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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 Montanaâs 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, itâs 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 isnât called the âQueen of Healthcareâ 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 Montanaâs state health plan?
08:11 Why Marilyn knew she would have enough power to make the changes needed in Montanaâs 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 âquick winsâ 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 Whatâs 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 Marilynâs time working on it?
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So, I had a chance to read Dr. Marty Makaryâs new book, which is called Blind Spots; and hereâs why I wanted to get him to come back on Relentless Health Value and talk to you, people of the healthcare industry. Itâs because of something that he said on page 127 and which Iâve been mulling over for probably years, actually.
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.
Itâs 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 shouldnât be done, and itâs 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 âIf you leave it to the medical profession to fix itself ⊠so far, itâs not going well.â
22:33 How does supporting health literacy affect appropriate care?
30:23 âPeople need to find their care based on quality and price.â
34:28 What proportion of medical care is deemed unnecessary right now?
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Fehlende Folgen?
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Maybe youâve already caught Part 1 of my conversation with Shawn Gremminger, and if so, you're ahead of the game. But if not, no worriesâhere'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 bothâitâs 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 donât have to be listened to in order, so youâre good to start here with Part 2. Letâs 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 whyâas in, Why do employers care about what amounts to a program that is or was supposed to be for low-income Americans and Medicaid?âyou 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 âwhat the whatâ 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. Hereâs 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 Iâm 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 Shawnâs 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, actuallyâprobably more than many people realize. All of that being said, when youâre 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 healthcareâbecause 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 thereâs 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 youâre still with me for this Part 1âand I hope you are, because ⊠wow, itâs a wild and tangled journeyâhereâs 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. Hereâs the outline.
Visit the full article to read more.
05:25 Shawnâs 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 isnât 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. Thereâs 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 youâre a self-insured employer and youâre hearing this, donât be thinking it doesnât impact you because your employees are highly compensated.
As Deborah Williams wrote the other day, she wrote, âCo-pays have gotten high enough that even higher-income patients canât afford them.â 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 wonât most health plans administer alternative payment models?
12:17 âWe do not have value in the US healthcare system.â
12:57 Why you canât do effective primary care on a fee-for-service model.
13:30 Why have we fragmented care out?
14:39 âNo one makes money in a fee-for-service system if people are healthy.â
17:27 âIf we think it is not at a crisis point, we are kidding ourselves.â
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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 âhealthcare wasteâ consist of?
07:46 What are the six categories of âhealthcare wasteâ?
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 âWeâve built a backbone of extraordinary waste on a fee-for-service chassis.â
22:16 EP409 with Larry Bauer, MSW, MEd.
24:24 EP359 with Dan OâNeill.
26:02 Dr. Shrankâs 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. Itâs 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, itâs becoming increasingly obvious that in order to stand up a practice that can take advantage of value-based care paymentsâpayments where primary care docs mainly at this time can get paid more and likely more fairly to care for patients wellâyou 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, âLike 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.â
Today as aforementioned, Iâm 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 itâs 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 âIt is really trying to think about, how do we help practices get there?â
11:48 âThe hard part is the in-between spaces.â
13:21 EP407 with Vivek Garg, MD, MBA.
14:12 âTeam-based care done badly is really just a series of handoffs.â
15:52 âWe have to get to that point where the culture of collaboration is more pervasive.â
19:58 âHow do we as healthcare providers step in and solve this problem?â
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 âItâs important to understand that we are in the middle of this change.â
31:18 Dr. Scanlanâs 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 Krishnanâs 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 âEpic strategyâ actually was a complete master plan to change behavior in clinic, healthcare has no ânationwide, everywhere itâs all the same, so figure out your thing once and youâre good to goâ thing going on.
There are 18,982 differences of opinion out there, but hereâs the actual and big kahuna real reason why Iâm leery. An Epic strategy is not equivalent to a change management strategy. Thatâs the real point that I want to make.
Itâs necessary, very necessary even, but not sufficient. You want to make the way as easy as possible once the âwhyâ goes down and the case for change is made, but even if itâs one click and not your usual 14 to 60 clicks, thereâs no âwhyâ there. Thereâs no automatic case for change that slithers out of anybodyâs 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, letâs 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 couldnât 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. Itâs re-edited for 2024âcall it a supercutâspecifically 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, thereâs five steps to effective change management that will ensure success:
1. Having great leadership
2. Creating a case for change. This includes the whole âwhyâ thing.
3. Finding championsâengaging 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 havenât done so and you appreciate the show, could I ask you to please leave a rating and review on Apple Podcasts or Spotify? We havenât 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 âCommunication [of change] in and of itself isnât change management.â
10:53 How does change management work on the provider organization side?
15:33 âYou want to ensure you are educating the operational folks.â
16:35 What is change management?
17:36 What does great leadership look like in change management?
18:55 âLeadership sets the tone.â
19:04 What makes change management so hard?
19:31 âWhatâs the company reason to make this change happen?â
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 Kranzbergâs Laws of Technology.
08:16 How do EHRs go right?
12:49 âEHRs empower us with information, yet they also overwhelm us with information.â
16:00 How do EHRs bring healthcare workers closer together?
19:35 The Digital Doctor by Robert Wachter.
21:33 âThe whole point of healthcare is to help people live healthier, happier lives.â
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 âValue is more about a mindset.â
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 âproductive middleâ?
36:27 Dr. Tom Leeâs message to payers.
39:55 Dr. Tom Leeâs 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 Paulâs usual observations when a PBM contract crosses his desk?
08:34 âIf you just sign ⊠one of their model contracts âŠ, youâre probably gonna pay 30% to 40% above market on your drug spend.â
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 Whatâs the problem with most ERISA lawyers today?
22:56 Lawsuit about PBM contract.
27:43 Whatâs Paulâs 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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In Episode 444 of Relentless Health Value, Stacey Richter speaks with healthcare consultant Ann Kempski about two state healthcare laws with unintended consequences: the Certificate of Need (CON) and the Certificate of Public Advantage (COPA) laws. They delve into the original intentions behind these laws, the ways in which they have often failed, and their impact on the competitive landscape.
The discussion also explores how CON laws have led to increased costs and market consolidation, while COPA laws have allowed potentially monopolistic mergers under state oversight. The episode sheds light on complex regulatory terrain and highlights the importance of vigilant oversight and diverse stakeholder involvement.
To read the full article with the links mentioned during the epsiode and a full transcript, visit the episode page. While on the site, please consider signing up for the free weekly newsletter.
00:00 Introduction
02:08 Understanding Certificate of Need (CON) Laws
02:57 Problems with CON Laws
04:02 Exploring Certificate of Public Advantage (COPA) Laws
05:25 Guest Introduction: Ann Kempski
06:05 In Memoriam: Suzanne Delbanco
06:20 Ann remembers Suzanne Delbanco.
06:55 EP224 with Suzanne Delbanco.
07:40 What are state Certificate of Need laws?
08:44 Why are states getting rid of these CON laws?
13:26 Why CON laws are created.
15:43 EP437 with Brian Klepper, PhD.
16:09 What are the conflicts of interest and problems that arise when CON laws are created?
20:55 What happens when states get rid of these CON laws?
24:10 How are Certificate of Public Advantage laws different from CON laws?
27:58 Why does the research show that COPAs donât usually accomplish their goals?
31:34 What encouraging current events are happening in the realm of COPA laws?
32:08 Gloria Sachdev, PharmD, of Employersâ Forum of Indiana.
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To read the full show notes with links mentioned, be sure to visit our episode page and consider signing up for our free weekly newsletter.
Episode 443 of Relentless Health Value pays tribute to the late Marshall Allen, an investigative journalist dedicated to exposing injustices within the American healthcare system. Hosted by Stacey Richter, the episode features Dave Chase, founder of Health Rosetta, who shares memories and insights into Marshall's tireless work in investigative reporting.
The episode highlights Marshall's impact on healthcare legislation, his significant contributions to ProPublica, and his book 'Never Pay the First Bill,' which empowers patients and employers to fight back against corrupt billing practices.
The episode also includes an earlier interview with Marshall, focusing on his perspective as an investigative reporter, the exploitation within the healthcare system, and the importance of patients and employers demanding transparency and fairness. The episode encourages listeners to continue Marshall's legacy by subscribing to the Marshall Health Academy and purchasing access for employees.
09:28 Whatâs the point of view that Marshall is coming from with his investigative reporting?
09:57 âHow does this affect the people who are paying for it and the people who are undergoing the care?â
10:49 âThereâs a lot of good people working within this very messed up system.â
11:03 Why are patients considered outsiders in the healthcare system?
11:45 âWhatâs happened in healthcare is that the stakeholders treat each other more as the customer.â
13:45 What is upcoding?
17:18 âThese are schemes that have been created within the industry to increase revenue.â
17:46 âThis system is not set up for the benefit of the patient.â
18:13 âOn the financial side, the industry is actually oppressing the American people.â
19:14 âWe have been expected to pay whatever aggregate sum is thrown at us.â
20:21 Why have patients been so passive toward this crooked healthcare system so far?
22:05 Whatâs the difference between making a profit and profiteering?
29:45 What are the first-order and second-order consequences of whatâs happening in health care right now, and which of these consequences will actually drive change?
30:45 âWhen you tell the truth about whatâs going on ⊠they become so ashamed ⊠that they change their behavior.â
32:00 âThe patient ⊠is not their most important customer.â
32:50 âThe sleeping giant is the employers.â
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In Episode 442 of 'Relentless Health Value,' host Stacey Richter shares an intriguing outtake from a previous episode featuring Andreas Mang, senior managing director at Blackstone, discussing the critical issue of cost management in oncology side effect treatment.
The conversation delves into the inefficiencies and patient harms caused by inadequate side effect management, particularly dehydration due to chemotherapy, and the resulting financial burdens on employers, taxpayers, and patients.
Stacey explores the importance of a value-based mindset in drug purchasing, integrating oncology care, and the potential financial and health benefits of better side effect management. She highlights various expert opinions and studies supporting these points, encouraging listeners to reconsider their approach to healthcare cost structures and patient care protocols.
If you enjoy this podcast, be sure to subscribe to the free weekly newsletter to be a member of the Relentless Tribe.
01:12 Andreas Mang on oncology medication side effect management.
03:12 Mark Lewis, MDâs Tweet.
03:39 Celena Lathamâs response.
04:22 How integrative oncology can save money and what it looks like.
04:47 EP157 with Ethan Basch, MD.
06:20 Why PBMs saving money doesnât necessarily mean savings for employers and payers.
07:36 EP435 with Dan Mendelson.
08:20 EP372 with Cora Opsahl.
08:40 EP331 with Al Lewis.
09:50 Staceyâs second rumination.
10:19 Why having a value mindset when purchasing is a thing.
10:42 Staceyâs third rumination.
12:03 EP370 with Erik Davis and Autumn Yongchu.
13:07 Why FFS does not pay or pay adequately for side effect management.
14:31 Staceyâs final rumination.
17:08 Summarizing Staceyâs four ruminations on this topic.
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To read the full article with show notes, mentioned links and a full transcript, visit relentlesshealthvalue.com
In this episode, Abby Burns from Radio Advisory interviews Stacey Richter, host of the Relentless Health Value podcast, during the Raising the Bar Value Summit. They discuss the complexities of defining and creating value in healthcare, focusing on the roles of various stakeholders including patients, providers, and payers. Stacey shares insights on the challenges and tensions in the healthcare system, such as the fragmentation of care, financial toxicity, and the cultural norms that inhibit progress. The conversation also highlights practical examples and potential strategies to drive value and sustain positive changes within the industry.
03:33 Staceyâs journey and mission.
04:16 The story of Scott Conard, MD (EP391).
09:28 Why itâs important not just to drive change but to sustain it.
12:23 Heart Failure: A Case Study in Value.
14:13 EP438 with John Lee, MD.
15:07 Why patient positive value often fails instead of succeeds.
18:07 How financial toxicity has become clinical toxicity in healthcare.
19:44 How cultural norms have evolved into healthcare challenges.
23:38 The story of Mike Tuggy, MD, in Washington.
25:13 Looking at the four tensions in measuring value as continuums.
25:37 Why timeline is important in creative value in healthcare.
27:52 Finding Allies by Michael Leavitt.
28:34 What are the four ways to measure value in healthcare?
29:27 How do payers and providers collaborate to align on value metrics?
31:26 Why will proven versus experimental treatments become more important in the next few years?
34:54 Staceyâs manifesto (EP400) and values for personal integrity in healthcare.
38:55 Staceyâs parting advice.
For more information, go to Radio Advisory or Aventria Health Group.
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In Episode 440 of 'Relentless Health Value,' host Stacey Richter engages with David Muhlestein to explore the optimal size for a medical practice, concluding that 10 to 20 physicians supported by a capable team provide the best balance of economies of scale and community integration. The conversation transitions into the challenges large healthcare systems face, particularly the Diversification Discount.
This diversification often impedes patient care and operational efficiency by misaligning values with business practices. The episode delves into the paradox of optimizing primary care while still supporting specialty care, reflecting on how organizational values impact healthcare outcomes. Muhlestein suggests implementing business units or decentralized models to realign with patient care values and efficiencies.
To read the full article and show notes with links mentioned as well as a full transcript, click here.
08:12 From a business and patient/better outcomes standpoint, what does an optimal provider practice look like?
11:48 EP412 with Robert Pearl, MD.
13:06 Why isnât the current landscape what David considers optimal?
14:53 What leads to the âcrisis of autonomyâ?
15:13 How do medical practices get to the phase of delegation?
17:39 EP438 with John Lee, MD.
18:55 EP437 with Brian Klepper, PhD.
20:53 EP432 with Kate Wolin, ScD.
20:55 EP421 with Jodilyn Owen.
23:48 Medicare Meet-Up podcast with Mai Pham, MD.
24:45 What metrics should boards of directors also be held accountable for?
28:48 Why is an efficiency-focused business not necessarily the best at managing population care?
31:13 What is the âdiversification discountâ?
32:49 Pivot podcast with Kara Swisher and Scott Galloway, MBA.
35:53 What can primary care doctors do to optimize their practices?
36:48 Why do we need to shift the mindset from âbiggerâ and âmoreâ?
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In Episode 439 of 'Relentlessly Seeking Value,' host Stacey Richter discusses the convoluted issues surrounding generic drug pricing with pharmacy consultant Luke Slindee.
To read the full article and show notes with links mentioned as well as a full transcript, click here.
They delve into the ways traditional Pharmacy Benefit Managers (PBMs) exploit the system to make immense profits, often leading patients to pay more even with insurance. The conversation explores various solutions, such as the removal of "Usual and Customary Prices" from PBM contracts, the advantages of bypassing insurance, and giving patients direct payment tools like health savings accounts.
Luke Slindee, with his extensive background in pharmacy and consulting, provides valuable insights into rebalancing the generic drug market to benefit patients, pharmacies, and plan sponsors alike. Additionally, the broader implications of these dysfunctional systems on pharmacy operations and staff conditions are discussed.
Love the show? Please consider signing up for our weekly newsletter. We'll send you an article covering the latest episode with show notes, mentioned links and a transcribed intro. Join the RHV Tribe.
08:12 Where do cash prices fall when pharmacies have contracts with PBMs?
08:39 What is a usual and customary price?
12:14 How is the usual and customary price affected by PBMs?
16:49 Should pharmacies be allowed to have two sets of cash prices?
17:14 Where does GoodRx fit into this because of the pharmacy/PBM dilemma?
19:06 Whatâs happening with Amazon and the anticompetitive contract lawsuit, and how does it relate back to pharmacy contracts with PBMs?
20:38 EP395 with Brennan Bilberry.
21:05 EP420 with Ge Bai, PhD, CPA.
23:27 Why is there a new wave of cash-only pharmacies?
24:02 EP418 with Mark Cuban and Ferrin Williams, PharmD, MBA, from Scripta.
25:41 What would allow the generic market to return to normal competitive pricing?
26:39 How does this dysfunction create a negative downstream effect?
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In this episode of Relentless Health Value we dive into the concept of Cognitive Dissonance in the healthcare industry with Dr. John Lee, an ER physician and chief medical information officer. We explore how healthcare professionals navigate the conflict between their beliefs and actions, especially in large healthcare organizations. Dr. Lee shares practical advice on celebrating small wins, incremental improvements, and fostering a supportive culture among colleagues.
This conversation sheds light on the challenges and solutions for those striving to deliver better patient care despite systemic obstacles.
To read the full article and show notes with links mentioned as well as a full transcript, click here.
Dr. John Lee is an ER (emergency room) doc by training, who is also an informaticist and chief medical information officer. I can tell you from personal experience that Dr. Lee is one of the most creative and pragmatic problem solvers that I have encountered. He says heâs dedicated to trying to help move the ball forward and changing our healthcare system using information technology and using our ability to be far more transparent with the things that we try to do in a positive way in healthcare.
Join us for an insightful discussion on balancing ideals and realities in modern healthcare.
Love the show? Please consider signing up for our weekly newsletter. We'll send you an article covering the latest episode with show notes, mentioned links and a transcribed intro. Join the RHV Tribe.
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The Unseen Influence of the RUC on Healthcare
This episode of 'Relentless Health Value' features a discussion with Brian Klepper, a healthcare analyst and former CEO of the National Business Coalition on Health, about the powerful yet obscure RUC (RBRVS Update Committee) and its significant impact on the economics of primary care and the broader healthcare system. The RUC, a committee within the American Medical Association, plays a critical role in determining the relative value of medical procedures, which directly influences Medicare payments. The episode reveals how the RUC's compositionâdominated by specialists over primary care physiciansâskews the financial incentives in healthcare, affecting the viability of primary care practices and mental health services. The discussion also explores the flawed assumption that the financial value assigned to healthcare services by the RUC equals their true value to patients, highlighting the need for a better understanding of the inner workings of American healthcare to address its shortcomings.
To Read the Full Article with Show Notes Including Links Mentioned, Visit Our Site.
00:00 Introduction
02:29 Unpacking the RUC: The Power Behind Healthcare Economics
04:26 The Financial Impact of the RUC on Primary Care
07:43 Exploring the Value of Healthcare Services
10:29 The Real-World Consequences of RUC Decisions
12:50 Debunking the Equivalence of Value and Money in Healthcare
15:09 Final Thoughts and How to Stay Informed
Brian Klepper, PhD, is principal of Worksite Health Advisors and a nationally prominent healthcare analyst and commentator. He speaks, writes, and advises extensively on the management of clinical and financial risk, on high-performance healthcare, and on realizing the potential of primary care.
His current focus is on high-performing healthcare organizations that consistently deliver better health outcomes at lower cost than usual approaches in high-value niches and how, integrated with advanced primary care, they can be configured into turnkey comprehensive high-value health plans that can disrupt the status quo.
Love the show? Please consider signing up for our weekly newsletter. We'll send you an article covering the latest episode with show notes, mentioned links and a transcribed intro. Join the RHV Tribe.
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In this episode of Relentless Health Value we follow up on the topic of employer inertia discussed with Lauren Vela in episode 406, turning our focus to third-party administrators (TPAs), administrative services only (ASOs), and health plans.
Elizabeth Mitchell from the Purchaser Business Group on Health (PBGH) joins us to discuss the roles of TPAs and ASOs, highlighting the gap in the market for independent, efficient TPAs not owned by health plans. We also delve into the trend of direct contracting between employers and providers to enhance access, quality, and outcomes.
Bottom line, right now, thereâs a gap in the market. What is needed are indie TPAs who are effective and efficient and not owned by a health plan because, if history is any predictor of the future, the second the TPA gets owned by a health plan, the TPA sort of ceases to be a TPA and becomes a health plan.
The conversation today with Elizabeth Mitchell pretty quickly gets into the shift toward direct contracting between employers and providers to improve access quality and outcomes. If you canât beat them, get ruthlessly practical is my takeaway. I have to say, I truly admire some of these HR folks and their leadership willing to do what it takes on behalf of protecting the people that work for them.
There are certainly some health plans at least trying here, so I donât want to imply otherwise. There are some interesting initiatives that are afoot at, Iâm gonna say, usually regional health plans. Elizabeth Mitchell has talked about some of these and made this clear also elsewhere.
Join us for a deep dive into these critical components of the healthcare system and their impact on self-insured employers.
To read the full article and show notes with links mentioned as well as a full transcript, click here.
Love the show? Please consider signing up for our weekly newsletter. We'll send you an article covering the latest episode with show notes, mentioned links and a transcribed intro. Join the RHV Tribe.
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