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In Episode 459, host Stacey Richter speaks with healthcare attorney Bill Sarraille about co-pay maximizers and accumulators, mechanisms designed to extract maximum co-pay support dollars from pharmaceutical companies.
They discuss the financial implications for patients, plan sponsors, and pharmacy benefit managers (PBMs), emphasizing the legal and ethical issues and potential patient harm due to high out-of-pocket costs and surprise expenses.
Sarraille provides five key pieces of advice for plan sponsors and highlights the importance of transparency and proper utilization management to minimize patient access problems and legal risks. Listen or read the show notes on our site for the full list.
(continued below the links)
=== LINKS ===
🔗 Show Notes with all mentioned links:
https://cc-lnk.com/EP459✉️ Enjoy this podcast? Subscribe to the free weekly newsletter: https://relentlesshealthvalue.com/join-the-relentless-tribe
🫙 Support the podcast with a small donation to the Tip Jar: https://relentlesshealthvalue.com/join-the-relentless-tribe
===CONNECT WITH THE RHV TEAM ===
✭ LinkedIn https://www.linkedin.com/company/relentless-health-value/
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✭ Bluesky https://bsky.app/profile/relentleshealth.bsky.social
Co-pay maximizers and accumulators are programs designed to capture maximum co-pay assistance from phara. Maximizers spread pharma co-pay support evenly throughout the year, ensuring plan sponsors benefit while, in theory, patients face minimal costs. More on how that can go wrong in the episode.
Accumulators, however, design their plan to deplete pharma dollar support quickly, surprising patients with significant out-of-pocket expenses mid-year when they go visit the pharmacy.
These programs usually exclude pharma assistance dollars from deductibles, potentially causing financial hardship because when pharma is paying your co-pay, those payments don't count against your deductible.
09:31 What should plan sponsors be aware of right now?
14:01 What is the justification for maximizers, and why is this at odds with the purpose of insurance?
18:05 Where does the issue of “fairness” land within cost containment?
20:00 Brian Reid’s LinkedIn post on insurance company access challenges.
21:30 What are the real legal issues presented by some of these co-pay maximizers and co-pay accumulator programs?
27:06 How are these programs creating perverse incentives?
29:28 EP450 with Marilyn Bartlett, CPA, CGMA, CMA, CFM.
32:16 “If you’re covered by the ACA, I think this is unlawful.”
32:57 What advice does Bill have in regard to these programs?
33:49 What potential litigations does Bill see coming in the near future in regard to these co-pay maximizers and co-pay accumulator programs?
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In this Inbetweenisode titled 'End of Year Wrap Up and My Personal Charter Encore,' Stacey Richter extends heartfelt thanks to listeners and healthcare workers for their dedication.
She reflects on the challenges of maintaining personal integrity in a profit-driven healthcare system and introduces her personal charter. This charter, focused on ensuring net positive outcomes for patients, acknowledges that achieving transformational change in healthcare requires a collective effort.
Stacey discusses the complexities of balancing ethical decisions, financial constraints, and the broader impact on patient care, urging others to reflect on their own guiding principles.
Here's her manifesto which she is now calling her Personal Charter below which she breaks down in this podcast episode:
"If the thing results in a net positive for patients, then I will do it. The timeframe is short-term or medium-term. And the assumption is that it will take a village and I am not alone in my efforts to transform healthcare or do right by patients."
=== LINKS ===
🔗 Show Notes with all mentioned links: https://cc-lnk.com/INBW41
✉️ Enjoy this podcast? Subscribe to the free weekly newsletter:
https://relentlesshealthvalue.com/join-the-relentless-tribe🫙 Support the podcast with a small donation to the Tip Jar:
https://relentlesshealthvalue.com/join-the-relentless-tribe=== CONNECT WITH THE RHV TEAM ===
✭ LinkedIn https://www.linkedin.com/company/relentless-health-value/
✭ Threads https://www.threads.net/@relentlesshealthvalue/
✭ X https://twitter.com/relentleshealth/
✭ Bluesky https://bsky.app/profile/relentleshealth.bsky.social06:52 “It’s a zero-sum game.”
07:02 Is the amount of profit fair?
07:13 What is an inescapable fact of the healthcare industry?
07:30 What does the financialization of healthcare mean?
07:55 Why does the self-interest in healthcare matter?
09:54 “It’s basically up to us as individuals to do the right thing.”
13:39 What is the first part of Stacey’s personal charter?
13:54 How does Stacey calculate the net positive of an impact?
14:17 What are two major upsides/downsides that Stacey contemplates?
17:08 Why are incremental change and disruptive change not mutually exclusive?
21:16 “I always try to keep in mind that it will take a village.”
22:55 Why finger pointing is killing innovation in healthcare.
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Saknas det avsnitt?
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Are you on the board of directors of a company? Or are you a shareholder of a publicly traded company? Or are you a CEO or a CFO or in-house counsel who reports to a board of directors or these shareholders? Well, this show is for you.
And it’s about how the healthcare industry has become financialized at the same time that providing health benefits has become the second-biggest line item after payroll for most companies. We talked about that in a recent encore with Mark Cuban (EP418) also, as well as the show with Cora Opsahl (EP452) and Claire Brockbank (EP453) from 32BJ.
In this encore episode of 'Relentless Health Value,' Stacey Richter interviews Andreas Mang from Blackstone about the financialization of health benefits for boards of directors and C-suites of self-insured employers.
They discuss the unseen financial layers in healthcare benefits and how companies can save significantly while improving employee satisfaction and health.
=== LINKS ===
🔗 Show Notes with all mentioned links: https://cc-lnk.com/EP458
✉️ Enjoy this podcast? Subscribe to the free weekly newsletter: https://relentlesshealthvalue.com/join-the-relentless-tribe
🫙 Support the podcast with a small donation to the Tip Jar: https://relentlesshealthvalue.com/join-the-relentless-tribe
=== CONNECT WITH THE RHV TEAM ===
✭ LinkedIn https://www.linkedin.com/company/relentless-health-value/
✭ Threads https://www.threads.net/@relentlesshealthvalue/
✭ X https://twitter.com/relentleshealth/
✭ Bluesky https://bsky.app/profile/relentleshealth.bsky.social04:55 Why Andreas starts every conversation with the question, “How’s your healthcare company?”
07:38 Why is it important, as a self-insured employer, to treat your business as a small healthcare company?
09:16 Why is it unnatural for companies to be providing health insurance?
10:47 What can be achieved when there is alignment between employers and insurers?
12:41 What things can a company do to reduce spend by 10%?
14:14 Why is it better to have CFO engagement in the benefits plan throughout the year?
16:25 Why does self-insurance save 5% to 9% for companies automatically?
18:14 “The funding isn’t a healthcare thing; it’s a CFO thing.”
18:27 Why is it vital to have a reliable, trustworthy broker?
25:12 When is the last time your company has RFP’d their health plan?
27:39 Why does changing a health plan feel scary but is necessary?
28:31 What is a dependent eligibility audit?
31:20 Why are employers better together?
34:34 How do employers truly get a flat-fee model with brokers?
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In Episode 458 of Relentless Health Value, host Stacey Richter speaks with Dr. Komal Bajaj about innovative strategies for addressing staffing shortages in the healthcare sector. They explore the importance of cultural alignment within organizations, emphasizing trust and shared values to retain staff.
Dr. Bajaj shares surprising findings from surveys indicating that healthcare workers are motivated by the goal of providing high-quality, planet-friendly care. The discussion highlights the interconnectedness of environmental sustainability and healthcare quality, presenting tangible ways to engage and empower healthcare workers while addressing both local community health and broader environmental concerns.
The episode underscores the strategic importance of aligning organizational goals with the aspirations of the workforce to foster trust and mitigate staffing shortages.
Stacey's guest today is Dr. Komal Bajaj. Dr. Bajaj is an ob-gyn who serves as the chief quality officer for a couple of hospitals in the Bronx, New York, that are part of the municipal health system of New York. She also now serves as medical director of sustainability for the municipal health system NYC Health + Hospitals.
=== LINKS ===
🔗 Show Notes with all mentioned links:
https://cc-lnk.com/EP458✉️ Enjoy this podcast? Subscribe to the free weekly newsletter: https://relentlesshealthvalue.com/join-the-relentless-tribe
🫙 Support the podcast with a small donation to the Tip Jar: https://relentlesshealthvalue.com/join-the-relentless-tribe
=== CONNECT WITH THE RHV TEAM ===
✭ LinkedIn https://www.linkedin.com/company/relentless-health-value/
✭ Threads https://www.threads.net/@relentlesshealthvalue/
✭ X https://twitter.com/relentleshealth/
✭ Bluesky https://bsky.app/profile/relentleshealth.bsky.social
08:20 How do we quantify the issue of staffing shortages?
11:18 Why do we need to look at the root cause of the shortages?
11:51 Deloitte survey on staffing shortages.
11:54 Why is trust one of the core problems when it comes to staffing shortages?
13:59 “Healthcare workers have choice.”
15:34 What are the strongest correlations that influence healthcare workers’ desire to stay?
18:17 What things give healthcare workers the most pause?
19:36 The U.S. Department of Health and Human Services Health Sector climate pledge.
20:20 The Commonwealth Fund survey on what health systems can do to address climate change.
22:29 What do we do about sustainable, climate-friendly healthcare being a driving factor in staffing?
27:28 How do you meet the desires of healthcare workers where they’re at?
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In this episode of 'Relentlessly Seeking Value,' host Stacey Richter is joined by healthcare entrepreneur Cynthia Fisher to discuss the crucial issue of medical spread pricing and the need for contract transparency.
Fisher explains how hidden fees and spread pricing by middlemen are leading to substantial overcharges for employers and patients in the U.S. healthcare system. The conversation delves into recent lawsuits that highlight these practices, the legislative strides made to enforce price transparency, and how transparency can potentially transform the industry.
Look, this is a thing now, medical spread. And similar to how PBM spreads adds up to millions, billions of dollars, medical spread is not change in the couch cushions. Did you see the lawsuit against Cigna? Cynthia Fisher mentions it in the conversation that follows. Spoiler alert, here’s the numbers: Self-insured employer paid $4 million for a claim.
There’s a slide on this Cynthia Fisher gave me, by the way, if you want to see all this written out. So, the employer pays $4 million. The provider was paid—drumroll, please—$876,000. I’m pausing so that sinks in: $4 million paid by the employer; $876,000 of that makes it across the trench to the provider.
To view the meme we created for how carriers are learning to do spread pricing from the PBMs, visit our show notes page below. (continued after the links below)
=== LINKS ===
🔗 Show Notes with all mentioned links:
https://cc-lnk.com/EP457✉️ Enjoy this podcast? Subscribe to the free weekly newsletter:
https://relentlesshealthvalue.com/join-the-relentless-tribe🫙 Support the podcast with a small donation to the Tip Jar:
https://relentlesshealthvalue.com/join-the-relentless-tribe=== CONNECT WITH THE RHV TEAM ===
✭ LinkedIn https://www.linkedin.com/company/relentless-health-value/
✭ Threads https://www.threads.net/@relentlesshealthvalue/
✭ X https://twitter.com/relentleshealth/
✭ Bluesky https://bsky.app/profile/relentleshealth.bsky.socialFisher emphasizes the importance of employers and unions demanding accountability, using existing laws to unveil true pricing, and advocates for a revolution in healthcare to ensure fair, equitable, and transparent billing. Insights are also shared from industry experts who were previous guests including Chris Deacon, Justin Leader, and Andreas Mang. You can find the links in the show notes on our site.
09:03 What is the goal of PatientRightsAdvocate.org?
10:28 Is American competitiveness being affected by healthcare spend?
13:47 Why is transparency a root cause to healthcare costs?
15:11 What’s going on across the country to empower transparency in healthcare?
19:31 “I think people are fed up.”
21:22 The Cigna lawsuit in California.
26:36 How do employers navigate contracts against anti-steering?
28:54 EP419 with Andreas Mang.
29:33 EP452 with Cora Opsahl and EP453 with Claire Brockbank.
29:45 EP433 with Justin Leader.
You can learn more at PatientRightsAdvocate.org.
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In this special Thanksgiving episode of Relentlessly Seeking Value, Stacey Richter discusses the significance of being 'givers' in healthcare, advocating for collaboration over transactional relationships to deliver real value to patients.
She touches on the challenges and necessary shifts in healthcare market dynamics, emphasizing that true value is determined through bi-directional conversations between providers and end-users, like patients and plan sponsors. Stacey concludes with a call to action for listeners to reflect on their support networks and consider supporting valuable media and publications.
To read the show notes with the mentioned links visit the epsiode page.
If you enjoy this podcast, be sure to subscribe to the free weekly newsletter to be a member of the Relentless Tribe.
I want to drop a thank you right here to those who have left a tip in our tip jar and/or offer up a monthly contribution. From the bottom of my heart, thanks for the support. Thank you to Dr. Scott Tromanhauser, Marilyn Bartlett, Ann Kempski, Dr. Matthew Bunte. Also, thank you to Brian Uhlig, Dr. William Gailmard, Dr. John Lee, Dr. Paula Muto, and Linda Krebs.
Plus everyone else who left a lesser amount. You guys are my village, and this matters because, as it’s been said by me and others a million times, it will take a village to transform healthcare. So, if you haven’t already done so, because … yeah, Thanksgiving, consider who is on your own list of villagers to thank right about now in your world.
So, yeah, long story long, all the more thanks to everyone who has donated to our tip jar, who has written a nice review on Apple Podcasts or Spotify, or who interacts with our posts on LinkedIn. Thank you.
This is how pods like this and any of the publications that you like are able to continue. It’s also, if you want to get really “why do givers succeed” about it, it’s through these interactions that like 99% of guests I’d estimate who get invited on a podcast, probably any podcasts, come from, or who likely get their name in any publication come from. As I said, this is true for this pod at least. But I would say that who are most hosts or most reporters going to reach out to when they need information or insight and are looking to quote somebody?
It’s gonna be somebody that they know. It’s gonna be somebody that they like.
So, giving, the healthcare industry. This is the actual point I wanted to make before I completely distracted myself. And I talked about this at length actually at a recent thINc360 panel about delivering better patient outcomes.
So, collaborate, give. And thank you to all of you who do both of these things every day, despite the cognitive dissonance and corporate forces and the lack of time and resources that may plague your efforts. I appreciate you very, very much. And it is this gang—the Relentless Tribe, that listens to this show—it is you who will transform healthcare. It’s really you. And again, from the bottom of my heart, I thank you.
01:33 How do you calculate the number of people you’ve helped?
02:46 Why is giving so important within healthcare?
03:16 Interview with Adam Grant.
05:47 How can you be a better giver?
07:50 Who is in charge of the bidirectional conversation of value?
11:35 Why is collaboration so important to value and being a giver?
12:58 Why is it important that plan sponsors are a part of all this giving and collaboration?
13:22 Encore! EP415 with Rob Andrews.
14:34 Summer Shorts 8 with Larry Bauer, MSW, MEd.
15:08 INBW39 with Stacey on the narcissism of small differences.
15:12 EP399 and EP400 with Stacey.
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In this encore episode, Mark Cuban discusses his insights and experiences on disrupting the healthcare and pharmacy benefits landscape with Stacey Richter. This show from last year was one of the most popular episodes of the past year. And it’s also extremely relevant right now, given all of the PBM (pharmacy benefit manager) goings-on, as well as ongoing litigation like the J&J lawsuit, etc. Listen to the show with Julie Selesnick (EP428) for more on that one.
You can find the show notes with all links mentioned and a transcript on our episode page.
If you enjoy this podcast, be sure to subscribe to the free weekly newsletter to be a member of the Relentless Tribe.
Joined by Ferrin Williams from Scripta, Cuban stresses the importance for CEOs and CFOs of self-insured companies to get actively involved in their healthcare plans to avoid overpaying. The conversation tackles the opaque practices of PBMs, the financialized nature of the healthcare industry, and introduces Mark Cuban's Cost Plus Drugs model which aims for transparency and cost reduction.
Key topics also include the potential legal implications for employers, the importance of trust in healthcare transactions, and the real-world savings and benefits achievable with greater involvement and transparency in healthcare management.
What do all of these numbers have in common: $140,000, $3 million, $35 million, and $3 billion?
These are all actual examples of how much employers, unions, and some public entities saved on healthcare benefits for themselves and their employees. The roadmap to saving 25% on pharmacy spend and/or 15% on total cost of care in ways that improve employee health and satisfaction always begins when one thing happens. There’s one vital first step.
That first step is CEOs and/or CFOs or their equivalents roll up their sleeves and get involved in healthcare benefits.
Read the full article/show notes with all the mentioned links here:
https://cc-lnk.com/Encore41806:29 What was Mark Cuban’s own journey as a self-insured employer with Cost Plus Drug Company?
07:44 What did Mark find when he decided to go through and look through his company’s benefit program?
09:12 “When you think it through, you start to realize that money is being spent primarily by your sickest employees.” —Mark
10:02 How do you get CEOs and CFOs of self-insured employers to realize that their sickest employees are the ones subsidizing their checks?
13:00 What is the role of insurance in healthcare?
14:30 “If you can’t convince them, confuse them and hide it.” —Mark
15:24 The reality behind getting a rebate check.
16:21 Why are rebates going away, and why isn’t that changing PBM earnings?
19:05 How do you get CEOs and CFOs to dig into their benefits plan?
20:59 Does morally abhorrent move the needle?
21:33 “What we’re trying to do is just simplify the [healthcare] industry.” —Mark
24:19 What’s been changing in consumer behavior?
25:04 “Transparency is a huge part of building that trust.” —Ferrin
25:19 Why CEOs and CFOs really have the power to change healthcare.
32:29 What are Cost Plus Drugs’ plans to expand?
39:21 Where is the future of the prescription drug market going?
42:09 What will happen to the prescription drug market in 10 to 20 years?
48:40 The wake-up call self-insured employers should be acknowledging now.
52:02 Where is the real change in the healthcare industry going to come from?
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In this episode, Stacey Richter speaks with Rob Andrews, CEO of the Health Transformation Alliance (HTA) and former Congressman, about the strategic steps jumbo employers can take to achieve improved health outcomes while reducing cost. They delve into the importance of using data to discern effective practices, negotiate contracts, and hold intermediaries accountable.
To Read The Show Notes With All Mentioned Links, Visit the Episode Page.
If you enjoy this podcast, be sure to subscribe to the free weekly newsletter to be a member of the Relentless Tribe.
The discussion highlights maternal health as a critical area of focus, with successful interventions shown to reduce NICU admissions and overall healthcare costs. Andrews emphasizes the role of self-insured employers in driving systemic changes that align financial incentives with health outcomes.
This encore is very relevant after the shows with Cora Opsahl (EP452), Claire Brockbank (EP453), and Marilyn Bartlett (EP450). Getting better health for the 160 million Americans covered by commercial insurance is all about rates, rights, and power.
07:34 How did Rob get to his current role?
09:08 The problem of maternal health and mortality rate, and how self-insured employers wind up directly and indirectly paying for this.
10:27 Why economic consequences move the needle, and why sometimes they don’t.
12:26 Why the best way to address costs isn’t to re-shift costs but to address them directly.
13:22 Why compensation that isn’t dependent on outcomes is a problem.
16:23 “Strategy’s not what people say; it’s what they do.”
18:21 How do you operationalize saving money with better outcomes?
26:26 How do employers turn conflict into collaboration?
28:20 What is the win-win-win structure among employers, payers, and providers in Rob’s eyes?
30:53 To whom should the task of risk adjustment fall?
34:43 “Better contracts do improve outcomes.”
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In this comprehensive episode host Stacey Richter sits down with Brian Reid to discuss pivotal aspects for the pharmaceutical industry. Key topics include understanding product value from the perspectives of plan sponsors, patients, and society, and the significance of benefit design in improving patient affordability.
For the show notes with all links mentinoed, visit the episode page.
If you enjoy this podcast, be sure to subscribe to the free weekly newsletter to be a member of the Relentless Tribe.
The discussion delves into the complexities of drug pricing, the roles of Pharmacy Benefit Managers (PBMs) and brokers, and the impact of healthcare consolidation on costs. Reid emphasizes the importance of transparent communication among stakeholders, the detrimental effects of cost containment strategies, and the necessity of considering policy and reputational impacts.
Throughout the conversation, examples such as the Hepatitis C drug illustrate the broader implications on drug access and affordability. Listeners are provided with critical insights into how pharmaceutical companies can better engage with ultimate purchasers to ensure patients receive necessary, cost-effective medications while navigating a changing healthcare landscape.
For the show notes with all links mentinoed, visit the episode page.
08:29 Why is it important to understand the term “value” in respect to medicine?
10:07 Why is it important to consider all the players affected by the idea of this “value”?
11:06 Who are the ultimate purchasers in Pharma?
12:23 Findings of the Kaiser Employer Health Benefits Survey.
14:52 Why does it matter that we consider what value looks like to all players affected by Pharma?
16:46 EP300 with Bruce Rector, MD.
18:38 EP448 (Part 1) with Shawn Gremminger.
20:04 What does Pharma need to do to showcase their value when PBMs are often “locked in” at the moment?
23:11 Why Brian is celebrating companies that put their prices in their press releases.
32:31 Why does Pharma have an obligation to explain their value?
33:16 EP426 with Nina Lathia, RPh, MSc, PhD.
33:39 Why is it important for Pharma to keep an eye on hospital monopoly behavior?
35:55 EP370 with Erik Davis and Autumn Yongchu.
37:44 Why Pharma needs to capitalize on alignment.
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In this conversation, Stacey Richter engages with healthcare leader Dr. Beau Raymond from Ochsner Health Network to explore the blueprint for better patient care through enlightened leadership, data-driven strategies, and localized health initiatives.
The discussion covers shifting from 'sick care' to preventative healthcare, integrating technology and data tools like glucometers for health coaching, and addressing health equity through accurate data and regional strategies.
To Read the Show Notes with Mentioned Links and a Full Transcript, Visit the Episode Page.
If you enjoy this podcast, be sure to subscribe to the free weekly newsletter to be a member of the Relentless Tribe.
The conversation explains the importance of stakeholder engagement, setting clear goals, financial incentives aligned with patient care, and continuous improvement through feedback loops. Practical steps such as weekly huddles for primary care teams and the role of digital health in managing chronic conditions like diabetes and hypertension are also highlighted to improve healthcare outcomes and operational excellence.
A rate critical to attain better care for patients, I’m gonna say, is enlightened leadership—maybe dyad leadership—at a clinical organization. I am saying this because without enlightened leaders, it’d be harder to build from the blueprint that Beau Raymond, MD, talks about today on the show.
10:44 Why is it important to be flexible while keeping your goals in sight?
11:48 Dr. Eboni Price-Haywood’s article on disparities in COVID.
12:29 How is equity a data point to achieving overall care improvement?
15:01 “If you can’t measure it … accurately, you’re not going to be able to do anything differently.”
20:52 What strategies have been successful in using data to improve healthcare outcomes?
23:17 Why did Ochsner Health avoid looking at the individual physician standpoint in regard to an equity standpoint?
30:40 Why engaging patients in their healthcare actually improved patient visits and did not necessarily reduce patient visits.
34:49 “It’s really about engaging with the patient.”
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In this episode, host Stacey Richter and guest Brendan Keeler dive deep into the significant legal clash between Epic and Particle over electronic health record (EHR) data access and market competition.
To Read the Show Notes with Mentioned Links and a Full Transcript, Visit the Episode Page.
This episode examines the broader repercussions on healthcare data exchange, including antitrust concerns, data liquidity, and the ethical considerations around secondary use of treatment data. The discussion brings to light how the outcome of such lawsuits could influence data transparency, interoperability, and the rules governing data sharing among plan sponsors, employers, and healthcare providers.
Notable points include the shift to a judicial era impacting health tech companies and the potential for regulatory and judicial actions to improve data access and efficiency within healthcare networks. The episode emphasizes the critical need for clear pathways, accountability, and structured regulations to enhance patient care and reduce fraud in the healthcare data ecosystem.
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07:21 Who can gain access to EHR data?
10:31 Are there limits to how EHR data can be used secondarily?
11:36 Can EHR data be shared secondarily?
15:47 Part one and part two of Brendan’s comprehensive account of the Epic/Particle dustup.
15:57 What was the dispute that started Epic v Particle?
18:21 What are the two viewpoints in this dispute with Epic’s actions?
26:16 What progress has been seen since this lawsuit began?
28:00 Who else will be impacted by the likely rule cementing from this lawsuit?
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In this episode, host Stacey Richter delves into the complexities of the Third Party Administrator (TPA) Request for Proposal (RFP) process with guest Claire Brockbank from 32BJUnion.
The discussion highlights the critical role of contracts in managing health plans effectively and the potential pitfalls of accepting contracts crafted by TPAs without thorough review. Drawing from Claire's experience, they explore tactics like starting with your own contract paper in RFP processes to gain negotiation leverage, and the benefits of employer coalitions in navigating health care complexities.
To Read the full article which includes mentioned links visit the episode page.
If you enjoy this podcast, be sure to subscribe to the free weekly newsletter to become a member of the Relentless Tribe.
Real-world examples underscore the financial impacts of poorly negotiated contracts and highlight successful strategies for health plan sponsors to optimize costs and services. The episode aims to empower employers with tools and insights to negotiate effectively and ensure their health plan contracts align with their strategic goals, ultimately paving the way for better population health management and cost-effective care delivery.
As but one example—and Cora Opshal spoke about this last week and Claire talked about this today—it’s about how allowing upside-down payments, for example, that are in a lot of ASO contracts, this allowing of upside-down payments. I mean, it turns out that 32BJ spent around $10 million paying more than the bill was for one year. If somebody signs that contract as handed to them by the carrier, then the plan is now contractually obligating themselves to pay more than the price the clinical practice was charging. So, doc sends bill for $100, and the carrier pays that practice $200 on behalf of the plan sponsor.
So now the plan sponsor is paying $200 for a $100 bill. Is this conflict of interest? Is it imprudent? Is it not reasonable? Said another way, is that a bit of a fiduciary breach on the plan sponsor?
So it's understandable why the team at 32BJ pushed back and pushed back hard. We all can see why the leading edge of plan sponsors and more and more C-suites are hotfooting it into conference rooms to plan their RFP process and doing it in the way that Claire Brockbank talks about today.
For an open-source contract and some other free tools, please do head over to the 32BJ Insights Web site.
05:36 How does the initial contract writing affect how events in your healthcare plan will go?
06:56 What happens if a plan sponsor or employer doesn’t do the contracting right?
10:42 How much could be saved by doing contracting right?
11:01 EP433 with Justin Leader.
12:22 How do you start an RFP process with your own contract?
14:06 What Claire Brockbank recommends doing to do a TPA RFP process in a way that’s best for you.
19:46 What factors do carriers need to get an ASO or TPA to respond to using your contract?
21:11 Open-source contract available from 32BJ.
21:57 Why it’s important to really probe brokers, despite loyalty to your broker/consultant.
24:30 Who are the reliable agents and experts when carriers are looking to start this process?
26:24 EP428 with Julie Selesnick.
27:56 What’s the silver lining to this effort?
29:17 Why is it important to make it clear why you’re doing what you’re doing for your lawyers and any other support team you need?
31:39 What does “good” look like in this process?
34:15 Why is it important to continue to hold your ASO accountable?
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In this episode I interview Cora Opsahl from the 32BJ Health Fund to examine the intricate dynamics between fiduciary duties and the entrenched status quo in healthcare. The discussion focuses on the challenges employers face when dealing with anti-competitive contracts and their responsibility to ensure plan expenses are reasonable. Cora Opsahl, my guest today, is the director of the 32BJ Health Fund, serving over 200,000 folks. Their ability to kick NewYork-Presbyterian, a big, consolidated, very expensive hospital, out of their network in 2018 enabled them to offer maternity benefits for $40 in total out-of-pocket for members. And also, employees got their biggest raise ever; employers got a premium holiday and a 3% rate increase for a bunch of years after that; and yeah … this is where we start the conversation today. Furthermore, you will find links to a template health savings calculator for plan sponsors and also a template contract (again for plan sponsors) that 32BJ has made available, in our show notes.
To Read the Full Show Notes with the Mentioned Links Visit the Episode Page.
If you enjoy this podcast, be sure to subscribe to the free weekly newsletter to be a member of the Relentless Tribe.
06:16 Why is it imperative for employers to do something differently when it comes to being plan sponsors?
09:22 How analyzing claims data allowed 32BJ Health Fund to reshape their benefit design.
12:09 What anticompetitive rights did 32BJ run into that limited 32BJ Health Fund from managing their benefit design?
14:12 How do these anticompetitive rights have quality implications as well as cost implications?
18:43 How did 32BJ Health Fund remove NewYork-Presbyterian from their network, and how much did it save 32BJ Health Fund per year?
19:46 What did the healthcare savings allow the unions and employers to do?
20:46 Study by Zack Cooper, PhD.
21:26 Why rising healthcare costs has pushed 32BJ Health Fund to move beyond benefit design to manage healthcare spend.
24:15 Why 32BJ Health Fund wants to control the contracting process.
26:00 EP419 with Andreas Mang.
27:18 What are 32BJ Health Fund’s four non-negotiables?
33:17 Wall Street Journal article on health insurance contract.
35:30 Upcoming episode with Claire Brockbank.
36:14 What is the challenge that exists in our current healthcare environment?
37:43 Cora’s advice on how to get high-quality healthcare at an affordable price.
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In this Spotlight Episode host Stacey Richter discusses the management of oncology side effects with Dan Nardi, CEO of Reimagine Care. Highlighting the challenges cancer patients face, especially following chemotherapy which often leads to nausea and readmissions, the conversation delves into how Reimagine Care facilitates at-home integrative cancer care. Their services focus on proactive and reactive support via AI-driven tools like 'Remy' to assist patients outside of clinical environments. This approach aims to reduce emergency visits and improve patient outcomes while easing the workload on healthcare providers. The discussion underscores the role of patient reported outcomes and the integration of technology with human care to improve the quality of oncology treatment pathways.
To Read the Full Article Notes with Mentioned Links, Visit Our Episode Page .
If you enjoy this podcast, be sure to subscribe to the free weekly newsletter to be a member of the Relentless Tribe.
Note from Stacey Richter: Pulling off a show like this one is not cheap, and my Aventria business partner Dave Dierk and I are happy to fund the vast majority of it. But yeah, breath of fresh air, and thanks much to the team over at Reimagine Care for their sponsorship. My one disclaimer is that I have not personally vetted the solution, but there is a white paper available where you will also find some insights from Reimagine Care’s work with Memorial Hermann Health System.
03:38 Why is it really important to keep track of oncology patients and their side effects?
04:27 Why is cancer treatment such a complex care journey?
05:57 Are there outcome and financial issues that compound when an oncology patient is left to navigate their care journey on their own?
08:53 What is difficult in navigating cancer treatment care pathways, and what does Reimagine Care tackle within that?
09:55 EP157 with Ethan Basch, MD.
10:17 How does Reimagine Care proactively check in with oncology patients to help them navigate their care pathways?
12:41 How does Reimagine Care measure their performance, and how did their work affect patient outcomes?
13:28 The Reimagine Care white paper.
14:57 How do providers feel about Reimagine Care services?
17:37 Where can technology really make a difference in cancer care?
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In Episode 451 of Relentless Health Value, host Stacey Richter converses with Dr. Spencer Dorn about the implications of AI in healthcare, referencing lessons learned from EHR implementations.
They discuss Kranzberg's first law of technology, which advises against labeling a technology as inherently good, bad, or neutral, emphasizing instead the importance of its application, configuration, and the human decisions surrounding its use. Dorn and Richter explore both the potential benefits and drawbacks of AI, drawing parallels with past experiences in healthcare digitization.
To read the full article with links mentioned or to sign up to the newsletter, visit our episode page.
The first takeaway from this short show focused on artificial intelligence is gonna be the same, really, as it was in episode 446 about EHRs. Do not ascribe any given technology a label of, as good, bad, or even neutral. That is Kranzberg’s First Law of Technology; and it applies here, too.
Second major takeaway—and again, this is the same as in that earlier show about EHRs, but today we’re talking about AI—if you’re thinking about the ultimate impact of the people and the processes that have some technology in their midst (technology, again, such as AI, artificial intelligence), the ultimate impact will not be a black-and-white binary.
We talk about some of these nuanced not binaries in the 10 minutes that follow, but for more, I’ve put some links in the show notes on our epsiode page for some newsletters et cetera to check out.
05:23 What could happen with AI in healthcare if we aren’t thinking about how we’re deploying it?
05:58 How could the lessons from digitizing healthcare help us with employing AI?
08:25 How could artificial intelligence make things better and simultaneously worse?
10:55 Why is it important to look beyond the hype and pessimism and make a clear-eyed assessment?
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In Episode 450 I speak with Marilyn Bartlett, a renowned CPA in the healthcare field, about her remarkable achievement of transforming the state of Montana’s employee health plan from $9 million in debt to a surplus of $112 million within three years.
You can read the full show notes with mentioned links on the epsiode page.
If you enjoy this podcast, be sure to subscribe to the free weekly newsletter to be a member of the Relentless Tribe.
Marilyn discusses the steps she took, including identifying financial inefficiencies, targeting high-cost areas, and implementing data-driven strategies to produce quick wins and sustainable results. The conversation delves into the importance of having the right team, communicating effectively with stakeholders, and staying focused amidst challenges. Listeners will gain valuable insights into strategic change management and actionable advice for improving healthcare plans.
Yeah, I made a meme for the show with Marilyn Bartlett. My very first meme ever. In this meme, I picture that Olympic silver medalist shooter from Turkey who showed up in a T-shirt and his hand in his pocket versus the others with all their fancy equipment that, turns out, may or may not be necessary, regardless of who might swear up and down that complexity requires even more complexity and plenty of expensive gear to shoot straight.
Point being, it’s amazing what a dedicated CPA with a spreadsheet and their eye on the target can accomplish in the real world when they just do their thing and follow the dollar.
And with that, Marilyn Bartlett has entered the chat. Marilyn Bartlett isn’t called the “Queen of Healthcare” for no good reason, and nobody is joking when they say this. She was probably the first person (or one of the first, at a minimum) to truly identify the amount of money getting sucked out of the wallets of taxpayers and employers and plan members and into the pockets of the healthcare and insurance and consulting industries. She is a through and through numbers person but also deeply cares. She is truly a senior stateswoman in our field.
To read the full article with mentioned links or the transcript, visit our epsiode page.
06:45 What gave Marilyn the confidence to fix Montana’s state health plan?
08:11 Why Marilyn knew she would have enough power to make the changes needed in Montana’s state health plan.
09:11 What Marilyn achieved in her time as the administrator of the Montana State Employee Health Plan.
10:38 What were the “quick wins” Marilyn was able to achieve when she first took over as administrator?
17:33 Stay tuned for an upcoming episode that covers RFP in detail.
17:50 How Marilyn structured her plan for the Montana State Employee Health Plan.
21:21 What’s the key to setting yourself up for success when doing what Marilyn was able to achieve?
25:02 Why putting together your own team is so important.
29:07 What happened when Marilyn left the Montana State Employee Health Plan?
31:08 Have the costs of the plan gone up since Marilyn’s time working on it?
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So, I had a chance to read Dr. Marty Makary’s new book, which is called Blind Spots; and here’s why I wanted to get him to come back on Relentless Health Value and talk to you, people of the healthcare industry. It’s because of something that he said on page 127 and which I’ve been mulling over for probably years, actually.
To Read The Full Article Including Links Mentioned, click here.
If you enjoy this podcast, be sure to subscribe to the free weekly newsletter to be a member of the Relentless Tribe.
It’s this idea of what is appropriate care and how good are we at ensuring that patients/members get said appropriate care. Lots of people are of the same minds because appropriate care has come up in the show with Ben Schwartz, MD, MBA (EP434); John Lee, MD (EP438); Spencer Dorn, MD, MPH, MHA (EP446); Tom Lee, MD (EP445).
I mean, an estimated 21% of all medical care is potentially unnecessary. And unnecessary is, of course, one category of things that are not appropriate. This is according to a national survey of physicians: 25% of diagnostic tests, 22% of all medications, and 11% of all procedures are unnecessary/inappropriate. This is billions of wasted dollars doing stuff that shouldn’t be done, and it’s not appropriate care.
But think about this: How many visions for how to fix healthcare and how to reduce waste depend upon a broad-stroke assumption that we will materially ensure that patients are getting best-practice (ie, appropriate) care? That we cut down on over-medicalization and surgeries on the back end and add appropriate preventative stuff and optimal medical therapy to the front end?
Dr. Makary and I delve into the challenges of ensuring patients receive appropriate care, touching on medical dogma, financial, business, and legal incentives, and the importance of measuring practice patterns. Dr. Makary provides practical advice for clinical leaders, payers, and plan sponsors on promoting transparency, improving health literacy, and steering members towards higher performing providers.
To Read The Full Article Including Links Mentioned, click here.
07:32 What is appropriate care?
10:19 Why what we think might be appropriate care might not be appropriate care.
10:34 Why is medical dogma damaging to appropriate care?
12:45 Why we need less absolutism in medical practice.
13:37 How is groupthink prevalent in medicine?
14:02 Why do we resist new ideas?
17:43 How do providers figure out what to believe and what not to believe?
20:59 “If you leave it to the medical profession to fix itself … so far, it’s not going well.”
22:33 How does supporting health literacy affect appropriate care?
30:23 “People need to find their care based on quality and price.”
34:28 What proportion of medical care is deemed unnecessary right now?
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Maybe you’ve already caught Part 1 of my conversation with Shawn Gremminger, and if so, you're ahead of the game. But if not, no worries—here's the deal: I decided to split this deep dive into the 340B program with Shawn into two parts. So, feel free to jump into one or both—it’s totally up to you.
To Read The Full Article Including Links Mentioned, click here.
If you enjoy this podcast, be sure to subscribe to the free weekly newsletter to be a member of the Relentless Tribe.
These episodes don’t have to be listened to in order, so you’re good to start here with Part 2. Let’s get into it!"
Right now, we are going to talk about how 340B impacts employers and commercial plans and other plan sponsors. So, if all you want to hear about is the why—as in, Why do employers care about what amounts to a program that is or was supposed to be for low-income Americans and Medicaid?—you are in the right place.
As just one example of the why should employers care if you are teetering on the edge of proceeding, did you know that if an employee or a member of a commercial plan gets a drug at a contract pharmacy participating in 340B, the employer does not get the rebate? The employer is gonna pay the list price for that med.
Wait, what? Yeah, details follow because Shawn Gremminger is gonna get into this and many other reasons why employers or anyone in the commercial market (or taxpayers, really) should care about this, as some may call it, Medicaid program. The fact is, 340B is currently so gargantuan that it creates market distortions that bleed into the prices and possibly the quality of healthcare for everybody, all Americans. And that could really matter to employer or Taft-Hartley plan sponsors.
After you listen to this show, if you want to drill in a little deeper on the “what the what” and the history of 340B, head back and take in Part 1 of this episode 448. Shawn Gremminger gives the skinny on how the program morphed over the years into a $53 billion juggernaut and is credited (or blamed) for all kinds of healthcare market consolidation and many other weird and unusual consequences that make me admire some of the folks who are truly gold medal winners in the sport of financial engineering.
If you want a summary of the points Shawn makes for why employers should care, it is your lucky day, because here you go. Here’s the four distortions in the market that Shawn talks about which impact employers:
To continue reading, please view our show notes/full article.
09:11 Why do employers care about 340B, which is a Medicaid program?
11:30 Why do I care as an employer, even if I’m not Pharma?
12:44 Why is 340B causing employers to pay significantly more for healthcare?
14:36 Study by Zack Cooper, PhD.
15:06 Why are there distorted pricing models at 340B hospitals?
21:22 Why do employers need to stop playing the blame game?
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So, after some pondering, I decided to release this conversation with Shawn Gremminger about 340B in two parts. So, listen to one, listen to both, pick your poison. Shawn Gremminger came up with three really important takeaways relative to 340B, which is a feat unto itself, considering how sprawling this conversation can be. So, if you came here for some concise and actionable takeaways, you have come to the right place.
To Read The Full Article Including Links Mentioned, click here.
If you enjoy this podcast, be sure to subscribe to the free weekly newsletter to be a member of the Relentless Tribe.
This first part you are listening to right now zeros in on Shawn’s first takeaway: whether or not the original intent, or the presumed original intent, of the 340B program has actually been met.
Many do not realize that 340B began life as a caterpillar. It originally, actually, was conceived as a lowly bureaucratic fix. But over the past 15 years, it has gone into a chrysalis and emerged into a 500-pound gorilla that sits in the corner of a lot of rooms, actually—probably more than many people realize. All of that being said, when you’re done listening to this first part of the convo, you should be able to competently assess whether or not 340B does, in fact, adequately help underserved communities get better healthcare—because 340B is supposed to help safety-net healthcare providers stretch scarce resources.
The second part of the show, which is a separate episode called Part 2, is how all of this impacts employers and commercial plans. And there’s two more takeaways there.
So, if you already have the gist of how we got from the beginnings of 340B to where we are in 2024 already and all you want to hear about is why do employers care about what amounts to a low-income program or was purported to be a low-income program, feel free to zip over to the second show and cut to that chase.
If you’re still with me for this Part 1—and I hope you are, because … wow, it’s a wild and tangled journey—here’s an outline of where this first part of the discussion is headed. So, for the sake of posterity and having this introduction transcribed in your inbox (be sure to sign up for the free newsletter), here you go. Here’s the outline.
Visit the full article to read more.
05:25 Shawn’s three takeaways from the 340B program.
06:04 What is the intent of the 340B program?
08:22 Read the full 32-page report of the Energy and Commerce Committee.
09:17 Why does Medicaid have to get the best price?
13:26 Why was there a shift in how the 340B program looked starting in the mid-2000s?
15:11 Why do more than half of acute care hospitals now qualify for 340B?
18:18 How has hospital consolidation affected 340B?
20:37 What is the misalignment between how a hospital qualifies for 340B and how it benefits said hospitals?
24:11 How is a 340B designed for hospitals to make a profit?
28:45 Why isn’t there a real patient definition in 340B?
31:46 Why is 340B still popular among policymakers?
33:05 Are 340B dollars being used in underserved communities?
33:57 EP394 with Vikas Saini, MD, and Judith Garber, MPP.
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In this Summer Short Episode of Relentlessly Seeking Value, host Stacey Richter discusses the hidden costs and inefficiencies of value-based care with Elizabeth Mitchell, President and CEO of the Purchaser Business Group on Health (PBGH).
To read the full article and show notes which include mentioned links, visit the episode page.
If you enjoy this podcast, be sure to subscribe to the free weekly newsletter to be a member of the Relentless Tribe.
They uncover how value-based care, often touted as the ideal system, can be manipulated by middlemen to extract more money from plan sponsors without delivering real value to patients.
Through a critical conversation involving examples and insights from various experts, they explore the disconnect between financial incentives and actual care quality in American healthcare.
Elizabeth argues for for-real alternative payment models that are transparent to the employer plan sponsors. She wants prospective payments or bundled payments, and she wants them with warranties that are measurable. She wants members to get integrated whole-person care in a measurable way, which most health plans (ie, middlemen) either cannot or will not administer.
Elizabeth says to achieve actual care that is of value, cooperation between employers, employees, and primary care providers is crucial (ie, direct contracts). She also says that this whole effort is really, really urgently needed given the affordability crisis affecting many Americans. There’s been just one article after another lately about how many billions and billions of dollars are getting siphoned off the top into the pockets of the middlemen and their shareholders.
These are dollars partially paid for by employees and plan members. We have 48% of Americans with commercial insurance delaying or forgoing care due to cost. If you’re a self-insured employer and you’re hearing this, don’t be thinking it doesn’t impact you because your employees are highly compensated.
As Deborah Williams wrote the other day, she wrote, “Co-pays have gotten high enough that even higher-income patients can’t afford them.” And she was referencing a study to that end.
To read the full article and show notes which include mentioned links, visit the episode page.
If you enjoy this podcast, be sure to subscribe to the free weekly newsletter to be a member of the Relentless Tribe.
So, yeah … with that, here is your Summer Short with Elizabeth Mitchell.
10:36 What are members and providers actually asking for in terms of value-based care?
10:56 Why won’t most health plans administer alternative payment models?
12:17 “We do not have value in the US healthcare system.”
12:57 Why you can’t do effective primary care on a fee-for-service model.
13:30 Why have we fragmented care out?
14:39 “No one makes money in a fee-for-service system if people are healthy.”
17:27 “If we think it is not at a crisis point, we are kidding ourselves.”
- Visa fler
