switzerland, Israel, Spain, Italy … basically everybody else in a cluster of pretty darn vertical lines: increasing life expectancies year over year without much cost increase at all. And then—wow!—off to the right, all by itself, you see the USA, costing nearly double the worst of the other countries with a life expectancy that is ye...
EP360: How to Deliver Value-Based Care That Meets Value-Based Payment Objectives, With Jeb Dunkelberger
March 24, 2022 11:30 - 28 minutes - 39.8 MBBefore I get into the show today, let me just remind everybody about our mailing list, which you can sign up for on our Web site, relentlesshealthvalue.com. You might follow Relentless Health Value on LinkedIn or Twitter, which is a great option, for sure; but I wanted to point out that what you see there is abridged at some level. Meanwhile, if you subscribe to our mailing list directly (again, by going to our Web site, relentlesshealthvalue.com—it’s over on the right sidebar where you can ...
EP359: Value-Based Payments—You Get What You Pay For, With Dan O’Neill
March 17, 2022 11:30 - 34 minutes - 47.6 MBLast week’s show was with Wayne Jenkins, MD, from Centivo; and we talked about how insurance design, when not done well, can lead, in a nutshell, to mental and physical health problems for employees. This is a great lead-in to the conversation in this healthcare podcast with Dan O’Neill. And before I get into why it’s a great lead-in, let me just start here—and don’t roll your eyes. What is value-based care? Consider this delineation: There’s value-based payments, and then there’s the type...
EP358: How Health Insurance Plan Design Can Lead to Patients Sacrificing Needed Care, Their Mental Health, and (Sometimes) Buying Groceries, With Wayne Jenkins, MD
March 10, 2022 12:30 - 33 minutes - 46.5 MBFirst of all, anybody who thinks that your average citizen in the United States today is unaware of the financial double jeopardy of going to a doctor, going to an emergency room, getting a procedure is sorely mistaken. Americans today are well aware of the financial risk that they are taking by seeking healthcare in this country. To illustrate this point, let me read the first couple of sentences from a New York Times best-selling book review: “The illness narrative, ending in financial r...
EP357: Standing Up Telehealth That Actually Advances Providers’ Core Business, With Liliana Petrova
March 03, 2022 12:30 - 34 minutes - 47.5 MBHere’s the biggest problem with a lot of telehealth endeavors: Someone decides that they need to be doing telehealth, for whatever reason. Maybe there’s a pandemic, for example. And the basic plan is this: Install some technology, give everyone a username and password and a link for patients, check that box, and move on to the next thing. My guest in this healthcare podcast, Liliana Petrova, has seen and talked about how, far too many times, the whole concept of telehealth is narrowed down...
EP356: PBMs React to GoodRx, Mark Cuban, and Amazon Pharmacy, With Ge Bai, PhD, CPA
February 24, 2022 12:30 - 36 minutes - 49.8 MBSo … let’s start here. Mostly this whole episode is about the so-called “Big Three” PBMs that provide between the three of them pharmacy benefit services for 95% of insured Americans. PBM stands for pharmacy benefit manager, and the Big Three PBMs being ESI, otherwise known as Express Scripts; OptumRx, which is a part (a big profitable part) of United Health Group; and then also CVS. Yes, CVS is not just for your retail pharmacy needs; they are also a huge pharmacy benefit manager. Now, we...
EP355: The 5 Business Models of Digital Health Companies, With Nikhil Krishnan
February 17, 2022 12:30 - 35 minutes - 48.2 MBMy guest in this healthcare podcast is Nikhil Krishnan, who is the founder of the Out-Of-Pocket newsletter. I was talking with Nikhil, and we identified—or, more accurately, he identified—five business models of digital health. What makes each model distinct is a few factors. If you weren’t in the healthcare industry, you’d probably expect that I’m going to say that the biggest factor a business model must hinge on must have something to do with patient outcomes or care or something that has...
EP354: 7 Vital Success Factors to Stand Up a CIN (Clinically Integrated Network), With Shawn Rhodes
February 10, 2022 12:30 - 32 minutes - 45 MBIn this healthcare podcast, we’re gonna talk about the realities of setting up a clinically integrated network, otherwise known as a CIN. If only the whole process was unicorns and rainbows, but—as you likely suspected—it’s not. Setting up a clinically integrated network is hard work, but the payoff for patients and clinicians alike can be worth fighting for. First of all, what is a clinically integrated network? It is a kind of ACO (accountable care organization). It is a legal entity tha...
EP353: What You Need to Know About Specialty Pharmacy Formularies and Rebating, With Pramod John, PhD
February 03, 2022 12:30 - 30 minutes - 42.3 MBThis episode is probably a 400-level class in specialty pharmacy rebating. If you want a 45-minute conversation on rebates in all their glory, go back and listen to the conversation with Chris Sloan (Encore! EP216). But if you’re still with me, what’s gonna follow is about an eight-minute overview of pharmaceutical rebating, just to make sure we’re all on the same page before we get into the show itself. So, if you know all there is to know about pharmaceutical rebating, you can jump ahe...
EP352: Some Big Actionable Surprises About the Efficacy and Effectiveness of Specialty Pharmaceuticals, With Pramod John, PhD
January 27, 2022 12:30 - 28 minutes - 38.9 MBAs a country, we spend approximately $500 billion on prescription drugs. Specialty drugs account for less than 2% of prescriptions but will cost us over $250 billion (that’s in 2021)—so, 2% of prescriptions but half the spend. Specialty is the fastest-growing segment of healthcare spend and is a dominant issue that self-funded employers and other purchasers face. But let’s dig into that $250 billion being spent on specialty drugs, shall we? I have to say, personally, that if we spent $250 ...
EP351: Everybody in the Healthcare Industry Getting Up in Everyone Else’s Business, With Eric Bricker, MD, From AHealthcareZ
January 20, 2022 12:30 - 36 minutes - 49.5 MBIn this healthcare podcast, I’m speaking with Eric Bricker, MD, about how so many entities in healthcare are getting up in other people’s business and swimming in other people’s traditional lanes. Consider last week’s show with Katy Talento, for example. She mentions employers who are not only doing their own direct contracting (ie, cutting out the traditional carriers and negotiating directly with provider organizations) but also employee benefit consultants who are working on setting up th...
EP350: Employers Direct Contracting With Hospitals, in Real Life, With Katy Talento
January 13, 2022 12:30 - 35 minutes - 48.8 MBIn this healthcare podcast, I’m talking about direct contracting IRL (in real life) with Katy Talento. This is a conversation that’s more about the reality of direct contracting than the theory of direct contracting, and this was not an accident. So much of healthcare transformation is really easy to say and much harder to actually do. So … direct contracting. In the context we discuss in this episode, generally direct contracting means when an employer or their benefits consultant, more l...
INBW33: Thank You, and a Few Thoughts
January 06, 2022 12:30 - 14 minutes - 19.2 MBAs one of our guests, Dr. Tony DiGioia (EP332), has said, healthcare has been pushed to its limits this past year; but that doesn’t mean that nothing good has come of it. Celebrating our bright spots and using our experiences to inform future innovations is really the key to more accessible, equitable, and higher quality of care. While the timing of the celebration could, in general, be better given the latest pandemic news, as they say, there’s no time like the present. So, let’s do this th...
INBW32: The Ultimate Impact of Telehealth: A Thought Experiment
December 30, 2021 12:30 - 18 minutes - 25.8 MBThis episode is a little bit of a thought experiment, so hang with me as I bumble my way through it and then hit me up with your comments. The plan is to do another episode in the future where some of you with thoughts share your version of your own thought experiment. Here’s the topic: The ultimate impact of telehealth—in 20 minutes or less. In my version of this thought experiment, I want to do something a little bit different (maybe) than everybody who seems to be putting up a poll on...
Encore! EP294: Building a Center of Excellence: A Playbook for Physician Entrepreneurs, With Steve Schutzer, MD
December 23, 2021 12:30 - 33 minutes - 46.5 MBBelieve me, filling in for the uncontested master of podcasts, Stacey Richter, is just a tad unnerving! My name is Dr. Steve Schutzer. I’m an orthopedic surgeon specializing in joint replacement surgery, and I think it’s fair to say that I’m more comfortable, in my own lane, doing complex surgery than doing this introduction to our encore podcast 294 entitled “Building a Center of Excellence: A Playbook for Physician Entrepreneurs,” which aired originally in October 2020. But when Stacey...
EP349: How Integrated Is a Clinically Integrated Network, Actually? With Lisa Trumble
December 16, 2021 12:30 - 31 minutes - 42.9 MBThis interview with Lisa Trumble is mostly about clinically integrated networks (CINs)—what they are, how they work, how data get shared. Furthermore, we talk about hybrid CINs, meaning, for example, a virtual front door that might lead to in-person care. After that, we talk about the potential impact of direct contracting, which Lisa says could significantly change the healthcare marketplace. The hybrid talk, by the way, is toward the middle of the show; and we talk about direct contracting...
EP348: Your Burning Questions About Payviders Answered! With Jeb Dunkelberger
December 09, 2021 12:30 - 32 minutes - 44 MBThe discussion to follow is probably a 400-level class in payviders. If I just said the word payvider and you’re scratching your head wondering where you may have heard that term before, this show is probably not the best place for you to start. I’d go back and get some context by listening first to the episodes with Steve Blumberg from GuideWell (EP304) and/or the one with John Moore from Chilmark (EP172); and for a really retrospective lookback, check out the one episode with Dr. Kris Smit...
EP347: Rolling Out Healthcare Initiatives That Actually Get Uptake With the Populations You Aim to Serve, With Ian Tong, MD, About the Black Community Innovation Coalition
December 02, 2021 12:30 - 34 minutes - 47.4 MBI attended the STAT Summit last week and heard the heart-wrenching story told by Charles Johnson, who is the founder of 4Kira4Moms, which is a group dedicated to improving maternal health equity. Charles’s family is African American. After a planned C-section, his otherwise-healthy wife died an avoidable death because 10 hours after the clinical team was alerted that she had internal bleeding—10 hours later—they got around to wheeling her into surgery. At that point, she had three liters of ...
Encore! EP288: The “Big Three” PBMs Spinning Up GPOs—What? With Mike Schneider
November 25, 2021 12:30 - 29 minutes - 41 MBOver the holiday season here, we’re running some of our favorite episodes from years past. This one is with Mike Schneider, who actually has taken another role since this show was recorded. Other than that, the information that Mike shares during this episode from 2020 is all good. So, let’s do this thing. Disclaimer before we get started here: This show is probably a 300-level class in pharmaceutical/PBM relations. If you are tuning in for the first time and you aren’t pretty familiar wit...
EP346: How Did Health Systems Get Addicted to the Inflated Prices They Charge Employers and Some Patients? 2021 Update, With Peter Hayes, President and CEO of the Healthcare Purchaser Alliance of Maine
November 18, 2021 12:30 - 36 minutes - 49.8 MBIn this healthcare podcast, I speak with Peter Hayes, who is president and CEO at the Healthcare Purchaser Alliance of Maine and a national presence in healthcare strategy, innovation, and a frequent keynote speaker. One thing, among many, that Peter said during our conversation struck me. He said it will take a village to fix what ails the healthcare industry in this country. There are too many interdependencies. This point obviously resonates around these parts because it’s the rationale f...
EP345: Can Pharma Imagine How Our Health System Will Look in the Future? With Paul Simms
November 11, 2021 12:30 - 31 minutes - 43.4 MBAt the beginning of 2021, my guest in this healthcare podcast, Paul Simms, had come up with a set of predictions for 2021. Some came true; some didn’t. But I was fascinated by a bunch of things, one of them being Paul’s sort of implicit and explicit assessment of the context of these predictions. Right now, Pharma is in a weird moment: It’s a confluence of technology, consumer expectations, changes in care delivery accelerated by the pandemic, policy at the state and federal level, and the f...
EP344: The High Cost of Generic Drugs, With Steven Quimby, MD
November 04, 2021 11:30 - 33 minutes - 45.9 MBI was on LinkedIn, and someone was saying, “Oh, there’s no real money in generic drugs. It’s not a huge issue if patients are paying 10 bucks instead of 93 cents for something. It’s not like anyone is getting rich off of that, and it’s not like patient impact here is super meaningful.” This is a pretty common refrain, actually; and from a conventional wisdom perspective, I get it, especially for those living comfortable middle- or upper-middle-class lives where an extra $9.07 for a prescript...
EP343: What Provider Leadership Teams Need to Know to Operationalize Value-Based Care, With David Carmouche, MD
October 28, 2021 11:30 - 30 minutes - 41.4 MBMost people who have been in the healthcare industry for a while have heard by now the metaphor about the two canoes. Provider organizations or health systems with some of their payments coming from a fee-for-service (FFS) payment model and some of them coming from value-based arrangements have the challenge of one foot in the FFS canoe and one foot in the value-based canoe. They’re probably going through a lot of metaphorical pants is the main takeaway that often comes to mind for me. But w...
EP342: How the Consolidated Appropriations Act (CAA) and ERISA Fiduciary Requirements Are an Anchor for Self-insured Employers to Navigate the Complexity of Healthcare, With Christin Deacon
October 21, 2021 11:30 - 36 minutes - 50.3 MBThis episode’s conversation is about the new Consolidated Appropriations Act (CAA), the fee disclosure part of it, as well as ERISA and the fiduciary responsibility that self-insured employers are responsible to comply with under the law. Don’t worry, the first thing my guest in this healthcare podcast, Christin Deacon, does is explain these terms, what they actually mean, and how they can be a tool actually in CEOs’ or CFOs’ toolboxes to get access to the employer’s own claims data, which i...
EP341: How to Cut Administrative Waste AND Attract and Retain Doctors and Nurses, With Gary Campbell
October 14, 2021 11:30 - 32 minutes - 45.1 MBFirst, let’s talk about reducing administrative waste in the US healthcare system. There was a pretty famous 2019 study by Shrank et al. that estimated about 25% of the $3.6 trillion the US spends on healthcare annually is potentially wasteful. This is each person spending $2500 unnecessarily. Robert Kocher wrote a really interesting article about getting rid of administrative waste and inefficiencies, and he said that it is the “safest form of health care cost savings; virtually no one ar...
EP340: How Digital Front Doors Can Enable Value-Based Care, With Kristin Begley
October 07, 2021 11:30 - 32 minutes - 44.1 MBThere’s a next generation of digital front doors being created that open up to a patient/member experience that folds in payer, provider, and employer data—plus behavioral data the patient themselves generates when they browse through content in there. Because that’s what it takes for a so-called personalized experience or patient journey to ensue. This is what I’m talking about in this healthcare podcast with Kristin Begley, PharmD. In an ideal world, you’d have, for example, a member/pat...
AEE17: Employers and Reference-Based Pricing—David Contorno’s Latest Thinking
October 05, 2021 11:30 - 9 minutes - 12.8 MBReference-based pricing, the way that most employee benefit consultants use the term anyway, refers to a methodology used by employers to pay providers for services. Usually we’re talking within a fee-for-service (FFS) environment here. The way it typically works ... there are different flavors, but how it typically works is this: Reference-based pricing (RBP) means that an employer starts with some reference-based price. Many times, it’s the Medicare rate. Medicare will pay X dollars for ...
EP339: Helping Employers Navigate the Perilous Medical-Industrial Complex, With David Contorno
September 30, 2021 11:30 - 30 minutes - 42.2 MBLet’s just start here: As a general construct, insurance carriers have every incentive for health insurance premiums to go up every year. If you’re an employer, that is a material fact. Is it counterintuitive? Maybe. Except if you’re an employer and your premiums are going up year after year, it begs the question why, every single year, the already-extravagant amount you pay continues to go up way more than the inflation rate. You’d think that if your broker and your plan administrator w...
EP338: Ideas to Meet Rural Healthcare’s Tough Challenges, With Nikki King, DHA
September 23, 2021 11:30 - 34 minutes - 47.3 MBMy overarching thought throughout a lot of this interview was that improving rural health will take everyone remembering to not let perfect be the enemy of the good. If I live in rural America, there’s no subspecialists. Forget about even seeing a garden-variety kind of specialist. I might have to drive hours to even get to a PCP. There are NPs (nurse practitioners) in a lot of these remote communities, but everybody’s fighting over whether to let them practice independently, even in places ...
EP337: A Patient-First Specialty Pharmacy, Not a Money-First Specialty Pharmacy, With Olivia Webb
September 16, 2021 11:30 - 32 minutes - 44.8 MBHere’s the cold hard truth: The whole specialty pharmacy operational model is not built to serve patients, a fact that becomes crystal clear when you’re a patient. Instead, the specialty pharmacy model is, rather, pretty blatantly dedicated to the power struggle for revenue and captive patient populations. It’s war between providers and the whole PBM/insurer/specialty pharmacy vertical consolidations. Employers and pharma manufacturers are, of course, on the battlefield as well. The pati...
EP336: The Barbarians at the Gate—Who Are They and How Do They Cause Trouble for the Healthcare Industry Status Quo? With Brandon Weber
September 09, 2021 11:30 - 32 minutes - 44.8 MBI was listening to a panel discussion and heard Brandon Weber use the phrase the “barbarians at the gate” of the healthcare industry. I think I reached out to invite him to come on the podcast before the end of the segment. But at risk of spoiler alerts, let me sum up what I think is so interesting about Brandon’s insights, which he talks about on the show. First of all, it isn’t an “oh, heavens, some companies out there are trying to disrupt the status quo,” like this is some sort of news...
INBW30: A Hot Take on Healthcare Stakeholders Not Collaborating
September 02, 2021 11:30 - 7 minutes - 10.4 MBHere’s a hot take for you. I just learned what a hot take was last week, so, of course, I needed to get me one on the quick. The thing with hot takes, from what I understand, is that they are open for discussion. What I’m talking about today is something I’ve been thinking about for a while, and I would be interested in your thoughts, since probably some finesse is needed here. I want to talk about the imperative of collaborating with organizations across the care continuum, even the ones ...
AEE16: The Destruction of Primary Care—A Short History, With Brian Klepper, PhD
August 31, 2021 11:30 - 9 minutes - 13.6 MBThis conversation starts out talking about the RUC, which is a committee run by the AMA, who has the sole source contract with CMS to figure out how many RVUs any given procedure or service is worth. There are roughly four times as many specialists on this RUC committee as PCPs. You might be able to see where this is going, but let me let our guest in this healthcare podcast, Brian Klepper, explain how primary care got trampled by the goings-on. Brian Klepper is a longtime healthcare analy...
EP335: Why Is Private Equity Willing to Pay $55,000 per Patient to Primary Care Start-ups? With Brian Klepper, PhD
August 26, 2021 11:30 - 33 minutes - 45.3 MBIn this healthcare podcast, I’m talking with Brian Klepper. If you haven’t heard of him, Brian’s a longtime healthcare analyst and former CEO of the National Business Coalition on Health. This interview takes off like a shot, as most of my conversations with Brian Klepper do. We’re talking about primary care and its various iterations. We start out with Exhibit A—the HMO version of primary care from the ’90s. This is a great comparator to really get a handle on what’s going on today. Durin...