Relentless Health Value

Cognitive Atrophy, Referral Incentives, Fragmented Care: Is Primary Care Inevitable or Fixable? Episode 519. Primary care physicians are leaving traditional practice for concierge medicine in visible numbers—and the question is whether that exodus is an unavoidable consequence of how the system is built, or something we've simply chosen not to fix. Stacey Richter talks with Dr. Lisa Rosenbaum, a c...

The ASO vs. TPA Decision That Quietly Costs Self-Funded Employers More What's the real difference between an ASO and a TPA — and why does it matter that self-insured employers working with an ASO pay, by one referenced estimate, about 4.7% more than the insured book of business for the same care? In this Ask Me Anything, Stacey Richter puts a listener question from Dr. Alex Sommers, MD, ABEM, DipA...

The PBM Rebate Math That Turns Prior Auths Into a Pharma Negotiating Tool What if a prior authorization has less to do with your medical need than with how big a rebate check a PBM is collecting on a competing drug? In this solo deep dive — a direct follow-up to last week's conversation with Ophelia Johnson on GLP-1s and cash pay (EP516 link below) — host Stacey Richter walks through a "Brand Darl...

Only about half of new GLP-1 prescriptions got approved for coverage in 2023 — a gap Ophelia Johnson says is why pharma manufacturers started building cash-pay and direct-to-employer channels instead of waiting on PBMs. Johnson, who built new channels for the manufacturer behind the GLP-1 boom and now runs e-fi.works, walks Stacey Richter through how the money moves with GoodRx and telehealth, inc...

Is it fraud — or is it just a perverse incentive? That question sits at the center of Hunterbrook Media's latest investigation into skilled nursing facilities (SNFs), and the answer, as Stacey Richter puts it, matters to self-insured employers and anyone else paying for healthcare. In this episode, Stacey speaks with Michelle Cera, PhD, investigative reporter at Hunterbrook Media, whose investigat...

How the Sutter Health Antitrust Case Opened the Door for Employers and Members to Recover Hospital Overcharge Damages What happens when a self-insured employer or health plan member finally says enough is enough and takes a consolidated hospital system to court over anticompetitive contracting practices? That's exactly what antitrust attorney Matthew Cantor did — and after 13 years of litigation,...

The Hospital Contract Playbook: Four Clauses That Turn Market Power Into Higher Prices. Episode 513. Across the country, hospital systems have used their growing market power to write four specific contract terms into their deals with insurers — terms that all but guarantee higher prices for employers, unions, and patients, regardless of quality or competition nearby. In this episode, Stacey Richt...

A Lawyer's Field Guide to Rent-Seeking Broker and EBC Payment Models. Epsiode 512. Brokers and employee benefit consultants often get compensated in ways health plans never fully see — and even when the dollars are technically disclosed, the math can hide an enormous overcharge. In this episode, Stacey Richter speaks with Doug Aldeen, JD, an ERISA healthcare attorney who has spent decades in the s...

When Risk-Based Payment Becomes Its Own Upcoding Arms Race. Episode 511 Medicare Advantage plans get paid more for sicker patients, which is why upcoding became a problem — and now health systems are upcoding visit complexity right back, with MA plans automatically downcoding in response. In this episode, Stacey Richter plays an unpublished clip from her conversation with Ahilan Sivaganesan, MD (D...

The Line Between Fair Profit and Profiteering in Medicare Advantage. Episode 510 There's a simple test for telling a fair profit from profiteering in Medicare Advantage: does the carrier make more money when the patients it serves are worse off? In this episode, Stacey Richter talks with Betsy Seals, co-founder of Rebellis Group and a Medicare Advantage consultant making her third appearance on th...

The Seven-Step Roadmap That Gets CFOs to Stop Being Passive Price Takers on Health Benefits. Episode 509. As a companion to last week's CEO-focused episode, Stacey Richter talks with Patrick Nelli — CEO of Aligned Marketplace and a former CFO himself — about how to bring finance teams into health benefits strategy using their own language. Patrick lays out a seven-step roadmap, starting with forec...

The Three False Dogmas Keeping CEOs From Fixing Their Health Plan. Episode 508. In the show's first-ever Ask Me Anything episode, Stacey Richter puts a listener's question to Lee Lewis, chief strategy officer and GM medical solutions at the Health Transformation Alliance: why do so few self-insured CEOs take bold action on their health benefits strategy? Lee walks through three false dogmas, four...

Buy Healthcare, Not Insurance: A Through-Line Review of the Four Concepts Behind High-Value Care. Episode 507. Stacey Richter pulls together clips from 14 past guests to lay out the four core concepts for buying or delivering the highest-value healthcare: buy healthcare (not just insurance), avoid the myth that less expensive automatically means lower quality, consider direct contracting between p...

The Price Transparency Arms Race: What Self-Insured Employers and Clinics Can Both Do With the Data. Episode 506. Health price transparency data isn't just a compliance exercise anymore — it's becoming a competitive weapon for plan sponsors, shareholders, and clinics alike. Stacey Richter talks with Jerry DiMaso, co-founder and CEO of Payerset, about how self-insured employers can use hospital and...

Time-Driven Costing and the Operative Value Index for Surgical Care, With Ahilan Sivaganesan, MD. Why "Value Equals Outcomes Over Cost" Doesn't Work Until You Can Actually Measure Both. Episode 505. What if the only way to know who's delivering high-value surgical care is to actually calculate it, instead of guessing? Stacey Richter talks with Ahilan Sivaganesan, MD—known as Dr. Siva—a practicing...

Why Evidence-Backed Primary Care Still Can't Scale, and a 3-Step Roadmap to Get Around It. Episode 504. Why isn't advanced primary care (APC) everywhere, if the evidence for it is this strong? Stacey Richter talks with Ryan Jacobs, SVP of Strategy and Partnerships at Marathon Health, about the two root causes blocking APC from scaling—conflicting fiduciary duties and what Jacobs calls "the black b...

Listener Insights on Better Decisions, Price Transparency, and PBM Spread Pricing Tricks. Why "Insight Is Common, Execution Is Rare" Is the Whole Game in Fixing Healthcare. Episode INBW46. In this inbetweenisode, Stacey Richter spotlights two Relentless Tribe members whose LinkedIn posts crystallized something she'd been trying to say all season: that healthcare doesn't lack frameworks or commenta...

Direct-to-Employer Specialty Care and Centers of Excellence 3.0, With Ryan Wells, Leo Spector, MD, and Adam Stavisky Why Self-Insured Employers and Specialists Need to Start Talking Directly Instead of Through a Lazy Middle. Episode 503. Self-insured employers and the specialists who actually deliver care sit on opposite ends of a long, crowded road—with carriers, ASOs, TPAs, and consolidated heal...

Why $3.5 Billion in Fake Catheters and an Even Bigger Skin Substitute Grift End Up Costing Self-Insured Employers Too. Episode 502. Hackers are using stolen medical data to bill CMS for catheters and other durable medical equipment that patients never actually received—and that's just one piece of a fraud scheme that adds up to 4% of the entire CMS budget. Stacey Richter talks with Brian Machut, a...

Two members of a plan received infusions at a hospital. If they had gone down the street, the plan would have spent $1 million less — for the same drug. That is the infusion nonmarket in 2026. In this episode, Stacey Richter speaks with Ivana Krajcinovic, the outgoing Vice President of Healthcare Delivery at UNITE HERE HEALTH, who spent over three decades protecting the health and wages of 230,000...

If you rank California's commercial health plans by member count and check back every year for 14 years, the ranking barely moves. Kaiser at the top. The big blues plans close behind. Everyone else exactly where they were. This is not a competitive market. It is a stalemate. And the stalemate has causes. In this episode — the first installment of Relentless Health Value's "No Market" series — Stac...

Ten years ago, Stacey Richter started Relentless Health Value because the healthcare industry felt like a Pachinko machine — you drop a program or a policy in, it bounces around a black box, and sometimes the result is the opposite of what you intended. Then she met the Relentless Tribe, who turned out to be the alchemists. Episode 500 is not about Stacey. It is about the listeners turning this sh...

Plan Sponsors Are Paying Millions for MSK Injuries That Would Have Healed Themselves — Here's Why Musculoskeletal spend runs roughly $16 PMPM and accounts for 20–30% of total plan costs depending on member demographics — making it the third most costly category of spend. About 80% of those MSK injuries are low or medium acuity. A large percentage of those would heal on their own with ice, rest, an...

Revenue cycle management is a $140 billion industry — already larger than the US auto industry and growing five times faster. RCM vendors use programmatic clearinghouses and increasingly sophisticated tools to maximize every cent of revenue from a claim. That is their job. On the other side sits the self-insured employer, often relying on less sophisticated processes and vendors who may be financi...

What FQHCs Can Teach Every Healthcare Leader About True Fiscal Discipline. There are two very different ways to end up with no profit. One is genuine struggle. The other is simply being very good at spending every dollar you are given. In healthcare, we have no functioning market to tell the difference — and the organizations that are crying poor may just be inefficient. Federally qualified health...