Relentless Health Value

Level-Funded Health Plan Risks: ERISA Contract Traps, Stop-Loss Gaps, and Surplus Fine Print. Episode 533. An employer with a fully insured plan told Stacey Richter his renewal this year was 69% — his broker negotiated it down to 50%, which she's not sure she'd classify as a victory. Level funding looks like a lifesaver in that spot, but as Frank Pennachio, author of The Silent Danger and a health...

Emergency Department High Utilizers and Real-Time Care Coordination, With Chris Klomp (Episode 532) Today we are dipping into the archives for an essential replay from 2016, one decade ago, featuring Chris Klomp back when he served as CEO of Collective Medical, and now nominated to serve as deputy secretary of the Department of Health and Human Services (HHS), a nearly $2 trillion federal health a...

Discount Illusions, Billing Errors, and Site-of-Care Markups: A Carrier Network Primer for Employers with Evan Anderson of Handl Health. Episode 531. Whatever the plan was at the very beginning, the big status quo carrier networks have evolved into what Stacey Richter calls a three-headed monster: the contractual illusion of discounts, payment integrity nobody with skin in the game is allowed to c...

The Hidden Link Between Expensive Infusions and Rising Stop-Loss Renewal Premiums. Episode 530. When an infusion claim lands on a self-insured plan's high-cost claims report, it's tempting to treat the price tag as fixed — but the exact same infusion drug can cost 10 times more depending on where a member receives it, and every expensive claim that breaches a stop-loss attachment point can push ne...

The Chain Reactions Wrecking Healthcare Affordability: Facility Fees, Stark Law, and Noncompetes. Episode 529. Why do hospital facility fees keep pace with inflation while professional fees fall behind—and how did a law meant to stop kickbacks end up fueling a stipend economy instead? Stacey Richter talks with Eric Bricker, MD, founder of AHealthcareZ and former co-founder and chief medical office...

Private Equity in Primary Care: Just Another Inflationary Business Model? What Does the Data Actually Show, With Yashaswini Singh, PhD (EP528) Private equity has been buying up primary care practices for years, promising the capital that chronically underfunded clinicians badly need. But does the money actually make care better? Yashaswini Singh, PhD, MPA, the Thomas J. and Alice M. Tisch Assistan...

How Discount Theater and Generic Compliance Ratios Quietly Overcharge Patients and Employers. Episode 526. Mark Cuban, co-founder of Mark Cuban Cost Plus Drug Company, and Cora Opsahl, managing director of Peterson Health Analytics and former director of the 32BJ Health Fund, join Stacey Richter for an outtake from their conversation last fall (EP488) on the operational mechanics of the pharmacy s...

Four Questions Plan Sponsors Should Ask Before Choosing PMPM or Fee-for-Service. Episode 525. This episode is a tangent that never made it into the final cut of Stacey Richter's original conversation with Cristin Dickerson, MD, founding partner of Green Imaging, a physician-led radiology network built on direct contracting for imaging. In episode 485, they discussed how imaging can run 6% to 11% o...

John Quinn, founder and CEO of Wellnecity, joins Stacey Richter in episode 524 for an outtake from their conversation last fall on rethinking how self-insured employers build their provider networks. Rather than treating the network as one big, undifferentiated system, Quinn argues employers should think like a manufacturing supply chain: break healthcare into defined "subassemblies," or pods of c...

Why Self-Insured Employers and Clinicians Keep Missing Each Other, With Suhas Gondi, MD. The Sleeping Giants of Healthcare: Why Employers and Clinicians Keep Missing Each Other. Episode 523. Dr. Suhas Gondi, MD, MBA, chief medical officer at Health Strategy and an attending physician at Massachusetts General Hospital, co-wrote a New England Journal of Medicine article — "A Sleeping Giant of Health...

Ask Me Anything: How Does GoodRx Actually Make Money, and Who Really Pays for the Discount? Episode 522. A listener asked Stacey Richter a deceptively simple question: how exactly does GoodRx make money? To answer it, this AMA episode revisits a 2021 conversation with Ge Bai, PhD, CPA, professor of accounting at the Johns Hopkins Carey Business School and of health policy and management at the Joh...

RCM: Why Revenue Cycle Management Is Healthcare's $200B Hot Potato, With Andrew Tsang (EP521) How Revenue Cycle Management (RCM) Became an Over $200 Billion Healthcare Hot Potato. Episode 521. Revenue cycle management (RCM) sounds like the least sexy phrase in healthcare — a back-office spreadsheet problem. It isn't. Andrew Tsang, an independent healthcare analyst and writer of the Substack Health...

Cash-Pay Generic Drugs and the PBM Spread Pricing Problem (EP520) Cash-pay generic drugs are one of the few corners of US healthcare where a real, functioning market already exists — which is why Stacey Richter argues policymakers need to tread carefully when trying to "fix" drug affordability. In this solo episode, Stacey explains why cash generic prices can run as low as $1 a prescription, then...

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...