Podcast
Relentless Health Value
Hosted by Stacey Richter · EN
Welcome to Relentless Health Value, the podcast for those working in the belly of the beast to fix our fundamentally broken healthcare system. If you are a self-insured employer, plan sponsor, benefits consultant, clinician, a C-suite executive or anyone in the business of healthcare tired of the "transformational theater" and marketing fluff, you have found your tribe.
The U.S. healthcare system isn't a rational market; it's a game of Pachinko where perverse incentives reign, and as we always say, where there's mystery, there's margin.
Hosted by Stacey Richter, we relentlessly hunt down the administrative "inches" of waste and expose the hidden fees draining the $5.6 trillion healthcare sector. We transform wonky healthcare theory into ruthlessly practical, actionable insights.
Whether it's demanding radical transparency, navigating complex PBM contracts, or buying actual healthcare instead of illusory discounts, our mandate is simple: If it results in a net positive for patients, we do it. Join the Relentless Health Value Tribe to equip yourself with the fiduciary armor needed to outwit the status quo, demand accountability, and drive real change.
42episodes
Episodes
Newest firstAll episodes
Revisiting Cunning Anticompetitive Hospital Contracts, With Brennan Bilberry - EP513
May 2700:36:22Tap to summarizeThe Hospital Contract Playbook: Four Clauses That Turn Market Power Into Higher Prices This is Episode 513 (EP513) of Relentless Health Value. Across the country, hospital systems have used their growing market power to write four specific contract terms into their deals with insurers — terms that all but guarantee higher prices for employers, unions, and patients, regardless of quality or competition nearby. In this episode, Stacey Richter speaks with Brennan Bilberry, founding partner of Fairmark Partners, an antitrust law firm that has sued multiple dominant hospital systems, about exactly how those four contract terms work, clause by clause, and why they set the stage for the litigation explored in next week's episode with Matt Cantor. WHAT YOU'LL LEARN ✅ How all-or-nothing contracting forces insurers and employers to accept every facility in a hospital system's network — including overpriced urban hospitals — just to get access to a single must-have rural facility, a tactic central to Sutter Health's $575 million antitrust settlement in one of two cases brought against it ✅ How anti-steering and anti-tiering clauses block health plans from directing members to lower-cost, equal-quality care — illustrated by a market where a C-section costs $44,000 at one hospital and $21,000 two miles away, and by the government's case against Atrium Health in North Carolina ✅ How price gag clauses prevent insurers and TPAs from telling self-funded employers what they're actually paying for care, even after recent transparency rules — including a case where North Carolina's state treasurer received hundreds of redacted pages when he requested UNC Healthcare's prices ✅ How dominant hospital systems squeeze nominally independent physician practices into charging hospital-level prices without ever buying them outright — in one North Texas market, this drove prices up $100 million in a single year ✅ Why these four contract terms reinforce each other — block steering and a plan can't build narrow networks; restrict independent providers and there's nowhere cheaper left to steer to — making each successive workaround harder for plan sponsors to use WHY THIS MATTERS From 1998 to 2015 there were 1,500 hospital mergers, and the pace has only accelerated since — today, most physicians no longer own the practices where they work. Anticompetitive contract terms are what let that consolidation translate directly into higher prices for employers and patients. Understanding the playbook clause by clause, as laid out here, is the first step toward fighting it. MENTIONED IN THIS EPISODE EP373 with Cora Opsahl: Apple Podcasts | Spotify | Other Apps EP452 with Cora Opsahl: Apple Podcasts | Spotify | Other Apps Post by Tricia Schildhouse EP249 with Dale Folwell: Apple Podcasts | Spotify | Other Apps EP391 with Scott Conard, MD: Apple Podcasts | Spotify | Other Apps EP389 with Mike Thompson: Apple Podcasts | Spotify | Other Apps EP390 with Gloria Sachdev, PharmD, and Chris Skisak, PhD: Apple Podcasts | Spotify | Other Apps === LINKS === 🔗 Show Notes with all mentioned links: Show Notes ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter 🫙 Support the podcast with a small donation to the Tip Jar 🎤 Follow us on Apple Podcasts 🎤 Follow us on Spotify 📺 Subscribe to our YouTube channel === CONNECT WITH THE RHV TEAM === ✭ LinkedIn ✭ Threads ✭ Bluesky ✭ X TIMESTAMPS 00:00 Introduction to this episode. 06:55 The conversation with Brennan Bilberry. 06:59 What happens after a hospital consolidates? 08:05 What an anticompetitive system looks like when a hospital consolidates. 11:12 Some anticompetitive "tricks" that hospitals employ. 13:13 Example: the Sutter case in northern California. 15:36 What to do if you're forced to engage in an all-or-nothing contract with a hospital system. 19:17 Example: the Atrium case in North Carolina. 22:12 Explaining price gag clauses. 23:48 How legacy gag clauses are designed to prevent scrutiny in litigation. 26:21 How hospital restrictions on other providers create an anticompetitive environment.
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3 Kinds of Broker/EBC Rent-Seeking Payment Models—A Lawyer's Perspective, With Doug Aldeen. EP512
May 2700:36:56Tap to summarizeA Lawyer's Field Guide to Rent-Seeking Broker and EBC Payment Models. Epsiode 512. Brokers and employee benefit consultants often get compensated in ways health plans never fully see — and even when the dollars are technically disclosed, the math can hide an enormous overcharge. In this episode, Stacey Richter speaks with Doug Aldeen, JD, an ERISA healthcare attorney who has spent decades in the self-funded space, about the legal danger zones where broker and EBC payment models go wrong: rent-seeking solution recommendations, undisclosed vendor payments, and front-loaded voluntary-benefits commissions — and the practical roadmap any plan sponsor can use to catch them before they cost millions. WHAT YOU'LL LEARN ✅ How a level-funded plan's broker was paid more than $2 million in fees while the plan itself ended up roughly $600,000 in deficit — a cautionary tale Stacey and Doug call the Ohio Potato Company story ✅ How reference-based pricing vendors using a "cost of savings" fee model can be incentivized by rising hospital prices — illustrated by a $10,000 CT scan repriced to $1,000, netting the vendor $1,800 on a $9,000 "savings," on top of underlying facility markups that can run as high as 17,000% ✅ How a balance-billing vendor collected $2.2 million in fees over three plan years to protect against just $94,320 in disputed claims — even in a state where the hospital had no legal authority to balance bill in the first place ✅ Why voluntary benefits commissions, often front-loaded at 70% to 90% in the first year, can make a product more profitable for the broker than useful for members ✅ A practical roadmap for plan sponsors to catch rent-seeking arrangements before they cost millions: ask why repeatedly, demystify the commission structure, run an independent broker RFP, audit plan and stop-loss documents for gaps, and build a real contract "out" WHY THIS MATTERS Self-funded employers often assume their broker or EBC's incentives are aligned with the plan's. But when compensation is tied to cost-of-savings formulas, undisclosed vendor relationships, or front-loaded commissions, the incentive can quietly flip — rewarding higher healthcare prices and unnecessary point solutions instead of genuine savings. Knowing where to look, and which questions to ask, is what separates a fiduciary from a rent-seeking target. MENTIONED IN THIS EPISODE EP457 with Cynthia Fisher: Apple Podcasts | Spotify | Other Apps EP508 with Lee Lewis: Apple Podcasts | Spotify | Other Apps EP379 with AJ Loiacono: Apple Podcasts | Spotify | Other Apps EP484 with Dave Chase: Apple Podcasts | Spotify | Other Apps EP478 with Andreas Mang and Jon Camire (Part 1): Apple Podcasts | Spotify | Other Apps EP479 with Andreas Mang and Jon Camire (Part 2): Apple Podcasts | Spotify | Other Apps EP419 with Andreas Mang: Apple Podcasts | Spotify | Other Apps === LINKS === 🔗 Show Notes with all mentioned links: Show Notes ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter 🫙 Support the podcast with a small donation to the Tip Jar 🎤 Follow us on Apple Podcasts 🎤 Follow us on Spotify 📺 Subscribe to our YouTube channel === CONNECT WITH THE RHV TEAM === ✭ LinkedIn ✭ Threads ✭ Bluesky ✭ X TIMESTAMPS 00:00 Introduction to this episode. 00:59 A caveat for the record on this episode. 02:11 The first problematic payment model discussed in this week's episode. 03:27 The second problematic payment model discussed in this week's episode. 06:16 The conversation with Doug Aldeen. 06:27 Why is reviewing broker/EBC compensation so important? 08:05 The Ohio Potato Company anecdote. 10:28 The first way brokers/EBCs might get paid. 11:45 What "cost of savings" means. 14:07 A rent-seeking solution that requires a cost-benefit analysis. 19:16 Why the broker/EBC is sometimes in the dark about vendor kickbacks. 21:46 Where the CAA is unclear. 24:04 Actionable advice for plan sponsors. 24:57 The second piece of actionable advice for plan sponsors. 25:22 The third piece of actionable advice for plan sponsors. 26:08 Demystifying the commission structure. 27:35 Using a broker RFP from an open source. 28:31 Why you should be auditing data and claims. 31:29 The importance of having an "out." 33:11 Why the broker community may be at substantial risk.
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The Perverse Incentive Trap Hidden Inside Value-Based Care — and What to Do About It. EP512
May 1400:29:37Tap to summarizeWhen Risk-Based Payment Becomes Its Own Upcoding Arms Race. Episode 511 Medicare Advantage plans get paid more for sicker patients, which is why upcoding became a problem — and now health systems are upcoding visit complexity right back, with MA plans automatically downcoding in response. In this episode, Stacey Richter plays an unpublished clip from her conversation with Ahilan Sivaganesan, MD (Dr. Siva), a neurosurgeon and head of quality and value at Mishe Health, on why physicians must understand their own costs before taking on financial risk, then revisits an earlier conversation with Monica Lypson, MD, MHPE, vice dean for medical education at Columbia University Irving Medical Center, on whether handing health systems that same risk-based incentive could end up worsening the very disparities value-based care is meant to fix. WHAT YOU'LL LEARN ✅ Why Medicare Advantage plans' incentive to upcode patient complexity is now mirrored by health systems upcoding visit complexity — triggering automatic downcoding wars between MA plans and providers ✅ Why physicians can't responsibly go at risk for outcomes and costs without first understanding their own costs through time-driven activity-based costing — without it, Dr. Siva says, you're "jumping blind into an abyss," straight toward cherry-picking and lemon-dropping patients ✅ How sliding-scale bundled payments, calibrated to patient and procedure complexity rather than a flat lump sum, could let practices take on bundled risk without being punished for treating sicker patients ✅ Why handing health systems a sliding-scale risk adjustment framework risks recreating the same upcoding incentives that plagued Medicare Advantage, just one level up the chain ✅ How perverse incentives baked into value-based and risk-based contracting can worsen existing healthcare disparities when systems are structurally rewarded for avoiding complex or costly patients WHY THIS MATTERS Risk-based and value-based payment models are often framed as the fix for fee-for-service's worst incentives. But if the underlying cost data and risk-adjustment frameworks aren't built carefully, the same gaming that plagued Medicare Advantage — and fee-for-service before it — can simply move up the chain to health systems and physician practices, with disparities in care quietly bearing the cost. MENTIONED IN THIS EPISODE EP505 with Ahilan Sivaganesan, MD: Apple Podcasts | Spotify | Other Apps EP485 with Cristin Dickerson, MD: Apple Podcasts | Spotify | Other Apps EP436 with Elizabeth Mitchell: Apple Podcasts | Spotify | Other Apps EP491 with Elizabeth Mitchell: Apple Podcasts | Spotify | Other Apps SUMS9 with Elizabeth Mitchell: Apple Podcasts | Spotify | Other Apps EP462 with Scott Conard, MD: Apple Podcasts | Spotify | Other Apps EP319 with Grace Terrell, MD: Apple Podcasts | Spotify | Other Apps EP431 with Kenny Cole, MD: Apple Podcasts | Spotify | Other Apps EP409 with Larry Bauer, MSW, MEd: Apple Podcasts | Spotify | Other Apps EP495 with Mick Connors, MD: Apple Podcasts | Spotify | Other Apps LinkedIn Post by Mark Weber EP484 with Dave Chase: Apple Podcasts | Spotify | Other Apps === LINKS === 🔗 Show Notes with all mentioned links: Show Notes ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter 🫙 Support the podcast with a small donation to the Tip Jar 🎤 Follow us on Apple Podcasts 🎤 Follow us on Spotify 📺 Subscribe to our YouTube channel === CONNECT WITH THE RHV TEAM === ✭ LinkedIn ✭ Threads ✭ Bluesky ✭ X TIMESTAMPS 00:00 Introduction to this episode. 05:22 What is the minimum requirement for physicians to go at risk? 07:22 How sliding scale bundle payments can reduce risk for physicians. 10:43 The question covered in the upcoming episode. 13:19 Is value-based care good for underserved communities? 15:01 "If you create perverse incentives, you actually might make known healthcare disparities worse … to meet the demand's value." —Dr. Lypson 16:18 "There actually might be systematic and structural ways that the healthcare system might say … we're not interested in taking care of you." —Dr. Lypson 16:51 "The incentive to have a good outcome is not there; the incentive to have another visit is there." —Dr. Lypson 17:49 "The only indictment I have on the fee-for-service system is that it's gotten us to where we are right now." —Dr. Lypson 18:41 "If you don't have any connection in that system, even the provider trying to … provide a good outcome might be disconnected because the system is not in place to … connect the dots." —Dr. Lypson 19:28 What are the must-haves for a value-based system that create the patient outcomes we need? 19:51 What is a whole health model? 25:31 Why we need to fix the structural issues if we want to fix health. 26:00 Why a patient's bias is the one we want in the room. 27:36 Stacey's conclusion on this week's episode.
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Why Employers Pay More Because of Vertically Integrated Medicare Advantage Carriers with Betsy Seals. EP510
May 700:35:30Tap to summarizeThe Line Between Fair Profit and Profiteering in Medicare Advantage. Episode 510 There's a simple test for telling a fair profit from profiteering in Medicare Advantage: does the carrier make more money when the patients it serves are worse off? In this episode, Stacey Richter talks with Betsy Seals, co-founder of Rebellis Group and a Medicare Advantage consultant making her third appearance on the show, about how vertically integrated carriers shift costs onto self-insured employers' commercial rates, why MA plans can end up paying providers they own more than independent practices, and the back-to-basics strategy Seals recommends for any MA plan that wants to make money the right way. WHAT YOU'LL LEARN ✅ How vertically integrated carriers negotiate the lowest possible Medicare Advantage rates with consolidated health systems, then let those systems make up the difference by raising commercial ASO rates — a cost-shifting pattern research puts at 4.7% above what employers would otherwise pay ✅ Why Medicare Advantage carriers that own provider organizations have a financial incentive to pay those owned providers more than independent practices, since MA rate increases are pegged to fee-for-service benchmarks ✅ How Goodhart's Law shows up in STARS and other quality measures — once a measure becomes the target, it stops reliably reflecting genuine member health improvement ✅ The back-to-basics strategy Betsy Seals recommends for Medicare Advantage plans: don't get caught with your hand in the cookie jar, focus on the beneficiaries you actually serve well, and use STARS and clinical programs to genuinely improve health rather than to check boxes ✅ Why squeezing independent primary care practices on reimbursement can ultimately raise the total cost of care for everyone, even though it looks like savings in the short term WHY THIS MATTERS Medicare Advantage runs on taxpayer dollars, and it's the care seniors, family members, and friends depend on. When the financial incentive flips — when a plan makes more money the worse its members do — that's profiteering, not business. Seals's back-to-basics framework offers a way to tell the difference, and a roadmap for plans willing to make a fair profit instead. MENTIONED IN THIS EPISODE EP481 with Benjamin Schwartz, MD, MBA: Apple Podcasts | Spotify | Other Apps EP495 with Mick Connors, MD: Apple Podcasts | Spotify | Other Apps YouTube Video: Eric Bricker, MD, on the financial performance of the U.S. healthcare system EP463 with Betsy Seals: Apple Podcasts | Spotify | Other Apps EP482 with Preston Alexander: Apple Podcasts | Spotify | Other Apps EP462 with Scott Conard, MD: Apple Podcasts | Spotify | Other Apps Article: STAT, "Trump Goes Soft on Medicare Advantage Medical Underwriting," by Bob Herman === LINKS === 🔗 Show Notes with all mentioned links: Show Notes ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter 🫙 Support the podcast with a small donation to the Tip Jar 🎤 Follow us on Apple Podcasts 🎤 Follow us on Spotify 📺 Subscribe to our YouTube channel === CONNECT WITH THE RHV TEAM === ✭ LinkedIn ✭ Threads ✭ Bluesky ✭ X TIMESTAMPS 00:00 Introduction to this episode. 01:25 How Medicare Advantage is relevant to everyone. 06:15 A preview of today's conversation. 07:49 The "state of the state" of Medicare Advantage plans. 09:32 Does Medicare Advantage's losses matter to the patients? 10:29 A recap of Betsy's insights so far. 11:19 The underlying strategic through line that needs to be considered. 13:04 The impact of Goodhart's Law. 14:12 What the players that are succeeding right now are doing. 14:22 The first pillar of a back-to-basics strategy: Don't get caught with your hand in the cookie jar. 16:50 Why short-term strategies don't work. 18:26 Stats report on prior authorizations serving the beneficiary. 19:38 Why prior authorization needs change. 21:28 The better strategy to use. 23:17 The second pillar of a back-to-basics strategy: Focus on the beneficiaries you actually serve well. 24:37 What it looks like to implement this focus on the beneficiaries you serve well. 25:29 How special needs plans play into this. 27:43 The third pillar of a back-to-basics strategy: Think about how STARS in clinical programs improve health. 30:04 The ethical component to implementing a Medicare Advantage program. 31:04 Betsy's advice for independent practices dealing with prior authorizations. 34:08 Betsy's final notes for all players impacted by what's currently happening.
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The 7.7% Wake-Up Call: A Roadmap to Align Finance Teams With Non-complacent Benefit Design, With Patrick Nelli. EP509
Apr 3000:37:48Tap to summarizeThe Seven-Step Roadmap That Gets CFOs to Stop Being Passive Price Takers on Health Benefits. Episode 509. As a companion to last week's CEO-focused episode, Stacey Richter talks with Patrick Nelli — CEO of Aligned Marketplace and a former CFO himself — about how to bring finance teams into health benefits strategy using their own language. Patrick lays out a seven-step roadmap, starting with forecasting healthcare trend at an accurate 7.7%-or-higher rate rather than the CPI, to show finance teams exactly why the status quo is financially untenable. WHAT YOU'LL LEARN ✅ Why healthcare inflation structurally outpaces the Consumer Price Index, driven partly by Baumol's cost disease — healthcare's low productivity gains force price increases just to keep pace with salaries in higher-productivity sectors ✅ Patrick Nelli's seven-step roadmap: stop the renewal surprise, confront an accurate trend, offer a win-win alternative to the status quo, lean into proven strategies like advanced primary care, align incentives and safeguards, optimize contracting, and steer and tier ✅ Why setting next-year forecasts at a real 7.7%-or-higher trend (two to three points above CPI) is the fastest way to get a finance team to find its own "why" for changing the health plan ✅ How direct contracting with independent practices fits into a finance-team-aligned contracting strategy, and why risk-stratifying and steering members to high-value organizations matters most for rising-risk populations ✅ Why advanced primary care keeps surfacing as the proven strategy to bend the cost curve, and what a plan sponsor's next step looks like once it commits to that model WHY THIS MATTERS Finance teams often forecast health benefits using the Consumer Price Index, but healthcare costs have been running two to three points above CPI for years — meaning the status quo is already financially untenable even before considering the human cost. Speaking to CFOs in their own language, with real numbers and a concrete roadmap, is what turns finance from a passive price taker into an active partner in fixing the health plan. MENTIONED IN THIS EPISODE EP504 with Ryan Jacobs: Apple Podcasts | Spotify | Other Apps Take Two: EP341 with Gary Campbell: Apple Podcasts | Spotify | Other Apps EP492 with Sam Flanders, MD, and Shane Cerone: Apple Podcasts | Spotify | Other Apps INBW46 with Stacey: Apple Podcasts | Spotify | Other Apps EP391 with Scott Conard, MD: Apple Podcasts | Spotify | Other Apps Sumemr Short with Stan Schwartz, MD: Apple Podcasts | Spotify | Other Apps Study: Milbank Memorial Fund on the role of primary care EP466 with Vivian Ho, PhD: Apple Podcasts | Spotify | Other Apps EP464 with Al Lewis: Apple Podcasts | Spotify | Other Apps EP503 with Ryan Wells; Leo Spector, MD, MBA; and Adam Stavisky: Apple Podcasts | Spotify | Other Apps EP430 with Barbara Wachsman: Apple Podcasts | Spotify | Other Apps === LINKS === 🔗 Show Notes with all mentioned links: Episode Page ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter 🫙 Support the podcast with a small donation to the Tip Jar 🎤 Listen on Apple Podcasts 🎤 Listen on Spotify 📺 Subscribe to our YouTube channel === CONNECT WITH THE RHV TEAM === ✭ LinkedIn ✭ Threads ✭ Bluesky ✭ X 00:00 Introduction to this episode. 02:48 Roadmap Step 1-7 highlights. 06:28 Introduction to the conversation with Patrick Nelli. 06:36 Step 1 to Patrick's roadmap: Open the conversation. 07:57 What Patrick thinks is sometimes missing in health benefits. 09:07 What finance teams need in order to change their behaviors. 09:53 What Baumol's cost disease is. 12:18 The second item stacked against employers: Being price "takers." 13:49 The percent inflation employers should expect if they follow the status quo. 16:54 Proven strategies to bend the health benefits finance curve. 20:18 How employers and plan sponsors can bend the cost curve. 21:47 The two distinct business models that finance teams need to consider when setting up their health benefits model. 24:53 A quick reminder of high-cost spending within health plans. 25:59 What finance teams need to hear right now to understand why disrupting their health benefits plan is worth it. 27:45 The next step when an employer recognizes that they should seek out an advanced primary care option for their members. 30:27 Next steps after an employer enlists an advanced primary care system and aligns values and incentives in their benefits plan. 34:26 A last word to benefit teams working with finance teams. 35:08 How Aligned Marketplace fits into this entire conversation.
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Why Don't More Self-insured CEOs Take Bold Action in Health Benefits Strategy? With Lee Lewis
Apr 2300:44:02Tap to summarizeOne company at the Health Transformation Alliance managed their health benefits well enough that when they were acquired, the acquiring company looked at the plans and found $2,300 less expense per employee — with better benefits. Moving 2,500 employees onto that plan, at a PE ratio north of 40, created over a quarter billion dollars of instant equity value that nobody had priced into the deal. Nobody had even thought to look. That story is where this conversation starts. In this episode — the first-ever Ask Me Anything installment of Relentless Health Value — Stacey Richter takes a question from benefits procurement leader Sarah Monroe about why executives rarely take bold action on health benefits, and answers it with Lee Lewis, Chief Strategy Officer and GM Medical Solutions at the Health Transformation Alliance (HTA) and host of the Broken Benefits podcast. WHAT YOU'LL LEARN ✅ The three false C-suite dogmas that Lee Lewis says lead to a "stay in the herd and keep it quiet" approach to benefits: that healthcare costs are a fixed expense you can't manage, that saving money necessarily hurts people through cost shifting, low quality, or narrow networks, and that fixing healthcare is never worth the effort or the disruption ✅ How those dogmas manifest in practice — including a company spending $700 million annually on benefits that turned down a roadmap to save $50 million because no one's bonus was tied to plan performance, and a culture that self-selects for complacent HR teams over mission-driven ones ✅ Four external forces that may keep C-suites locked in place: the social circles CEOs travel in that include health system leaders, balance-of-trade threats from large carriers and vendors who hold commercial business as leverage, personal incentives offered to key decision-makers by status quo vendors, and executives who don't feel the weight of a $5,000 deductible the way a $25-an-hour employee does ✅ Why the competitive stakes are rising — because healthcare is now nine to 14% of total employee compensation, transparency data lets anyone look up what rival employers are paying, and companies that mismanage this expense face both shareholder and fiduciary risk while falling behind competitors who don't ✅ De-risking tactics for benefits teams operating inside conservative cultures, including same-network TPA changes, carrier-enabled vendor additions, narrow pilots, and mid-year tests that move the plan forward without requiring C-suite sign-off on a full transformation ✅ Direct advice for any CEOs in the building: encourage bold action explicitly, tie bonuses to health plan performance, and staff benefits teams with the diverse financial and clinical skills the role actually requires WHY THIS MATTERS Health benefits are the second largest line item after payroll in most industries, and the companies that are minding this business carefully are accumulating real competitive advantage over those that aren't — quarter billion dollar M&A surprises notwithstanding. The three dogmas Lee describes are false, but they are sincerely held, and that makes them stubborn. As Stacey frames it, financial toxicity is clinical toxicity: when employees are functionally uninsured because their deductible exceeds what they can afford, the ER becomes the only option. That is disruption too — it just shows up on the back end. The question isn't whether to accept disruption. It's which kind you're choosing. === LINKS === 🔗 Show Notes with all mentioned links: https://cc-lnk.com/EP508 📺 Visit Lee's YouTube Channel https://www.youtube.com/@brokenbenefits ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter: https://relentlesshealthvalue.com/join-the-relentless-tribe 🫙 Support the podcast with a small donation to the Tip Jar: https://relentlesshealthvalue.com/join-the-relentless-tribe 🎤 Listen on Apple Podcasts https://podcasts.apple.com/us/podcast/feed/id892082003?ls= 🎤 Listen on Spotify https://open.spotify.com/show/6UjgzI7bScDrWvZEk2f46b 📺 Subscribe to our YouTube channel https://www.youtube.com/@RelentlessHealthValue === CONNECT WITH THE RHV TEAM === ✭ LinkedIn https://www.linkedin.com/company/relentless-health-value/ ✭ Threads https://www.threads.net/@relentlesshealthvalue/ ✭ Bluesky https://bsky.app/profile/relentleshealth.bsky.social ✭ X https://twitter.com/relentleshealth/ 00:00 Introduction to this episode. 00:43 Ask Me Anything Question 1: Why don't more self-insured executives take bold action toward their benefits strategy? 03:09 A summary of the three dogmas covered in the following conversation. 05:53 A look ahead at next week's episode. 06:36 An introduction to today's guest, Lee Lewis. 08:23 Why there is an aversion to digging into health benefits for some executives. 09:43 The first dogma: Healthcare costs are fixed expenses. 09:56 The second dogma: Saving money in healthcare hurts people. 12:01 The third dogma: Fixing healthcare is never worth the effort. 12:26 How these dogmas trickle down to HR teams. 13:47 Anecdote: One company that turned down saving $50 million and why. 16:28 A quick reminder about the context behind where CEOs' mindsets are. 17:10 The kinds of employers HTA seeks out. 19:20 EP500 with Stacey. 20:03 The power of C-suites in health systems. 21:33 EP466 with Vivian Ho, PhD. 21:36 EP404 with Suhas Gondi, MD, MBA. 21:42 Why a CEO may pull the plug on health plan/health benefit improvements. 22:37 An anecdote about Lilly cancelling their health plan. 23:21 Items that CEOs need to be thinking about. 24:33 EP506 with Jerry DiMaso. 26:07 EP501 with Ivana Krajcinovic, PhD. 26:32 A summary of why CEOs should care about their health benefits costs now. 29:02 How do personal incentives play into CEOs' decisions about health benefits? 30:44 Another quick reminder about C-suites. 31:53 Why perverse incentives make it difficult for C-suites to accept change. 33:11 LinkedIn post by Patrick Moore. 33:28 Why the salary gap plays into health benefit decisions in a perverse way. 34:58 EP488 with Mark Cuban and Cora Opsahl. 36:13 Lee Lewis's advice to people in benefits who are aligned to the mission. 40:06 Lee Lewis's advice for CEOs. Lee Lewis of @HTACOOP discusses #benefitsstrategy for #selfinsuredemployers on our #healthcarepodcast. #healthcare #podcast #financialhealth #commercialpayermarketplace #digitalhealth #healthcareleadership #healthcaretransformation #healthcareinnovation Recent past interviews: Click a guest's name for their latest RHV episode! Stacey Richter with 15 experts (EP507); Jerry DiMaso; Dr Ahilan Sivaganesan; Ryan Jacobs; Stacey Richter (INBW46); <a href="https://relentlesshealthvalue.com/...
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4 Core Concepts to Buy or Deliver the Highest Value Healthcare — A Review With 14 Expert Voices
Apr 1600:33:58Tap to summarizeEmployers pay roughly $1.20 to $1.30 for every dollar of actual healthcare their members receive. In one documented California lawsuit, a carrier charged a plan $4 million for a single inpatient stay and paid the hospital $877,000 — pocketing over $2.5 million, with MultiPlan collecting another $677,000. Knowing that, what should plan sponsors actually be trying to buy? Stacey Richter distills four core concepts for buying or delivering the highest value healthcare, illustrated with direct clips from 14 prior guests — Jonathan Baran, Cynthia Fisher, Mark Newman, Justin Leader, Elizabeth Mitchell, Dr. Sam Flanders, Shane Cerone, Jerry DiMaso, Ivana Krajcinovic, Ryan Jacobs, Adam Stavisky, Ryan Wells, Dr. Mick Connors, Dr. Ahilan Sivaganesan (Dr. Siva), and Dr. Kenny Cole. WHAT YOU'LL LEARN ✅ Core Concept 1 — Buy healthcare, not insurance: the difference is not semantic — it is the gap between what a plan pays and what a provider receives, illustrated by spread pricing, weekly claims wire mysteries, and administrative extraction that consumes 20 to 30 cents of every healthcare dollar before any care is delivered ✅ Core Concept 2 — Avoid the myth of less expensive care: price and quality are largely uncorrelated in healthcare, and the highest-quality, safest care often costs the least — as Dr. Sam Flanders puts it, doing things well eliminates the waste and errors that drive up costs ✅ How price transparency data now shows rate disparities from one employer to another for the exact same service codes — including one plan paying $38,000 for four infusions that cost $5,000 at an independent practice, and two members whose infusion site choice cost their plan $1 million more for the exact same drug ✅ Core Concept 3 — Consider direct contracting: connecting plan sponsors directly with independent clinicians and pharmacies eliminates administrative extraction and creates real incentives — provider organizations that can actually lose business have reason to compete on quality and price ✅ How Centers of Excellence networks represent direct contracting at scale — and why a physician-by-physician analysis showed bottom-15% physicians practicing medicine standard deviations differently from the median in their own market ✅ Core Concept 4 — Buy true value, outcomes over cost, measured across the entire care journey: not readmission rates in isolation but patient-reported outcomes anchored to what actually matters to the patient — including whether they ever should have had the procedure in the first place WHY THIS MATTERS Most big corporatized health systems are optimized for revenue growth, not outcomes. When a plan sponsor buys coverage instead of care, those incentives go unchallenged. Direct contracting creates a functioning demand curve where provider organizations compete on quality and price. As Dr. Kenny Cole shows, buying value ultimately means anchoring care to the patient: not an A1C below seven as an abstract target, but controlling diabetes so a fisherman can still feel the line when the fish bites. === LINKS === 🔗 Show Notes with all mentioned links: https://cc-lnk.com/EP507 ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter: https://relentlesshealthvalue.com/join-the-relentless-tribe 🫙 Support the podcast with a small donation to the Tip Jar: https://relentlesshealthvalue.com/join-the-relentless-tribe 🎤 Listen on Apple Podcasts https://podcasts.apple.com/us/podcast/feed/id892082003?ls=1 🎤 Listen on Spotify https://open.spotify.com/show/6UjgzI7bScDrWvZEk2f46b 📺 Subscribe to our YouTube channel https://www.youtube.com/@RelentlessHealthValue === CONNECT WITH THE RHV TEAM === ✭ LinkedIn https://www.linkedin.com/company/relentless-health-value/ ✭ Threads https://www.threads.net/@relentlesshealthvalue/ ✭ Bluesky https://bsky.app/profile/relentleshealth.bsky.social ✭ X https://twitter.com/relentleshealth/ Featured Experts by Core Concept Concept 1: Buy Healthcare, Not Insurance Jonathan Baran, CEO, Self Fund Health (EP483) Cynthia Fisher, founder and chairman, PatientRightsAdvocate.org; co-founder and chairman of Power to the Patients (EP457) Mark Newman, co-founder and CEO, Nomi Health (EP496) Justin Leader, founder and CEO, BenefitsDNA (EP433) Concept 2: Avoid the Myth of Less Expensive Healthcare Elizabeth Mitchell, president and CEO, Purchaser Business Group on Health (EP436) Sam Flanders, MD, senior advisor, Kada Health (EP490) Shane Cerone, CEO, Kada Health (EP492) Jerry DiMaso, co-founder and CEO, Payerset (EP506) Ivana Krajcinovic, PhD, former vice president for healthcare delivery (retired), UNITE HERE HEALTH (EP501) Concept 3: Consider Direct Contracting Ivana Krajcinovic, PhD, former vice president for healthcare delivery (retired), UNITE HERE HEALTH (EP501) Suhas Gondi, MD, MBA, chief medical officer, HealthStrategy (EP404) Ryan Jacobs, senior vice president of health plan strategy and partnerships, Marathon Health (EP504) Komal Bajaj, MD, professor of obstetrics and gynecology, Albert Einstein College of Medicine (EP458) Ad...
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How Other Employers, Shareholders, and Clinics Are Using Price Transparency Data—And It's an Arms Race, With Jerry DiMaso
Apr 900:35:51Tap to summarizeHospital price transparency mandates took effect in 2019. Carrier transparency mandates followed in 2022. That means plan sponsors have had access to negotiated rate data for every billing code, every provider, and every carrier in the country for years — and most still aren't using it. The rate disparities from one employer to another for the exact same service codes are, in Jerry DiMaso's words, huge. In this episode, Stacey Richter speaks with Jerry DiMaso, CEO of Payerset, a healthcare pricing intelligence and price transparency data company, about what self-insured employers, unions, and independent clinical organizations can actually do with this data — and why the carriers and consolidated health systems are already using it against them. WHAT YOU'LL LEARN ✅ How self-insured employers can search transparency files by EIN to benchmark their own negotiated rates against competitors in the same industry — and why, given that health benefits are often the second largest corporate line item, activist shareholders may not be far behind ✅ How to use billing code-level data to identify high-cost outliers, expose "discount shell games" — validating whether a TPA's claimed 90% discount reflects real savings or just a gross aggregated discount on codes nobody actually uses — and calculate objective savings without relying on vendors to grade their own homework ✅ How plan sponsors can use this data to direct TPA negotiations, implement service carve-outs and direct contracts for high-volume codes like musculoskeletal procedures, and model whether an HMO plan would save money while keeping access to the providers employees already use ✅ Why independent clinical organizations are using transparency data to discover carriers active in their geography they didn't know existed, justify rate increases by pairing price benchmarks with quality and outcomes data, and avoid being forced to sell their practice — because when an independent practice gets acquired, prices go up ✅ How carriers are already running the transparency arms race in the other direction — sending letters to providers saying they spotted lower rates accepted from a competitor and will now renegotiate accordingly — and why having the data at your fingertips is the only defense ✅ Why price transparency is shifting fiduciary responsibility for plan sponsors: since hospital data has been available since 2019 and carrier data since 2022, "I didn't know" is no longer a viable explanation for a plan that spent a million dollars more than necessary on the same drug at a provider down the street WHY THIS MATTERS A dysfunctional market is defined by wildly divergent prices for the exact same service in the exact same geography. That is precisely what price transparency is exposing — and it is making steering and tiering not just a strategy but a fiduciary obligation. The goal, as Jerry DiMaso frames it, is a regression to the mean: a fair price for a given procedure in a given market, after which competition shifts to quality. We are not there yet, but the data to get there now exists. === LINKS === 🔗 Show Notes with all mentioned links: https://cc-lnk.com/EP506 ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter: https://relentlesshealthvalue.com/join-the-relentless-tribe 🫙 Support the podcast with a small donation to the Tip Jar: https://relentlesshealthvalue.com/join-the-relentless-tribe 🎤 Listen on Apple Podcasts https://podcasts.apple.com/us/podcast/feed/id892082003?ls=1 🎤 Listen on Spotify https://open.spotify.com/show/6UjgzI7bScDrWvZEk2f46b 📺 Subscribe to our YouTube channel https://www.youtube.com/@RelentlessHealthValue === CONNECT WITH THE RHV TEAM === ✭ LinkedIn https://www.linkedin.com/company/relentless-health-value/ ✭ Threads https://www.threads.net/@relentlesshealthvalue/ ✭ Bluesky https://bsky.app/profile/relentleshealth.bsky.social ✭ X https://twitter.com/relentleshealth/ 00:00 Introduction to this episode. 00:50 How does transparent pricing data fit into the "inches all around us"? 03:13 A quick overview of what plan sponsors do with these price transparency insights. 05:52 The specific ways that clinical organizations can leverage price transparency data. 08:13 How price transparency infrastructure started and how it's grown to where we are now. 09:21 What are the insights that can be gleaned from the price transparency data available? 10:01 How price transparency data is a treasure trove for self-insured employers. 11:21 How employers can utilize this transparency data. 12:31 EP472 with Eric Bricker, MD. 14:48 How employers can help TPAs negotiate. 15:18 Why employers should be thinking about carving out services. 16:11 EP503 with Ryan Wells; Leo Spector, MD, MBA; and Adam Stavisky. 16:21 Why employers need to direct contract. 17:16 LinkedIn post by Chris Deacon. 17:38 A quick summary of advice for plan sponsors. 18:04 LinkedIn post by Andrew Tsang. 18:41 LinkedIn post by Pearly Chen. 19:32 How rates get set and how small providers can see this and benefit from it. 20:55 How small providers can use rate transparency to negotiate better rates. 22:18 EP489 with Dan Greenleaf. 25:46 Have prices increased due to price transparency? 29:25 Why price transparency makes it more important to eliminate lazy networks. 29:41 EP501 with Ivana Krajcinovic, PhD. 31:10 What is the transparency arms race, and what is happening because of it? 34:39 What Payerset does.
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The Death of the "What Is Value" Guessing Game for Clinical and Plan Decision-Makers Ready to Move On, With Ahilan Sivaganesan, MD
Apr 200:43:38Tap to summarizeMost hospitals cannot tell you the true internal cost of a single care episode. Not the medical device costs, not the personnel, not the consumables — the actual cost. And yet we operate a $5.6 trillion sector asking clinical organizations to take on risk for outcomes and costs they cannot quantify. As Dr. Siva puts it, you can never expect a physician to go at risk if they don't understand their own costs. Jumping in without that data is jumping blind into an abyss. In this episode, Stacey Richter speaks with Dr. Ahilan Sivaganesan, MD (Dr. Siva), a practicing neurosurgeon, researcher, and national leader in value-based care whose work focuses on the costs and outcomes of spine surgery, about a framework he calls the Operative Value Index (OVI) — and why it may represent the infrastructure shift that value-based care has always required but never had. WHAT YOU'LL LEARN ✅ Why the current approach to value measurement is backwards — we roll costs up to the highest level possible and drill outcomes down to the most granular metric available (handwashing rates, readmission rates, A1C), when what's needed is the exact opposite: unit-level costs via time-driven activity-based costing (TDABC) and whole-person, patient-reported outcomes across the full care journey ✅ How the Operative Value Index creates a common mathematical language — combining TDABC-derived costs with condition-specific patient-reported outcomes into a quotient that can compare surgeons, practices, or health systems, risk-adjusted for key confounders, giving self-funded employers something concrete to steer and tier toward ✅ Why appropriateness is the foundation of quality: a surgeon who sends patients to PT when that's the highest-value next step will look like a rockstar on OVI bubble charts — better patient-reported outcomes, lower total spend — while a surgeon who operates on everyone looks great under fee-for-service and terrible under any value-based framework ✅ How bubble chart transparency alone drove clinician behavior change without any payment incentive — surgeons are competitive, and once they can see where their bubble sits relative to peers on a value plot, the gears start turning immediately ✅ Why TDABC is existential for surgeons as procedural bundles expand: if a payer offers a fixed payment for a 90-day spinal fusion global, a surgeon who doesn't know their true cost of delivering that episode is going to get screwed — and there's no way to know which patients are favorable for a bundle without that cost infrastructure ✅ The "Yahoo vs. Google" moment: maximizing fee-for-service volume is Yahoo — stable, dominant, and confident it understands the business model. The ability to actually deliver and quantify high value is Google. Yahoo laughed. Until it didn't. WHY THIS MATTERS The value equation — outcomes divided by cost — is recited at every value-based care conference. But across most of this sector, both numbers are question marks. The OVI is an attempt to make them real, scalable, and comparable. When that infrastructure exists, self-funded employers can finally make intelligent direct contracting decisions. Clinical organizations that genuinely deliver high value can finally prove it. And the learning healthcare system — where transparency drives a feedback loop of improvement — becomes something more than a slogan. === LINKS === 🔗 Show Notes with all mentioned links: https://cc-lnk.com/EP505 ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter: https://relentlesshealthvalue.com/join-the-relentless-tribe 🫙 Support the podcast with a small donation to the Tip Jar: https://relentlesshealthvalue.com/join-the-relentless-tribe 🎤 Listen on Apple Podcasts https://podcasts.apple.com/us/podcast/feed/id892082003?ls= 🎤 Listen on Spotify https://open.spotify.com/show/6UjgzI7bScDrWvZEk2f46b 📺 Subscribe to our YouTube channel https://www.youtube.com/@RelentlessHealthValue === CONNECT WITH THE RHV TEAM === ✭ LinkedIn https://www.linkedin.com/company/relentless-health-value/ ✭ Threads https://www.threads.net/@relentlesshealthvalue/ ✭ Bluesky https://bsky.app/profile/relentleshealth.bsky.social ✭ X https://twitter.com/relentleshealth/ 00:00 Introduction to this episode. 00:38 The goal of this episode. 01:28 What the Operative Value Index (OVI) is. 02:04 A quick episode overview. 04:23 EP434 with Benjamin Schwartz, MD, MBA. 04:44 How this episode came about. 09:24 How Dr. Siva got involved in the research around outcomes and costs. 11:51 How the value equation doesn't add up to true quality. 14:12 What measuring quality across the entire care journey means. 15:00 EP326 with Rishi Wadhera, MD, MPP. 15:08 EP295 with Rebecca Etz, PhD. 16:07 Why appropriateness is the foundation of quality. 19:08 Why practicing clinicians need to be thinking about the true costs of delivering care. 21:20 Time-driven activity-based costing (TDABC). 23:44 The two things that must be known for value-based care to succeed. 24:06 Article by Dana Prommel Strauss. 27:09 A quick summary of the conversation thus far. 30:42 The power of transparency in Dr. Siva's bubble plots. 32:39 EP449 with Marty Makary, MD, MPH. 34:05 Why these bubble plots work not just at the procedural level but at the diagnosis level, too. 36:13 EP503 with Ryan Wells; Leo Spector, MD, MBA; and Adam Stavisky. 36:21 EP501 with Ivana Krajcinovic, PhD. 36:30 EP398 with Jacob Asher, MD. 37:28 The "big blue ocean" opportunity for forward-looking providers. 38:52 Substack post by John Lee, MD. 40:37 The incredible opportunity for entities and groups that can help provide the infrastructure needed for this value index. 41:42 Essay written by Dr. Siva. 43:19 Last thoughts by Dr. Siva on TDABC and competition on value.
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EP504: A Back-to-Basics Roadmap Through the Perverse Incentives to Advanced Primary Care, With Ryan Jacobs
Mar 2600:33:36Tap to summarizeWhy Advanced Primary Care Doesn't Scale: Conflicting Incentives, Complacency, and a 3-Step Roadmap Stacey Richter interviews Ryan Jacobs (SVP Strategy and Partnerships, Marathon Health) on why evidence-backed advanced primary care (APC)—focused on managing risk, improving outcomes, and lowering costs—still isn't widespread. They argue APC struggles to scale due to two root barriers: conflicting fiduciary duties (health systems and payers driven by volume, "heads in beds," and market-power growth, while APC keeps patients out of hospitals) and a "black box of complacency," where innovators often lose to the status quo because dominant organizations can rationally avoid investing without gaining share. Jacobs offers a three-step roadmap: perform a reality-based assessment by following the money and identifying who is financially harmed by prevention; anticipate stakeholders' math by framing value as CFOs, benefits leaders, and plan sponsors do; and proceed from strategic conclusions such as direct contracting to bypass misaligned intermediaries. === LINKS === 🔗 Show Notes with all mentioned links: https://cc-lnk.com/EP504 ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter: https://relentlesshealthvalue.com/join-the-relentless-tribe 🫙 Support the podcast with a small donation to the Tip Jar: https://relentlesshealthvalue.com/join-the-relentless-tribe 🎤 Listen on Apple Podcasts https://podcasts.apple.com/us/podcast/feed/id892082003?ls=1 🎤 Listen on Spotify https://open.spotify.com/show/6UjgzI7bScDrWvZEk2f46b 📺 Subscribe to our YouTube channel https://www.youtube.com/@RelentlessHealthValue === CONNECT WITH THE RHV TEAM === ✭ LinkedIn https://www.linkedin.com/company/relentless-health-value/ ✭ Threads https://www.threads.net/@relentlesshealthvalue/ ✭ Bluesky https://bsky.app/profile/relentleshealth.bsky.social ✭ X https://twitter.com/relentleshealth/ 00:00 A refresher on advanced primary care (APC). 02:36 Why APC isn't everywhere. 04:39 The problem of complacency in the healthcare system. 05:27 Ryan Jacobs' roadmap. 08:59 The pitfalls of advanced primary care. 09:58 What primary fiduciary responsibility means. 10:51 Growth on the payer side. 11:51 SUMS5 with Jacob Asher, MD. 12:36 EP483 (Part 1 and Part 2) with Jonathan Baran. 12:48 EP465 with Chris Crawford. 13:27 The reality of the healthcare system in the United States. 14:11 The flywheel created by the tension within the healthcare system. 15:25 EP391 with Scott Conard, MD. 15:51 The tension between APC's goals and fiduciary responsibility. 17:52 The black box of complacency. 19:25 EP436 with Elizabeth Mitchell. 20:05 What's driven most of the change in the advanced primary care space. 20:54 EP398 with Jacob Asher, MD. 21:01 What would happen if there was a functioning market in healthcare. 21:41 EP286 with John Rodis, MD, MBA. 21:52 Why complacency may be a rational move in healthcare. 22:41 EP438 with John Lee, MD. 23:22 A roadmap to success in advanced primary care. 23:55 Step 1: Follow the money. 24:50 Step 2: Someone's gonna do math. 25:17 What strategic thinking looks like as an employer. 28:34 Step 3: Proceed based on strategic conclusions. 30:20 How self-insured employers have created their own market. 31:07 The strategic decision for physicians wanting to create change. 32:25 A reiteration of the episode's discussion. 33:49 Better payment structures.
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