Relentless Health Value

I was out drinking martinis with Cora Opsahl, director of 32BJ Health Fund, and Cora said, "Look, most plan sponsors' biggest expense is health system spend, hospital spend." I know this is an unexpected start to an episode about pharmaceutical pricing and value featuring Sarah Emond, CEO of ICER (Institute for Clinical and Economic Review). But yeah, 50% of most plan sponsors' spend these days goes to health systems. Fifty percent! One half! For a full transcript of this episode, click here. If you enjoy this podcast, be sure to subscribe to the free weekly newsletter to be a member of the Relentless Tribe. So, if a patient who is adherent to a drug and that drug keeps that patient out of the hospital, why do I want to make a patient have excessive skin in the game to get that drug, which everybody knows at this point this "skin in the game" can cause said patient to not be adherent in many cases, cost being a very big reason patients give for not taking medications as prescribed. So then we have this not adherent patient who winds up in the hospital, via the ER often enough. The core issue here that surfaced, bottom line—and I'm not sure if this was in spite of the martinis or as a result of them—but while hospital spend is the largest health expense, high-value drugs that prevent hospitalization often face patient cost sharing and access restrictions, which leads to poor patient adherence and ultimately higher system cost potentially. So then Cora and I spent the next half hour debating when the statement is empirically true and when it's not. And you know what it all boils down to? What's the value of the drug? Do we even know what that means to start? But if it's determined that the drug is relatively high value, then the plan desperately should want to do everything possible to keep that patient on that medication, and cost sharing is a huge barrier to adherence. Today, as I said, I'm speaking with Sarah Emond, CEO over at ICER, and we get into all of this in the conversation that follows. In fact, most of the conversation that follows explores the tensions that exist in the current way that we sell and buy pharmaceutical products. I'm just gonna sum up these tensions in a list here at the top of this show. There's six of them that Sarah Emond and I discussed today by my counting, and each of these we explore in some depth. So, here's the list. Tension 1: The value of any given drug (in other words, what is the fair price for that drug considering the health gains that it delivers) versus the total cost to the plan for the total population taking that drug. GLP-1s have entered the chat. GLP-1s (by ICER's analysis, at least) are super high-value drugs that also can bankrupt plans due to the number of folks who may benefit from taking the drug. Definitely a tense tension to kick off our list here. Tension 2: The list or net price of a drug versus patient access and affordability. Again, this can be tense in an area of much misalignment. You can have a great well-priced drug with huge patient affordability and access challenges because drug net price and coinsurance amounts often have nothing to do with each other. Tension 3: Lifetime value of a drug versus a 3-, 2.5-year, whatever time horizon that many plan sponsor actuaries use in their value assessment. We discussed this today, but there's a Summer Short (SUMS7) on actuarial value horizons with Keith Passwater and JR Clark if you wanna dig in on this further. Tension 4: The tension between the societal value of a drug or even the patient's perceived value of a drug versus what an employer plan sponsor might perceive as the value. What is the formula used to determine value? What's in and what's out? So, that's a bigger conversation just beyond the time horizon for what's included in this calculation. Tension 5: Exacerbating the what's included in the value contemplation beyond just what you include in there is the tension between what is hypothetically of value and what is possible to measure. If you have pharma datasets and medical datasets separate in silos, who knows how many hospital readmissions were prevented by whatever drug? And how much presenteeism or absenteeism exists. I mean, it is an outlier, again, if anyone even knows the net price they paid for a drug, just to level set context here. Tension 6: Lowering financial barriers for patients to take drugs that are of value versus status quo goals and incentives. Like, for example, PBMs (pharmacy benefit managers) are often told that their goal is to reduce drug spend. Okay … so, how do I do that? Oh, reduce access either by prior auths or delay tactics or really high coinsurance, which is gonna reduce adherence by design. And it's someone else's problem—if I'm just thinking like a status quo PBM—if medical spend goes up, right? So, that's our last and not insignificant tension. And look, who comes out the loser in all of these tensions when they get tense? Patients. Not pricing based on value and not buying and setting up cost sharing based on value punishes patients and also plan sponsors or any other ultimate purchaser in the long term, given that the plan is but a population of patients if you start thinking about it in that context. Here is Sarah's advice in a nutshell: Pharma, sell. Pick your price based on something other than market power. And some pharma companies are actually dipping their toe into these waters and doing it. But then PBMs and plan sponsors have to hold up their end of the bargain here and buy drugs based on their value, not just the size of their rebates or some other discounting promise. And then we gotta continue the through line through to member affordability and access. High-value drugs should get preferred. So, right, do a high-value formulary. Listen to the show with Nina Lathia, RPh, MSc, PhD (EP426) on high-value formularies and then listen (after you're done with that one) to episode 435 with Dan Mendelson entitled "Optimized Pharmacy Benefits Are Required if You Want to Do or Buy Value-Based Care." Also, as I said, GLP-1s come up in this conversation, so … yeah, buckle up. One last thing, besides my normal thank you to Aventria Health Group for sponsoring this episode, I am so pleased to thank Payerset for donating to help Relentless Health Value stay on the air. Payerset is a price transparency company with a mission to create fair and equitable healthcare for everyone. Love that. Payerset empowers healthcare organizations, employers, and patients with the most complete set of healthcare price transparency data. They benchmark every negotiated rate and claim and delivering the actionable insights needed for smarter contract negotiations and a more transparent healthcare system. As I have said several times today, my conversation is with Sarah Emond, CEO of ICER. Also mentioned in this episode are Institute for Clinical and Economic Review (ICER); Cora Opsahl; 32 BJ Health Fund; Keith Passwater; JR Clark; Nina Lathia, RPh, MSc, PhD; Dan Mendelson; Aventria Health Group; Payerset; Antonio Ciaccia; Elizabeth Mitchell; Purchaser Business Group on Health (PBGH); Shane Cerone; Sam Flanders, MD; Mark Cuban; Morgan Health; and Tom Nash. For a list of healthcare industry acronyms and terms that may be unfamiliar to you, click here. You can learn more at ICER.org and follow Sarah on LinkedIn. Sarah K. Emond, MPP, is president and chief executive officer of the Institute for Clinical and Economic Review (ICER), a leading nonprofit health policy research organization, with 25 years of experience in the business and policy of healthcare. She joined ICER in 2009 as its first chief operating officer and third employee and has worked to grow the organization's approach, scope, and impact over the years. Prior to joining ICER, Sarah spent time as a communications consultant, with six years in the corporate communications and investor relations department at a commercial-stage biopharmaceutical company and several years with a healthcare communications firm. Sarah began her healthcare career in clinical research at Beth Israel Deaconess Medical Center in Boston. A graduate of the Heller School for Social Policy and Management at Brandeis University, Sarah holds a Master of Public Policy degree with a concentration in health policy. Sarah also received a bachelor's degree in biological sciences from Smith College. Sarah speaks frequently at national conferences on the topics of prescription drug pricing policy, comparative effectiveness research, and value-based healthcare. 08:18 Why list prices are a lie. 10:59 How does the rebate model sometimes get in the way of paying for value? 12:50 Bonus clip with Sarah Emond. 13:14 EP491 with Elizabeth Mitchell. 13:20 EP490 and EP492 with Shane Cerone and Sam Flanders, MD. 14:37 The tension that is created between affordability and adherence. 15:03 When cost sharing makes sense in pharmaceutical drug pricing. 17:26 INBW42 with Stacey on moral hazard. 18:53 How GLP-1s are "wildly cost effective." 21:32 Why the sticker shock on cost-effective drugs is a failure in the system for paying for value. 22:38 ICER's report on GLP-1s. 26:59 EP385 with Dan Mendelson. 28:57 How employers and payers can have a value assessment approach and a health insurance system that allows access to cost-effective drugs. 29:48 How cost-effective prices are calculated. 31:55 One of the core value underpinnings for value assessment of drugs. 34:54 Why manufacturers and pharmacy benefit managers should work together more by referencing something like an ICER report. 36:55 EP426 with Nina Lathia, RPh, MSc, PhD. 38:21 "We can make different choices." You can learn more at ICER.org and follow Sarah on LinkedIn. @sarahkemond discusses #pharmaceutical #drugpricing on our #healthcarepodcast. #healthcare #podcast #financialhealth #patientoutcomes #primarycare #digitalhealth #healthcareleadership #healthcaretransformation #healthcareinnovation Recent past interviews: Click a guest's name for their latest RHV episode! Stacey Richter (INBW43), Olivia Ross (Take Two: EP240), John Quinn, Dr Sam Flanders and Shane Cerone (EP492), Elizabeth Mitchell (EP491), Shane Cerone and Dr Sam Flanders (Part 1), Dan Greenleaf (Part 2), Dan Greenleaf (Part 1), Mark Cuban and Cora Opsahl

Not gonna give much of an introduction here because this is a short bonus level set, but I did just wanna call everyone's attention to the "arms race" created by our status quo purchasing and selling of many things, pharmaceuticals included. For a full transcript of this episode, click here. If you enjoy this podcast, be sure to subscribe to the free weekly newsletter to be a member of the Relentless Tribe. For example, raise the list price of a drug to maximize rebates, because the higher the list, the bigger the discount you can give, which then exacerbates patient affordability because coinsurance is often based on list price. But then Pharma starts offering co-pay cards, which messes up the whole PBM (pharmacy benefit manager) plan to drive patients to their highest-rebate products (ie, the most profitable products). So then maximizers and accumulators enter the chat, and prior auths ramp up because plans start having to raise premiums after enough 340B drugs with high lists and no rebates, and then there's no cost containment and raise deductibles and around and around we go. Meanwhile, is this drug fundamentally worth the list price or even the net price? Is it an effective drug? What's the right price to be paying for this drug? Should be the operative question, right? Just like what's the quality and appropriateness of any medical service? Maybe we should just quit it and just pay for value. And with that, let me introduce Sarah Emond, CEO of ICER (Institute for Clinical and Economic Review), and I will let Sarah tell the rest of the story. Also mentioned in this episode are Institute for Clinical and Economic Review (ICER); Cora Opsahl; 32 BJ Health Fund; Payerset; Aventria Health Group; Dea Belazi, PharmD, MPH; and Tom Nash. For a list of healthcare industry acronyms and terms that may be unfamiliar to you, click here. You can learn more at ICER.org and follow Sarah on LinkedIn. Sarah K. Emond, MPP, is president and chief executive officer of the Institute for Clinical and Economic Review (ICER), a leading nonprofit health policy research organization, with 25 years of experience in the business and policy of healthcare. She joined ICER in 2009 as its first chief operating officer and third employee and has worked to grow the organization's approach, scope, and impact over the years. Prior to joining ICER, Sarah spent time as a communications consultant, with six years in the corporate communications and investor relations department at a commercial-stage biopharmaceutical company and several years with a healthcare communications firm. Sarah began her healthcare career in clinical research at Beth Israel Deaconess Medical Center in Boston. A graduate of the Heller School for Social Policy and Management at Brandeis University, Sarah holds a Master of Public Policy degree with a concentration in health policy. Sarah also received a bachelor's degree in biological sciences from Smith College. Sarah speaks frequently at national conferences on the topics of prescription drug pricing policy, comparative effectiveness research, and value-based healthcare. 02:28 What is ICER? 02:47 What does the Institute for Clinical and Economic Review do? 05:09 The importance of still showing up, even when others don't understand or disagree. 06:51 EP293 ("Game Theory Gone Wild") with Dea Belazi, PharmD, MPH. 09:04 Why it's important to think about population health and how our choices impact affordability for everyone. You can learn more at ICER.org and follow Sarah on LinkedIn. @sarahkemond discusses #ICER and the status quo of #pharmaceuticaldrug #pricing on our #healthcarepodcast. #healthcare #podcast #financialhealth #patientoutcomes #primarycare #digitalhealth #healthcareleadership #healthcaretransformation #healthcareinnovation Recent past interviews: Click a guest's name for their latest RHV episode! Stacey Richter (INBW43), Olivia Ross (Take Two: EP240), John Quinn, Dr Sam Flanders and Shane Cerone (EP492), Elizabeth Mitchell (EP491), Shane Cerone and Dr Sam Flanders (Part 1), Dan Greenleaf (Part 2), Dan Greenleaf (Part 1), Mark Cuban and Cora Opsahl

This episode is gonna drop on Thanksgiving, but whenever you are listening, I'd like to suggest taking this moment to be grateful. Everybody has someone to be thankful for: colleagues, our mentors, our cheerleaders, our support system, our community, our strategic alliance partners. For a full transcript of this episode, click here. If you enjoy this podcast, be sure to subscribe to the free weekly newsletter to be a member of the Relentless Tribe. It will take a village to transform healthcare. Also, just to level set, you are listening to a Thanksgiving show; and the term "demand curve" is going to come up. Just locking in our wonky bona fides, which definitely says as much about you as it does about me … just saying. But yeah, it's on or about Thanksgiving. So, consider who is on your own list to thank right about now in your world. The older I get, the more I am realizing just how important it is to give thanks and be grateful. And so, this year (because just keeping it orderly), I have devised my top five baskets of thank yous to hand out Relentless Health Value style. Not sure what that means exactly. We like our top fives around here. First basket of thank yous goes to … I'd like to thank everyone in our big tent of healthcare transformation who does not succumb to the narcissism of small differences. I did a whole episode on the narcissism of small differences a year ago (INBW39), so please go back and listen to that if you are so intrigued. But in short, in every fundamental way, if I agree with somebody—like I'm 99% in agreement with another person or even 80% in agreement—then our discussion about the 1% or the 20% where we're a little misaligned can and should be respectful and in context. There's way more agreement than disagreement. I'm reminded of what Winston Churchill said one time. He said, "The only thing worse than fighting with your allies is fighting without them." So, I wanna thank everyone who retains directional alignment and remembers the conversation is about a relatively small disagreement that could be around the edges. Some of you folks do this so beautifully on LinkedIn or otherwise, and there are so many of you who are so good at engaging in really positive ways that furthers everyone's understanding. This is so important because we need collective action. We need collaboration. I heard recently someone say effective collaboration will be the next breakthrough innovation, and I could not agree more. In fact, as I'm thinking about this, I do believe I said that myself five years ago on at least one show (INBW37), which I have linked here as evidence. But it will inarguably take a village to do pretty much anything in healthcare, which is why the "It will take a village" is the third prong from my manifesto/personal charter (EP399, EP400) that I look at every single day because it's on a Post-it note taped to my wall at this point because the Post-it glue sticky stuff is long gone. So, I had to tape it. So, in sum, thank you to all of you with the self-awareness and the abundant mindset who are reflective and inclusive in ways that I truly admire and really try to emulate. Rob Marty: Hi, this is Rob Marty, and I'll be the first to admit that working in healthcare can be stressful. I have my good days, and I have days where I feel like our broken healthcare system is here to stay. On bad days, I find hope by listening to the Relentless Health podcast, and I feel as if Stacey is speaking directly to me when she reminds us we are all part of a tribe. We are not alone in our pursuit of high-quality, cost-effective, accessible, and inclusive healthcare. Stacey: And this civility and big tent and self-awareness really, really matters … to me, at least. As I've said to any number of you, right now, at this moment, I have honestly not seen in my 25-year career in healthcare more downright just—I'm gonna call it flat out—meanness in business. Downright whatever you can take, just take it if you can get away with it. You might feel this, too. Again, I've spoken to many who agree, but this view that it's okay to defy most any rules of basic civility, it certainly creates this pervasive feeling of, like, emptiness or aloneness for everyone involved—including those who are the ones twisting the knife, ironically enough. So, yeah, this has been a really hard year, to be frank. I've been doing my day job for a very long time, and there's definitely always been a sort of, I don't know, socially acceptable business relationship. And just like I said, this year has been a total low point in just what constitutes acceptable levels of decency and integrity. The antidote here is, of course, community. I read somewhere that the secret to a fulfilled life is relationships, purpose, and service. And this Relentless Health Value tribe, you all, you offer the opportunity to each other to fulfill all three. So, with all my heart to you who take the high road when it's so easy apparently to go low, thank you. It's nice to be in this tent with you. It's nice to be in this village with you, and you are the very first folks I wanna thank with my first basket of thank yous. Second basket of thank yous, and all of these are probably very interrelated, but the second basket of gratefulness goes out to all of you in the Relentless Health Value tribe who are so happy to pay it forward. In fact, here's something that Dan Greenleaf said at the end of episode 489 that really resonates with me. Dan Greenleaf: If people wanna reach out to me, I'd be happy to talk with people who are involved here. I've done something very similar. I've shared with you, I've reached out to a few people who I've heard on the podcast, so I certainly wanna extend that invitation as well. Stacey: And I really like what Kelly Kirby Fisher wrote the other day on LinkedIn. She wrote, "[Look, I love the Relentless Health Value podcast.] I've learned so much and keep pushing links [of] the podcasts to my coworkers so we can talk about them later. It's like a book club, but better!" I love that idea. Here's the thing, tribe: I get a lot of messages from folks who are looking for an intro to a guest or someone else in this community village, tribe of ours. You don't need me. And I say that with pride. If you hear someone on the show, they were invited because of who they are as much as, or maybe even more than, what they are currently up to. Here's something that Vivian Ho, PhD, said. Dr. Vivian Ho: I listen to Relentless Health Value religiously because this is the show for those who are part of the tribe that wants to improve the quality of healthcare, improve access to care, and make it affordable. Stacey: This is a community that has grown way bigger than me. And again, I say that with great pride. If you listen to Relentless Health Value and you are part of the conversations or even just the thought processes that we undertake around here, that is all the calling card that you need. Please reach out directly. And don't forget, collaboration will be the next breakthrough innovation. And I want that for you. So, go for it. Call up or message whoever you want. And I'm so grateful that you decided to do that, that you chose to do that. And also for any of you who take up that conversation and pick up that call, it will take a village. I've said that 10 times, but it really will. And I'm so grateful for all of you here who are part of that. Chris Skisak: Hi, my name is Chris Skisak. I am the executive director of the Houston Business Coalition on Health, as well as Texas Employers for Affordable Health Care. I've been a longtime listener and have had the privilege of getting to know and work with Stacey Richter. There is no doubt in my mind that Relentless Health Value is the best podcast out there that addresses the financial challenges and opportunities in healthcare delivery. Episode 452 with Cora Opsahl gives hope and encouragement to what can be accomplished through collective perseverance and resolve. I highly encourage listeners to pay attention to this episode, as it truly will require a village of employers locally, at the local market level, to change what needs to be changed. Thank you very much. Stacey: Third basket of thank yous to hand out, I wanna thank anybody who is or aids and abets the demand curve in the healthcare sector. All of you who listened to the past, I don't know, bunch of shows will know exactly what I'm talking about here. But short version, there is, in general, absolutely not a market in healthcare. There's no healthcare market, especially relative to hospital prices or hospital quality—if anyone can even agree on what quality means. Same thing largely applies on the pharma side of the supply chain as well. If all of this about markets and the healthcare industry is sounding intriguing but confusing, listen to episodes 490, 491, and 492 with Shane Cerone; Sam Flanders, MD; and Elizabeth Mitchell and you will be totally up to speed. Shane Cerone: Hi, this is Shane Cerone with Kada Health. I like to think of Relentless Health Value as a solution center. A unique place where industry insiders and experts gather to break down the failures of our nation's health system and talk honestly about the problems we confront and the solutions we need. It's a rare place where you hear strategies that are actually being used to drive the changes we all want and need to see in the industry. Stacey: Here's the bottom line who I want to thank relative to this no market business. You're in two groups. Those of you who help self-insured employers and unions who, like it or not, are the ultimate purchasers for 160 million Americans, because the purchaser has to be the demand curve for there to be a market that rationalizes prices and quality. You not only need a supply curve; you need a demand curve so the invisible hands can find that point where those two lines cross. But look, you can't get sellers. This is as ridiculous as it sounds. You can't get sellers to get buyers to not buy if the seller raises their prices above what the seller thinks the buyer shouldn't be willing to buy it at. Ridiculous. Okay … one exception aside—and I only mention it because this has been living in my brain rent-free for at least, I don't know, 10 years—there was that one time, not at band camp but at the annual Blacksmith Charity Pig Roast Pig Iron Fest. (I know. I get around.) Anyway, long after the bar opened, it came time for the charity auction. The auctioneer/blacksmith gets up there. And if you've ever seen those Drunk History shows, this was extremely similar … just drunk auctioneering. Here we have a Uri Hofi hammer in fine condition. Bidding starts at $400. Who would pay $400 for this hammer? Let's start at $50. Oh, I'll put in a bid. I bid $50. Who's in for $55? Was it hella entertaining? Yes. Did a friend I dragged along wind up purchasing a two-foot-long solid steel decorative nail? Well, yes … she did. I say all this to say, in real life, for prices to be rationalized, the demand curve has to exist robustly and elastically and not just when the auctioneer happens to be a blacksmith who just happens to be very drunk. But look, as I said in multiple episodes, is it fair that employers find themselves needing to be the demand curve in order to create a healthcare market? Are they capable? Is this optimal? All are excellent, open questions and, to be fair, beside the point, because as it stands, our entire healthcare sector is built to function around the construct that there is, in fact, a market and there's not a market without a demand curve. So, thanks to all of you who are or help, for real now, employers and unions be all the demand curve they can be. Cora Opsahl: Hi, this is Cora Opsahl, 32BJ Health Fund director. Relentless Health Value is the place to get a deep understanding of all aspects of healthcare. I used it to learn about the complex system of healthcare years ago, and I still learn something new almost every episode. I truly believe it is the collective action of the Relentless Health Value tribe that will change healthcare for the better. Stacey: I also just wanna say thanks much to all you doctors and clinicians and indie practices and others who offer options. A market requires competition to work. So, thanks to all of you who work so hard to be those options. I am so grateful to all of you and offer you this basket of my thanks as a patient, as a member, and a U.S. and state taxpayer. Thank you for helping out the demand curve. Chris Deacon: Hi, I'm Chris Deacon with VerSan Consulting. If you're listening to Relentless Health Value, we already have something important in common. You care about fixing what's broken in healthcare. This isn't just a podcast I tune into. It's one that I revisit, reflect on, and highly recommend. Stacey's conversations don't stop at the mic. They spark ideas, challenge assumptions, and fuel the work so many of us are doing to fix healthcare. If you're here for real change, you're in the right place. Subscribe to the podcast, sign up for the newsletter, and let's keep the momentum going. Thanks for listening. Stacey: Here's the fourth basket of thanks I want to hand out here: to those of you who have contributed financial support to the Relentless Health Value podcast. And look, this is weird to go off on because originally, 10 years ago, I kind of poked away at this passion project of mine off the side of my desk with very little editing, very little production, and very little fanfare. But now the show is, well, it's a pretty big show; and with that comes additional real expenses. Couple that with the fact that I'm just a maniac about not taking advertising from folks I do not want to take advertising from. And I'm just being totally honest that it can be really hard, which is why I am so thankful to those of you who offer your financial support. We definitely have a great advantage because Tom Nash, our producer, sound engineer, and editor extraordinaire is also a volunteer; and I am so, again, thankful for that. Could not do this without him or the rest of our amazing Relentless Health Value team who helps us off the sides of their Aventria desks. This includes Sandra Arts, Kathleen Kurtz, Hannah Cassel, Eric Hoch, David Umla, Tasha Cerny, Marko Etar, Lorraine Davis. I'm also so thankful for those of you who have donated enough to cover or almost cover the cost of one episode. Many who make these donations are eager for us to address a particular topic that they think is interesting for you, Relentless Health Value listeners. And if that topic aligns with ones that we think you would like to hear about, it is definitely something I knew from the very beginning would be a win-win to invite these individuals to be guests. But one thing I did not anticipate, actually, was how having guests who are so deeply in the tribe with enough conviction to be willing to contribute financially, just how much that conviction adds up to some really good episodes and furthers the sense of community that at least I feel. Then lastly, thank yous in this basket go to the number of you who have signed up for a monthly contribution. Wow, you are amazing! I am sure I am going to finally, I've been threatening this for a while, but really I am at this time working on setting up some Zoom calls so we all can get to know each other a little bit better. I'm saving the biggest basket of thank yous for last, and these thank yous go out to all of you listening—and sure, thank you for listening—but even more, thank you for making what we talk about on these shows actionable. Thank you for doing what you do for members and patients every single day. You are why I continue to plug away at this each and every week. Happy Thanksgiving, really, from the bottom of my heart. Thank you so much for being here. Also mentioned in this episode are Aventria Health Group; Rob Marty; Dan Greenleaf; Kelly Kirby Fisher; Vivian Ho, PhD; Chris Skisak, PhD; Houston Business Coalition on Health; Texas Employers for Affordable Health Care; Cora Opsahl; Shane Cerone; Sam Flanders, MD; Elizabeth Mitchell; Kada Health; 32 BJ Health Fund; Chris Deacon; VerSan Consulting; Tom Nash; Sandra Arts; Kathleen Kurtz; Hannah Cassel; Eric Hoch; David Umla; Tasha Cerny; Marko Etar; Lorraine Davis; and Mark Cuban. For a list of healthcare industry acronyms and terms that may be unfamiliar to you, click here. For more information, go to aventriahealth.com. Each week on Relentless Health Value, Stacey uses her voice and thought leadership to provide insights for healthcare industry decision makers trying to do the right thing. Each show features expert guests who break down the twists and tricks in the medical field to help improve outcomes and lower costs across the care continuum. Relentless Health Value is a top 100 podcast on iTunes in the medicine category and reaches tens of thousands of engaged listeners across the healthcare industry. In addition to hosting Relentless Health Value, Stacey is co-president of QC-Health, a benefit corporation finding cost-effective ways to improve the health of Americans. She is also co-president of Aventria Health Group, a consultancy working with clients who endeavor to form collaborations with payers, providers, Pharma, employer organizations, or patient advocacy groups. 01:25 First thank you: to those who do not succumb to healthcare narcissism. 01:36 INBW39 with Stacey. 02:51 INBW37 with Stacey. 03:00 EP399 and EP400 with Stacey. 05:40 Second thank you: to those willing to pay it forward. 05:53 EP489 with Dan Greenleaf. 08:12 EP452 with Cora Opsahl. 08:38 Third thank you: to those who aid the demand curve in healthcare. 09:14 EP490 with Shane Cerone and Sam Flanders, MD. 09:16 EP491 with Elizabeth Mitchell. 09:17 EP492 with Sam Flanders, MD, and Shane Cerone. 09:49 Why healthcare needs a demand curve. 13:34 Fourth thank you: to those who have contributed financial support to the Relentless Health Value podcast. 15:47 The final thank you: to the listeners. For more information, go to aventriahealth.com. Our host, Stacey Richter, discusses #demandcurve and gives thanks on our #healthcarepodcast. #healthcare #podcast #financialhealth #patientoutcomes #primarycare #digitalhealth #healthcareleadership #healthcaretransformation #healthcareinnovation Recent past interviews: Click a guest's name for their latest RHV episode! Olivia Ross, John Quinn, Dr Sam Flanders and Shane Cerone (EP492), Elizabeth Mitchell (EP491), Shane Cerone and Dr Sam Flanders (Part 1), Dan Greenleaf (Part 2), Dan Greenleaf (Part 1), Mark Cuban and Cora Opsahl, Kevin Lyons (Part 2), Kevin Lyons (Part 1)

This OG of directly contracted high-value networks or Centers of Excellence networks came up, name dropped and everything in the episode with Elizabeth Mitchell from PBGH, the Purchaser Business Group on Health, from two weeks ago. That was episode 491. So, welcome to this deep cut episode with Olivia Ross from way back, pre-pandemic times. For a full transcript of this episode, click here. If you enjoy this podcast, be sure to subscribe to the free weekly newsletter to be a member of the Relentless Tribe. This high-value network—its official name is the Employers Centers of Excellence Network, or ECEN—and it really came up in a meaningful way in that Elizabeth Mitchell episode, and it came up for two reasons. (1) Because the work in that recent PBGH data demonstration project—and again, listen to the show with Elizabeth Mitchell for more on that if you didn't already—but here's the bottom line, whether you did or you didn't. The PBGH demonstration project now gives plan sponsors like self-insured employers, with currently available transparency data and claims data, you can see the quality, price, and safety of any given service; and you can compare that price, quality, and safety with other hospitals. Having this information enables any given self-insured employer or other plan sponsor to create a high-value network or Centers of Excellence network. They can do this all by themselves. They can create a high-value network all by themselves. So, there's that, and that is a really, really big sea change. (2) ECEN was, again, as I just said, a direct contracted network. And you know what Elizabeth Mitchell said during that recent show, episode 491? She said it's now confirmed that direct contracts between employers and clinical organizations perform way better than anything that most other third parties have negotiated. I liked how Jeff Hogan summed this all up. It's a great post. But Jeff wrote, "Direct contracts have more measurable value than generic blunt instrument networks. Direct contracts serve the specific interests of the specific group. They also give unique care delivery organizations the opportunity to align their specific services with unique populations without the involvement of confiscatory middlemen." And, yeah, this is really good news for all you unconfiscatory TPAs and others out there. This is really an opportunity to prove differentiation from those who enjoy the arbitrage maybe a little too lavishly. And maybe lavishly is a really great word here, actually, because it's allegedly and apparently (as per more than one person who would certainly know) self-insured employers pay on average about 30% more in their claims wire for a service than whoever provided said service got paid. There's 30% added onto the top. And look, I am certainly not saying that, you know, administrators shouldn't be paid or anything like that. Nobody should be working for free. The only problem here is when this 30% is not being disclosed, and it's often not. Brokers are in this arbitrage mix as well, of course—the not transparent ones, I mean, plus others. I saw Andrew Tsang's graphic that showed 27 streams of payment coming out of the middle between plan sponsors paying and a clinician getting paid. Okay … so, this directly contracted ECEN movie actually does have a sad ending, just FYI. The ECEN high-value network that we talked about in the pod that follows? It was ultimately dismantled. Why was it dismantled? I don't know. It did happen right around the time that the independent and really capable TPA who was administering this whole thing and doing great member engagement also, this TPA was bought out by a larger firm. Maybe the timing was coincidental, though. One last point before I roll tape. TPA obviously stands for third-party administrator. ASO stands for administrative services only. I've been hearing more than once lately that the right way to proceed, in the future, is for employers to negotiate their own direct contracts for all the reasons that we just talked about with high-value clinical organizations. And then the TPA should just administer those contracts—administrative services only. Which is exactly what was going on in this ECEN. So, let the old be new again. And all this is very good news, again, for great clinicians, great clinical organizations, and truly transparent TPAs and brokers who align themselves with the fiduciary responsibilities of their clients. Themes that come up today include employers ganging up to get better prices on direct contracts. Cora Opsahl and Mark Cuban (EP488) talked about this some. Olivia also in the show that follows, she gets kind of deep into how quality was assessed, just the depth of the value assessment that went on there. It actually went down to the physician level, and all this is really important ingredients here to really be able to select a center of excellence based on actual value. Because as has been said multiple times by multiple people on the show, most carrier "high-value networks," when you actually look at who's included in those high-value networks, you look at their quality and their price, these places are not high value by most normal definitions of high value anyway. So, question mark. One last thing besides my normal thank you to Aventria Health Group for sponsoring this episode, I am so pleased to thank Payerset for donating to help Relentless Health Value stay on the air. Payerset is a price transparency company with a mission to democratize healthcare pricing. Love that. Payerset empowers healthcare organizations, payers, employers, and benefits coalitions with the most complete set of real market pricing data. They benchmark every negotiated rate and claim tracking reimbursement trends and delivering the actionable insights needed for smarter contract negotiations and a more transparent healthcare system. Also mentioned in this episode are Transcarent; Elizabeth Mitchell; Purchaser Business Group on Health (PBGH); Jeff Hogan; Andrew Tsang; Mark Cuban; Cora Opsahl; Payerset; Matt McQuide; Christine Hale, MD, MBA; Eric Bricker, MD; The Leapfrog Group; National Quality Forum; Sam Flanders, MD; and Kada Health. For a list of healthcare industry acronyms and terms that may be unfamiliar to you, click here. You can learn more at Transcarent and follow Olivia on LinkedIn. Olivia Ross, MBA, MPH, is senior director, product AI enablement, at Transcarent. Previously, Olivia led the development and implementation of the Employers Centers of Excellence Network (ECEN) for the Purchaser Business Group on Health. 07:40 Prospective bundles and the cost of care. 08:22 How the largest cost savings come from the improvements in quality. 09:51 What Olivia looks for in choosing centers of excellence. 10:36 Creating market pressure and avoiding consolidation. 11:17 Creating positive disruption in the healthcare system. 12:17 How Olivia chooses the centers and providers she works with in the Purchaser Business Group on Health. 13:12 The quality metrics Purchaser Business Group on Health looks at when assessing providers and centers. 14:04 What a team assessment is, and why it's important. 15:07 How local PCPs have to factor into this health care model. 17:57 How Purchaser Business Group on Health intervenes in the patient journey to ensure that the patient and the employer are getting the best quality care for the best price. 19:39 Olivia's suggestions on how to have an intervening conversation with a patient who has already been told he or she needs surgery. 20:18 EP468 with Matt McQuide. 20:20 EP471 with Christine Hale, MD, MBA. 20:22 EP472 with Eric Bricker, MD. 25:27 "Even at a more competitive price point, there's still an upside to them getting this new business." 25:52 How choosing specific physicians is part of the COE designation process. 27:35 How COEs and their physicians are also involved in continuous quality improvement. 30:56 Employers Centers of Excellence Network collaboration with The Leapfrog Group. 32:24 How the Employers Centers of Excellence Network program is open to any employer, no matter the size. 32:54 What it takes to join the Employers Centers of Excellence Network. You can learn more at Transcarent and follow Olivia on LinkedIn. Olivia Ross, MBA, MPH, discusses the development of @TheECEN for @PBGHealth on our #healthcarepodcast. #healthcare #podcast #financialhealth #patientoutcomes #primarycare #digitalhealth #healthcareleadership #healthcaretransformation #healthcareinnovation Recent past interviews: Click a guest's name for their latest RHV episode! John Quinn, Dr Sam Flanders and Shane Cerone (EP492), Elizabeth Mitchell (EP491), Shane Cerone and Dr Sam Flanders (Part 1), Dan Greenleaf (Part 2), Dan Greenleaf (Part 1), Mark Cuban and Cora Opsahl, Kevin Lyons (Part 2), Kevin Lyons (Part 1), Dr Stan Schwartz (EP486)

Hello, all you great people trying to figure out how to do right by patients. Welcome to it. I was and am always extremely curious if any of what we talk about over here on Relentless Health Value has, in any way, percolated over to your average employer CEO—the ones who do not listen to this show, I mean. For a full transcript of this episode, click here. If you enjoy this podcast, be sure to subscribe to the free weekly newsletter to be a member of the Relentless Tribe. This is what I try to figure out during my conversation upcoming here with John Quinn from Wellnecity® today, and I score some advice to boot for employers in the face of any of these revelations that they may have. That's what's gonna go down today, and this whole endeavor is a decent plan, if I do say so myself, because John Quinn chats up a lot of employer CEOs. He's certainly got a bit of a catbird seat there. So, taking it from the top, I wanted to see how clued in these employer C-suites might be to a fundamental myth, which, if employer folks don't realize it is in fact a myth, it means that a whole lot of transformational power is going nowhere fast. And this myth is the mother of all myths: the "there is a market in healthcare" myth. We've been on a tear about this for three episodes now, at least as it relates to hospitals and health systems. I'm gonna refer everybody to LinkedIn because Luke Trocchio put up a, I don't know what you call it, a reel, highlighting something that Shane Cerone said in episode 490. And then I'm gonna tell you why whatever CEOs at self-insured employers are thinking here makes all the difference in the world. But what Shane said is this, "The myth is that we have a functioning marketplace, and we don't." Shane continues, "What I mean by [there is no actual healthcare market], as somebody who's been a CEO of multiple hospitals and health systems, hospitals don't compete on price for patients. It … doesn't work that way. And so, we don't really have a normal market incentive to reduce cost or, in this case, the price of services in order to remain competitive." Now look, and this isn't rocket science, but it needs to be said out loud. The reason there is no healthcare market largely is because self-insured employers have not insisted upon there being one. Is that fair? I don't know. And whether or not it's fair is irrelevant to this point. Self-insured employers pay for healthcare for, like, 160 million Americans. They are largely the demand curve. They are the demand side of any market that exists. Because you know something that doesn't our market make? You can't ask the supply side to create demand elasticity. You can't get a seller to get a buyer to buy or not buy at some price point. That would be like a comedy skit. Except in this case, you know, patients die or go bankrupt because they can't afford care. So, it's not really all that funny. But if in this country we are depending on health system prices being constrained by a market, and then you don't have a buyer who doesn't buy when the price is higher than the buyer wants to pay or a buyer who doesn't buy unsafe stuff or low-quality goods or services, you're gonna get sky-high prices. Welcome to it right now. Also, if there's no competition, again, no market. But competition a lot of times doesn't surface if there's no point in starting up a business because there's no demand for lower prices or higher-quality care. I mean, if no one cares if you have lower prices or higher quality, then how are you gonna attract patient volume or steal market share, right? Like, unless you're really good at marketing, I guess, or have accumulated market power. I'll say this again. If our whole, the whole healthcare sector pricing structure is built on the myth that there is a market and then there's no market and employers aren't filling for whatever reason, the vital demand side role that they have to play for there to be a market, then, right … hello, 37% renewals like we see coming up in New Jersey. Listen to the show with Kevin Lyons (EP487, Part 1). So, I say all this to say, do employer CEOs even know they have one job here? And I'm not talking about, again, whether or not this is fair, whether they're capable of pulling this off. I'm just distilling this whole thing down to this is the question that remains on the ground. So anyway, this is first and foremost what I go after John Quinn from Wellnecity to figure out today: Where's your average CEO in this learning curve? Now here's some demand curve optimism. The show from two weeks ago with Elizabeth Mitchell (EP491) from PBGH, the Purchaser Business Group on Health. In that show from a couple weeks ago, we talk about what PBGH members, who are very large employers, what they're up to. So, certainly go back and listen to that if you haven't. Okay, so with that, here's my conversation with John Quinn from Wellnecity, as I have mentioned; and you'll get two things out of this conversation. Number one, a level set on what employers' leadership teams are figuring out and why they are figuring this out. (Renewal shocks and employees complaining about affordability much?) But also how the mindset needs to shift in the C-suite for anything to really happen here. In other words, what's the assignment and what's some very top-line advice to get there? That's how I finish up the conversation with John Quinn today. Do just wanna note that Wellnecity so kindly offered to pick up some of the tab to produce this Relentless Health Value show, which, as I keep saying is … yeah, it is expensive to keep this train on the track. People often forget it's not just what goes into the recording, the hosting, the producing, the editing of a podcast, but there also is a whole Web site and an API feed and headshots and graphics and transcriptions and a proofreader. It's a whole thing, guys, even if the host is a volunteer with a day job. So, thanks much to Wellnecity for the contribution to the fund and for coming on the pod today. John Quinn is CEO of Wellnecity. Wellnecity does health plan management for employers that self-fund their health plan. The key role Wellnecity plays is how do they help those employers better manage the spend category called health benefits. This podcast, as I said, is partially sponsored by Wellnecity and also Aventria Health Group. Also mentioned in this episode are Wellnecity; Luke Trocchio; Shane Cerone; Kevin Lyons; Elizabeth Mitchell; Purchaser Business Group on Health (PBGH); Paul Holmes; Peter Hayes; Healthcare Purchaser Alliance; Mark Cuban; Lauren Vela; Cora Opsahl; Andreas Mang; Jon Camire; Eric Bricker, MD; and Christine Hale, MD, MBA. For a list of healthcare industry acronyms and terms that may be unfamiliar to you, click here. You can learn more at Wellnecity and follow John on LinkedIn. John Quinn is the founder and CEO of Wellnecity, a health tech innovator on a mission to measurably improve the quality and affordability of employer-sponsored health plans in the United States. Under John's leadership, Wellnecity developed the groundbreaking Smart Hub platform, which integrates data from multiple vendors to simplify health plan management. Smart Hub enables organizations to measure ROI objectively, uncover savings, enhance member engagement, and reduce fiduciary risk. Building on this foundation, Wellnecity has launched its next-generation plan management platform, equipping HR leaders with real-time oversight, vendor accountability, and measurable ROI. The platform empowers leaders to act in the moment, redirecting spend, simplifying oversight, and delivering better healthcare for employees. John is also the author of Benefits Revolution: The Next Generation of Employer-Sponsored Healthcare and is widely regarded as a thought leader in the healthcare space. He believes healthier businesses are built on smarter healthcare for employees, and that data is the key to driving this transformation. Prior to founding Wellnecity, John spent 25 years at Andersen Consulting, Diamond Technology Partners, and McKinsey & Company. He advised Global 1000 companies and high-growth start-ups, helping them build new businesses, products, and channels. His expertise in digitized information and network effects has driven meaningful business model innovation. John is a sought-after speaker on topics such as the benefits revolution, the power of data, fixing what's broken, and health tech leadership. Helping organizations deliver innovation is his mission; fixing what's broken is his passion. 07:06 Why CEOs are looking more closely at healthcare spend. 08:06 EP397 with Paul Holmes. 08:21 How savings and health benefits are directly connected. 10:45 EP436 with Elizabeth Mitchell. 11:46 What missed earnings look like in relation to healthcare. 14:27 How costs have been shifting to employees for years, and why this doesn't work anymore. 17:36 EP475 with Peter Hayes. 18:23 What employers need to do instead of cost shift. 19:12 EP406 with Lauren Vela. 21:30 Why it's important to make health benefit changes at the speed of business, not at the speed of the benefits year. 26:17 Why is it important to put a finance function into your benefits? 27:10 EP488 with Mark Cuban and Cora Opsahl. 27:33 EP478 (Part 1) with Andreas Mang and Jon Camire. 27:35 Why daily data matters. 31:10 EP487 (Part 1) with Kevin Lyons. 31:21 Why it's important to hold vendors accountable. 31:47 Why it's important to move on from vendors who can't hold up to your scrutiny and needs. 33:46 EP472 with Eric Bricker, MD. 34:46 EP471 with Christine Hale, MD, MBA. You can learn more at Wellnecity and follow John on LinkedIn. John Quinn gives advice to #employer #CEOs on the #healthcaremarket on our #healthcarepodcast. #healthcare #podcast #financialhealth #patientoutcomes #primarycare #digitalhealth #healthcareleadership #healthcaretransformation #healthcareinnovation Recent past interviews: Click a guest's name for their latest RHV episode! Dr Sam Flanders and Shane Cerone (EP492), Elizabeth Mitchell (EP491), Shane Cerone and Dr Sam Flanders (Part 1), Dan Greenleaf (Part 2), Dan Greenleaf (Part 1), Mark Cuban and Cora Opsahl, Kevin Lyons (Part 2), Kevin Lyons (Part 1), Dr Stan Schwartz (EP486), Dr Cristin Dickerson

Here's something that one of my guests today, Shane Cerone, says coming up here pretty quick. Shane Cerone and Dr. Sam Flanders are my return guests. Shane says, "We created a management model for our health system that was focused on surviving at 150% of Medicare. [Normally] there's a lot of layers of inefficiency in healthcare and in our health systems. Some of them can absolutely be reduced without any significant impact [to quality]." For a full transcript of this episode, click here. If you enjoy this podcast, be sure to subscribe to the free weekly newsletter to be a member of the Relentless Tribe. So, while this show today focuses on solutions for health systems, it's inside information also that is really relevant to plan sponsors as well as others. So, here we go. You'll like this. It's actionable. Two weeks ago, just reviewing real quick here, Shane Cerone and Dr. Sam Flanders from Kada Health talked with me (EP490) about the problems that any given solution needs to solve for at any given health system. So, this solution show is, or really should be, really timely because there really should be urgency now amongst health systems to solve inefficiency problems and solve them fast. Two reasons for the need to speed: (a) The myths that enable some of these problems to proliferate are being dismantled (these myths), and more people realize that they are well and truly myths. Listen to that show from two weeks ago where we get into these myths in detail. But also (b) is per the show last week with Elizabeth Mitchell from PBGH, the Purchaser Business Group on Health. Elizabeth Mitchell talks about what the newly complete PBGH transparency demonstration project accomplished, and it's a done deal, folks. None of this is theoretical. Elizabeth Mitchell says, what this project does, this transparency demonstration project does, first of all, it tells plan sponsors how much a health service costs. Second of all, it tells the plan sponsor how much the range for that service is. So, are they paying a fair price or not? If a member goes to one facility and it's literally five times more than the facility across the street with the same quality, that is really important information for a plan sponsor trying to effectively manage their plan, reduce costs, and improve access to high-quality providers. And you know what else now becomes possible? Plan sponsors creating their own high-value networks becomes possible. Plan sponsors creating their own centers of excellence networks becomes possible. Plan sponsors who steer and tier away from low-quality but really high-priced health systems becomes possible. And it won't matter how many billboards that health system puts on the highway. The value of the service is transparent, and I'm saying all this with the intent of protecting from financial harm patients, plan sponsors. But I'm also saying this again on behalf of those individuals who work at health systems who are trying to grab a foothold to do the right thing. And further, my intent here is to actually help hospitals because there are health systems out there who have margins that are bigger than Amazon's. Their charity care at the same time comes in at 2% or 3% of their revenues, which is abysmal. And it's very weird and sad when senior leaders cry poor when they underpay clinicians and then raise prices that are harmful to the very community that they claim to serve. Maybe some of these insights will help anybody so inclined to fix that. And look, I get that now is a crappy time given Medicaid and what's up with the ACA markets. But honestly, never let a good crisis go to waste. So, maybe this is actually the perfect time to embark on some of the solutions discussed today. If I wanna open the "let's get real" drawer, though, if you want to know why many health systems will not actually do any of this that we're talking about today, listen to the shows with Suhas Gondi, MD, MBA (EP404); the show with Vivian Ho, PhD (EP466); and also the one with Scott Conard, MD (EP462) for more insight into what some CEOs and boards may or may not be up to. And in short, their goals may be less about serving their communities at this point and more about other things. The show coming up with Mick Connors, MD, also touches on this. Now let's talk solutions. Some of what gets discussed today definitely reminded me of that show with Beau Raymond, MD (EP455) and the one with Eric Gallagher (EP405) from Ochsner. The conversation today also reminded me of something Jerry Durham wrote, where he was talking about how everybody talks about the importance of creating trust between doctor and patient. But so few discuss that this is really hard to do with the infrastructure or even other people around said clinical care team are not acting in ways that are worthy of trust. And that might happen any variety of ways when the front desk disrespects a patient or doesn't listen. It might happen when the bill comes. So, right, having the right culture is the one ring to rule them all, followed by being actually good at strategy and then deploying said strategy effectively, not just making spaghetti diagrams on some whiteboard and the end. Doing this effectively means having a management model focused on every level of the organization being tasked to solve the problems they see as, like, part of their job—to spot and solve problems. As I have said multiple times already, my guests today are Shane Cerone and Dr. Sam Flanders. These two were leadership colleagues at Beaumont Hospital (Royal Oak), where Shane served as president of the flagship 1000-bed teaching hospital and Dr. Flanders oversaw all quality and patient safety programs as chief quality and safety officer for the entire system. Under their leadership, Beaumont Hospital was #1 nationally recognized in nine medical specialties, got awards for seven consecutive years as one of the top hospitals in the country for care quality and patient safety, and also they charged 143% of Medicare—143% of Medicare and high quality. This podcast is sponsored by Aventria Health Group, but I do need to mention that Kada Health, which is the organization that both Shane Cerone and Dr. Sam Flanders work for, so generously offered some financial support to Relentless Health Value. So, I will also say that this show is partially sponsored by Kada Health, and I couldn't appreciate it more. Also mentioned in this episode are Kada Health; Elizabeth Mitchell; Purchaser Business Group on Health (PBGH); Suhas Gondi, MD, MBA; Vivian Ho, PhD; Scott Conard, MD; Mick Connors, MD; Beau Raymond, MD; Eric Gallagher; Jerry Durham; Jonathan Baran; Dan Greenleaf; Mark Cuban; Charlie Voss; Cindy Voss; John Lee, MD; Benjamin Schwartz, MD, MBA; Kathy Pawlicki; Dan O'Neill; Zack Cooper; Cora Opsahl; National Alliance of Healthcare Purchaser Coalitions; John Rodis, MD, MBA; and Tom Nash. For a list of healthcare industry acronyms and terms that may be unfamiliar to you, click here. You can learn more at Kada Health and follow Dr. Flanders and Shane on LinkedIn. Sam Flanders, MD, FAAP, is a seasoned healthcare executive and physician with a distinguished career in quality, safety, and performance improvement leadership. He most recently served as executive vice president for quality, safety, and population health at St. Luke's Hospital in St. Louis, Missouri. Prior to joining St. Luke's, Dr. Flanders held the position of senior vice president and chief quality and safety officer at Beaumont Health (now Corewell Health) in Michigan. Prior to Beaumont, he served in a similar role at Indiana University Health (formerly known as Clarian Health Partners). Dr. Flanders earned his medical degree from the University of Illinois College of Medicine and has an undergraduate degree in computer science from University of Michigan. He is board-certified in pediatrics. For over 30 years, he has served as a volunteer physician at summer camps for children with diabetes, helping to educate and support young campers to better control their disease. Shane Cerone is the CEO of Kada Health, LLC, a consulting, management, and leadership practice that supports employers in reducing the cost of exceptional healthcare and advises hospitals, health systems, outpatient centers, and physician groups on practices that improve care quality and efficiency. Prior to establishing Kada Health, Shane spent more than 20 years leading high-performing hospitals and physician group practices in both community and academic health systems. He has served as the president/chief executive for Beaumont Hospital (Royal Oak), Mercy Iowa City, Virginia Commonwealth University Hospitals, and St. Luke's Hospital & Health Network in St. Louis. During his tenure as its president, Beaumont Hospital (Royal Oak) was recognized as one of the nation's highest-performing hospitals and health systems, consistently ranked as a national leader for clinical excellence (US News & World Report), care quality and safety (University HealthSystem Consortium), and affordability (the RAND Corporation). Shane earned a bachelor of arts degree in biology from Nebraska Wesleyan University and a master of arts degree in hospital and health administration from the University of Iowa, where he serves as adjunct assistant professor. 07:08 What are the many problems that health systems deal with? 08:44 EP483 (Part 1 and Part 2) with Jonathan Baran. 09:43 What was the real achievement in building this hospital system? 10:25 EP489 (Part 1 and Part 2) with Dan Greenleaf. 10:42 Why productivity and patient access are the top two things to focus on. 11:36 EP488 with Mark Cuban and Cora Opsahl. 12:32 EP455 with Beau Raymond, MD. 12:58 The lean model versus the Toyota model. 16:06 EP438 with John Lee, MD. 16:40 EP481 with Benjamin Schwartz, MD, MBA. 17:44 Why small changes accumulated create greater change than big changes. 21:01 How an efficiency mindset can increase improvement faster. 27:42 Why administrators should not be negotiators. 28:11 EP491 with Elizabeth Mitchell. 29:06 What are the steps to this multifaceted process? 30:17 EP286 with John Rodis, MD, MBA. 30:48 Study by Suhas Gondi, MD, MBA, on hospital boards. 33:03 Why it's important to focus on the pricing issue first. 33:49 What Kada Health is all about. You can learn more at Kada Health and follow Dr. Flanders and Shane on LinkedIn. Sam Flanders and Shane Cerone discuss operating #highquality #hospitals at 143% #medicare on our #healthcarepodcast. #healthcare #podcast #financialhealth #patientoutcomes #primarycare #digitalhealth #healthcareleadership #healthcaretransformation #healthcareinnovation Recent past interviews: Click a guest's name for their latest RHV episode! Elizabeth Mitchell (EP491), Shane Cerone and Dr Sam Flanders (Part 1), Dan Greenleaf (Part 2), Dan Greenleaf (Part 1), Mark Cuban and Cora Opsahl, Kevin Lyons (Part 2), Kevin Lyons (Part 1), Dr Stan Schwartz (EP486), Dr Cristin Dickerson, Elizabeth Mitchell (Take Two: EP436)

Today, back on the pod, we have Elizabeth Mitchell, CEO of PBGH, the Purchaser Business Group on Health. Elizabeth Mitchell is talking about the why, as in why did PBGH embark on a big cost and quality safety transparency data demonstration project that they just finished up? They did said project, by the way, with Milliman, Embold, and it was funded by Peterson. For a full transcript of this episode, click here. If you enjoy this podcast, be sure to subscribe to the free weekly newsletter to be a member of the Relentless Tribe. This episode is a little longer than usual, and I did consider breaking it into two. But the thoughts that Elizabeth Mitchell shares are so vitally intertwined and the impact of all of this is big enough that, yeah, if you don't get through this whole show in one sitting, do come back and listen to the rest of it later on. Make your own part 2. Okay, so on the show today, first of all, we start out by diving right into the why. Why do this demonstration project, and why do I call it a game changer? Well, simple, really. The second I saw the data showing the real price of any given healthcare service, along with its quality and safety scores for clinical organizations, and down to the individual NPIs (National Provider Identifiers) actually, I had eyebrows glued to my hairline. Turns out (ruining the suspense, I guess), those big-brand health systems with the flashiest billboards and sports sponsorships, not always the highest quality. This isn't speculation. It's right in the scores. There is zero correlation between price and quality. Zero. So look, this insight and ability to see prices, quality, and safety all together now done by PBGH for its large employer members—who spend, by the way, over $350 billion (that's with a "b") a year on healthcare, thus representing a very, very profitable gang of customers for many in the healthcare industry—this whole thing has big game-changing energy for these employers themselves but also game-changing ripples that extend into the businesses of other stakeholders as well. Again, let's consider a few of these. What's the game-changing impact on consultants and TPAs (third-party administrators)? I'd say this project opens up opportunities for good unconflicted consultants and indie TPAs who know their stuff inside and out. Because now employers have the wherewithal to deduce who the good consultants and TPAs are, which has been hard heretofore (check this post by Bryce Platt, PharmD). That's great news. Still speaking of the impact on TPAs and consultants—but this time ones probably not listening right now—in the middle of the episode, Elizabeth Mitchell talks about TPAs and consultants getting called into their client's corporate boardroom to explain themselves after some of the results from this demo project were released to PBGH members. Awkward. When the client knows more about the prices they're paying and the quality and safety they're getting, then they're a longtime consultant or TPA or ASO (which means administrative services only) vendor, all of whom are supposed to be the experts. It becomes real clear, real fast that discounts are irrelevant and anybody selling discounts is gonna not look so good, even if they buy everyone in the HR department box seats to see Disney on Ice, which is just another point to ponder. Speaking of getting called onto the carpet, Elizabeth Mitchell, again, my guest today, says during the early part of the conversation that follows, she says, "One of the other things that [our PBGH transparency] project demonstrated was that [for these jumbo employers] the directly contracted arrangements [the direct contracts] were higher value than anything negotiated by the TPAs." Oh, snap! Elizabeth said that right after I said that I've been hearing more and more that TPAs (ie, third-party administrators) hired by self-insured employers to administer their health plan benefits, I've heard multiple times in the past several weeks that maybe TPAs should maybe just stick to administrating—administrative services only, as they say. Let someone else do the negotiating. For example, let employers just direct contract themselves. There's only so many times you can hear that the cash price is cheaper than the TPA- or carrier-negotiated rate before this occurs to someone. Check this link to a crazy Instagram that Kurt Christie sent me on this topic that just highlights the ludicrousness of how a single patient with no insurance somehow is a better negotiator than the largest corporate entities in this country for whom this is their day job. And you know what else game changing can happen when employers have access to cost, quality, and safety information? They can create their own so-called high-value networks of the best docs and care teams. They can design their own specialist networks. And again, as far as game-changing impact goes, that's probably good news for the great docs and care teams out there, especially if the way the quality and safety results are tabulated are transparent, which is something I was talking about with Siva, otherwise known as Ahilan Sivaganesan, MD, the other day. It's a mystery to the docs as much as the employers how value is calculated in some of these carrier so-called high-value networks. Elizabeth talks about this. Okay … so, call this whole now there's transparent cost, quality, and safety data that is being used by big self-insured employers, call it one mighty insight of many actionable actions for many folks, TPAs, consultants, health systems, even down to the clinician level that you will hear about on the show today. And again, it's great news for those in our Relentless Health Value tribe doing the right thing by the CAA (Consolidated Appropriations Act) and their patients and their members and not-so-great news, honestly, for those who are likely not listening anyway, again, which leads me to self-insured employers and the impact of this project on them specifically and for them. And Elizabeth says this in so many words. She says as a self-insured employer, not using this new transparency data is irresponsible. Period. It's not just a compliance thing, which it is. It's a basic fiduciary duty, smart business, and also your edge in attracting and retaining talent with real high-value health benefits that are actually affordable. Also mentioned in this episode are Purchaser Business Group on Health (PBGH); Bryce Platt, PharmD; Kurt Christie; Ahilan Sivaganesan, MD; Julie Selesnick; Chris Deacon; Antonio Ciaccia; Cristin Dickerson, MD; Stanley Schwartz, MD; Mark Cuban; Cora Opsahl; Jonathan Baran; Keith Hartman, RPh; Autumn Yongchu; Erik Davis; Olivia Ross; Kevin Lyons; Al Lewis; John Rodis, MD, MBA; Shane Cerone; and Sam Flanders, MD. For a list of healthcare industry acronyms and terms that may be unfamiliar to you, click here.   You can learn more at PBGH, by emailing Elizabeth at emitchell@pbgh.org, and by connecting with Elizabeth on LinkedIn.   Elizabeth Mitchell, president and CEO of the Purchaser Business Group on Health (PBGH), advances its strategic focus areas of advanced primary care, functional markets, and purchasing value. She leads PBGH in mobilizing healthcare purchasers, elevating the role and impact of primary care, and creating functional healthcare markets to support high-quality affordable care, achieving measurable impacts on outcomes and affordability. At PBGH, Elizabeth leverages her extensive experience in working with healthcare purchasers, providers, policymakers, and payers to improve healthcare quality and cost. She previously served as senior vice president for healthcare and community health transformation at Blue Shield of California, during which time she designed Blue Shield's strategy for transforming practice, payment, and community health. Elizabeth served as the president and CEO of the Network for Regional Healthcare Improvement (NRHI), a network of regional quality improvement and measurement organizations. She also served as CEO of Maine's business coalition on health (the Maine Health Management Coalition), worked within an integrated delivery system (MaineHealth), and was elected to the Maine State Legislature, serving as a State Representative. Elizabeth served as vice chairperson of the U.S. Department of Health and Human Services Physician-Focused Payment Model Technical Advisory Committee, board and executive committee member of the National Quality Forum (NQF), member of the National Academy of Medicine's "Vital Signs" Study Committee on core metrics, and a guiding committee member for the Health Care Payment Learning & Action Network. Elizabeth holds a degree in religion from Reed College and studied social policy at the London School of Economics.   06:35 How did PBGH's transparency project start? 07:35 EP428 with Julie Selesnick. 07:37 EP408 with Chris Deacon. 07:39 Why the changes to the CAA and ERISA meant heightened risk for employers and individuals within companies. 09:09 "You can't outsource the risk." 11:10 How PBGH's transparency project demonstrated some clients being noncompliant. 12:52 Why is it irresponsible not to use the data presented if you're a self-insured employer? 15:06 How did PBGH use the transparency data and apply it effectively to improve their offerings and business? 18:37 Why TPAs should not negotiate contracts. 19:17 EP485 with Cristin Dickerson, MD. 19:22 EP486 with Stan Schwartz, MD. 19:24 EP488 with Mark Cuban and Cora Opsahl. 20:58 "There is no good price for unsafe care." 21:36 How PBGH found using the transparency data to be totally feasible. 25:03 EP483 (Part 1) with Jonathan Baran. 25:32 Why the market will evolve with this data. 28:04 EP369 with Keith Hartman, RPh. 28:06 EP370 with Erik Davis and Autumn Yongchu. 28:34 What PBGH discovered about high-value centers and centers of excellence. 28:59 EP240 with Olivia Ross. 32:26 Why incentives are another challenge. 33:49 Why this is good news for unconflicted benefits consultants. 36:04 EP487 (Part 1) with Kevin Lyons. 39:48 Why transparency is going to become the new normal. 40:22 The Innovator's Dilemma by Clayton M. Christensen. 42:14 EP436 with Elizabeth Mitchell. 44:07 EP286 with John Rodis, MD, MBA. 45:22 Why there is a great incentive to be a great clinician right now. 46:18 How this information can motivate competition in the right place. 46:52 EP490 (Part 1) with Shane Cerone and Sam Flanders, MD.   You can learn more at PBGH, by emailing Elizabeth at emitchell@pbgh.org, and by connecting with Elizabeth on LinkedIn.   Elizabeth Mitchell discusses PBGH's #transparency project on our #healthcarepodcast. #healthcare #podcast #financialhealth #patientoutcomes #primarycare #digitalhealth #healthcareleadership #healthcaretransformation #healthcareinnovation   Recent past interviews: Click a guest's name for their latest RHV episode! Shane Cerone and Dr Sam Flanders (Part 1), Dan Greenleaf (Part 2), Dan Greenleaf (Part 1), Mark Cuban and Cora Opsahl, Kevin Lyons (Part 2), Kevin Lyons (Part 1), Dr Stan Schwartz (EP486), Dr Cristin Dickerson, Elizabeth Mitchell (Take Two: EP436), Dave Chase  

Here’s a quote: “The reality is you can have razor-thin hospital margins if you are good at just spending all the money that is given to you.” Shane Cerone says this coming up and throw hot, right? Razor-thin hospital margins may be due to high costs or some problematic market condition or uncompensated care. Or razor-thin operating margins could also transpire because you’re just really inclined to spend every dollar you’re given. For a full transcript of this episode, click here. If you enjoy this podcast, be sure to subscribe to the free weekly newsletter to be a member of the Relentless Tribe. Kind of shines a new light on the nonprofit word, right? Anyway, after Shane Cerone raises his eyebrows at the razor-thin hospital margin cliché at this point, then he continues, “And I think that’s what goes on without a competitive healthcare marketplace. It’s impossible to separate those things.” Meaning is it some problem associated with providing care in a community, or is it too much money gassing up the private jet? “It’s impossible to separate [these] things and understand what’s really possible.” Yep. That’s something that one of my guests today, Shane Cerone, will say in about T minus 19 minutes or something. So, spoiler alert. Now, let me start from the beginning. What happens when there is a market, an actual market, for any good or service? Well, prices are rationalized, supply and demand curves meet at an equilibrium point, and the invisible hand knocks sellers and buyers into line. Abracadabra. We have fair prices. If I continue down memory lane to our freshman Econ 101 microeconomics class (just in case it was that 8:00 a.m. and any of us slept through it), those aforementioned supply and demand curves, for them to do their equilibrium thing, these curves require a series of transactions that “trial and error” themselves into that aforementioned equilibrium fair for buyers and sellers price. Transactions was the key word there. In other words, a market is the sum or whatever the average of its transactions, right? It’s like a group of crows is called a murder, a herd of cows. Well, a group of transactions is called a market. Now what is required for a transaction to be an actual transaction? Let’s see. Oh, here’s a start. Both the buyer and the seller must be aware of the price at the time of the transaction as one fundamental rate critical. And this is not just textbook economics that I’m talking about right now. It’s also contract law. And yeah, anyone who has spent five minutes at this rodeo, you listening, you have immediately cottoned on to the fact that this is already not going well for anyone planning to argue that there is, in fact, a healthcare market in the United States, because does anyone even know the price that they are buying or selling at for any given healthcare transaction prior to agreeing to buy or sell? Status quo carriers and TPAs (third-party administrators) have entered the chat. But if you don’t have transactions with transparent cost or quality of the goods purchased, then yeah, real tough to have competition, which is another market rate critical that is dependent on there being, for reals, transactions. Real hard to shop for quality when you don’t know what the quality is. We often talk about this topic from the standpoint of the buyer here at Relentless Health Value. Listen to the shows with Kevin Lyons (EP487, Part 1), Jonathan Baran (EP483, Part 1), Wayne Jenkins, MD (EP358). Today, though, we’re gonna talk about this from the point of view of the health system. How does a non-market affect health systems? I’m thinking now about something John Rodis, MD, MBA, talked about in episode 286 that I repeat in the show that follows. Short version: Dr. Rodis was CEO of a hospital that threw their backs into improving quality and safety, and they got zero volume, zero demands for their efforts—no increase in demand—nor were they able to negotiate higher carrier rates. So, like, why bother? Just put a snazzy billboard on the highway, “We are number one,” and call it a day. And yeah, what a loss for the community, for patients, for members, but also for folks working in any given hospital trying really hard to get their organization to do right by patients. So, wow, was I on the edge of my seat today to get a chance to talk with Dr. Sam Flanders and Shane Cerone from Kada Health, who, by the way, donated to the pod to help out with our expenses. My goodness, do I love this tribe that we have created here and those of you who step up and help out. It costs a lot of cash, actually, to keep this show on the air. So, thank you so much to Kada Health and also to everybody who pops up and drops a couple of bucks in the tip jar on our Web site that we do absolutely nothing to promote. We get five bucks here and $500 there, and it all adds up, and it makes my heart happy to see how great people are on days when things look so dark sometimes. Sorry, we were talking about the non-market that is the healthcare industry. Okay, I was thrilled to capture Shane Cerone and Dr. Sam Flanders, as I said, and get them on the show today because they were responsible together for running a hospital—a hospital that ran at 158% of Medicare and which had highly rated quality and safety—because I wanted to get my mitts on someone who had done this successfully, because I’m trying to figure out why it seems so hard for others to emulate. Now the solutions show is gonna be in two weeks where Shane and Dr. Sam Flanders get into how they kept prices low and delivered high quality and safety to their community. And if you can’t stand waiting two weeks, do go back and listen to the show with Dan Greenleaf—there’s two of them (EP489, Part 1 and Part 2)—and he talks about this from the standpoint of a multispecialty group. Dr. Sam Flanders and Shane Cerone are talking about this from the standpoint of a hospital system. Today, however, we are exploring, deeply and with great insight, problematic healthcare myths. Now, these myths are warmly embraced by those who kind of benefit from them being embraced, which is probably some pretty good foreshadowing for the solutions show. But these 3 myths are, first, let’s just lay out the mother of all myths, that there is a functioning healthcare market where carriers control the prices of consolidated health systems etc. Myth 2: Hospitals simply cannot afford to operate when prices paid by commercial contracts are less than 150% or 200% of Medicare. There has to be wild cost shifting to local employers; otherwise, they will go out of business in some kind of clearance sale. Myth 3: When prices go down, so does quality, as a general rule. Now there’s gonna be one show in between this show, our problematic myth show, and the “okay, now let’s help hospitals solve for all of this” show. And the show I’m gonna pop right in the middle of these two bookends is a show with Elizabeth Mitchell from PBGH, the Purchaser Business Group on Health, because toothpaste is out of the tube. And anyone banking on the nonmarket bonanza continuing … yeah, heads up. Here’s what it looks like around the corner in the future coming up, because (oh, my God, I’m terrible at keeping the suspense under wraps) but PBGH just took all the transparency data and a whole bunch of claims data and quality data, and now they can see actual prices being charged and actual quality and safety being delivered by any given health system or organization. And—oh, wow!—is that powerful, because it actually creates the potential for actual transactions, which are the building blocks of markets, and—oh, wow!—does it have an impact on health systems on consultants, on TPAs, and ASOs (administrative services only). I’m controlling myself from going off on a whole tangent about this impact on consultants and TPAs, but I will not because that’s what half the show is about next week, so come back next week. In the meantime, enjoy this episode with Dr. Sam Flanders and Shane Cerone. Then again, as I said, come back next week, listen to Elizabeth Mitchell. Then come back for the solutions part of this episode, where we talk about, yeah, solutions, where Dr. Sam Flanders and Shane Cerone, just with such wisdom and experience, tick through how to slow the raising prices roll; how to make things work fine, just fine, on 150%, 200% of Medicare; how there is zero reason any hospital should be thumping its chest and saying quality will go down or dire this or dire that if they don’t get their double-digit rate increases. So, onward here is my problematic myths conversation with, as I’ve said 19 times already, Shane Cerone and Dr. Sam Flanders from Kada Health; and the show is sponsored by Aventria Health Group with an assist from Kada Health. Also mentioned in this episode are Kada Health; Kevin Lyons; Jonathan Baran; Wayne Jenkins, MD; John Rodis, MD, MBA; Dan Greenleaf; Elizabeth Mitchell; Purchaser Business Group on Health (PBGH); Vivian Ho, PhD; Stanley Schwartz, MD; ZERO.health; Mark Cuban; Cora Opsahl; Eric Bricker, MD; Dan O’Neill; and Lisa Bari.   You can learn more at Kada Health and follow Shane and Dr. Flanders on LinkedIn.   Shane Cerone is the CEO of Kada Health, LLC, a consulting, management, and leadership practice that supports employers in reducing the cost of exceptional healthcare and advises hospitals, health systems, outpatient centers, and physician groups on practices that improve care quality and efficiency. Prior to establishing Kada Health, Shane spent more than 20 years leading high-performing hospitals and physician group practices in both community and academic health systems. He has served as the president/chief executive for Beaumont Hospital (Royal Oak), Mercy Iowa City, Virginia Commonwealth University Hospitals, and St. Luke’s Hospital & Health Network in St. Louis. During his tenure as its president, Beaumont Hospital (Royal Oak) was recognized as one of the nation’s highest-performing hospitals and health systems, consistently ranked as a national leader for clinical excellence (US News & World Report), care quality and safety (University HealthSystem Consortium), and affordability (the RAND Corporation). Shane earned a bachelor of arts degree in biology from Nebraska Wesleyan University and a master of arts degree in hospital and health administration from the University of Iowa, where he serves as adjunct assistant professor. Sam Flanders, MD, FAAP, is a seasoned healthcare executive and physician with a distinguished career in quality, safety, and performance improvement leadership. He most recently served as executive vice president for quality, safety, and population health at St. Luke’s Hospital in St. Louis, Missouri. Prior to joining St. Luke’s, Dr. Flanders held the position of senior vice president and chief quality and safety officer at Beaumont Health (now Corewell Health) in Michigan. Prior to Beaumont, he served in a similar role at Indiana University Health (formerly known as Clarian Health Partners). Dr. Flanders earned his medical degree from the University of Illinois College of Medicine and has an undergraduate degree in computer science from University of Michigan. He is board-certified in pediatrics. For over 30 years, he has served as a volunteer physician at summer camps for children with diabetes, helping to educate and support young campers to better control their disease.   09:28 EP466 with Vivian Ho, PhD. 09:31 EP486 with Stan Schwartz, MD. 09:42 EP488 with Mark Cuban and Cora Opsahl. 10:08 Why we need to focus on prices in healthcare. 11:50 The first myth that holds change back: the healthcare “market.” 15:04 EP286 with John Rodis, MD, MBA. 15:51 The reality behind why there is no functional market in healthcare. 17:11 Why price simplicity is so important. 19:15 EP472 with Eric Bricker, MD. 19:31 How there is pricing failure while hospitals are still facing razor-thin margins. 22:11 The second myth: Can a hospital survive on Medicare rates alone? 25:21 What is the best hospitals can achieve? 26:01 List of hospitals recognized as national leaders for care quality and affordability. 29:23 The third myth: When you lower prices, do you get lower quality? 33:11 Why a decentralized approach at improvement is the way to lower cost and raise quality.   You can learn more at Kada Health and follow Shane and Dr. Flanders on LinkedIn.   Shane Cerone and Sam Flanders discuss #hospital myths on our #healthcarepodcast. #healthcare #podcast #financialhealth #patientoutcomes #primarycare #digitalhealth #healthcareleadership #healthcaretransformation #healthcareinnovation   Recent past interviews: Click a guest’s name for their latest RHV episode! Dan Greenleaf (Part 2), Dan Greenleaf (Part 1), Mark Cuban and Cora Opsahl, Kevin Lyons (Part 2), Kevin Lyons (Part 1), Dr Stan Schwartz (EP486), Dr Cristin Dickerson, Elizabeth Mitchell (Take Two: EP436), Dave Chase, Jonathan Baran (Part 2)  

Ben Schwartz, MD, MBA, wrote an article recently, and yeah, he makes a really compelling point. Dr. Schwartz wrote, “Ultimately, the most successful care models are those that create value inherently. The goal isn’t simply cost arbitrage; it’s creating a sustainable system that makes value attainable. Care delivery innovation is about more than optimizing for VC [venture capital] returns or maximizing operational efficiency.” For a full transcript of this episode, click here. If you enjoy this podcast, be sure to subscribe to the free weekly newsletter to be a member of the Relentless Tribe. That mention of value and how to achieve it for real—like, actually create a care model that delivers value inherently—is a great segue to introduce the show this week. It’s a continuation of our mission/margin theme, and this week, we’re talking about the margin part of the “no margin, no mission” cliché. So, taking this from the top, last week—and go back and listen to that show if you have not yet (and you can listen to both of these parts in no particular order; you do you)—but last week, we talked mission. That part about value and creating value inherently? The tie-in here to mission and margin could be a value equation, really. Like, mission divided by margin is how you calculate the value delivered (less carrier spread), but that’s a whole other show with Cynthia Fisher (EP457). So, let me introduce my guest this week, who was also my guest last week: Dan Greenleaf, CEO of Duly, which is a multispecialty group in Chicago. So, last week Dan and I talked mission, as I said; but today we’re talking margin, which is, again, gonna be the denominator of so many value equations. Last week in that mission show, quick review (or spoiler alert, depending on the order in which you may be listening to these shows), but last week, Dan Greenleaf broke mission, Duly’s mission, into four quadrants. The four quadrants of mission being affordability, access, consumer experience, and quality. In this conversation today, the margin conversation, Dan Greenleaf emphasizes that achieving these four quadrants reduces friction for patients and clinicians that leads to not only better care outcomes but also financial sustainability (ie, margin). Margin can therefore be a function of mission. And again, as Dr. Ben Schwartz put it, “Ultimately, the most successful care models are those that create value inherently.” So, here we go. To be noted with one big fat fluorescent highlighter marker, a big part of this mission that comes up over and over again last week, it’s about making prices reasonable and predictable and transparent for patients. Financial toxicity is a thing. Financial toxicity not only is clinical toxicity when so many people are delaying needed care. And look, I don’t often quote Marjorie Taylor Greene, but recently she was in the New York Times and was quoted as saying, “The cost of health care is killing people.” This is what we should be focusing on. I just read the other day that one-third of adults in this country are currently delaying or forgoing care due to cost. One-third! Not one-third of low income or something like that. One-third of adults in this country are delaying or forgoing care due to fear of cost. In today’s world, affordability and price transparency is part of what customer experience means—not just, like, lemon water in the waiting room. This is what struck me the most about the conversation from last week. But wait. Does affordable for patients spell trouble when it comes to the margin part of the operation? Will an affordability mission wreak havoc on margin? Is this business model doomed? Is there even a successful care model that creates value inherently that is sustainable? Such a good question, which is why I ask it to Dan Greenleaf right out of the gate. So, just to sum this all up in the conversation that follows, Dan Greenleaf gets into the challenges and the strategies involved in balancing mission-driven healthcare with financial realities. Duly’s approach to being fiscally solid includes, well, I’m just gonna say many of the same types of efficiency things to maintain and retain margin that other more mainstream health systems might deploy. But I’d say there’s a really striking difference in the why and the how. And the impact of this why and how is striking when you look at Duly’s prices and the impact it has on its overall community. So, even though it’s using similar types of strategies, maybe, as big consolidated health systems or other organizations, the impact and what it all adds up to is, again, very, very different. This is what I mean. At health systems, and maybe my head is just lost in a couple of anecdotal bits of evidence right now, but I just had two conversations in the past two days with physician leaders at big health systems (different ones), but both of these individuals said variations of the same theme. And if you wanna picture the scene, picture the saddest expressions, and one of them had a martini and the other one had a big-boy glass of wine. And both of them said, Look, my organization has lost sight of patient care, but also my organization has lost sight of, like, financial goals in most parts of the organization. All I seem to do all day is play politics with a whole lot of middle managers or even senior leaders jockeying for position and having turf wars within these sprawling bureaucracies. These are just great people who are trying so hard to do the right thing and are just struggling to find the foothold to do so within their own organizations. So, let’s just say it was refreshing to hear Dan Greenleaf talk about an alignment of incentives and hook the margin up with the mission train in a really tight way throughout the entire organization. And to do this really well—achieve that mission/margin alignment across the whole entire organization—Dan underscores the value of clinician involvement in leadership and having, as I just said, aligned incentives with clinical teams. Keep in mind, this is the margin show, where clinical leadership came up and the number of doctors on their board and the level of physician ownership in the organization. I’m highlighting that this is the margin show here because usually so-called dyad leadership with physicians in leadership roles only comes up in mission conversations, right? Like, in situations where somebody wants the doctor to be the defender of mission and the battle to keep the MBAs in check. And I say this as the comic book stereotype, obviously. But yeah, it’s true often enough. But then we have Dan, who is thinking about clinicians who have, again, aligned incentives across the organization so you don’t have your physician leaders day drinking while I’m sitting across from them finding myself quoting Sun Tzu The Art of War and helping them craft the perfect PowerPoint slide to weaponize a reorg. Honestly, in my experience, there’s no better way to waste metric assloads of money than in an organization where personal power grabs start to supersede anything that smells vaguely like an organizational imperative. And again, these just big bureaucracies at many health systems … yeah, too big not to fail at this is often the way of it. Then lastly, I grilled Dan Greenleaf about capital partners and how to manage to achieve private equity (PE) funding, where there’s support for a model that delivers inherent value—a model that benefits both patients and providers as well as investors. And I’m saying this, keeping all of the things that Yashaswini Singh, PhD, said in that episode (EP474) about private equity a few weeks ago. Go back and listen to that. And by the way, Dan Greenleaf in this show has roughly the same ideas as Tom X. Lee, MD (EP445), founder of One Medical and Galileo told me, and also Rushika Fernandopulle, MD (EP460), founder of Iora. Great minds think alike. So, should figuring out how to work with PE be a topic of interest, there you go. Listen to my conversation today with Dan Greenleaf and then go back and listen to those other two shows. Dan Greenleaf, CEO of Duly, my guest today, has been in healthcare for 30 years. He’s a six-time CEO: three public companies and has also run three companies backed by private equity and thus very aware of the many different funding mechanisms that exist in the marketplace. This podcast is sponsored by Aventria Health Group, but I do just wanna mention that Duly offered Relentless Health Value some financial support, which we truly appreciate. So, call this episode not only sponsored by Aventria but also Duly. And with that, here is my conversation with Dan Greenleaf. Also mentioned in this episode are Duly Health and Care; Benjamin Schwartz, MD, MBA; Cynthia Fisher; Cristin Dickerson, MD; Yashaswini Singh, PhD; Tom X. Lee, MD; Galileo; Rushika Fernandopulle, MD; Vivian Ho, PhD; Scott Conard, MD; Stanley Schwartz, MD; Vivek Garg, MD, MBA; and Dave Chase. You can learn more at Duly Health and Care and follow Dan on LinkedIn. You can also email Dan at dan.greenleaf@duly.com.   Daniel E. Greenleaf is the chief executive officer of Duly Health and Care, one of the largest independent, multispecialty medical groups in the nation. Duly employs more than 1700 clinicians while serving 1.5 million patients in over 190 locations in the greater Chicago area and across the Midwest. The Duly Health and Care brand encompasses four entities—DuPage Medical Group, Quincy Medical Group, The South Bend Clinic, and a value-based care organization. Its scaled ancillary services include 6 Ambulatory Surgery Centers, 30 lab sites, 16 imaging sites, 39 physical therapy locations, and 100 infusion chairs. Its value-based care service line provides integrated care for 290,000 partial-risk and 100,000 full-risk lives (Medicare Advantage and ACO Reach). Dan has nearly 30 years of experience leading healthcare services organizations. He is a six-time healthcare CEO, including prior roles as president and CEO of Modivcare; president and CEO of BioScrip, Inc.; chairman and CEO of Home Solutions Infusion Services; and president and CEO of Coram Specialty Services. Dan graduated from Denison University with a bachelor of arts degree in economics (where he received the Alumni Citation—the highest honor bestowed upon a Denisonian) and holds an MBA in health administration from the University of Miami. A military veteran, he was a captain and navigator in the United States Air Force and served in Operation Desert Storm.   09:56 How does Dan achieve his mission given the realities of margin? 14:49 How Duly Health’s approach and incentives differ from other health systems. 16:04 EP466 with Vivian Ho, PhD. 16:28 EP462 with Scott Conard, MD. 16:31 Summer Shorts episode with Stan Schwartz, MD. 17:27 EP460 with Rushika Fernandopulle, MD. 17:29 EP445 with Tom X. Lee, MD. 17:30 EP407 with Vivek Garg, MD, MBA. 18:50 How having physicians on the hospital board greatly improves margin and mission. 20:04 How Dan explains his approach to his capital partners. 22:23 Fee for service vs. institutional care.   You can learn more at Duly Health and Care and follow Dan on LinkedIn. You can also email Dan at dan.greenleaf@duly.com.   @d_greenleaf of @dulyhealth_care discusses #margin creating a path to #mission in #multispecialtycare on our #healthcarepodcast. #healthcare #podcast #financialhealth #patientoutcomes #primarycare #digitalhealth #healthcareleadership #healthcaretransformation #healthcareinnovation   Recent past interviews: Click a guest’s name for their latest RHV episode! Dan Greenleaf (Part 1), Mark Cuban and Cora Opsahl, Kevin Lyons (Part 2), Kevin Lyons (Part 1), Dr Stan Schwartz (EP486), Dr Cristin Dickerson, Elizabeth Mitchell (Take Two: EP436), Dave Chase, Jonathan Baran (Part 2), Jonathan Baran (Part 1), Jonathan Baran (Bonus Episode)  

This show today is a continuation of our mission/margin series because I wanted to drag into my investigation here what clinical organizations are up to, especially ones that have brought in professional capital, as they say. For a full transcript of this episode, click here. If you enjoy this podcast, be sure to subscribe to the free weekly newsletter to be a member of the Relentless Tribe. Before I kick in here, let me just remind everyone of a few themes that we have been poking in the eyeballs in the past few months over here at Relentless Health Value. First, patients cannot afford care. Listen to the show with Mark Cuban and Cora Opsahl (EP488) mentioning middle-class wage stagnation. Listen to the show with Merrill Goozner (EP388). Listen to the show with Wayne Jenkins, MD (EP358). It is a crapshoot to get medical care these days. Roll the dice and hope you don’t get a bankrupting bill at the end. There’s no transparency (or very little) for patients. No accountability or interest from many. Not all but many take no responsibility for their financial impact on their patients or members. And look, I am in no way speaking for the vast majority of doctors or nurses or pharmacists or PAs or even really good administrators or anybody else involved in clinical care. In fact, if you listen to the show with Komal Bajaj, MD (EP458) about how many clinicians do not actually trust their leadership will do right by patients or even the clinicians themselves, then yeah. This is undeniably the broad stroke of this industry we all work in. Many take no responsibility for their financial impact on their patients or members. That is the first theme. Here’s the second theme. It’s this motto: If you can take it, take as much as you can get. And throwing no shade, but let’s just get real about that. Right now, healthcare is an industry just like any other industry. And when I say industry, I mean the tax-exempt so-called nonprofits as much as anybody else. Said another way, corporate healthcare leaders, just like any other business leaders, have every incentive to see prices go up. That is just the way commerce works. Listen to the show with Jonathan Baran (EP483, Part 1), the ones with Kevin Lyons (EP487, Part 1 and Part 2). But what is different than most other commerce endeavors when it comes to healthcare, and Shane Cerone from Kada says this in an upcoming episode, he says, “We don’t have a broken healthcare market. In many parts of the country, there is no healthcare market. The market does not exist.” And thus prices can go up like rocket ships, because self-insured employers—and also public plan sponsors a lot of times, like state health plans—are, on the whole, just such unsophisticated buyers, price elasticity is, like, nonexistent. No matter how high the price, plan sponsors still contract for who’s ever in the network; and they and their members ante up and pay the price. Many good and maybe not-so-good reasons for this (not getting into them), but net net, the result is a nonmarket. Anyone who wants to debate my corporate healthcare entities or big consolidated healthcare entities act just like any other corporate entity, read the recent Substack by Preston Alexander. It’s about hospitals raising capital with bonds. Preston Alexander wrote, “The financial design of the system has turned what should be a largely altruistic service, one designed for public good and societal benefit, and forced it to act like a financial institution.” And so, with those bonds, welcome Wall Street. What do Wall Street bankers think about patient care and access and community health? Oh, they don’t think about those things at all. Municipal bond returns, baby. That’s it. Bonds are an investment where people who invest in them, returns are expected, just like shareholders who want their dividends. Preston Alexander wrote, “Most larger health systems carry billions (that was a ‘b’ back there) in bond liabilities.” It costs money to build buildings and add beds and consolidate, yo; but now they are subject to the same pressures as publicly traded companies. So then I got my hands on Dan Greenleaf, CEO of Duly, a multispecialty group in Chicago. I was absolutely intrigued from the starting gate because Dan told me that mission can actually beget margin in his view, and he even, at Duly, has private equity investors. So, yeah, I was all ears. Dan Greenleaf, who is my guest today, by the way, if you haven’t figured that out, told me that because of, but not limited to, the trends above wildly high prices, high premiums, high deductibles, more consolidation, fewer options, scared, confused, and maybe outraged patients—listen to the show with Peter Hayes (EP475)—Dan said that, given this backdrop, actually focusing on mission is a huge competitive advantage. Justina Lehman (EP414) actually also said this in a show from a few years ago. Dan told me, Dan Greenleaf, when you succeed at mission, you can get yourself decent margin these days. So, in this first episode, we will talk about this mission of which Dan Greenleaf speaks; and then in part 2 coming at you next week, we’ll get into how that all spells margin. Here’s what I thought was super important about this whole mission/margin conversation, and Mick Connors, MD, in a show coming up, also touches on this: To achieve mission, you really have to define what mission means. Ben Schwartz, MD, MBA (EP481) said this, too, in so many words in the show from last summer. And that doesn’t mean just have a gloriously well-written Web page, and you just can’t have spreadsheets of random quality metrics either. You have to treat the mission like you treat any strategic imperative. You gotta break it down and figure out how you’re gonna measure what you’re actually doing. Rik Renard (EP427) talked about this one, too. At Duly, which Dan Greenleaf talks about in this episode, the focus is on four quadrants of mission: (1) affordability, (2) access, (3) consumer experience, and (4) quality. In this conversation, Dan emphasizes that achieving these four quadrants reduces friction for patients and clinicians and leads to better care outcomes and financial stability. To be noted with one big fat fluorescent highlighter marker is this: A big part of this mission, in almost each of these quadrants, is about making prices reasonable and predictable and transparent for patients. In today’s world, that’s what customer experience must include—not just, like, lemon water in the waiting room. That struck me the most. And all this focus on affordability really adds up across the community. In Chicago, lower-cost alternatives to hospital services can save up to $2 billion. That is also with a “b.” And the communities are also healthier. Crazy. Hey, make sure patients and members can afford and have access to quality healthcare, and the community gets healthier. Who would’ve thought? Dan Greenleaf, CEO of Duly, my guest today, has been in healthcare for 30 years. This podcast is sponsored by Aventria Health Group, but I do just wanna mention that Duly so kindly offered Relentless Health Value some financial support, which we truly, truly appreciate. So, call this episode also sponsored with an assist by Duly. Here’s my conversation with Dan Greenleaf, and do come back next week for part 2 like I said earlier. Today we talk mission. Next week we talk margin. Also mentioned in this episode are Duly Health and Care; Merrill Goozner; Wayne Jenkins, MD; Komal Bajaj, MD; Jonathan Baran; Kevin Lyons; Shane Cerone; Kada Health; Preston Alexander; Peter Hayes; Justina Lehman; Vivian Ho, PhD; Mick Connors, MD; Benjamin Schwartz, MD, MBA; Rik Renard; Mark Cuban; Dave Chase; Patrick Moore; Sam Flanders, MD; and Tom Nash. You can learn more at Duly Health and Care and follow Dan on LinkedIn. You can also email Dan at dan.greenleaf@duly.com.   Daniel E. Greenleaf is the chief executive officer of Duly Health and Care, one of the largest independent, multispecialty medical groups in the nation. Duly employs more than 1700 clinicians while serving 1.5 million patients in over 190 locations in the greater Chicago area and across the Midwest. The Duly Health and Care brand encompasses four entities—DuPage Medical Group, Quincy Medical Group, The South Bend Clinic, and a value-based care organization. Its scaled ancillary services include 6 Ambulatory Surgery Centers, 30 lab sites, 16 imaging sites, 39 physical therapy locations, and 100 infusion chairs. Its value-based care service line provides integrated care for 290,000 partial-risk and 100,000 full-risk lives (Medicare Advantage and ACO Reach). Dan has nearly 30 years of experience leading healthcare services organizations. He is a six-time healthcare CEO, including prior roles as president and CEO of Modivcare; president and CEO of BioScrip, Inc.; chairman and CEO of Home Solutions Infusion Services; and president and CEO of Coram Specialty Services. Dan graduated from Denison University with a bachelor of arts degree in economics (where he received the Alumni Citation—the highest honor bestowed upon a Denisonian) and holds an MBA in health administration from the University of Miami. A military veteran, he was a captain and navigator in the United States Air Force and served in Operation Desert Storm.   08:32 What should mission be in multispecialty? 08:54 Are mission and margin mutually exclusive? 10:47 What are the four “vectors” of Dan’s mission? 11:32 Why does affordability matter? 12:11 EP466 with Vivian Ho, PhD. 12:40 EP488 with Mark Cuban and Cora Opsahl. 13:32 Who are the three payers in the marketplace? 17:31 EP388 with Merrill Goozner. 19:19 How does access play into mission? 20:28 EP464 with Al Lewis. 21:07 EP467 with Stacey. 22:56 Why price transparency is important to consumer experience. 24:16 LinkedIn post from Patrick Moore. 29:06 EP481 with Benjamin Schwartz, MD, MBA.   You can learn more at Duly Health and Care and follow Dan on LinkedIn. You can also email Dan at dan.greenleaf@duly.com.   @d_greenleaf of @dulyhealth_care discusses #mission and #margin in #multispecialtycare on our #healthcarepodcast. #healthcare #podcast #financialhealth #patientoutcomes #primarycare #digitalhealth #healthcareleadership #healthcaretransformation #healthcareinnovation   Recent past interviews: Click a guest’s name for their latest RHV episode! Mark Cuban and Cora Opsahl, Kevin Lyons (Part 2), Kevin Lyons (Part 1), Dr Stan Schwartz (EP486), Dr Cristin Dickerson, Elizabeth Mitchell (Take Two: EP436), Dave Chase, Jonathan Baran (Part 2), Jonathan Baran (Part 1), Jonathan Baran (Bonus Episode), Dr Stan Schwartz (Summer Shorts)

If you are listening to this prior to October 9, 2025, go to the 32BJ Changing the Playbook on Hospital Prices event, where Mark Cuban will be keynoting. Cora Opsahl will also be speaking, and I will be there listening. For a full transcript of this episode, click here. If you enjoy this podcast, be sure to subscribe to the free weekly newsletter to be a member of the Relentless Tribe. So, trust, simplicity, and a chicken. Yeah, this is where this whole conversation with Mark Cuban and Cora Opsahl winds up. And it is a barnstormer because you know what some really good advice is for anybody trying to do right by patients and taxpayers and plan sponsors? It will take trust. It will take making the complicated as simple as possible. And also if you could pay with a chicken, like in the good old days, that would be messy—I can say with confidence, having grown up in Pennsylvania Dutch country, where there are many, many chickens—but also being able to pay with a chicken could also indicate that healthcare prices are reasonably chicken proportionate and that the doctor-patient relationship is good enough to break bread (or have chicken). That last part is really important, and Cora Opsahl says this at one point in the episode that follows. It doesn’t matter how wonderful the transparency or the financing. If the prices are insane and there’s no more reasonably priced options in any given market, then yeah. Shane Cerone says in an upcoming show, he says, “We do not have a broken healthcare market. We do not have a healthcare market. There is no market.” Okay … so, you could call this conversation a continuation of the episode with Ann Kempski (EP444), entitled “Two State Healthcare Laws Often Don’t Go as Planned.” But it’s not just healthcare laws that often don’t go as planned. It’s some very foundational constructs that we have built the healthcare sector upon that may also not go as planned. The healthcare sector is like a game of pachinko. You chuck an input into the mix, and it will bounce all around into all the perverse incentives and human beings and the non-market that we have. And who the heck knows what is gonna pop out the other side? It’s like game theory at its most unpredictable. So, in healthcare, there are many, many examples of when the solution to a problem arguably creates worse problems than the problems the solution was trying to solve for. But we—Mark Cuban, Cora Opsahl, and I—are gonna shake our fists at two such solutions today: high deductible health plans (or just high deductibles in general) and then self-insured employers trying to solve the complexity of the healthcare industry by hiring consultants and middlemen, middle people, and other vendors to navigate the pachinko parlor (that is, our $4.9 trillion healthcare sector) on their behalf. Now, I am not in any way saying the spirit of these two endeavors—high deductibles and hiring consultants and middlemen—weren’t wholehearted. They seem just like many other well-intentioned solutions: very logical on their face. What I am saying is there are many ways in the real world for even the most, again, genuine endeavor to turn into a money grab for those so inclined. While at the same time I’m saying all this, I’m also very much saying that there are some amazing consultants and middle folks such as independent third-party administrators, otherwise known as TPAs, and PBMs (pharmacy benefit managers) who are transparent and hold themselves accountable to the fiduciary responsibilities that their clients are held to in real terms—not just in marketing speak with 40 pages of disclaimers following. There are great folks out there, many of whom listen to this podcast and are part of our tribe on the regular. And to you, I say thank you for being here, because it takes all the knowledge and more from every one of the guests featured in these past 487 Relentless Health Value episodes plus treating every day like a school day to make sure that we all are not getting shanked from behind by some innocent-looking contract term that turns out to be anything but. The conversation that follows starts out talking about high deductibles; naturally segues into how third-party intermediaries can actually exacerbate the issues here; then we get into transparency, financing, clinical organizations taking on risk, and the benefits and challenges of direct contracts; then Mark lays out a vision for the future. Okay … I wanna get to this conversation. If you are a new listener here—and you might be because … yeah, Mark Cuban—let me just inform you that this podcast is largely listened to by those who work in the healthcare industry. So, you are going to encounter acronyms. You will also encounter me referencing earlier episodes because surveys say listeners really appreciate these callbacks to go get additional information about any given topic. You can get what amounts to a personalized Master’s of Healthcare Administration curriculum if you follow the episode threads long enough. And that was a direct quote from a listener. About the acronyms: They are holy terrors, and we in the healthcare industry are chock-full of them. See the list of acronyms that come up so that you can follow along at home if this is your first day at our rodeo. Also in the show notes is a transcript of this show, along with links to all of the mentioned episodes. Okay … here’s my conversation with Mark Cuban, who is Mark Cuban and also CEO and founder of Mark Cuban Cost Plus Drugs. Also, we have Cora Opsahl, who is health fund director of the 32BJ Health Fund and an expert in many things healthcare. Also mentioned in this episode are Shane Cerone; Ann Kempski; Mark Cuban Cost Plus Drugs; 32BJ Health Fund; Preston Alexander; Stanley Schwartz, MD; Elizabeth Mitchell; Kimberly Carleson; Andreas Mang; Jonathan Baran; Claire Brockbank; Dave Chase; Cristin Dickerson, MD; Green Imaging; Kevin Lyons; and Vivian Ho, PhD.   You can learn more at markcubancompanies.com and costplusdrugs.com and follow Mark on LinkedIn, Bluesky, Threads, and X. You can follow Cora on LinkedIn.   Mark Cuban, a native of Pittsburgh, PA; a graduate of Indiana University; and now a Dallas, TX, resident, has always been an entrepreneur. From selling and trading baseball cards, selling garbage bags and magazines door-to-door, to starting a business buying and selling stamps at age 16, there have been few years in his life when he wasn’t starting or running a business. He got a job at one of Dallas’s first retail software stores, Your Business Software. He spent nine months doing everything from learning how to code, supporting and installing every type of business software, and of course, making sure the store opened on time. That went well until he made the executive decision to turn over the store opening duties to a peer so he could pick up a check for a sale. He was fired. Mark decided it was time to start on his own. The next day, MicroSolutions was founded. Over the next seven years, MicroSolutions became a national leader in Systems Integration and custom applications for local and wide area networks. Growing to 80 employees, never having a losing month of operations and nearly $36M in annualized sales, in 1990, MicroSolutions was sold to CompuServe. At that point Mark “retired” to investing in public and private companies. His knowledge of the networking industry led to success and brought returns of 80% and more each year. Mark purchased the Dallas Mavericks for $285M. The Mavs would have the second-best record in the NBA during his ownership tenure. Mark sold majority control of the Mavs in 2023 but continues to be actively involved with the team. He first appeared as a “Shark” on ABC’s Emmy Award–winning hit business show Shark Tank in 2011 and quickly established himself as one of the most popular and tough Sharks, investing millions of dollars in hundreds of small businesses. He’s been nominated nine times for an Emmy for Shark Tank. His last appearance on the program was during season 16 in May 2025. In 2019, Mark co-founded costplusdrugs.com. Its launch on January 19, 2022, with transparent pricing and a limited markup, has fundamentally changed the pricing of medications in the United States. Cora Opsahl is the director of the 32BJ Health Fund, a self-insured Taft-Hartley benefit fund that sets comprehensive design parameters to ensure the 200,000 members and families of SEIU 32BJ have easy and sustained access to affordable, high-quality healthcare. Cora has prioritized a data-driven approach, focusing on reducing trend, solving the affordability challenge on behalf of union members, and, most important, keeping members at the center of every decision. Under her leadership, the 32BJ Health Fund has saved more than $35 million annually—which it has reinvested in new and better benefits, including the first fertility benefit for members—by removing NewYork-Presbyterian hospitals and physicians from its network, transitioning to a new pharmacy vendor and pharmacy group purchasing coalition, and establishing an expanded Centers of Excellence program. In 2024, Cora conducted an innovative medical request for proposal, stipulating that all finalists have a signature-ready contract drafted by the 32BJ Health Fund prior to award. As a result, the Fund negotiated an agreement that brought unprecedented visibility and increased accountability to its benefit. In 2025, the Health Fund is focused on direct-contracting opportunities that allow it to carve out key benefits and ensure quality while managing spend. Cora is regarded as an expert in pharmacy benefit management and was recently appointed to the Board of Governors for the National Alliance for Healthcare Purchaser Coalitions and the Purchaser Advisory Council for the National Quality Forum and Joint Commission. She previously worked at Express Scripts, where she held a variety of roles, ranging from Medicare Part D to operations, strategy, and acquisitions. Cora earned an MBA from Saint Louis University.   06:25 What was the original rationale behind high deductibles? 07:38 How high deductibles are creating a class of functionally uninsured people. 09:29 EP482 with Preston Alexander. 10:20 “We’re using health insurance as a proxy for healthcare.” —Mark 12:30 How providers are now in the debt collecting business rather than the healthcare business. 12:55 EP486 with Stan Schwartz, MD. 15:16 “We have a fundamental reasonability problem.” —Cora 16:07 EP425 with Marshall Allen. 18:25 Direct contracting versus self-funded employers. 19:27 EP436 with Elizabeth Mitchell. 19:30 EP480 with Kimberly Carleson. 19:33 EP372 with Cora Opsahl. 23:53 Why the current system doesn’t allow the accountability that is needed. 24:39 EP452 with Cora Opsahl. 26:34 How direct contracting gives strength back to independent practices that high deductible plans take away. 27:46 Who pays, what’s the price, and where does the power lie? 31:24 EP419 with Andreas Mang. 34:45 How it comes down to power and leverage when controlling healthcare costs. 38:13 EP483 (Part 1 and Part 2) with Jonathan Baran. 38:35 Why putting together a network and just buying healthcare—not discounts—is not as difficult as it seems. 40:10 Why we need to stop talking about disruption and start talking about change. 40:56 EP453 with Claire Brockbank. 41:02 EP484 with Dave Chase. 43:07 EP485 with Cristin Dickerson, MD. 44:32 EP487 (Part 1) with Kevin Lyons. 46:34 EP466 with Vivian Ho, PhD. 47:40 Why it’s the incentives that are different between American hospitals and hospitals in a single-payer program. 50:25 The main takeaways from the conversation. 51:08 Why you can’t fix the problems in healthcare without transparency.   You can learn more at markcubancompanies.com and costplusdrugs.com and follow Mark on LinkedIn, Bluesky, Threads, and X. You can follow Cora on LinkedIn.   @mcuban of @costplusdrugs and Cora Opsahl discuss trust and simplicity in #healthcare on our #healthcarepodcast. #podcast #financialhealth #patientoutcomes #primarycare #digitalhealth #healthcareleadership #healthcaretransformation #healthcareinnovation   Recent past interviews: Click a guest’s name for their latest RHV episode! Kevin Lyons (Part 2), Kevin Lyons (Part 1), Dr Stan Schwartz (EP486), Dr Cristin Dickerson, Elizabeth Mitchell (Take Two: EP436), Dave Chase, Jonathan Baran (Part 2), Jonathan Baran (Part 1), Jonathan Baran (Bonus Episode), Dr Stan Schwartz (Summer Shorts), Preston Alexander

In Part 1 of this episode, we explored the barriers to stopping the flywheel that is driving up healthcare costs for the public sector. In short, and you really should go back and listen to the first part of this episode, but if you didn’t, these barriers are number one, profit defends profit. In other words, if you have legislatures in charge of the contracts that are being awarded to carriers and PBMs (pharmacy benefit managers) and point solutions and consultants etc (which is how it works in many states), and if these aforementioned entities make a lot of money, now they have a lot of money to make campaign contributions to the legislatures in charge of their contracts and also lobby. You have a lot of money, you can buy a lot of influence, in short. For a full transcript of this episode, click here. If you enjoy this podcast, be sure to subscribe to the free weekly newsletter to be a member of the Relentless Tribe. The second barrier discussed in Part 1 is when public entities like states or etc don’t have unconflicted experts on their side of the table. That’s a problem. As you and me, we know very well. You’re listening to this show, so this is totally self-evident. There is just no way without hearing, for example, episodes with Vivian Ho, PhD (EP466) or Eric Bricker, MD (various episodes), Jonathan Baran (EP483, Part 1), Cora Opsahl (EP452), Mark Cuban (EP418). Just think about the kind of insight you gotta have if you are sitting on the other side of a table from a TPA (third-party administrator) or whoever who tells you something like, “You cannot have your data because …” or “No, you can’t put in that maternity or doula program because we have a contract and it’s impossible and …” or “It’s fine if we audit ourselves and do our own payment integrity program. We have a great branch of our own company who does this, and it’s totally not a conflict of interest. Pinkie swear.” Imagine if you didn’t have the information that you who listens to the show probably do. And it sort of comes at no surprise if you think about it in this light the wildly escalating prices that some state and even federal plans have. And this is hard, complicated stuff; and it takes years to figure out. But think about this. The state of New Jersey that is in 2026 gonna spend $3.5 billion, there is no (among other things) medical director who works for the state. So, there’s just a lack of unconflicted experts with a for real seat at the table. That is our number two barrier. And then the third barrier, it’s kind of an offshoot of profit defends profit. What profit also does is influence the media. When the media’s biggest advertisers are often the healthcare industry, how are legislatures and taxpayers and even public employees themselves, how are they gonna get the real story? Okay, so that was Part 1. In the conversation that follows with Kevin Lyons, he shares some of the skills that he learned in detective training to deduce what is going on with his healthcare dollars being spent by and on behalf of his union members, where those dollars are disappearing to, what he writes in that little detective notebook I’m imagining he still carries around to this very day. So, with that, here is the advice portion of my conversation with Kevin Lyons. Kevin is a former police detective and current executive director, law enforcement, labor/employee benefits at the New Jersey State PBA (Policemen’s Benevolent Association). Also mentioned in this episode are NJ State Policemen’s Benevolent Association (NJSPBA); Vivian Ho, PhD; Jonathan Baran; Eric Bricker, MD; Cora Opsahl; Mark Cuban; Chris Deacon; VerSan Consulting; Claire Brockbank; Susan Hayes; Cynthia Fisher; Justin Leader; and Tom Nash. You can learn more at njspba.com and follow Kevin on LinkedIn. Kevin Lyons is a retired police detective from Long Beach Township, NJ, where he served over 25 years in many roles. He is currently the executive director of the New Jersey State Policemen’s Benevolent Association, New Jersey’s largest law enforcement union, representing over 32,000 active and 6000 retired members. His current responsibilities include operating the organization’s legal protection plan, where he manages $4 million worth of claims a year, 500 attorneys, and over $34 million in reserves, advising his members on health benefit issues and managing the staff and day-to-day operations of the organization. Kevin has a bachelor of arts degree from Richard Stockton College (now Stockton University) and numerous certificates in healthcare-related fields. In 2012, he was appointed to the NJ State Health Benefit Plan Design Committee, a body that manages plan design for a plan that has over 800,000 lives. In 2017, he was appointed to Governor Murphy’s Task Force on Quality and Affordability. Kevin has also served on the Southern Regional Board of Education since 1997, where he currently serves as the chair of the finance committee, which manages a budget of over $70 million. Kevin has done numerous op-ed articles and has been featured in Bloomberg News, the Wall Street Journal, NPR, Fortune magazine, and PBS. He is committed to making healthcare more affordable for his members.   03:53 How asking questions and being prepared can help you identify bad actors when assessing TPAs. 08:07 “If people aren’t guilty, they don’t plead the Fifth.” 08:57 What lessons does Kevin want those in government to learn about navigating health benefits? 09:34 “Never let a good crisis go to waste.” 11:39 EP453 with Claire Brockbank.   You can learn more at njspba.com and follow Kevin on LinkedIn.   @bluekcl discusses following the #healthcaredollar on our #healthcarepodcast. #healthcare #podcast #financialhealth #patientoutcomes #primarycare #digitalhealth #healthcareleadership #healthcaretransformation #healthcareinnovation   Recent past interviews: Click a guest’s name for their latest RHV episode! Kevin Lyons (Part 1), Dr Stan Schwartz (EP486), Dr Cristin Dickerson, Elizabeth Mitchell (Take Two: EP436), Dave Chase, Jonathan Baran (Part 2), Jonathan Baran (Part 1), Jonathan Baran (Bonus Episode), Dr Stan Schwartz (Summer Shorts), Preston Alexander, Dr Tom X Lee (Take Two: EP445), Dr Tom X Lee (Bonus Episode)

Did everyone see that video of the CEO snatching the tennis hat out of that kid’s hands at the US Open a few weeks ago? Short version and watch the video (it’s all over the internet): A tennis star who had just won his match is walking off the court signing autographs and he hands a kid—this cute towheaded preteen—the tennis star kind of haphazardly hands this kid a hat as he walks off the court. And as soon as that kid’s fingers, you know, start to take the hat, this grown-ass man reaches down, forcefully grabs that hat … the kid starts crying. For a full transcript of this episode, click here. If you enjoy this podcast, be sure to subscribe to the free weekly newsletter to be a member of the Relentless Tribe. This man now, turns out, speaking of investigations, the internet deduced in T-minus 30 minutes that this hat grabber man is actually a CEO of some paving company in Poland. But after the kid starts crying and pointing, the CEO has a moment of reflection. He gives the kid a millisecond once-over, and then he jams the hat into his wife’s handbag finders keepers, losers weepers–style. Watch the video if you haven’t seen it. It’s sort of shocking to behold, honestly. What is also shocking, maybe even more shocking, was the guy’s reaction afterwards, which wasn’t a “wow, I was caught up in the moment and I did a crappy thing.” Nope. His reaction was, “First come, first served.” He actually wrote this in a response apparently, according to several, somewhat unreliable sources. This whole thing, if I wanted to get metaphorical about it, which I apparently do, the whole thing could be a five-second summary of the big problem I have with that Charlie Munger quote, Warren Buffett’s partner. Charlie Munger famously said, “Show me an incentive, and I’ll show you an outcome.” And I got an issue with that when it comes to healthcare because it implies just because it is possible to shake down a kid for a hat or shake down a firefighter for another 10 grand, you should do it. I’m moving along real fast with this metaphor, but it’s really something to think about as the introduction to this conversation coming up with Kevin Lyons, who is a former police detective and current executive director, law enforcement, labor/employee benefits over at the New Jersey State PBA (Policemen’s Benevolent Association). And let’s keep in mind the family plan in the state of New Jersey for state workers now costs $67,000, having almost doubled in the past five years in price. That’s the total cost. And the crazy backwards thing is the unions are the ones who are fighting to rationalize the cost of healthcare to make it affordable for themselves and taxpayers alike to put forth innovative solutions that actually reduce costs, which you think the legislature would be doing. It’s a strikingly weird role reversal. Okay, so back to first come, first served. Here’s the undeniable thing. The healthcare industry, its corporate leaders, I’m gonna say—not everybody—operate just like any other business with a first come, first served guiding principle. If you can get the money from your customers, you’d be a dummy not to take it. I mean, to do otherwise would be a violation of your fiduciary duty to your board or your shareholders, right? If you are the sales team at one of these corporate healthcare companies, their corporations, you’ll get fired if you say, “Well, we knew how to get our customer to pay $10, but I said, ‘Oh, only pay me $6.’” Imagine announcing that at the shareholders meeting or to the board. We forget this is reality at our own peril. Many would love to plug their ears and do the ignorance is bliss thing. But yeah, it is not possible to argue with any unbiased integrity that the healthcare industry in New Jersey and in this country is an industry just like any other industry. And first come, first served is their motto, just like any other industry. No judgment here. Just stating very easily proven facts. And look, the state of New Jersey, just like many other buyers of healthcare, is a really unsophisticated buyer right now. You’d think that wouldn’t be the case considering healthcare for state workers is coming up here going to be a $3.5 billion spend, and it’s been rapidly escalating, way higher than inflation and almost any other benchmark you can compare it to, like the healthcare costs of other state health plans. It’s also one of the state’s biggest line items in the state budget. But yeah, we get one rookie error after another being made dealing with these vendors operating just like any other vendor. First come, first served. And tragically, as a result, the state employees and taxpayers are getting wildly taken advantage of for billions of excess dollars, getting first come, first served right into industry pockets. Why is the state and many others getting first come, first served? Well, Kevin Lyons walks us through three barriers, very articulately, for what goes on in the public sector, which we have not discussed heretofore on the pod. So, I was all over it. Bottom line is this: Even though the metaphorical man grabs the metaphorical hat and wrote “first come, first served” on the internet, there are many who smile and believe everything that man’s metaphorical, highly compensated lobbyists put on their desks and fancy full-color glossy reports year after year after year. They continue to believe what the man tells them. And look, in all fairness, this is complex stuff, this healthcare stuff. We are 487 episodes into it here and still going strong. Listen to the show with Vivian Ho, PhD (EP466) about the ways that consolidated hospital systems are in this mix. Listen to the flywheel shows with Jonathan Baran (EP483: Part 1 and Part 2). Listen to the payment integrity show with Kimberly Carleson (EP480). Yeah, there are container ships of hats going missing, but once you know where to look, you can find them. So, here’s my conversation with Kevin Lyons about the three barriers for getting the healthcare-escalating costs flywheel to slow its roll. Next week, come back for Part 2, where Kevin Lyons shares how he uses some of the skills he learned in detective training to deduce what’s going on with his healthcare dollars, where they are disappearing to, what he writes in that little detective notebook I am imagining he carries around even to this day. Also mentioned in this episode are NJ State Policemen’s Benevolent Association (NJSPBA); Cristin Dickerson, MD; Vivian Ho, PhD; Jonathan Baran; Kimberly Carleson; Chris Deacon; Tony Wieners; and Cora Opsahl.   You can learn more at njspba.com and follow Kevin on LinkedIn.   Kevin Lyons is a retired police detective from Long Beach Township, NJ, where he served over 25 years in many roles. He is currently the executive director of the New Jersey State Policemen’s Benevolent Association, New Jersey’s largest law enforcement union, representing over 32,000 active and 6000 retired members. His current responsibilities include operating the organization’s legal protection plan, where he manages $4 million worth of claims a year, 500 attorneys, and over $34 million in reserves, advising his members on health benefit issues and managing the staff and day-to-day operations of the organization. Kevin has a bachelor of arts degree from Richard Stockton College (now Stockton University) and numerous certificates in healthcare-related fields. In 2012, he was appointed to the NJ State Health Benefit Plan Design Committee, a body that manages plan design for a plan that has over 800,000 lives. In 2017, he was appointed to Governor Murphy’s Task Force on Quality and Affordability. Kevin has also served on the Southern Regional Board of Education since 1997, where he currently serves as the chair of the finance committee, which manages a budget of over $70 million. Kevin has done numerous op-ed articles and has been featured in Bloomberg News, the Wall Street Journal, NPR, Fortune magazine, and PBS. He is committed to making healthcare more affordable for his members.   08:17 Why is it important to “dig in” right now on health benefit cost increases? 10:16 The first barrier to better health benefits: profit defending profit. 16:38 Why “throw money at the problem” isn’t a real solution. 18:31 The second barrier: why a lack of employed experts costs more money. 25:58 The third barrier: media sponsorship from incumbents prevents change. 28:55 EP483 (Part 1 and Part 2) with Jonathan Baran.   You can learn more at njspba.com and follow Kevin on LinkedIn.   @bluekcl discusses #barriers to affordable #healthbenefits on our #healthcarepodcast. #healthcare #podcast #financialhealth #patientoutcomes #primarycare #digitalhealth #healthcareleadership #healthcaretransformation #healthcareinnovation   Recent past interviews: Click a guest’s name for their latest RHV episode! Dr Stan Schwartz (EP486), Dr Cristin Dickerson, Elizabeth Mitchell (Take Two: EP436), Dave Chase, Jonathan Baran (Part 2), Jonathan Baran (Part 1), Jonathan Baran (Bonus Episode), Dr Stan Schwartz (Summer Shorts), Preston Alexander, Dr Tom X Lee (Take Two: EP445), Dr Tom X Lee (Bonus Episode), Dr Benjamin Schwartz    

Let us begin with something Ramy Khalil, MD, wrote on LinkedIn the other day. He wrote, “Is it just me, or is the world of healthcare claims designed to make people feel dumb? Asking for … well, myself.” You and me both, my friend. You and me both. For a full transcript of this episode, click here. If you enjoy this podcast, be sure to subscribe to the free weekly newsletter to be a member of the Relentless Tribe. And then Ann Lewandowski, she wrote, “David Bolduc and I sat down this morning. The clear message we need to be delivering to self-funded plans is that you are not purchasing health insurance. Full stop. End of story. You are not offloading risk to their risk pool. You simply purchase their administrative services to manage your healthcare finance dollars.” And right? We’re telling employees to go get screened, to go get a wellness exam, go get a knee replacement, go see your cardiologist. In general, some pretty predictable things. And then every week we’re gonna reactively let a third party tally up the volume. And after it’s all over, tell us how much it costs, vis-à-vis the so-called “Mystery of the Weekly Claims Wire.” Listen to the show with Justin Leader (EP433). This feels very, I don’t know, submissive. Kind of chaotic. It also feels very expensive, and it is of course very expensive. I’ve heard multiple times from multiple guests—Cynthia Fisher (EP457), amongst others—that medical spread, some TPAs (third-party administrators), not all for sure but some TPAs, are scraping off the top 30% plan total spend times 0.3. That’s a lot of money. And add to that (and Leon Wisniewski has posted plenty on this topic) how common it is for prices for any given healthcare service to vary wildly in the same geographic region. Check out an example of one service where you go one place in a local geography and it will cost 10 times more than some other place—10 times more expensive! Or just for, you know, kind of normal stuff, an employee could wind up getting a colonoscopy for $14,000; or they could get one same quality for $2000 or $3000. It’s not chump change that we’re talking about here. It’s $5000, $10,000, $600,000 differences I’ve seen. And what do these two factors, the spread pricing and also some entities in any given market charging lots and lots of money, what do they all add up to if you’re a plan sponsor? Well, big renewals. Lots of effort needing to be placed into trying to figure out how to balance the budget. So, now what if you’re a plan sponsor? Well, a very common gambit here is to cost shift to employees—for example, raise deductibles. But one (there are many), but just one point to ponder as a downstream consequence of this “raise the deductibles” strategy, the higher the deductible, the more clinical organizations become subprime lenders. Mark Cuban wrote this to me the other day, and (massive spoiler alert) he’s coming back on the pod to discuss this topic with Cora Opsahl—and I could not be more excited. But, yeah, if I was in a mood, I could easily argue that when deductibles start to sky, clinical organizations take on more risk for self-insured employers than carriers who literally take on no risk in actuality when the employer is, as I said, self-insured. I’ve heard way more than once about indie practices, and this really matters because obviously indie practices tend to charge a whole lot less than consolidated health systems. So, if you’re a plan sponsor, you sort of want to make sure that you’ve got options in your market. And I have heard way more than once about indie practices who simply cannot stay in business because they don’t have the infrastructure or the capital reserves to basically be a bank. And not just any bank, but one really bad at vetting who they give loans to because, yeah, they actually aren’t able to vet who they give loans to. That would be in violation of their TPA contracts and/or network agreements. If you’re in network and a patient has an insurance card, you gotta follow the financial terms as per the card. Cristin Dickerson, MD, said something in the interview from last week, in the episode from last week (EP485) that stuck with me. We had to cut it for time, but maybe I’ll put it in a bonus show sometime in the future. She said sometimes some kind of slick clinical organizations, when it comes to ordering imaging, they will try to schedule a high-deductible patient’s image for as late in the year as possible in the hopes that, by that time, the patient will have met their deductible and some other schmo healthcare organization will be the one on the hook to have to collect the patient portion. Nothing like not-at-all-timely follow-up, depending on when this happens. I hope I just didn’t give somebody some ideas. Nah! That type wouldn’t be listening to the show. So, all this being said, listen to the show with Preston Alexander (EP482). Listen to the show with Vivian Ho, PhD (EP466). Listen to the two flywheel shows with Jonathan Baran (EP483: Part 1 and Part 2). And all of the deep heavy topics I just glossed over here are deeply raked over the coals in those earlier episodes I just mentioned. But in all cases, you know, one solution to all of the above? Yeah, direct contracting. Now, this Relentless Health Value direct contracting as a solution trifecta, of course, began with Elizabeth Mitchell talking about it in the Take Two (EP436) from two weeks ago. Last week, I discussed the upsides and also three barriers to doing direct contracting for imaging with the incredibly wise and articulate Dr. Cristin Dickerson from Green Imaging. Dr. Dickerson gave a bunch of proven suggestions to overcome said three barriers, by the way (she did not leave you hanging). And now this week, we’re talking mostly about how to think about and operationalize a direct contract with an OG of direct contracting, Dr. Stan Schwartz. What an honor to get Dr. Schwartz on the pod, and I am doubly thankful because he stepped up and offered to help support Relentless Health Value financially as well as spending his time with me and you. So, thanks to everyone over at ZERO.health for being part of the kind of folks who support shows like this one. Dr. Stan Schwartz is co-founder over at ZERO.health. ZERO gets members access to high-quality providers for $0 out of pocket, leveraging bundled payments and direct contracting. This episode, as I just said, is sponsored by ZERO.health, with an assist from Aventria Health Group. Also mentioned in this episode are ZERO.health; Ramy Khalil, MD; Ann Lewandowski; David Bolduc; Justin Leader; Cynthia Fisher; Leon Wisniewski; Mark Cuban; Cora Opsahl; Tom Nash; Cristin Dickerson, MD; Preston Alexander; Vivian Ho, PhD; Jonathan Baran; Elizabeth Mitchell; Green Imaging; Jim Millaway; Kimberly Carleson; Ge Bai, PhD, CPA; Dan Ross; Mark Flores; Purchaser Business Group on Health (PBGH); Peter Hayes; Keith Smith, MD; and Dave Chase.   You can learn more at ZERO.health or email info@zero.health. You can also follow Dr. Schwartz on LinkedIn.   Stan Schwartz, MD, FACP, FIDSA, is the co-founder and chief medical officer at ZERO.health, an employer-facing digital health company created by Stan and his co-founder James Millaway in 2016. ZERO provides direct contracting services between self-funded employers and providers offering pre-priced bundled healthcare services at significant savings. All ZERO services are at no cost to the covered members—healthcare simplified to $0. His time at Warren Clinic and participation in Centers for Medicare and Medicaid Innovation’s landmark Comprehensive Primary Care initiative sparked a drive to work on future transformative projects. He founded WellOK, the Oklahoma Business Coalition on Health, a not-for-profit organization dedicated to improving the value of healthcare for Oklahoma businesses. The coalition later became the Oklahoma Business Coalition on Health at Oklahoma State University. Dr. Schwartz serves on the Medical Director Advisory Council of the National Alliance of Healthcare Purchaser Coalitions and on the Clinical Quality Committee of MyHealth Access Network, a multistate Oklahoma-based health information exchange.   07:59 How did ZERO.health start? 10:38 EP480 with Kimberly Carleson. 11:04 Why does the emotional energy behind understanding how the problem of healthcare affects individuals matter in changing healthcare? 12:45 “If you can schedule it, you can put a price on it.” 15:32 EP420 with Ge Bai, PhD, CPA. 16:38 EP436 with Elizabeth Mitchell. 18:21 How do employers ensure that patients and clinicians are coordinated and on board with direct contracting within their health plans? 20:26 EP475 with Peter Hayes. 22:52 Why is it important that this direct contracting system isn’t mandatory for health plan members? 24:50 How does direct contracting affect excessive utilization? 26:41 EP477 (Through Line Show) with Stacey. 27:29 Why is it important that your plan benefits benefit health? 29:39 Why is it important to educate not only members but also providers who agree to participate in the program? 31:06 “It’s all about simplicity.” 33:11 How do you ensure plan members use the service after it is installed?   You can learn more at ZERO.health or email info@zero.health. You can also follow Dr. Schwartz on LinkedIn.   @stanschwartzmd discusses operationalizing #directcontracting on our #healthcarepodcast. #healthcare #podcast #financialhealth #patientoutcomes #primarycare #digitalhealth #healthcareleadership #healthcaretransformation #healthcareinnovation   Recent past interviews: Click a guest’s name for their latest RHV episode! Dr Cristin Dickerson, Elizabeth Mitchell (Take Two: EP436), Dave Chase, Jonathan Baran (Part 2), Jonathan Baran (Part 1), Jonathan Baran (Bonus Episode), Dr Stan Schwartz (Summer Shorts), Preston Alexander, Dr Tom X Lee (Take Two: EP445), Dr Tom X Lee (Bonus Episode), Dr Benjamin Schwartz, Dr John Lee (Take Two: EP438)

Welcome, Relentless Health Value listeners. Today on the show, we’re talking direct contracting for imaging. Imaging costs can be in the range of 6% to 11% of total plan sponsor spend, and you can figure that out if you have the data to add up the imaging charges themselves plus contrast charges plus professional services, facility fees, etc. For a full transcript of this episode, click here. If you enjoy this podcast, be sure to subscribe to the free weekly newsletter to be a member of the Relentless Tribe. But let me ask you this: Why would anybody direct contract for services such as imaging? This “Why bother despite the significant cost?” is not some kind of rhetorical question, by the way, even though to longtime listeners it might feel like it. And to make this even more rhetorical, let’s just forget about TPAs (third-party administrators) for the moment and disregard what Elizabeth Mitchell, CEO of PBGH, said to me about some of them who may or may not be skimming 30% off the top of plan spend (Take Two: EP436). Let’s just forget about that now and just discuss one other foundational point that has to be locked in to justify why direct contracting is a solution. Are there actually cost differences between different clinical organizations or quality differences for that matter? Is that true? Is that the case? Do cost differences exist? Let me tell you about this, I’m gonna say, pretty upsetting but also pretty revealing conversation I had the other day with a friend of mine—someone who is a professor at a top university. So, a smarty by any definition but also a normal civilian. Healthcare is not her day job, as it is not mostly the day job of many plan sponsors, people in HR. So, it came up. (I swear I don’t launch into healthcare industry diatribes at random dinners with random people—or not that often, at least.) But anyway, healthcare costs came up; and I found myself talking about all of the stuff going on with NewYork-Presbyterian. That DOJ investigation had dropped earlier that day. And also, they have a hospital up the street from actually where we were having dinner. Now recall that part of that DOJ investigation (and there’s a couple of class action lawsuits afoot), but part of that whole thing, what is being alleged, is Presy charging way more for knee replacements and colonoscopies etc. Like, charges double or sometimes three times as much as other local hospitals or ASCs (ambulatory surgery centers), with the same quality. And my friend, she bursts out, “Come on!” She says this really aggressively, actually, like she’s saving me from a conspiracy theory. She says, “It is not possible that one hospital would be able to charge that much and others so much less. The market would even it out. No one would go to the expensive place.” In that moment, I took off my tinfoil hat and laid it gently by my side. No, my heart broke. Let me tell you. Just that morning, I had been helping a friend of the family whose kid got cancer; and I was helping them not lose their house to majorly inflated medical bills. These are the people who are harmed by anticompetitive contracts, by plan sponsors getting trapped into discount-based contracts with conspicuously missing net prices. This is not a “no harm, no foul” arrangement from any given patient’s point of view, what is being alleged in that DOJ investigation. So, I’ve been ruminating over the “why” here, as in why this person and others indubitably like her, why are they so aggressively opposed to reality? Is it just that … it does actually sound illogical on its face because, yeah, it kind of does. Or, for sure, it could be the age-old story that those who are healthy and well resourced enough are well and truly insulated. They aren’t sick, and they have good enough insurance—at least so far—and enough in their bank account to cover their deductible. But I don’t know. I’m still reflecting. I’m confident that many of you have encountered similar situations. What did you do? But I will tell you one thing that I am very sure about. It was in that moment that I appreciated you, Relentless Health Value listeners, and all of you who have spent the time and the energy and came face-to-face with these really unappealing realities. You have followed the dollar as it travels through this labyrinth that is a feature, not a bug. Because you all know the folks who are struggling to meet rent and, at the same time, paying their share of $5000 MRIs when down the street there’s just-as-high-quality imaging for $300 or $500. And as we all know, it’s anticompetitive contracts that often prevent those of us who do get it to steer and tier and educate members. And this is why the show today about direct contracting is so important, because direct contracting can help make sure that members get a fair price. Okay … I’m back on track now. Sorry. It’s been a rough week. My conversation today with the one and only Dr. Cristin Dickerson delves into the merits of direct contracting for imaging, and the conversation emphasizes the significant savings that this can offer, given that imaging, again, constitutes 6% to as much as 11% of plan sponsor healthcare spending. What I think is interesting (slight sidebar here) is, you know, Al Lewis talks about in that episode (EP464) how ER spend has crept up to around 6% of your average plan sponsor’s total spend. And, I don’t know, maybe it’s just the 6% callback that maybe wants to say this. But don’t forget a big point that Al made in that ER show and that I underlined in the ER through line episode (EP477) that came right after that Al Lewis show. And also this comes up in the pod (EP438) with John Lee, MD, who is an ER doc. The more a plan sponsor tries to control imaging or diagnostic, in general, spend, the more patients wind up going to the ER because either they realize or are told that if they wanna just get to the bottom of what’s going on with their bodies without getting caught in prior auth rigamarole, they should just go to the ER. So, paradox and just another example of how what could seem very logical on its face, you know, control costs this way actually leads to higher costs. Anyway, as you listen to the show that follows, I also would think about what Jonathan Baran talked about in the flywheel show (EP483, Part 1) from a few weeks ago, how a plan sponsor can save, again, double digits when they buy good healthcare as their prime directive, not buy discounts or try to math their way into a solution that just adds even more mystery and more middle people. Direct contracting is certainly a way to think about that, and it is something that certainly Jonathan Baran mentioned. Shows to listen to or reflect upon adjacent to this one: Brennan Bilberry (EP395) about anticompetitive contracts, and there’s also a Summer Short about why they are so intractable. Vivian Ho, PhD (EP466) talking about what drives up premiums. Spoiler alert: It’s costs driven by big, consolidated health systems. We had Kimberly Carleson on recently (EP480) echoing many of the themes you’ll hear in the conversation that follows. Also the show with Dave Chase (EP484) talking about figuring out whether your TPA and/or benefit consultant is truly working for you. Wow, that matters. My guest today, Cristin Dickerson, MD, as I have mentioned several times, is the founding partner of Green Imaging, a physician-led radiology network, pioneering affordable, high-quality medical imaging for patients, employers, and health plans nationwide. Green Imaging (round of applause now) has grown to be an $18-million company. Love it when you hear a doing well by doing good story. I also very much appreciated Dr. Dickerson offered a very, very lovely donation to support the work of this podcast. Thank you to her and Green Imaging for this. This podcast is sponsored by Aventria Health Group and also Green Imaging. If you’re a plan sponsor, please give them a call. Also mentioned in this episode are Green Imaging; Elizabeth Mitchell; Purchaser Business Group on Health (PBGH); Al Lewis; John Lee, MD; Jonathan Baran; Brennan Bilberry; Vivian Ho, PhD; Kimberly Carleson; Dave Chase; Keith Passwater; Havarti Risk; Andrea Cockrell; Houston Business Coalition on Health (HBCH); Peter Hayes; Anthony Ciaccia; Dawn Cornelis; Cynthia Fisher; Justin Leader; Cora Opsahl; Preston Alexander; Kurt Christie; Claire Brockbank; Andreas Mang; Chris Deacon; Stanley Schwartz, MD; and ZERO.health.   You can learn more at Green Imaging and follow Dr. Dickerson on LinkedIn.   Cristin A. Dickerson, MD, is the founding partner of Green Imaging. She is a graduate of the University of Texas (UT) Medical School at Houston, where she was elected to Alpha Omega Alpha Honor Medical Society. Dr. Dickerson completed her radiology residency at UT Houston, where she was a chief resident, with extensive training in cancer imaging at MD Anderson Cancer Center. Dr. Dickerson practiced for 13 years at the Diagnostic Clinic of Houston, where she served as a two-term president of the 50-physician clinic and oversaw a self-funded health plan.  She founded Green Imaging in 2011 to provide affordable, high-quality medical imaging for uninsured and high-deductible patients in Houston and rapidly expanded the company to provide services throughout most of the United States and to employer-sponsored health plans. She loves being able to provide quality services to patients who otherwise couldn’t afford them and delivering significant imaging cost savings to patients with healthcare coverage and their employers without compromising quality.    09:52 Who has figured out that direct contract imaging is a great avenue to saving money? 11:12 EP475 with Peter Hayes. 12:39 What are the barriers to getting started with direct contracting imaging? 15:33 EP480 with Kimberly Carleson. 15:36 EP285 with Dawn Cornelis. 16:45 EP457 with Cynthia Fisher. 17:39 EP433 with Justin Leader. 18:03 EP452 with Cora Opsahl. 18:05 EP484 with Dave Chase. 18:12 What do you do when TPAs become a barrier to direct contracting? 20:47 Why going through a TPA actually makes direct contracting more complicated. 22:16 EP482 with Preston Alexander. 25:01 Instagram video on insured rate versus cash rate. 25:26 EP425 with Marshall Allen. 25:52 EP453 with Claire Brockbank. 26:02 EP419 with Andreas Mang. 26:29 How is the “down the hall” mentality a barrier to direct contracting? 31:25 EP395 with Brennan Bilberry. 32:25 Why is it important to change member behavior?   You can learn more at Green Imaging and follow Dr. Dickerson on LinkedIn.   @DrDgreenimaging discusses #imaging and #directcontracting on our #healthcarepodcast. #healthcare #podcast #financialhealth #patientoutcomes #primarycare #digitalhealth #healthcareleadership #healthcaretransformation #healthcareinnovation   Recent past interviews: Click a guest’s name for their latest RHV episode! Elizabeth Mitchell (Take Two: EP436), Dave Chase, Jonathan Baran (Part 2), Jonathan Baran (Part 1), Jonathan Baran (Bonus Episode), Dr Stan Schwartz (Summer Shorts), Preston Alexander, Dr Tom X Lee (Take Two: EP445), Dr Tom X Lee (Bonus Episode), Dr Benjamin Schwartz, Dr John Lee (Take Two: EP438), Kimberly Carleson      

Right up front here, let me just state loudly that there are some amazing independent TPAs (third-party administrators) out there who have the expertise, the scrappy willfulness, and the deep desire to do right by their clients, their self-insured employer clients. For a full transcript of this episode, click here. If you enjoy this podcast, be sure to subscribe to the free weekly newsletter to be a member of the Relentless Tribe. And look, they may be facing some of the same headwinds that plan sponsors themselves face, like anticompetitive contracts, brokers who are up to no good, etc. So, just keep that in mind as you listen. And the main point of all of this if you are a plan sponsor is, find a good TPA partner, which, as Bryce Platt has said about consultants but same rules apply about TPAs here, the difficulty is being informed enough to tell the difference. So, the goal of this show is to help with that, the “be informed enough to tell the difference.” All of this being said, this is technically a Take Two; but we trimmed it down and welcome to a whole new intro. So, call this a refresher and an update about a really, really important topic from last year that is becoming extremely (maybe even more) relevant this year. Really relevant. Consider, for example, the show with Claire Brockbank (EP453) about carrier/TPA RFPs (requests for proposal) and all of the landmines that are really expensive, that are buried in some of these contracts. Then there was the Cynthia Fisher show (EP457) from last year about the millions, maybe billions of dollars in aggregate going missing in medical (ie, TPA or ASO [administrative services only]) spread pricing. We had “The Mystery of the Weekly Claims Wire” show with Justin Leader (EP433), again, revealing money that’s being disappeared when the TPA is withdrawing dollars from plan sponsor checking accounts. And then there’s the payment integrity episode with Kimberly Carleson (EP480) from a few weeks ago with just another wrinkle on this, namely TPAs or ASOs who insist on auditing themselves and how that turns out for members and plan sponsors. Oh, and last, but certainly not least, is the whistleblower show with Ann Lewandowski (EP476) on how a TPA arm of an EBC (employee benefit consultant) allegedly pocketed $20 million—$20 million of their client’s pharma rebates—and used that $20 million to fund their executive bonus pool. What a time to be alive! All of this just highlights the huge stakes for plan sponsors to really understand what their TPA is all about. And when I say high stakes, I mean from both a legal standpoint and also just vast dollars in play here. But this episode with Elizabeth Mitchell is also, I’m gonna say, extremely relevant given just a few ripped from the headlines and news articles such as these. I’m gonna start actually with a post from Kimberly Carleson, and I like the comment by Jeff Evans, who wrote, “How does $8,710 equal $104,266?” Spoiler alert, it doesn’t. Lots of missing dollars there. Someone’s hands are in the cookie jar. Oh, look, the TPA has entered the chat. In a nutshell, and I’m quoting something Peter Hayes wrote, he wrote, “TPAs have received relatively little public attention. [There’s an article in Health Affairs] that describes how TPAs impose hidden fees, benefit from their own form of spread pricing, and otherwise prioritize their own financial interests over those of their plan clients.” Also, here’s a totally other issue. Let me quote Luke Prettol highlighting something Jason Shafrin had written about a paper by Jeff Marr, Daniel Polsky, and Mark Meiselbach. Let me slightly rephrase what Luke said. He wrote, “Employers pay, on average, a 4.7% [so almost 5%] price markup when hospitals are in their TPA’s [Medicare Advantage] network.” Right? Dr. Eric Bricker talked about this in that episode (EP472) just how TPAs with MA (Medicare Advantage) business negotiate their commercial clients to pay higher rates so that then they can pay lower rates for their own MA members. As Luke wrote, “On its face, this overpayment does not appear to be solely in the interest of participants.” No kidding. Now, let’s spin the wheel here. There are barriers for TPAs themselves, even the ones who have a deep desire to do the right thing. As Patrick Moore wrote, “Most TPAs still can’t do [many of the things that employers might want because there are] PPO contracts.” So, is it a rock in a hard place situation? I mean, if the TPA has no other options than using a carrier’s PPO (preferred provider organization) network with all its attendant contractual issues, then yeah, that is one definite challenge. Along these lines, let me read a post by Rina Tikia, because I think she sums up this really well. “When independent TPAs … push for transparency, they’re blocked under the banner of ‘fiduciary risk.’ “Meanwhile, the largest carriers and PBMs, with Cayman shell subsidiaries, DOJ kickback probes, [huge] hedge fund ties, [$10 million-plus] lobbying budgets, and antitrust violations continue unchecked. They are not only allowed to operate but celebrated as mainstream options. “Why the double standard? Political donations? Foundation smokescreens? Nonprofit status as a PR shield?” These are excellent questions. And here’s another challenge: brokers. Ramesh Kumar Budhani wrote about this one, just how hard it is sometimes to find—for TPA, an independent TPA, trying to do the right thing—to find brokers who prioritize doing the right thing for employers and helping their clients save money. The summary of all of this: There are TPAs and there are ASOs who aren’t even trying. They are going to ride the flywheel, the gravy train, and catch all of the dollars flying off of it for as long as they can manage to cling to it with all 10 of their fingers. Then there are TPAs, mostly indies, trying super hard to do the right thing. But how successful they are is going to depend on how boxed in they are by the PPO networks or the carriers that the brokers or even plan sponsors may insist on. Just how courageous they are and just how smart they are and experienced they are about the market and how it actually operates. So, the show that follows is about all of this, including how we can inspire TPAs, which, in the show that follows, subsumes ASOs kind of into it. But in the show that follows, I hope it’s inspiring to create an environment so that the market demands TPAs that do all of the things, and we make inertia not a viable business strategy. Elizabeth Mitchell, my guest today, currently serves as the president and CEO of the Purchaser Business Group on Health. Also mentioned in this episode are Purchaser Business Group on Health; Bryce Platt; Claire Brockbank; Cynthia Fisher; Justin Leader; Kimberly Carleson; Ann Lewandowski; Jeff Evans; Peter Hayes; Luke Prettol; Jason Shafrin; Jeff Marr; Daniel Polsky; Mark Meiselbach; Eric Bricker, MD; Tom Nash; Patrick Moore; Rina Tikia; Ramesh Kumar Budhani; Mark Cuban; Harold Miller; Chris Deacon; Moby Parsons, MD; Benjamin Schwartz, MD, MBA; Mishe Health; Rik Renard; and Cora Opsahl. You can learn more at PBGH and by connecting with Elizabeth on LinkedIn.   Elizabeth Mitchell, president and CEO of the Purchaser Business Group on Health (PBGH), advances its strategic focus areas of advanced primary care, functional markets, and purchasing value. She leads PBGH in mobilizing health care purchasers, elevating the role and impact of primary care, and creating functional healthcare markets to support high-quality affordable care, achieving measurable impacts on outcomes and affordability. At PBGH, Elizabeth leverages her extensive experience in working with healthcare purchasers, providers, policymakers, and payers to improve healthcare quality and cost. She previously served as senior vice president for healthcare and community health transformation at Blue Shield of California, during which time she designed Blue Shield’s strategy for transforming practice, payment, and community health. Elizabeth served as the president and CEO of the Network for Regional Healthcare Improvement (NRHI), a network of regional quality improvement and measurement organizations. She also served as CEO of Maine’s business coalition on health (the Maine Health Management Coalition), worked within an integrated delivery system (MaineHealth), and was elected to the Maine State Legislature, serving as a State Representative. Elizabeth served as vice chairperson of the U.S. Department of Health and Human Services Physician-Focused Payment Model Technical Advisory Committee, board and executive committee member of the National Quality Forum (NQF), member of the National Academy of Medicine’s “Vital Signs” Study Committee on core metrics, and a guiding committee member for the Health Care Payment Learning & Action Network. Elizabeth holds a degree in religion from Reed College and studied social policy at the London School of Economics.   08:06 What is the overarching context for health plans in healthcare purchasing? 11:31 Why is it important to reestablish a connection between the people paying for care and people providing care? 13:47 What are the needs of a self-insured employer when managing employee benefits? 19:00 Is it doable for employers to set their own contracts? 21:24 Is transparency presumed? 22:39 Will the new transparency upon us actually expose wasted expense? 24:23 EP408 with Chris Deacon. 25:58 “This is not about individual bad actors. … The systems … that is not aligned.” 27:39 Are there providers who want to work directly with employers? 30:53 Why is it important that incentives need to be aligned? 32:42 EP427 with Rik Renard. 33:51 What’s missing from the conversation on changing health plans?   You can learn more at PBGH and by connecting with Elizabeth on LinkedIn.   @lizzymitch2 of @PBGHealth discusses #TPA and #healthplan vs. #jumboemployer inertia on our #healthcarepodcast. #healthcare #podcast #financialhealth #patientoutcomes #primarycare #digitalhealth #healthcareleadership #healthcaretransformation #healthcareinnovation   Recent past interviews: Click a guest’s name for their latest RHV episode! Dave Chase, Jonathan Baran (Part 2), Jonathan Baran (Part 1), Jonathan Baran (Bonus Episode), Dr Stan Schwartz (Summer Shorts), Preston Alexander, Dr Tom X Lee (Take Two: EP445), Dr Tom X Lee (Bonus Episode), Dr Benjamin Schwartz, Dr John Lee (Take Two: EP438), Kimberly Carleson, Ann Lewandowski (Summer Shorts)  

Today I am speaking with Dave Chase from Health Rosetta, and I’m asking Dave Chase three inferno-level burning questions—questions that, across the country, many self-insured employers are trying to find the answers to. For a full transcript of this episode, click here. If you enjoy this podcast, be sure to subscribe to the free weekly newsletter to be a member of the Relentless Tribe. Now, an important underlying point that comes across loud and clear but remains unsaid, actually, in the conversation that follows is this: There are amazing brokers and EBCs (employee benefit consultants) and benefits advisors or TPAs (third-party administrators) who put their clients first and have the receipts (ie, they have data and they’re willing to share it to prove this). And then there are those with the exact same titles, often enough, who are very much the opposite of this but super charming, I’m sure. I mean, it’d be a stretch to assume that the same roles don’t apply to brokers or EBCs that apply for titles like hospital administrators where there’s great ones and really not great ones; but everybody often gets lumped into the same category or even the term hospitals. Each of these terms is a broad stroke and contains multitudes. And do listen to the bonus clip from two weeks ago with Jonathan Baran for just more on this point. We dig into it for like 10 minutes or something. I also talk about this same concept in an upcoming episode with Mick Connors, MD. So, keep that underlying and unsaid theme in mind because a lot of these questions do boil down to, How do you figure out who’s on the up-and-up and who’s not? And if you need an example of the latter category, listen to the show with Ann Lewandowski (EP476) about the whistleblower lawsuit or the show with AJ Loiacono (EP379) about the myriad of brokers taking $7 or $14 per script written payable by the PBM (pharmacy benefit manager) and not reported on, as far as I know. This is very much still going on today, by the way, despite the CAA (Consolidated Appropriations Act) and the 5500 forms. Alright, so, first burning question, Question 1: After seeing J&J (Johnson & Johnson) and Wells Fargo sued for fiduciary breaches, what specific questions do I need to ask my benefits advisor to prove that my benefits advisor actually protects my interests? Okay, paraphrased, this question is employers trying to figure out what they can ask or how they can figure out if their benefits advisor or broker or employee benefit consultant is really as trustworthy as they’d like you to believe they are. There’s been a whole bunch of shows that circle up on this. The thing is, though, the stakes are very, very high right now. So, yeah, I can see why this is turning into a burning question for anyone worried they might get sued personally unless they can figure out how to vet, for real in writing, who their broker, EBC, or advisor serves actually at the end of the day. Question 2 that I ask Dave Chase, and I’m not giving you the answers to these questions. You gotta listen to the show. But here’s the second question I ask: How do I avoid personal liability when my TPA contract has hidden conflicts that could trigger an ERISA (Employee Retirement Income Security Act) lawsuit? Kind of a continuation of Question 1, but yeah, you can tell that self-insured employer teams are really digging in here and many, many are very aware of, first of all, the extent and depth of middle people doing things like, again, allegedly taking $20 million of employer clients’ money and funding their executive bonus pool. So, yeah, definitely this is another doozy of a burning question. Also on these same topics, listen to the show with Justin Leader (EP433) and also the one with Cynthia Fisher (EP457) about spread pricing. Question 3 that I ask Dave Chase: My pharmacy costs keep climbing despite PBM guarantees. How do I tell if I am being systematically overcharged? Well, if your consultants are taking your rebates to fund their executive bonus pools, as I just mentioned there’s a whole show about with Ann Lewandowski, or if they’re taking $7 a script for every script that gets written for your members, which, yeah, that’s afoot. I’ve seen the contracts and the cease and desists currently flying around our industry about that one. Or read that Osceola County lawsuit against their longtime brokers. Bottom line and end of this intro, informed employer teams are, for sure, wondering these questions. But even more than just wondering, what these questions signify to me, kind of at the macro level, they’re realizing the danger of kind of sitting on that knowledge or just assuming that because everybody else is doing whatever, it’s somehow safe—though status quo is getting kind of more and more dicey every single day. As some additional foreshadowing, this show finishes up with Dave Chase talking about the open-source resources that are available so that you too can create a high-performance health plan where members get higher-quality healthcare and, as Dave Chase says, the cost savings for free. There are links to many things that you can get from Health Rosetta and their sister company, Nautilus. Again, all the stuff is for free. Go to nautilushealth.org. That’s their main Web site. Dave Chase, who has been on this podcast—I think this is his third time, although it has been a while—Dave Chase is co-founder and CEO of Health Rosetta. Also mentioned in this episode are Health Rosetta; Jonathan Baran; Mick Connors, MD; Ann Lewandowski; AJ Loiacono; Chris Deacon; VerSan Consulting; Justin Leader; Cynthia Fisher; Nautilus; Andreas Mang; Blackstone; Jon Camire; Claire Brockbank; Elizabeth Mitchell; Scott Haas; Paul Holmes; Chris Crawford; Luke Slindee, PharmD; Mark Cuban; Marilyn Bartlett, CPA, CGMA, CMA, CFM; Leah Binder; and Dawn Cornelis.   You can learn more at Health Rosetta and follow Dave on LinkedIn.   Dave Chase is on a mission to restore hope, health, and economic well-being to communities through healthcare transformation. As creator of the community-owned health plan (COHP) model, he is building a nationwide movement that turns health plans from drivers of wage stagnation into vessels for well-being and wealth creation. As founder of Health Rosetta, Dave has helped transform healthcare for thousands of employers covering more than five million Americans. What began with identifying just five successful health plans nationwide has grown into a movement with thousands of sustainable successes that deliver superior care at 20% to 50% lower costs. In 2024, his team launched Nautilus Health Institute, catalyzed with $4 million in Health Rosetta intellectual property and investment. Nautilus provides open-source standards, contracting templates, and technology infrastructure (including METL, an open-source healthcare data platform) that establish new market norms benefiting employers, clinicians, and communities. Dave’s work in healthcare transformation has reached over 10 million people through best-selling books (The CEO’s Guide to Restoring the American Dream, The Opioid Crisis Wake-up Call, Relocalizing Health), media, TED Talks, and TV/film appearances. He has received the World Health Care Congress’s Lifetime Achievement Award for Health Benefits Innovation. Dave is dedicated to transforming healthcare through transparency, community ownership, and proven solutions that restore the American Dream.   06:36 What questions does a plan sponsor need to ask their consultant, EBC, or broker to ensure they are protecting the interest of the plan sponsor? 07:59 EP478 with Andreas Mang and Jon Camire. 08:49 EP453 with Claire Brockbank. 09:51 EP433 with Justin Leader. 09:53 EP436 with Elizabeth Mitchell. 11:03 How can plan sponsors avoid personal liability when their TPA has hidden conflicts of interest? 11:40 Tiara Yachts v. Blue Cross Blue Shield of Michigan lawsuit. 13:48 EP483 (Part 1) with Jonathan Baran. 14:18 EP457 with Cynthia Fisher. 16:18 The Marshall-Hickenlooper bill called the Price Tags Act. 16:50 Summer Short with Elizabeth Mitchell. 17:36 How do plan sponsors figure out if they are being overcharged for pharmacy benefits? 18:09 EP365 with Scott Haas. 20:18 EP397 with Paul Holmes. 20:22 EP465 with Chris Crawford. 20:37 EP429 with Luke Slindee, PharmD. 22:56 EP476 with Ann Lewandowski. 28:38 Where to find open-source resources to help guide plan sponsors with making better health plan decisions. 29:47 How the open-source trend is growing for health transparency. 30:48 What to look forward to at RosettaFest.   You can learn more at Health Rosetta and follow Dave on LinkedIn.   @chasedave discusses questions #plansponsors need to ask on our #healthcarepodcast. #healthcare #podcast #financialhealth #patientoutcomes #primarycare #digitalhealth #healthcareleadership #healthcaretransformation #healthcareinnovation   Recent past interviews: Click a guest’s name for their latest RHV episode! Jonathan Baran (Part 2), Jonathan Baran (Part 1), Jonathan Baran (Bonus Episode), Dr Stan Schwartz (Summer Shorts), Preston Alexander, Dr Tom X Lee (Take Two: EP445), Dr Tom X Lee (Bonus Episode), Dr Benjamin Schwartz, Dr John Lee (Take Two: EP438), Kimberly Carleson, Ann Lewandowski (Summer Shorts), Andreas Mang and Jon Camire (EP479)

Okay, to review from Part 1 of this conversation, and if you didn’t listen to it because you think you know how this whole skyrocketing healthcare costs thing works, let me tell you, I myself had a few revelations. So, go back and listen. For a full transcript of this episode, click here. If you enjoy this podcast, be sure to subscribe to the free weekly newsletter to be a member of the Relentless Tribe. But to be fair, if you didn’t already, sure, fine. Listen to Part 2 here first and then do it backwards. It probably won’t make that much difference, except you’ll need to contend with me totally ruining the Part 1 suspense because here’s the negative flywheel, starting with the axle. Employers and other plan sponsors have been convinced to buy discounts, including discounts or discounts by their other aliases: rebates and probably shared savings, too, I would throw in this category. This is the grease that keeps the flywheel spinning. What’s the “why” there? It’s a genius idea if you think about it. And if you’re not fully understanding what I’m about to say, go back, for sure, and listen to Part 1 of this episode because this is a very fundamental concept that has come up over and over and over again on this podcast. Cora Opsahl (EP452) talked about it. Claire Brockbank (EP453); Eric Bricker, MD (EP472); Chris Crawford (EP465) for just four shows off the top of my head in the past, you know, eight months or so. Here’s the concept: If you buy discounts, your costs will go up. Am I saying this theoretically? No, I’m not. Look at the last 20 years. Have costs gone up way higher than inflation? Yes, they have. What are we doing? We’re buying discounts. So, it’s hard to argue. Renewals every single year will just keep going up the longer that we buy discounts. We talk about this, Jonathan Baran and I, in Part 1, how carriers have created a really very self-serving buying framework where employers are trained to buy discounts. Discounts are the axle, and the buying of discounts becomes the top of our flywheel. And then some so inclined hospital system executives, there are certainly executives standing 10,000 feet from any bedside, so they really have zero idea how care or patients or even clinicians are impacted. But if plan sponsors buy discounts, those at health systems who are so inclined now have no real incentive to rein in prices or focus on appropriate care even. And if you are so inclined, if you’re very margin focused as a healthcare executive, you know, first things first, go gut primary care. That is step one in every playbook, and we definitely talk about that in Part 1 of this episode. And also, again, in about 10 episodes from earlier this year. Another thing that you’re gonna wanna do if your prime imperative is margin at a healthcare system is maximize the revenue off of every transaction. So, hey … hello, EHR systems. So now you have health system prices creeping up and up, unfettered, you know, just exacerbated by consolidation and a bunch of other different things. But you’ve got healthcare prices creeping up, you have volume the same or higher because we’re not preventing chronic disease like you would with advanced primary care, for example. And now we’re back at the “Oh wow, let me sell you another discount. And renewal is only 9% or whatever.” Thus, the flywheel spins. Alright, so let’s turn this wheel around, shall we? Flip it 180. What’s the fix? This is what Jonathan Baran talks about in the episode that follows, but he says, Hey, how about this? Instead of putting “get bigger discounts” in the middle of the flywheel, why don’t we put “buy better member health”? That’s a good start. Buy a health plan that delivers better member health at an affordable price. Buy the care, not buy a discount off of a price we can’t see for net price we can’t see. Is it insurance? I don’t know. Right? Like, just buy the healthcare. Cutting to the chase, Jonathan Baran advocates for a paradigm shift where employers invest in primary care, adopt better benefit designs, more aligned to cost and quality so that members are incented toward better cost and quality, employee navigation services to guide employees to make more informed healthcare decisions. So again, by changing the focus from buying discounts to buying actual healthcare, Jonathan says, we can reverse the negative cycle and improve overall health outcomes. As I’ve said multiple times already, my guest today is Jonathan Baran. He has been, for a long time, a healthcare entrepreneur. Today he is co-founder and CEO of Self Fund Health in Wisconsin, committed to challenging the expensive healthcare system in Wisconsin. Self Fund Health, I am always so pleased to tell you, did make a really, really kind offer to help out RHV (Relentless Health Value) financially. You and the tribe here are really great folks who I truly, truly appreciate. So, please do support Self Fund Health if you are in Wisconsin. This podcast is sponsored by Self Fund Health today. Also mentioned in this episode are Self Fund Health; Cora Opsahl; Claire Brockbank; Eric Bricker, MD; Chris Crawford; Cynthia Fisher; Scott Haas; Peter Hayes; Matt McQuide; RxSaveCard; Mark Cuban; Ramy Khalil, MD; Candace Shaffer; and Tom Nash.   You can learn more at Self Fund Health and follow Jonathan on LinkedIn.   Jonathan Baran is a serial healthcare IT entrepreneur and the co-founder and CEO of Self Fund Health, a fast-growing health plan redefining how employers buy and manage healthcare. With a mission to eliminate waste and realign incentives in the healthcare system, Self Fund Health empowers employers to take control of rising costs by giving employees access to high-value providers at no cost, while replacing traditional insurance with real-time technology, dedicated nurses, and an aligned ecosystem of care. Prior to founding Self Fund Health, Jonathan was the co-founder and CEO of Healthfinch, one of the pioneering companies to build apps on top of electronic medical records. Healthfinch automated routine workflows for physicians using clinical data, significantly improving efficiency and patient care. Under Jonathan’s leadership, Healthfinch raised over $15 million in venture capital and scaled to more than 50 employees. The company received national recognition, including being named a “Cool Vendor” by Gartner, a “Top Emerging Vendor” by KLAS, and one of Modern Healthcare’s “Best Places to Work.” In 2020, Healthfinch was acquired by HealthCatalyst. Jonathan holds both a bachelor’s and master’s degree in biomedical engineering from the University of Wisconsin–Madison. He lives in Madison, Wisconsin, and continues to push the boundaries of innovation in employer-sponsored healthcare.   05:23 Where to start in reversing the flywheel. 06:57 Why investing in primary care is pivotal to containing healthcare costs. 10:02 EP453 with Claire Brockbank. 10:04 EP452 with Cora Opsahl. 10:07 EP457 with Cynthia Fisher. 10:12 EP365 with Scott Haas. 10:13 EP465 with Chris Crawford. 10:14 EP475 with Peter Hayes. 11:11 EP468 with Matt McQuide. 11:13 EP472 with Eric Bricker, MD. 12:14 “The most expensive thing in healthcare is the pen of the primary care doctor.” 13:04 How the role of the broker has to fundamentally change. 16:16 What will the single most challenging aspect of this restructuring become? 20:20 How self-funded employers can be amazing customers in containing the rising cost flywheel in healthcare. 22:56 How do EHRs and other medical record systems play into reversing the flywheel of rising healthcare costs? 23:57 Ramy Khalil, MD’s post on interoperability. 24:59 Why is it important for employers to drive volume differently? 25:38 How Self Fund Health is helping in this regard.   You can learn more at Self Fund Health and follow Jonathan on LinkedIn.   @JonathanBaran discusses how to contain increasing #healthcarecosts on our #healthcarepodcast. #healthcare #podcast #financialhealth #patientoutcomes #primarycare #digitalhealth #healthcareleadership #healthcaretransformation #healthcareinnovation Recent past interviews: Click a guest’s name for their latest RHV episode! Jonathan Baran (Part 1), Jonathan Baran (Bonus Episode), Dr Stan Schwartz (Summer Shorts), Preston Alexander, Dr Tom X Lee (Take Two: EP445), Dr Tom X Lee (Bonus Episode), Dr Benjamin Schwartz, Dr John Lee (Take Two: EP438), Kimberly Carleson, Ann Lewandowski (Summer Shorts), Andreas Mang and Jon Camire (EP479), Justin Leader (Take Two: EP433)  

Okay … This clip, you could call it a reel, I guess, because kids these days; but I think it is a really important four or five minutes or whatever, because it’s my guest on the pod this week, Jonathan Baran, and next week, actually. For a full transcript of this episode, click here. If you enjoy this podcast, be sure to subscribe to the free weekly newsletter to be a member of the Relentless Tribe. And Jonathan Baran makes a very important point, and this also comes up, by the way, in the show with John Lee, MD (EP438) from a couple of weeks ago: large consolidated health systems, large vertically integrated carriers, and their PBMs (pharmacy benefit managers) and their GPOs (group purchasing organizations) in Switzerland or Ireland or whatever, and some of these large benefit consulting firms. The hundreds of thousands of folks who work in these places, some of them, for sure, are on board for the ride who don’t really care about their ultimate impact that they are having on patients, members, or the non-healthcare economy in the United States. That’s probably true. It’s also probably true that the majority don’t actually understand what’s going on and the impact of their actions. But there definitely is a cohort—there’s a gang in there, and many of this gang listen to the show—and these folks are trying desperately against every personal incentive against lashback, against all odds, they’re trying to figure out how to get their organization to do a little bit better for patients or members or plan sponsors, actually, if we’re talking about anybody who works at some of these large benefit consulting firms. We are not one with the stakeholder that we work with, and if the object is to do better by members and patients, it’s really incumbent on us to understand what is going on in our very own neck of the woods. We can’t improve if we don’t really understand what the problem is. So, the conversation that follows is Jonathan Baran offering up a plea, really, on behalf of these folks (our “knights,” if you will) to please not generalize the intentions and values of everyone who works somewhere and assume that when a C-suite embarks on some margin-focused endeavor, that everybody who works at that place is in full agreement with that path. That’s kind of like throwing babies out with bath water territory, and ultimately, we need as many on our side as we can get. I actually did a whole show on this called “The Narcissism of Small Differences” (INBW39). If you’re so inclined, please do go back and listen to it. Also, listen to the show with Larry Bauer, MSW, MEd. It was a Summer Short from a couple of years ago called “Knights, Knaves, and Pawns.” My guest for this short segment is Jonathan Baran. He has always been a healthcare entrepreneur. Today he is co-founder and CEO of Self Fund Health, which is committed to challenging the expensive healthcare system in Wisconsin. This episode is sponsored by Self Fund Health. Also mentioned in this episode are Self Fund Health; John Lee, MD; Larry Bauer, MSW, MEd; and Tom Nash.   You can learn more at Self Fund Health and follow Jonathan on LinkedIn.   Jonathan Baran is a serial healthcare IT entrepreneur and the co-founder and CEO of Self Fund Health, a fast-growing health plan redefining how employers buy and manage healthcare. With a mission to eliminate waste and realign incentives in the healthcare system, Self Fund Health empowers employers to take control of rising costs by giving employees access to high-value providers at no cost, while replacing traditional insurance with real-time technology, dedicated nurses, and an aligned ecosystem of care. Prior to founding Self Fund Health, Jonathan was the co-founder and CEO of Healthfinch, one of the pioneering companies to build apps on top of electronic medical records. Healthfinch automated routine workflows for physicians using clinical data, significantly improving efficiency and patient care. Under Jonathan’s leadership, Healthfinch raised over $15 million in venture capital and scaled to more than 50 employees. The company received national recognition, including being named a “Cool Vendor” by Gartner, a “Top Emerging Vendor” by KLAS, and one of Modern Healthcare’s “Best Places to Work.” In 2020, Healthfinch was acquired by HealthCatalyst. Jonathan holds both a bachelor’s and master’s degree in biomedical engineering from the University of Wisconsin–Madison. He lives in Madison, Wisconsin, and continues to push the boundaries of innovation in employer-sponsored healthcare.   03:11 A brief background on Jonathan and Self Fund Health. 04:24 Why is it imperative that individuals stop identifying wholly with the organization that they work with? 05:48 Why is it important to be direct and call out the behavior without calling out the individual? 07:14 EP483 (Part 1) with Jonathan Baran.   You can learn more at Self Fund Health and follow Jonathan on LinkedIn.   @JonathanBaran discusses addressing issues in #healthcare diplomatically on our #healthcarepodcast. #podcast #financialhealth #patientoutcomes #primarycare #digitalhealth #healthcareleadership #healthcaretransformation #healthcareinnovation   Recent past interviews: Click a guest’s name for their latest RHV episode! Dr Stan Schwartz (Summer Shorts), Preston Alexander, Dr Tom X Lee (Take Two: EP445), Dr Tom X Lee (Bonus Episode), Dr Benjamin Schwartz, Dr John Lee (Take Two: EP438), Kimberly Carleson, Ann Lewandowski (Summer Shorts), Andreas Mang and Jon Camire (EP479), Justin Leader (Take Two: EP433), Andreas Mang and Jon Camire (EP478)  

We’re gonna talk about EHR systems today (electronic health records). It was unexpected when Jonathan Baran brought them up, I gotta say. And yet, part of the flywheel, for sure. I see that. But let me start from the beginning. For a full transcript of this episode, click here. If you enjoy this podcast, be sure to subscribe to the free weekly newsletter to be a member of the Relentless Tribe. Did you listen to the show with Preston Alexander (EP482)? Here’s the short version: Carriers and the not transparent brokers and EBCs (employee benefit consultants), they actually, this crew, actually benefits, they make more money when employers pay more for healthcare prices going up—not usually a problem. Whoa. Did I just blow your mind? That’s not what the marketing says, and sure, no one wants a midyear unexpected anything that the actuaries didn’t predict. But if we’re talking commercial markets, where the ultimate purchaser is not the carrier but some self-insured employer or other plan sponsor, then yeah. I mean, it’s always true that someone’s cost is someone else’s revenue stream. It’d be problematic to forget that. And carriers make a percentage of premiums. This is their underwriting profit. But they also make a percentage off of float, right? Take those premium dollars and invest ’em in the bank until the bills come due. Again, there’s a whole show on this with Preston Alexander (EP482) from a couple of weeks ago. All this said, how does a carrier ensure max revenue from its commercial service lines? Well, don’t actually control underlying healthcare costs. The best way for a carrier to make the most money is for premiums to be as high as they possibly can be, because anyone making a percentage of a higher number makes a higher number. Anyone investing a higher number makes a higher number in interest. But conundrum: What do you put in your marketing so that it looks like you’re controlling costs but you actually don’t have to control costs because you kind of don’t want to if you’re obeying your fiduciary responsibility to your shareholders to margin it up? It’s impressive, actually, how they have achieved this. You know, have your marketing cake and eat the profits, too. And spoiler alert, this is the concept our flywheel spins around. It’s the axle of our flywheel. It is so very, very clever. Here it is. Talk in terms of discounts, not underlying costs. Sell discounts. Honestly, whoever came up with this—get the employers to buy discounts—this deserves a prize from the “your margin is my mission” set. Someone at some conference in Boca Raton 20 years ago probably got some Stanley Cup–sized trophy. So again, if I was gonna make one concept, the greased-up axle of the flywheel we’re gonna talk about today, it’d be discounts. And when I say discounts, I also kind of mean anything that is a discount, just spelled with different letters, like rebate or shared savings, to a certain extent. Listen to the show with Chris Crawford (EP465) and Cynthia Fisher (EP457) for more on those two terms. Ann Lewandowski talks about this also. In fact, now that I’m thinking about this, the Employer Coalition of Louisiana quoted Ann Lewandowski from that episode (Summer Short). They said, “Health plans continue chasing rebates simply because they are presented as savings and dangled like a golden carrot. However, it does not address the cost problem.” Before I get into what discounts/rebates/shared savings even mean as a general construct and why I’m nominating them for the honor of claiming that middle of the flywheel prime real estate, let me just quickly explain the term “flywheel” in case anyone is unfamiliar. Jim Collins, the author of that famous book Good to Great, he coined the concept of a flywheel; and he wrote, “No matter how dramatic the end result, business sea changes, where some company makes lots and lots of money, never happen in one fell swoop. … There is no single defining action, no grand program, no one killer innovation, no solitary lucky break, no miracle moment. Rather, the process resembles relentlessly pushing a giant, heavy flywheel, turn upon turn, building momentum until a point of breakthrough, and beyond.” And this is why renewals can be 9% or 22% or 36% when inflation is a fraction of that. It’s because we have ourselves a flywheel in the healthcare industry that is spiraling on behalf of companies who are starting that flywheel spinning. And the faster it spins, the more revenue flies out of it. Jonathan Baran, my guest today, really nails what the healthcare flywheel is and how it works in the episode that follows. So, I am not gonna get into it right now. I’m gonna focus on the middle of the flywheel, this whole discount thing, as kind of our tee-up and lead-in. So, middle of the flywheel. What do discounts even mean? I bought a shirt the other day that had a list price of $600. I’m not making this up, but before you think I’m all that and a bag of chips, let me tell you, it was 90% off. So, I got a bargain, and I bought it for $60. I’m thinking I’m amazing, right? Super shopper. Except it was a $60 shirt. Like, it was made of cotton with no thread count, and the hemline was a little crooked. You get my point. Scott Galloway, I get his newsletter. Anyway, he wrote the other day, “The way you become a billionaire or create massive shareholder value is by inventing a product that exploits a flaw in human instincts.” And right, selling discounts does that for sure. Buyer thinks they’re amazing, and seller is laughing all the way to the bank because, keep in mind, in healthcare world, you wouldn’t know the original price of the shirt and you wouldn’t know the final price. All we’d know is we saved 90%. Next year, I could be super pleased with myself because I got a 95% discount on my new replacement shirt. Did I get a better price, though? Who knows? The new blouse list price could have been $1800 or whatever, but just try to get that data point and you’ll find out fast enough whether your broker, carrier, or PBM (pharmacy benefit manager) or out-of-network network has any interest in transparency. Listen to the show with Dave Chase that’s coming up for a whole lot about that. Okay … so, that’s your lead-up to where you’re gonna drop into the healthcare flywheel today with Jonathan Baran. So, what you’re gonna hear today, you can call this part 1 of the conversation; and this is the flywheel as it spins, I’m gonna say, a direction that does not behoove plan sponsors, plan members, taxpayers. Next week, though, come back because we’re gonna have part 2 of this conversation, where we reverse the flywheel and send it spinning the other direction. That’s gonna be part 2 of the show, so do come back next week to hear that uplifting segment. Also, in the podcast feed today, there’s a bonus clip, and in this bonus clip—it’s like four minutes or five minutes long—but Jonathan Baran and I do spend a little bit of time talking about how, as we have conversations like this, it’s really important to keep in mind that we’re talking about an entire, you know, stakeholder, if you wanna use that term. We’re not talking about every single individual. As I just said at least three times, my guest today is Jonathan Baran. He has always been a healthcare entrepreneur. Today he is co-founder and CEO of Self Fund Health, which is committed to challenging the expensive healthcare system in Wisconsin. If you are in Wisconsin, do look them up. Self Fund Health, I am so pleased to tell you, as I am always so pleased to tell you, did make such a kind offer to help out Relentless Health Value financially. You and the tribe here are really, really great folks who I truly appreciate. Please support Self Fund Health again if you are in Wisconsin. And with that, here we go. This episode is sponsored by Self Fund Health. Also mentioned in this episode are Self Fund Health; Preston Alexander; Chris Crawford; Cynthia Fisher; Ann Lewandowski; Scott Galloway; Dave Chase; Stanley Schwartz, MD; ZERO.health; Rina Tikia; Ge Bai, PhD, CPA; and James Gelfand, JD.   You can learn more at Self Fund Health and follow Jonathan on LinkedIn.   Jonathan Baran is a serial healthcare IT entrepreneur and the co-founder and CEO of Self Fund Health, a fast-growing health plan redefining how employers buy and manage healthcare. With a mission to eliminate waste and realign incentives in the healthcare system, Self Fund Health empowers employers to take control of rising costs by giving employees access to high-value providers at no cost, while replacing traditional insurance with real-time technology, dedicated nurses, and an aligned ecosystem of care. Prior to founding Self Fund Health, Jonathan was the co-founder and CEO of Healthfinch, one of the pioneering companies to build apps on top of electronic medical records. Healthfinch automated routine workflows for physicians using clinical data, significantly improving efficiency and patient care. Under Jonathan’s leadership, Healthfinch raised over $15 million in venture capital and scaled to more than 50 employees. The company received national recognition, including being named a “Cool Vendor” by Gartner, a “Top Emerging Vendor” by KLAS, and one of Modern Healthcare’s “Best Places to Work.” In 2020, Healthfinch was acquired by HealthCatalyst. Jonathan holds both a bachelor’s and master’s degree in biomedical engineering from the University of Wisconsin–Madison. He lives in Madison, Wisconsin, and continues to push the boundaries of innovation in employer-sponsored healthcare.   08:46 Entering the health system “flywheel” at the renewal phase. 09:46 What goes on in the renewal season that contributes to the health system “flywheel”? 12:28 Why is the standard 9% increase in healthcare costs during renewal season actually problematic? 13:22 How does the purchase of discounts contribute to the skyrocketing cost of healthcare and distract from discussing the actually underlying cost of healthcare? 16:07 EP465 with Chris Crawford. 17:01 Why do employers need to learn to buy healthcare and not insurance? 20:32 Rina Tikia’s post on self-funded plans. 23:18 Why are hospital executives incentivized to buy and own all of the primary care in a market? 26:35 How big electronic medical record systems play into this increase in healthcare costs. 28:27 Acquired podcast on one EHR system. 31:09 What needs to happen to reverse this flywheel of increasing healthcare costs?   You can learn more at Self Fund Health and follow Jonathan on LinkedIn.   @JonathanBaran discusses the flywheel of increasing #healthcarecosts on our #healthcarepodcast. #healthcare #podcast #financialhealth #patientoutcomes #primarycare #digitalhealth #healthcareleadership #healthcaretransformation #healthcareinnovation   Recent past interviews: Click a guest’s name for their latest RHV episode! Dr Stan Schwartz (Summer Shorts), Preston Alexander, Dr Tom X Lee (Take Two: EP445), Dr Tom X Lee (Bonus Episode), Dr Benjamin Schwartz, Dr John Lee (Take Two: EP438), Kimberly Carleson, Ann Lewandowski (Summer Shorts), Andreas Mang and Jon Camire (EP479), Justin Leader (Take Two: EP433), Andreas Mang and Jon Camire (EP478)