Relentless Health Value

The show on direct contracting with Doug Hetherington ( EP367 ) and also the one with Katy Talento ( EP350 ), both of these experts have said that if an employer direct contracts with a provider organization, in general, the employer gets about 20% savings over the status quo. This makes sense—just cut out the middleman with an MLR (medical loss ratio) of plus or minus about 15% and you're at thre...

This show was one of the most popular episodes in the past 12 months, so enjoy this encore while I am in Chicago moderating a panel on pharmacy benefit management at the WTW Conference Board. But while I have you, I just wanted to thank everyone for listening. You really are a part of our Relentless Tribe, and I could not thank you enough for your commitment to doing the right thing for patients a...

I saw a Tweet from Farzad Mostashari, MD , the other day; and I'm gonna rewrite it in the context of today's show: This is why we can't have nice things! As soon as someone comes up with something that might accomplish some good things when done in moderation and with good intent, it gets exploited for revenue maximization. I have to admit, this conversation with Aaron Mitchell, MD, MPH, and actua...

I was at the PanAgora Pharma Customer Experience (CX) Summit earlier this summer. Let me tell you one of my big takeaways. Many at pharma companies who are trying to convince their organizations of the need to be provider- and/or patient-centric are having a tough go of it. Heard that coming from every direction. Seems there are quite a few pharma organizations out there who are not actually custo...

It's been said that healthcare in this country will not be transformed because of some incremental government policy, nor will this industry transform because of some tech company who techs the crap out of healthcare. It's been said that the only way the healthcare industry in this country is going to fundamentally change is vis-à-vis a seismic shift in the way Americans view the healthcare indust...

This show with AJ Loiacono is different than others you may have heard with him because in this healthcare podcast, we are not talking about PBMs (pharmacy benefit managers). We're talking about brokers and EBCs (employee benefit consultants). So, say I'm a self-insured employer. Here's the big question: Is my broker or EBC helping me make the right decisions, or is he or she helping me make decis...

Okay, so … telehealth for Medicare patients. Currently, there's payment parity, meaning a clinician gets paid the same amount for a Medicare patient visit regardless of whether that patient comes in the office or has a telehealth encounter. Right? Or did that end already? And if it didn't end, how much longer will payment parity continue? Also, is it the same for commercial and Medicaid patients?...

Late in May of this year, three-ish months ago, I did an inbetweenisode that explores the "why with the no collaboration" amongst healthcare stakeholders and what the lack of collaboration signifies. That episode got a lot of traction and engagement.   This episode that follows is a pretty good approximation of a presentation that I made at the MTVA (Moving to Value Alliance) symposium that happen...

I wanted to resurface this episode because when it originally aired over a year ago, the topic may have been ever so slightly ahead of its time. Look, here we are right now with everybody trying to do three big things relative to measuring PCP (primary care provider) performance: Come up with a fair measure for PCP performance. Account for diverse populations with diverse risks so that some docs d...

This encore episode seemed really apropos at this moment in time, since we've just basically published a course in the specialty pharmacy ecosystem, including who all of the various stakeholders are and what their vested interests are. Weirdly, in many of the episodes in the series/course, you'll find the word patient in short supply. And that's not a weird oversight in our podcast production. It...

Members taking specialty drugs represent about 2% of any given employer's population but often consume as much as 30% of an employer's total cost of care. As Pramod John, PhD, in EP353 has said, this isn't just small companies we're talking about here. Some of the largest employers in the US are dropping big bucks on specialty drugs, and they are obviously overpaying and don't need to.   No employ...

Interoperability. Let's just review a few key points that probably everybody listening knows but certainly bear repeating because they matter. I don't want to dig into the technical or regulatory details of interoperability. That is above my pay grade. But I want to talk about the really important stuff that maybe doesn't get talked about a whole lot because you say the word interoperability and i...

Medicare Advantage (MA), otherwise known as the "money machine," is often the most profitable parts of many payers' business lines. Medicare Advantage plans can make a lot of cash if they are good at what they do. Look at any of these large, consolidated carriers' financial statements to get the magnitude of that statement. Also, in 2022, Medicare Advantage plans have enrolled 28 million participa...

So, let's put the last, I don't know, 300 episodes of Relentless Health Value into perspective here. The USA wastes about $1.5 trillion a year on some combination of paying way too much for low-value care, fraud, and waste—$1.5 trillion down the drain. As my guest, Dave Chase, says in this healthcare podcast, if this was a country, what we waste would be the 11th biggest GDP in the world. We could...

In this healthcare podcast, I am speaking with Cora Opsahl, who directs the 32BJ Health Fund. This is the second conversation I'm having with Cora (last one was EP372 ), but these two conversations are not really linear—so listen in whatever order you want to.   Important to know about Cora's background, in previous roles, she has worked deep in the inner sanctums of the healthcare industry. So, s...

In this healthcare podcast, I am speaking with Cora Opsahl, who directs the 32BJ Health Fund. Important to know about Cora's background is this: In previous roles, she's worked deep in the inner workings of the healthcare industry. So, she came to 32BJ armed with a BS meter that is finely tuned, which is, unfortunately, an essential skill for anyone trying to help the patients and members relying...

I wanted to remind everyone about this show from last year because it's becoming increasingly relevant. We have this weird thing going on where everybody seems to be talking about physician incentives and payments and financial implications but so often disregards patient incentives and payments and financial implications. Consider that we're at a place in the time-space continuum where it is inar...

So, this is a 400-level episode in specialty pharmacy options for plan sponsors, meaning here are your prerequisites: You gotta know what buy and bill is, and you gotta know what pharmacy bagging is, meaning white bagging, for example. If you do not, I would listen to Encore! EP282 with Aaron Mitchell, MD, MPH, where we go deep on buy and bill. And then listen to EP369 for the skinny on pharmacy b...

I have been on a mission to figure out why some health systems, particularly in the oncology space but not limited to the oncology space, could manage to mark up the price of infused specialty pharmacy drugs up to 6x. Some employers and patients are paying six times the cost of a specialty pharmacy drug in markup for some already incredibly expensive specialty pharmacy drug at some oncology center...

Last week's show was an encore episode with Dr. Aaron Mitchell ( Encore! EP282 ), and we talked about buy and bill. To continue our exploration of specialty pharmacy intrigue, let's talk about so-called "bagging." I wanted to get an overview of all of the different kinds of specialty pharmacy bagging. Bagging is a big deal. If you have anything to do with trying to control pharmacy costs or the cl...

After that recent episode with Scott Haas ( EP365 ), where we talked about the real deal with PBM contracting, I kicked into high gear trying to untangle this whole apocalyptic honky-tonk we call benefits for prescription drugs. Notice I did not say prescription drug benefits because that would imply that pharmaceuticals are only charged for under the umbrella of pharmacy benefits. Ha ha, that wou...

In INBW32 , I talked about telehealth. In this episode, I'm talking about collaboration between healthcare stakeholders or the lack thereof. My grandfather suffered from heart failure. This was many years ago now. But when I say suffered, I mean it. As many of you know, when heart failure is uncontrolled, it is painful to go through or even watch a loved one go through. There was that one time whe...

People are averse to change. It's a thing. It's a thing that affects even those of us who consider ourselves highly educated and/or very smart. Nobody likes disruption or, even worse, the prospect of disruption and the uncertainty that goes along with that. Nobody likes to feel like the rug just got pulled out from under them or that they've lost control of something, especially something importan...

Lots of talk about direct contracting going on these days. Many of you will be familiar with the term, but in short, direct contracting means when a self-insured employer directly contracts with a provider organization with no payer in the middle of that arrangement. And when I say "employer," I mean the employer and all their peeps—their TPAs, repricers, other vendors, and consultants. Most of th...

First of all, this is a 400-level discussion. If you think you already know all about our dysfunctional healthcare benefits market, then this show is for you. Before we begin, I just want to say something. I'm gonna refer back to David Muhlestein's episode ( EP364 ), where he talks about the first step toward healthcare transformation. It is, let's just say, for incumbent health systems and payers...