1 00:00:00,443 --> 00:00:01,583 Stacey Richter: Inbetweenisode. 2 00:00:01,766 --> 00:00:06,056 "Extremely Actionable Themes That We Covered Throughout 2025." So 3 00:00:06,056 --> 00:00:10,736 this is themes four and five, and also a recap of a one star review. 4 00:00:18,877 --> 00:00:21,236 Tom Nash: American Healthcare Entrepreneurs and Executives 5 00:00:21,236 --> 00:00:22,616 You Want to Know, Talking. 6 00:00:25,346 --> 00:00:26,816 Relentlessly Seeking Value. 7 00:00:27,641 --> 00:00:31,151 Stacey Richter: What I thought could be a good idea to experiment with here 8 00:00:31,151 --> 00:00:35,771 at the end of the year or the beginning of the year, is to dissect shows from 9 00:00:35,771 --> 00:00:42,578 2025 and distill out the major themes that have come up repeatedly and in 10 00:00:42,578 --> 00:00:44,558 different contexts throughout the year. 11 00:00:44,719 --> 00:00:47,539 Our big five takeaways maybe is another way to put it. 12 00:00:47,719 --> 00:00:51,769 Last week we covered takeaway themes one through three, and today 13 00:00:51,769 --> 00:00:53,869 we're gonna cover four and five. 14 00:00:53,899 --> 00:00:58,114 Themes four and five, by the way, are a lack of transparency in data access, 15 00:00:58,204 --> 00:01:02,434 which allows for wild overspending and undermines fiduciary duty. 16 00:01:02,494 --> 00:01:03,484 So that's theme four. 17 00:01:03,664 --> 00:01:06,964 Theme five is this, the need to shift purchasing from 18 00:01:06,964 --> 00:01:10,084 discounts slash volume to value. 19 00:01:10,354 --> 00:01:14,134 Here's another apparent theme that we won't cover today, but I'm gonna 20 00:01:14,134 --> 00:01:16,054 ask you to think about it as I have. 21 00:01:16,264 --> 00:01:19,804 This theme comes from a one star review that someone took the 22 00:01:19,804 --> 00:01:23,674 time to pen on Spotify the other day, and this is the review. 23 00:01:23,914 --> 00:01:24,424 Headline. 24 00:01:24,454 --> 00:01:25,534 "The Rich Get Richer". 25 00:01:25,809 --> 00:01:26,619 And here's the review. 26 00:01:26,829 --> 00:01:31,509 "An echo chamber for CEOs and other out of touch executives that care about 27 00:01:31,509 --> 00:01:37,689 money and no care or making healthcare a sustainable career choice for providers." 28 00:01:37,899 --> 00:01:41,469 I left in the typos just to avoid misinterpreting them, but I'm throwing 29 00:01:41,469 --> 00:01:43,929 this in here into the ring for context. 30 00:01:44,109 --> 00:01:47,839 If you are average in air quotes "provider", which is interesting, 31 00:01:47,989 --> 00:01:50,479 just right outta the gate that they labeled themselves a "provider", 32 00:01:50,509 --> 00:01:55,069 given how many dislike that term and feel, it is a term assigned by 33 00:01:55,249 --> 00:01:59,509 out of touch execs for the purposes of undervaluing clinical education. 34 00:01:59,509 --> 00:02:01,159 So question mark who actually wrote this. 35 00:02:01,393 --> 00:02:05,306 But if any given clinician is so far out of the loop that they do not 36 00:02:05,306 --> 00:02:09,476 understand the topics that we talk about on Relentless Health Value and also 37 00:02:09,566 --> 00:02:14,076 the impact a CEO having the experience and the integrity to do the right thing 38 00:02:14,076 --> 00:02:18,126 by patients or members, how much that trickles up or down to doing the right 39 00:02:18,126 --> 00:02:23,856 thing by providers in air quotes, then yeah, that's a big deal in and of itself. 40 00:02:24,036 --> 00:02:25,686 Interested in your perspectives. 41 00:02:25,810 --> 00:02:28,960 My name is Stacey Richter, by the way, and this episode is sponsored by 42 00:02:29,140 --> 00:02:31,550 Payerset and of Aventria Health Group. 43 00:02:32,627 --> 00:02:37,817 Payerset is a price transparency company with a mission to create fair 44 00:02:37,817 --> 00:02:40,187 and equitable healthcare for everyone. 45 00:02:40,367 --> 00:02:40,817 Love that. 46 00:02:41,187 --> 00:02:44,397 Payerset empowers healthcare organizations, employers, and 47 00:02:44,397 --> 00:02:49,227 patients with the most complete set of healthcare price transparency data. 48 00:02:49,377 --> 00:02:53,277 They benchmark every negotiated rate and claim and deliver the insights needed 49 00:02:53,277 --> 00:02:57,687 for smarter contract negotiations and a more transparent healthcare system. 50 00:02:58,592 --> 00:03:02,692 So now let's cover the remaining two themes, and again, all links, 51 00:03:02,692 --> 00:03:05,207 every single one of them that I mentioned today are in the show notes. 52 00:03:05,742 --> 00:03:09,342 You'll find some of them actually in the introduction that you may have 53 00:03:09,342 --> 00:03:10,992 received in the email newsletter. 54 00:03:11,112 --> 00:03:14,572 So yeah, that's your subliminal message to potentially sign up for 55 00:03:14,592 --> 00:03:18,132 the email newsletter should you wish to have all of this and more 56 00:03:18,222 --> 00:03:20,052 in your inbox on a weekly basis. 57 00:03:20,202 --> 00:03:24,432 And by the way, the fact that we manage one email a week is a gold star for us, 58 00:03:24,462 --> 00:03:26,022 so certainly don't worry about spam. 59 00:03:26,052 --> 00:03:28,962 You and me both do not have time for that extravagance. 60 00:03:29,187 --> 00:03:29,727 Enough runway. 61 00:03:29,727 --> 00:03:30,297 Let's get to it. 62 00:03:30,327 --> 00:03:37,437 Theme four: lack of transparency and data access allows for wild overspending 63 00:03:37,737 --> 00:03:39,957 and undermines fiduciary duty. 64 00:03:40,457 --> 00:03:44,507 A continuing, lack of transparency regarding pricing costs, 65 00:03:44,687 --> 00:03:48,557 quality, and vendor compensation prevents accountability. 66 00:03:48,742 --> 00:03:50,602 It enables conflicts of interest. 67 00:03:50,722 --> 00:03:55,412 It enables, as Dr. Mick Connors and I talked about with Sarah Emunds, it enables 68 00:03:55,472 --> 00:04:01,232 us to not pay for value or not understand what value is in a really tangible way, 69 00:04:01,232 --> 00:04:02,852 which is a problem in and of itself. 70 00:04:03,032 --> 00:04:04,292 Is this getting better? 71 00:04:04,552 --> 00:04:07,582 Yeah, and when I say is it getting better, I mean, is there more 72 00:04:07,582 --> 00:04:11,392 transparency now regarding pricing and costs and vendor compensation? 73 00:04:11,542 --> 00:04:12,052 For sure. 74 00:04:12,082 --> 00:04:16,262 Listen to the show with Elizabeth Mitchell about the PBGH Pacific Business Group 75 00:04:16,282 --> 00:04:20,782 on Health data demonstration project, but we have your status quo TPAs, 76 00:04:20,782 --> 00:04:23,842 PBMs, and brokers who often enough, and as their standard course of doing 77 00:04:23,842 --> 00:04:29,687 business, will still withhold essential claims data creating these data hostage 78 00:04:29,717 --> 00:04:34,187 situations that guests have talked about this year, which exposes self-insured 79 00:04:34,187 --> 00:04:38,837 employers to wild overspending and also fiduciary legal risk. 80 00:04:38,987 --> 00:04:42,527 Here's Elizabeth Mitchell and this quote that I'm about to play is from 81 00:04:42,527 --> 00:04:45,407 the Take Two with her this year. 82 00:04:45,817 --> 00:04:49,417 Elizabeth Mitchell: Jumbo self-insured employers are spending their 83 00:04:49,417 --> 00:04:53,407 own money and their employees money on healthcare services. 84 00:04:53,407 --> 00:04:58,487 Our members spend over $350 billion a year on healthcare services and 85 00:04:58,557 --> 00:05:00,242 people's health is not improving. 86 00:05:00,482 --> 00:05:06,572 All of those dollars seem to be getting lost in the system, and it 87 00:05:06,722 --> 00:05:13,862 is particularly ironic because that money is also not going to providers 88 00:05:13,862 --> 00:05:16,239 in the way that our members would like. 89 00:05:16,298 --> 00:05:19,898 They're very much aligned with providers, particularly primary care providers 90 00:05:19,898 --> 00:05:24,248 and mental health providers, and yet there is some disconnect between 91 00:05:24,248 --> 00:05:27,548 the amount they are paying and the amount the providers are getting. 92 00:05:27,728 --> 00:05:33,938 You would be amazed at how resistant many of the plans are to doing 93 00:05:33,998 --> 00:05:35,733 what employers ask them to do. 94 00:05:36,368 --> 00:05:42,548 Even it's sharing data effectively or things that employers know are 95 00:05:42,548 --> 00:05:46,418 the right thing for their employees and to effectively manage their plan. 96 00:05:46,778 --> 00:05:48,638 It is remarkably challenging. 97 00:05:48,908 --> 00:05:50,858 In a market, someone gives you a bad bid. 98 00:05:50,858 --> 00:05:51,848 You don't take it. 99 00:05:51,908 --> 00:05:52,868 You don't buy it. 100 00:05:52,958 --> 00:05:53,978 Here's the challenges. 101 00:05:54,278 --> 00:05:59,738 One, there's been no transparency and they have not been able to get their data to 102 00:05:59,738 --> 00:06:01,988 actually even evaluate the performance. 103 00:06:02,163 --> 00:06:07,803 One of the changes within the CAA, it absolutely clarifies that employers 104 00:06:07,803 --> 00:06:11,703 are entitled to the data they need to evaluate cost and quality. 105 00:06:11,913 --> 00:06:15,093 But then the other problem, there are not any alternatives. 106 00:06:15,213 --> 00:06:19,963 If all of the plans are doing the same thing, where are they supposed to go? 107 00:06:20,578 --> 00:06:25,138 I think that there are some new market entrants, but right now, if 108 00:06:25,138 --> 00:06:30,148 you are looking for a big health plan administrator, there's not, not a lot of 109 00:06:30,148 --> 00:06:32,758 options for something really different. 110 00:06:32,948 --> 00:06:36,608 Stacey Richter: All of this hinders informed purchasing decisions and 111 00:06:36,608 --> 00:06:39,788 it also hinders trying to buy value. 112 00:06:40,058 --> 00:06:43,208 And I know we're using a lot of acronyms and kind of jargon right 113 00:06:43,208 --> 00:06:47,618 now, but this has so much impact, this whole thing on patients and members 114 00:06:47,618 --> 00:06:49,448 and that cannot be understated. 115 00:06:49,598 --> 00:06:53,048 The overwhelming complexity and non-transparency regarding cost 116 00:06:53,113 --> 00:06:57,403 creates intense financial stress and anxiety for plan members. 117 00:06:57,463 --> 00:06:59,743 It forces a percentage into bankruptcy. 118 00:06:59,893 --> 00:07:02,263 As we all know, the biggest reason for bankruptcy in 119 00:07:02,263 --> 00:07:03,703 this country is medical debt. 120 00:07:03,703 --> 00:07:05,833 Get sick, lose your health and your money. 121 00:07:05,833 --> 00:07:06,643 It's so efficient. 122 00:07:06,733 --> 00:07:11,563 Peter Hayes mentioned this in an episode with him that there's a new vector 123 00:07:11,563 --> 00:07:16,063 of change that has not been present before, which is why he is predicting 124 00:07:16,063 --> 00:07:18,013 a tipping point finally coming. 125 00:07:18,163 --> 00:07:20,683 He says it's a combination of new legislation that 126 00:07:20,683 --> 00:07:22,153 has increased transparency. 127 00:07:22,303 --> 00:07:24,343 Still have a ways to go, but yeah, there's a lot more 128 00:07:24,343 --> 00:07:25,963 transparency than there was before. 129 00:07:26,113 --> 00:07:31,363 Plus legal risk for plan sponsors given the CAA plus that transparency. 130 00:07:31,928 --> 00:07:35,078 Plus, and this is the new one, public outrage as he terms it. 131 00:07:35,198 --> 00:07:40,118 So yeah, we might be at a moment that will become a movement, but in 132 00:07:40,118 --> 00:07:44,438 the meantime, we have patients and members fearing unexpected costs. 133 00:07:44,438 --> 00:07:46,208 John Quinn talked about this some. 134 00:07:46,388 --> 00:07:51,588 Members and patients are aware now that they could be struck by unexpected costs. 135 00:07:52,038 --> 00:07:56,328 So they fear going and getting care despite the fact that they may be 136 00:07:56,328 --> 00:08:00,468 paying huge premiums in order to have an air quote, access to said care. 137 00:08:00,588 --> 00:08:05,418 But there is a recognition that even those with so-called good insurance may 138 00:08:05,418 --> 00:08:10,043 have so much fear that they delay or abandon necessary, and turns out high 139 00:08:10,043 --> 00:08:14,693 value care, such as seeking treatment for suspicious moles or chest pain, 140 00:08:14,873 --> 00:08:19,973 or getting their asthma inhaler, which thus worsens long-term health outcomes 141 00:08:19,973 --> 00:08:22,823 and evil spirals start to develop here. 142 00:08:22,883 --> 00:08:26,873 Also, there's such an awareness of hidden facility fees or markups that consolidated 143 00:08:26,873 --> 00:08:30,143 health systems and provider organizations, which means that patients pay 144 00:08:30,143 --> 00:08:33,743 substantially more for the same service than they would at an independent clinic. 145 00:08:33,773 --> 00:08:38,183 Again, just raising the both fear and public outrage as a result. 146 00:08:38,428 --> 00:08:42,028 A lack of transparency and data access allows for wild overspending, 147 00:08:42,028 --> 00:08:45,358 overcharging, and undermines fiduciary decision making. 148 00:08:45,358 --> 00:08:48,268 We've talked about this so often on many shows this year. 149 00:08:48,418 --> 00:08:50,248 Obviously, otherwise it wouldn't be a theme. 150 00:08:50,405 --> 00:08:55,945 Other shows where this theme has come up we have the show with Christine Hale, 151 00:08:55,945 --> 00:08:58,135 episode 471 on high cost claimants. 152 00:08:58,285 --> 00:09:03,085 Dr. Christine Hale highlights the critical problem of siloed or insufficient claims 153 00:09:03,085 --> 00:09:08,155 data relative to high cost claimants and that prevents plan sponsors from 154 00:09:08,235 --> 00:09:12,075 verifying if high cost treatments are appropriate or cost effective 155 00:09:12,075 --> 00:09:15,195 or frankly in the optimal setting. 156 00:09:15,435 --> 00:09:17,865 Then we had Justin Leader, and this was a Take Two. 157 00:09:18,015 --> 00:09:21,105 Justin talked about "The Mystery of the Weekly Claims Wire". 158 00:09:21,285 --> 00:09:26,715 And this show is really dedicated to, I'm gonna say exposing how TPAs, some of them, 159 00:09:26,835 --> 00:09:31,665 hide fees and engage in spread pricing which is possible because of that mystery. 160 00:09:31,665 --> 00:09:34,905 You know, where there's mystery, there's margin and all that, but the show really 161 00:09:34,905 --> 00:09:39,105 and Justin stresses that obtaining transparent data is really vital. 162 00:09:39,285 --> 00:09:44,115 Then we had a banger of a show, episode 480 with Kimberly Carleson and she was 163 00:09:44,115 --> 00:09:48,405 talking about payment integrity, but it really underscored that plan sponsors have 164 00:09:48,405 --> 00:09:53,355 a legal right under the CAA and ERISA to itemize bills and contracts so that they 165 00:09:53,355 --> 00:09:56,085 can audit and verify claims accuracy. 166 00:09:56,235 --> 00:10:01,265 Up to 80% of hospital bills may contain errors like duplicate billing, 167 00:10:01,445 --> 00:10:05,615 upcoding charging for non-billable items, which often results in wildly 168 00:10:05,615 --> 00:10:10,145 excessive charges paid for by the plan sponsor, but also often enough 169 00:10:10,145 --> 00:10:13,475 at least passed on to the member. 170 00:10:13,625 --> 00:10:18,635 Then Dave Chase in episode 484, he talks about the data hostage situation that 171 00:10:18,635 --> 00:10:23,715 I mentioned earlier and the lack of compensation disclosure as warning signs 172 00:10:23,715 --> 00:10:25,995 for untrustworthy benefits advisors. 173 00:10:26,065 --> 00:10:29,305 So just all of this back to the theme, a lack of transparency 174 00:10:29,305 --> 00:10:32,785 and data access allows for wild overspending, overcharging, and 175 00:10:32,785 --> 00:10:35,065 undermines fiduciary decision making. 176 00:10:35,065 --> 00:10:38,395 So you can see how all these shows are aligned to this theme. 177 00:10:38,395 --> 00:10:43,645 Then we had 487 with Kevin Lyons, who describes how organizations leverage in 178 00:10:43,645 --> 00:10:48,085 air quotes, proprietary or also in air quotes, trade secret claims to avoid 179 00:10:48,085 --> 00:10:53,470 disclosure and that forces purchasers to use detective skills to find hidden 180 00:10:53,470 --> 00:10:55,000 costs and conflicts of interest. 181 00:10:55,150 --> 00:10:59,560 And considering that Kevin Lyons was talking about the State of New Jersey and 182 00:10:59,560 --> 00:11:04,675 there was recently a false claims lawsuit that the state health plan carrier in New 183 00:11:04,675 --> 00:11:10,180 Jersey just lost and had to pay a hundred million dollars in fines for overcharging. 184 00:11:10,330 --> 00:11:15,370 You can see why with the trade secret fronting here, there is a 185 00:11:15,370 --> 00:11:20,765 lot of money that sits behind those proprietary trade secrets, which plan 186 00:11:20,765 --> 00:11:25,625 sponsors and those actually paying the bills do have a right to see. 187 00:11:25,745 --> 00:11:29,045 And then I also wanna mention the shows with Vivian Ho from earlier 188 00:11:29,045 --> 00:11:32,255 this year, and Dan Greenleaf who talk about this whole concept from 189 00:11:32,255 --> 00:11:36,965 the standpoint of, I'm gonna say the hospital system or provider organization. 190 00:11:36,965 --> 00:11:40,835 If it's unclear how much a hospital or provider organization is charging 191 00:11:40,835 --> 00:11:44,650 for something, then there's ample opportunity for there to be carrier 192 00:11:44,650 --> 00:11:46,750 markups, number one, and spread pricing. 193 00:11:46,810 --> 00:11:50,470 Sure, which, by the way, is estimated to be about 30% that 194 00:11:50,470 --> 00:11:53,890 plan sponsors are paying on top of the hospital or provider charges. 195 00:11:53,950 --> 00:11:54,130 Right. 196 00:11:54,130 --> 00:11:58,210 But how would you know that if you don't know how much the hospital or provider 197 00:11:58,210 --> 00:11:59,620 organization is actually charging? 198 00:11:59,760 --> 00:12:03,600 If all you see is the amount that hits the claims wire, you don't know how 199 00:12:03,600 --> 00:12:07,123 the money is getting divvied up and how much the doctors and nurses or actual 200 00:12:07,123 --> 00:12:11,023 clinicians doing the service are getting paid out of the money that you are paying. 201 00:12:11,193 --> 00:12:15,543 And again, usually it's estimated to be about 30% added to the top there. 202 00:12:15,633 --> 00:12:19,653 But there's another issue here that is big consolidated health systems 203 00:12:19,653 --> 00:12:24,363 raising prices way higher than inflation, way higher also than raises 204 00:12:24,363 --> 00:12:25,773 that doctors and nurses are getting. 205 00:12:25,773 --> 00:12:29,163 So a lot of times the second somebody starts complaining about high hospital 206 00:12:29,163 --> 00:12:34,353 prices, someone points to nurses, for example, and that math doesn't add up. 207 00:12:34,508 --> 00:12:39,278 So not understanding what the underlying charges are can kind of cut both ways, 208 00:12:39,338 --> 00:12:46,628 because while it leaves carriers able to take 30% off the top, it also removes or 209 00:12:46,628 --> 00:12:51,668 doesn't spotlight the culpability here to some of these consolidated health systems 210 00:12:51,728 --> 00:12:56,768 that are raising prices at the rate and level that they are raising prices and 211 00:12:56,768 --> 00:12:59,408 then pointing to carriers as the culprit. 212 00:12:59,668 --> 00:13:02,518 And not saying that they aren't in the mix, but let's just say there's 213 00:13:02,518 --> 00:13:04,288 a lot of culpability to go around. 214 00:13:04,528 --> 00:13:09,808 But then what happens, which is a miss, is that it leaves actionable opportunities 215 00:13:09,808 --> 00:13:14,038 on the table to negotiate, for example, with hospitals or recognize where some 216 00:13:14,038 --> 00:13:16,558 of these excess dollars are coming from. 217 00:13:16,718 --> 00:13:19,492 And then lastly, this is a different take on transparency, 218 00:13:19,492 --> 00:13:21,069 but it is also kind of interesting. 219 00:13:21,159 --> 00:13:25,269 There's also the transparency around ownership transparency, and this is 220 00:13:25,269 --> 00:13:30,489 really relevant for policymakers, but also for any ultimate purchaser as well. 221 00:13:30,579 --> 00:13:36,099 Yashaswini Singh talked about this in episode 474 about private equity, and 222 00:13:36,099 --> 00:13:40,179 what she emphasizes is that there's a lack of ownership transparency, as I just 223 00:13:40,179 --> 00:13:45,404 said, especially when it comes to private equity owned provider organizations. 224 00:13:45,494 --> 00:13:49,154 And that prevents policymakers and really physicians a lot of times 225 00:13:49,154 --> 00:13:54,344 from fully understanding the forces, driving practices and also costs. 226 00:13:54,464 --> 00:13:59,594 So consider this a wrap on theme number four, which is a lack of 227 00:13:59,594 --> 00:14:03,799 transparency and data access allows for wild overspending slash overcharging 228 00:14:04,094 --> 00:14:05,864 and undermines fiduciary duty. 229 00:14:05,924 --> 00:14:08,204 Let's move on to theme number five. 230 00:14:08,579 --> 00:14:12,989 Theme number five is the need to shift purchasing from buying 231 00:14:13,019 --> 00:14:16,679 discounts or volume to buying value. 232 00:14:16,829 --> 00:14:23,759 This industry really to transform has got to transition away from flawed purchasing 233 00:14:23,759 --> 00:14:28,504 methods, such as buying discounts off of inflated list prices, which only 234 00:14:28,614 --> 00:14:31,109 perpetuates the cost increasing flywheels. 235 00:14:31,199 --> 00:14:35,354 Stop doing that and instead, purchase actual care based on 236 00:14:35,354 --> 00:14:38,564 demonstrably high value and outcomes. 237 00:14:38,654 --> 00:14:42,044 The imperative for plan sponsors to stop buying based on, you know, in 238 00:14:42,134 --> 00:14:45,764 quote, discounts off inflated list prices, and instead focus on mastering 239 00:14:45,914 --> 00:14:49,664 unit cost and directly purchasing high value healthcare services. 240 00:14:49,814 --> 00:14:51,554 Here's Mark Cuban on this topic. 241 00:14:51,704 --> 00:14:53,929 Mark Cuban: Core competency to understand their benefits at all. 242 00:14:54,509 --> 00:14:58,139 And even though it's the second largest line item, expense line 243 00:14:58,139 --> 00:15:02,299 item after payroll, as Cora knows very well, it's hard to dig in. 244 00:15:02,349 --> 00:15:06,119 I was just as much of an idiot with the Mavericks and my other companies. 245 00:15:06,299 --> 00:15:08,969 I had no idea I was getting ripped off. 246 00:15:09,299 --> 00:15:13,384 But for our employees and their families now, as Coral 247 00:15:13,384 --> 00:15:16,684 knows, we're doing all direct contracting, all direct contracting. 248 00:15:16,984 --> 00:15:19,834 And slowly but surely, we're adding more and more providers. 249 00:15:19,834 --> 00:15:23,884 We're up to like 8,800 providers in our network right now, 250 00:15:24,274 --> 00:15:25,654 and so we're getting there. 251 00:15:25,954 --> 00:15:29,104 But what we tell them and the reason they're willing to give us their 252 00:15:29,489 --> 00:15:31,409 cash price or something close to it. 253 00:15:31,409 --> 00:15:34,049 Sometimes we work off of Medicare as a reference. 254 00:15:34,169 --> 00:15:36,929 We tell them, A, we're gonna pay you cash upfront. 255 00:15:37,289 --> 00:15:40,139 B, there is no employee deductible. 256 00:15:40,469 --> 00:15:43,169 You know it is compensation for our employees one way or the 257 00:15:43,169 --> 00:15:44,549 other, and their families, right? 258 00:15:44,849 --> 00:15:48,959 You can pay it upfront, pay it via healthcare, whatever it may be, and so 259 00:15:49,019 --> 00:15:51,119 you're not taking that collection risk. 260 00:15:51,329 --> 00:15:55,499 You're getting paid the full amount, and we'll do all of the pre-auths in advance. 261 00:15:55,499 --> 00:15:59,344 By the time it gets to you, it's already been approved and you 262 00:15:59,344 --> 00:16:03,364 take no preauthorization denial or preauthorization or denial risk. 263 00:16:03,844 --> 00:16:06,974 And they're like, no credit risk, no underpay risk, no pre-auth 264 00:16:06,974 --> 00:16:08,884 risk, where do I sign up? 265 00:16:09,304 --> 00:16:11,704 Stacey Richter: Thinking about one star provider guy, when employers 266 00:16:11,704 --> 00:16:16,744 shift purchasing to value, they can compensate high value providers more. 267 00:16:17,059 --> 00:16:17,599 Upfront. 268 00:16:17,719 --> 00:16:21,919 Which helps eliminate provider organization risk and reduces the need 269 00:16:21,919 --> 00:16:26,239 for costly administrative debt collection efforts, again, which is just gonna 270 00:16:26,239 --> 00:16:30,859 create a virtuous flywheel resulting in lower overall prices for patient, 271 00:16:30,859 --> 00:16:32,659 member, and any ultimate purchaser. 272 00:16:32,714 --> 00:16:34,574 And then here's from Sarah Emond. 273 00:16:35,124 --> 00:16:38,904 Sarah Emond: Well, and that's part of where I have observed that sometimes 274 00:16:38,904 --> 00:16:42,924 the rebate model gets in the way of paying for value because your market 275 00:16:42,924 --> 00:16:47,154 dominance or your market position can have more to do with how much of 276 00:16:47,154 --> 00:16:49,614 a discount you are offering or not. 277 00:16:50,034 --> 00:16:55,554 And the ultimate goal of the negotiators to get a big 278 00:16:55,554 --> 00:16:57,864 rebate, to get a big discount. 279 00:16:58,104 --> 00:17:01,554 That is not necessarily the same thing as paying for value. 280 00:17:02,184 --> 00:17:05,334 And one of the things that we have been talking about for years, and we're 281 00:17:05,334 --> 00:17:12,054 still looking for a purchaser who wants to do this, which is pay for value. 282 00:17:12,324 --> 00:17:17,874 Waive pretty much most prior auth and eliminate cost sharing. 283 00:17:18,124 --> 00:17:22,494 Because if you are paying a value based price as the ultimate payer, 284 00:17:22,734 --> 00:17:24,474 why would you have cost sharing? 285 00:17:24,504 --> 00:17:28,944 You are not trying to get the patient to do something different with their 286 00:17:28,944 --> 00:17:31,224 choice of medicine with their doctor. 287 00:17:31,644 --> 00:17:35,934 So if we had a system that had full transparency into the value-based 288 00:17:35,934 --> 00:17:39,144 price and all of the payers were paying that value-based price, we 289 00:17:39,144 --> 00:17:40,554 actually wouldn't need rebates. 290 00:17:40,884 --> 00:17:43,674 We would just have a formulary. 291 00:17:44,064 --> 00:17:47,664 Imagine what it could do for patients with rheumatoid arthritis. 292 00:17:47,964 --> 00:17:50,574 There are a lot of drugs approved for rheumatoid arthritis. 293 00:17:51,144 --> 00:17:56,214 If you don't respond to some of the older drugs like methotrexate, your 294 00:17:56,214 --> 00:18:00,924 choice of which drug you get has to do with the negotiation between 295 00:18:00,924 --> 00:18:02,664 the manufacturer and the PBM. 296 00:18:02,664 --> 00:18:05,814 It doesn't have anything to do with what's the best choice for you as a patient. 297 00:18:06,114 --> 00:18:08,784 If we paid a value-based price for every rheumatoid arthritis 298 00:18:08,784 --> 00:18:11,424 drug that doctor could prescribe whatever drug was best for you. 299 00:18:11,689 --> 00:18:15,679 We're just far away from that reality, but I still wanna put it 300 00:18:15,679 --> 00:18:19,309 out there as a different choice we could make that again, would work 301 00:18:19,309 --> 00:18:21,049 towards deescalating this arms race. 302 00:18:21,355 --> 00:18:23,305 Stacey Richter: So, right, like a lot of these themes, 303 00:18:23,305 --> 00:18:25,345 we've covered this one deeply. 304 00:18:25,525 --> 00:18:29,515 This whole idea of bringing big demand curve energy. 305 00:18:29,625 --> 00:18:32,115 If there is not a demand curve, there's no market. 306 00:18:32,205 --> 00:18:36,985 If purchasers, such as self-insured employers or otherwise, do not not 307 00:18:37,035 --> 00:18:41,205 buy healthcare services from entities that are too expensive or who have 308 00:18:41,205 --> 00:18:45,555 crappy quality, what incentive, what market incentive does anyone have 309 00:18:45,555 --> 00:18:47,325 to lower prices or improve quality. 310 00:18:47,445 --> 00:18:52,715 If nobody cares and is just gonna buy it whenever, whatever, then anybody 311 00:18:52,835 --> 00:18:56,165 on the supply side who spends any amount of money or effort to get more 312 00:18:56,165 --> 00:19:00,725 efficient or raise quality will not result in, again, improved market 313 00:19:00,725 --> 00:19:04,265 share or any increase in revenue, which is the incentive of a market. 314 00:19:04,415 --> 00:19:08,128 Now look, are markets the correct way to run healthcare in this country? 315 00:19:08,405 --> 00:19:10,625 Not the point at all. 316 00:19:10,745 --> 00:19:15,965 The point is containing healthcare costs in this country right now in 2025 the 317 00:19:15,965 --> 00:19:20,315 whole way that the industry is structured, the whole way incentives work, et cetera, 318 00:19:20,315 --> 00:19:22,505 is dependent upon there being a market. 319 00:19:22,505 --> 00:19:24,785 And there isn't a market without a demands curve. 320 00:19:24,845 --> 00:19:26,345 There isn't a market, in other words. 321 00:19:26,495 --> 00:19:29,435 There will never be a market again without a demand curve. 322 00:19:29,555 --> 00:19:34,415 And self-insured employers right now provide and pay for care for 160 323 00:19:34,635 --> 00:19:39,045 million Americans, meaning self-insured employers have one really big job here. 324 00:19:39,045 --> 00:19:40,215 It's an important job. 325 00:19:40,425 --> 00:19:41,775 Be an elastic demand curve. 326 00:19:42,165 --> 00:19:46,815 This comes up so often this past year, and this really matters again for members 327 00:19:46,815 --> 00:19:50,895 and patients because shifting purchasing toward value and outcomes, it creates 328 00:19:50,895 --> 00:19:53,235 opportunities to lower members costs. 329 00:19:53,235 --> 00:19:55,485 Remove financial barriers to necessary care. 330 00:19:55,575 --> 00:19:58,660 Improve the consistency and predictability of care delivery. 331 00:19:59,270 --> 00:20:03,050 It also has a great opportunity to increase outcomes because if you're 332 00:20:03,050 --> 00:20:07,250 buying value, outcomes are part of the mix in a way that's simply reducing 333 00:20:07,715 --> 00:20:12,635 costs even doesn't take into account, and that can go horribly wrong, which 334 00:20:12,635 --> 00:20:14,015 is probably a whole other topic. 335 00:20:14,115 --> 00:20:15,600 How can you go about this? 336 00:20:15,610 --> 00:20:17,260 Direct contracting is one example. 337 00:20:17,290 --> 00:20:20,680 So plan sponsors can offer members access to high quality care. 338 00:20:20,740 --> 00:20:24,310 This could be for imaging or surgery at $0 out of pocket. 339 00:20:24,310 --> 00:20:27,400 Discussed this with Dr. Cristen Dickerson on a show, and also 340 00:20:27,400 --> 00:20:29,590 Dr. Stan Schwartz, among others. 341 00:20:29,920 --> 00:20:35,680 Other shows where this theme has come up big time is the two part show, episode 342 00:20:35,680 --> 00:20:41,210 483 with Jonathan Baran that defines discounts which by the way includes 343 00:20:41,270 --> 00:20:45,585 rebates and shared savings with the solution being reject discounts, focus 344 00:20:45,585 --> 00:20:50,505 on mastering unit cost, investing in primary care, redesigning benefits to 345 00:20:50,505 --> 00:20:52,575 buy actual healthcare, not insurance. 346 00:20:52,665 --> 00:20:56,748 Then also the show 488 with Mark Cuban and Cora Opsahl that 347 00:20:56,780 --> 00:20:58,040 that earlier quote was from. 348 00:20:58,303 --> 00:21:03,343 We also have episode 492 with Dr. Sam Flanders and Shane Cerone. 349 00:21:03,463 --> 00:21:07,127 They're talking about this from the hospital system perspective, and they 350 00:21:07,127 --> 00:21:12,175 really provide a call to action for employers to insist health systems submit 351 00:21:12,175 --> 00:21:17,410 pricing, and also create competition which ultimately is going to drive high quality 352 00:21:17,410 --> 00:21:20,110 care at significantly reduced unit costs. 353 00:21:20,260 --> 00:21:24,280 But also provide rewards for those organizations who 354 00:21:24,280 --> 00:21:25,990 are able to do this well. 355 00:21:26,200 --> 00:21:30,220 Which generally speaking physicians and other clinicians appreciate. 356 00:21:30,220 --> 00:21:35,275 We also have episode 493 with John Quinn, who advises c-suites on their 357 00:21:35,275 --> 00:21:39,655 need to review healthcare as a supply chain to be managed and must move 358 00:21:39,655 --> 00:21:43,495 absolutely, again, past buying discounts and focusing on steering members to 359 00:21:43,495 --> 00:21:45,055 lower cost, high quality alternatives. 360 00:21:45,312 --> 00:21:48,912 We also have the show with Sarah Emond that the earlier quote was from. 361 00:21:49,092 --> 00:21:52,632 So that is theme five, which again is the need to shift 362 00:21:52,632 --> 00:21:57,522 purchasing from buying discounts or buying volume to buying value. 363 00:21:58,227 --> 00:22:02,637 Okay, so lastly, I might have missed a few shows that did in fact touch on one 364 00:22:02,637 --> 00:22:06,477 or more of these themes, these through lines, which were just so everywhere, 365 00:22:06,477 --> 00:22:08,427 everything, and occasionally all at once. 366 00:22:08,547 --> 00:22:13,077 But we did have a few shows that dug in on other very timely ideas, such 367 00:22:13,077 --> 00:22:17,727 as the shows with James Gelfand on the impact of some of the legislation 368 00:22:17,727 --> 00:22:22,722 currently ongoing and its impact on Medicaid and HSAs and other policy changes 369 00:22:22,722 --> 00:22:24,522 which affect self-insured employers. 370 00:22:24,642 --> 00:22:28,092 And also we talked stop-loss coverage, which is a big deal with Andreas 371 00:22:28,092 --> 00:22:33,012 Mang and Jon Camire, or we did a show on Medicare Advantage Trends 372 00:22:33,162 --> 00:22:35,062 earlier this year with Betsy Seals. 373 00:22:35,082 --> 00:22:37,872 So all this stuff is interrelated for sure. 374 00:22:37,992 --> 00:22:39,892 With that, my name is Stacey Richter. 375 00:22:40,067 --> 00:22:44,117 Cora Opsahl: Hi, this is Cora Opsahl, 32BJ Health Fund Director. 376 00:22:44,177 --> 00:22:47,987 Relentless Health Value is the place to get a deep understanding 377 00:22:48,017 --> 00:22:49,727 of all aspects of healthcare. 378 00:22:49,967 --> 00:22:52,667 I used it to learn about the complex system of healthcare 379 00:22:52,667 --> 00:22:56,297 years ago, and I still learn something new almost every episode. 380 00:22:56,447 --> 00:23:00,557 Join Stacey every week to hear practical insights and advice from 381 00:23:00,557 --> 00:23:01,907 people who are making a difference. 382 00:23:02,342 --> 00:23:05,402 I encourage you to subscribe to the newsletter, follow on your 383 00:23:05,402 --> 00:23:09,032 favorite podcast app, and follow Relentless Health Value on LinkedIn. 384 00:23:09,272 --> 00:23:12,752 I truly believe it is the collective action of the Relentless Health 385 00:23:12,752 --> 00:23:15,979 Value tribe that will change healthcare for the better.