Relentless Health Value

This episode would not be happening, to be frank, if Cora Opsahl hadn't asked me what my plans were for episode 500. A few weeks ago, we were in the lobby bar at the legendary Hotel Chelsea—Sid Vicious, Patti Smith, you know the place. In our defense, the Hotel Chelsea is, in fact, probably about the halfway point between our two places of business. They are known for their martinis. The show just started, and it's already off the rails. For a full transcript of this episode, click here. If you enjoy this podcast, be sure to subscribe to the free weekly newsletter to be a member of the Relentless Tribe. Anyway, Cora said (casually, mind you), "Whatcha you gonna do for episode 500?" I said, "Oh, I have that all figured out. I'm gonna do episode 499, and then I'm gonna do episode 501, and then I'm gonna figure out episode 500 when I have a little bit more time to think about it. Because right now I'm really, really busy at my day job." As I've said many times, I used to crastinate, then I went pro. Cora just stared at me, gathering her thoughts maybe. Finally, Cora goes in response to my do episode 499 and then do episode 501 and then do episode 500 sometime later on when I get around to it. Cora goes, "Yeah, well, that is a truly terrible idea." Then she helped me figure out a good plan. So, welcome to episode 500. This podcast is sponsored by Aventria Health Group. While I'm talking about sponsored by, and I know I covered this in the Thanksgiving Show (INBW43), but I really, really wanna thank all of the individuals who have contributed moral and/or financial support. Back to how episode 500 came to be. The plan I concocted with Cora started out as a LinkedIn post. Here's the post: "Ten years ago and 500 episodes ago, I started Relentless Health Value because the healthcare industry felt like a game of pachinko. You drop a program or a policy or a technology in. It bounces around a black box. And sometimes the result is the opposite of what you intended or what you wanted." I keenly felt my lack of not just essential knowledge but just how to actually deploy that knowledge to move the needle and secure a really patient-centric system. But then I met the Relentless Health Tribe. You lot. "You are the alchemists of this industry. You take the words [that] you hear here and turn them into [tangible programs and solutions]," things that actually work in this hot mess that we call the healthcare sector. So, look, the whole reason for Relentless Health Value continuing for all of these years is the impact that you have. Some of this impact I hear about, but a lot of it, frankly, I don't. So, this is what I asked for on that LinkedIn post. I wrote, "I want to hear from you." And then I asked everyone reading to write their own accountings for how Relentless Health Value and its guests may have influenced their own trajectories toward a better way forward. Because here's the thing, and how do I wanna say this? Not everyone listens to the show. We are not everyone's cup of tea. We meaning, for sure, me; but yeah, if you're here listening, you, too. So, don't try to claim otherwise. I'm onto you. We are not only worried about patients/members, but we are also a bunch of deeply knowledgeable wonks who understand—because we need to—how the pipes have been laid and how the dollars flow through them. Because we get that you cannot actually manage to do the right thing by patients and members a lot of times, unless you have a handle on how this deeply opaque and often wildly counterintuitive world actually works that functions, in many ways, the opposite of what the press release says or the first three pages of the contract, as the case may be. So, I'm proud of you, and I'm proud that you are listening because if I added up the number of lives that you lot serve—like when you make decisions, how many are impacted by your choices—it's, I don't know, if I had to add it all up, I'd say back of envelope over 80 million people...

Hello, all you and the Relentless Health Tribe trying to figure out how to do right by patients and the folks footing the bill. Welcome to it. This is episode 499, one episode before episode 500. So, come back next week for that one. For a full transcript of this episode, click here. If you enjoy this podcast, be sure to subscribe to the free weekly newsletter to be a member of the Relentless Tribe. All right, so today, let's talk about the inches that are all around us. Let's find some. Musculoskeletal spend, otherwise known as MSK spend, for any given plan sponsor adds up to the tune of something like 20% or 30% of total plan spending, depending on the member demographic. MSK rolls in at $16 PMPM, I just saw, according to a report Keith Passwater sent me a couple of weeks ago. It's the third most costly spend apparently overall. And it's easy to see why, right? On any given day, odds are good any given plan member is gonna do something that, in hindsight, was fairly obviously a bad idea and wind up getting hurt in some low-acuity way. For example, I remember that one time I twisted my ankle on a curb getting outta my car. Given the right space, enough time, and concentration, I can do the worst parking job you've ever seen in your life and manage to twist my ankle in the process. But I digress. Here's the point. MSK spend adds up really fast. Add to that something like 50% of spine surgeries are said to be unnecessary. The same thing goes true from injuries like twisted ankles, for example, that would have healed themselves without an ER visit, without any intervention aside from ice, rest, and elevate. Because it turns out that something like 80% of those twisted-ankle, banged-up-the-back types of MSK injuries are actually low acuity, and a huge percentage of those will heal by themselves. On that point, let me bring in some context here, some late-breaking news. I was reading Dana Prommel's newsletter. She wrote, and I'm reading this, she wrote, "The 2026 National Healthcare Expenditure data reports are out, and it is another sobering reflection of our current system. Personal healthcare spending has surged by over 8%, and our healthcare spend as a share of the GDP has followed that same aggressive trajectory." Then Dana writes, "The most troubling takeaway from the 2026 report is the lack of a 'health dividend.' Despite [this] 8% increase in spending, we aren't seeing a corresponding 8% increase in longevity, wellness, or chronic disease management. People aren't getting significantly healthier; they are just getting more 'care.' And that 'care' isn't always good care, or the right care, or care by the right type of clinician, at the right time, in the right setting." Is that not the perfect segue or what? Because this is what we're talking about on the show today in regard to, again, MSK care—care that can wind up costing millions of dollars across plan members, and it might be unnecessary because, again, the twisted ankle or the pain in the lower back would have healed itself without any care, without an ER visit. But if an ER visit was had, that patient probably is gonna wind up with a bunch of imaging. Probably is gonna wind up with a referral to a surgeon. And now there's a surgery scheduled, and the patient has been off work for however long all that took. There's a lot of direct and indirect costs that may or may not add up to any given health dividend or health span or whatever you wanna call it—better quality of life. Why does all this happen? How does it happen? One reason is what Dr. Jay Kimmel calls the white space of MSK care. This is where a patient does a truly breathtaking job parking the car, twists her ankle, starts to swell up, and now a decision has to be made: Go to the ER. Go to urgent care. Go home. Or what if it's a parent making this choice for a kid? In the olden days, maybe that patient would've called up his or her longtime family doctor and asked what to do, and maybe if...

This episode is part of the "Inches Are All Around Us" series because … yeah, you'll see why fast enough. So, last week or two weeks ago, if you listened to that episode about clearinghouses with Zack Kanter (EP497), you may or may not recall. And if you didn't listen to that episode, no worries. Just go back and soak it in when you have a sec. For a full transcript of this episode, click here. If you enjoy this podcast, be sure to subscribe to the free weekly newsletter to be a member of the Relentless Tribe. But in that episode about clearinghouses, I said something about how self-insured employers are bringing a knife to a gunfight if they do not have real programmatic, integrated payment integrity programs. Because an arms race is afoot whether or not the self-insured employer or other plan sponsors recognize they're in one. The arms race, by the way, is with revenue cycle management (RCM). Here's a quotable quote that my guest today, Mark Noel, says in the conversation that follows. Spoiler alert, I suppose, but around the 27-minute mark or something he says (and some light editing by me), but he says: It's an arms race. It's a tug-of-war. It's a zero-sum game. Because you have the RCM folks on the front trying to maximize revenue, and you have the self-insured employers and plan sponsors on the back end trying to pay as little as they need to. And so, it is imperative that the payment integrity vendor is keeping their policies up-to-date as of the minute because these things change all the time, and the rev cycle management side is gonna be up-to-date. So, right … on one side you have RCM, the RCM industry—a $140 billion behemoth, by the way, that is already larger than the U.S. auto industry and growing five times faster. These RCM vendors are using programmatic clearinghouses as discussed two weeks ago. Plus, they're ever more sophisticated with automatic tools to maximize every cent of revenue they can squeeze out of a claim. That is their job. On the other side sits the self-insured employer, often relying on less sophisticated processes and/or maybe even vendors who are effectively phoning it in. Because they have an incentive to not do a great job here because … right: perverse incentives. Who is surprised? No one is surprised. Listen to the show with Justin Leader (EP433) on the mystery of the weekly claims wire. So, prepayment integrity is what I talk about today with Mark Noel, my aforementioned guest today. Mark is from ClaimInsight, who I do need to thank, by the way. I need to thank ClaimInsight for donating some financial support to help Relentless Health Value here cover expenses. But here's gonna be the three prepayment integrity revelations that Mark Noel brings up in the conversation that follows. Revelation 1: The small-claim gold mine, I'm gonna call it. We often obsess over the—for good reason, don't get me wrong—but we obsess over the million-dollar babies or the cancer case, right? These high-cost claimants. But 80% of claims volume is actually small claims, right? Not 80% of the spend but 80% of the volume. Overpaying or double billing on thousands of, like, $200 claims adds up to millions of dollars in wasteful inches very quickly. Stan Schwartz, MD, talked about this on an earlier episode (EP486) from a little bit of a different angle, but same result applies. Revelation 2: The "conflict of interest" trap. It is a fundamental business mistake to hire the same company to do the work as you do to check the work. Asking a TPA (third-party administrator) or an ASO (administrative services only) to report on their own errors is like asking for a tax penalty audit from the same person who filed your return, right? It is just an inherent conflict of interest. It's almost not fair to either party. Just … yeah. So, that was Revelation 2. Revelation 3: The perverse incentives of many things, but one of them is shared savings that we talk about today. Many carrier contracts allow them to...

This episode is part of the "Inches Are All Around Us" series looking for all the little pockets—inches, if you will—that comprise the greater than $1 trillion in healthcare waste in this country annually. For a full transcript of this episode, click here. If you enjoy this podcast, be sure to subscribe to the free weekly newsletter to be a member of the Relentless Tribe. Many of these inches, if we hack them out, will actually improve patient care because these inches are just like the friction that's in the middle. To this end, I started thinking about FQHCs (Federally Qualified Health Centers), which are (these FQHCs in this context, if you think about it) kind of a great laboratory for scrappy and amazing case studies about finding and cutting out waste with some serious fiscal discipline. The thing with FQHCs and why they are great places to I spy inches of waste is really because if an FQHC has a budget shortfall, they cannot solve it by cost shifting to commercial patients, commercial members, commercial plans. They have no commercial patients. Also, they have a patient population that many would consider challenging, and they cannot restrict access. They gotta make do with what they have. They must have actually true fiscal discipline. They either figure out how to be efficient, or their patient population does not get care. But what tipped me over the edge to revisit this episode from 2021 with Gary Campbell—who is the CEO of an FQHC, by the way—I picked the show to revisit because of my conversation with Nikki King, DHA, that I had earlier this year (EP470). Nikki and I caught up, and she is now the CEO of an FQHC in Indiana. I had interviewed Nikki, by the way, about rural health a few years ago (EP338). So, go back and listen to that if anything I say today you find intriguing for other reasons. Tribe, this is interesting to think about what I'm about to tell you. Really. I've been thinking about it for six months. I wanna start out here recapping my aforementioned catch-up conversation with Nikki King as the lead-in to my conversation with Gary Campbell to follow. And to be specific here, Gary Campbell is the CEO of an FQHC in Virginia called Johnson Health Center; and Nikki King is CEO at Alliance Health Centers in Indiana. Let me tell you one thing that Nikki King did. There are many things that she did, but here's one that she told me about. Nikki realized after talking and listening to their patients that one of the biggest barriers to getting care at her FQHC for patients was no transportation. Also, as most FQHCs, they were short on funds. So, doing things like free Ubers or something like that was not an option. So, you know what Nikki did? She thought about where her patients are. For example, most referrals to their addiction treatment services came from the courthouse—a judge remanding, if that's the right word, someone to treatment. So, two birds with one stone style, Nikki marched over to the courthouse facilities person and asked if they had any open office space at the courthouse, you know, work from home and all of that. Maybe there were some open offices. Well, the courthouse did. They had some open offices. So, now rent-free or almost rent-free, I don't, I'm not sure, when a judge says to somebody, "Go get addiction treatment," that judge can also point down the hall and the patient can just walk over. Nikki did the same thing, setting up a clinic in a day care center. She set up a clinic in a homeless shelter and right by a big basketball court. You compare and contrast this, I don't know, "just get it done" approach to all of the times that you hear about "some cash-strapped entity" who decides the best thing to do immediately is new construction. Pay to build brick and mortar and then in perpetuity, of course, pay all the costs and the snow removal and the security and the utilities and repair for that new construction. And they could be an FQHC building new buildings—one of...

Okay. This show today is part of our Relentless Health Value "The Inches Are All Around Us" series. This Inches Talk is a metaphor for finding all those little places where there is healthcare waste as a first step in an effort to excise all these little pockets of waste. For a full transcript of this episode, click here. If you enjoy this podcast, be sure to subscribe to the free weekly newsletter to be a member of the Relentless Tribe. Shane Cerone said this phrase during episode 492, and I loved it because there are inches all around us for sure. And the thing with all these inches that we're gonna talk about today and last week and next week and the week after that, yeah, these are inches that actually you could cut them. And there are millions and billions of dollars, and you actually improve patient care. You improve clinical team experience. Also, you're cutting out friction and making it easier to do the right thing to care for patients. These are no-brainer kinds of stuff if your North Star is better and more affordable patient care, but they are also somebody else's bread and butter in a "one person's cost is another person's revenue" kind of way. So, yeah … what makes perfect common sense might not be as easy as it might look on paper, as we all know so well. So, last week we dug into all of the inches of expensive friction that develop when stakeholders interact—like, a clinical organization and a payer and a plan sponsor, self-insured employer. They try to get paid or pay. They try to direct contract because what will be found fast enough is that the data is not the data is not the data, as Mark Newman talked about last week (EP496); and a dollar is not a dollar is not a dollar. Again, you'll find this out fast enough. All of you know when you talk to entities up and down the patient journey or across the life of a claim, otherwise known as a healthcare transaction. It's mayhem to get a claim paid often enough. Each stakeholder comes in with their own priorities and views and accounting methods and various rollups. I like how Stephanie Hartline put it. She wrote, "Healthcare … moves through many hands without a rail that preserves truth along the way. Attribution breaks, and truth gets reassembled later. The difference isn't capability—it's infrastructure. Line-item billing ≠ line-item settlement." Or I also like how Chris Erwin put it. He wrote, "When the blueprint isn't standardized, you aren't scaling. You're just compounding chaos." And yeah, then all of a sudden when there's no through line, there's no rail that connects all the data to the data to the data, or all the dollars to the dollars to the dollars. Suddenly 30% of any given healthcare transaction goes to trying to straighten it all back out again—to reassemble it, as Stephanie said. It's like unleashing 100 chaos monkeys and then having to pay to recapture them all. Listen to the show with David Scheinker, PhD (EP363) from last year about "Hey, how about we all just use the same template and avoid a lot of this." Or read Zeke Emanuel's book about how the USA should potentially consider copying the Netherlands model because they have private insurance. But they cut admin costs 75% or something like that. Oh, right … through standardization. Jesse Hendon summarized this the other day. He wrote, "Providers don't need armies of coders to fight 50 different insurance rule books [when you have some standardization here]." I say all this to say after recording the episode with Mark Newman from last week, I have become intently fascinated by what goes on in this non-standardized or otherwise friction points between stakeholders. There are a lot of inches in this gray area land of confusion. This show today digs into one of them, which is what does it take to process a claim? Just technically. What are the pipes involved to submit a claim and, again, get paid for it, which is a healthcare transaction—just simply the technology moving the...

I'm gonna do a little series here called "The Inches Are All Around Us," and in this series, at least to start, all of the inches I'm gonna mention are full-on administrative waste—waste that is particularly egregious because it has nothing to do with patient care. That's why when Shane Cerone said, "The inches are all around us" in episode 492 about hospitals and hospital prices, I really perked up. Because by fixing this friction, this administrative waste, we can actually improve patient care and reduce costs simultaneously. For a full transcript of this episode, click here. If you enjoy this podcast, be sure to subscribe to the free weekly newsletter to be a member of the Relentless Tribe. Along these same lines, I have also heard Zack Cooper, PhD, talk about the 1% steps to healthcare reform project, where he's like, look, find 10 or 30 or whatever 1% problems, and you'll probably transform healthcare faster than if you're trying to find a 10% or 30% solution. So, same idea. And finding these inches, these 1 percents, even in and of themselves, it's big dollars when it comes to how much the U.S. spends on healthcare, which is, by the way, projected to reach $5.6 trillion in 2025, according to NHE (National Health Expenditure) projections from federal actuaries. So, I decided to go on a bit of a quest for these inches—you know, get a bead on where they may be nestled for anyone looking on behalf of their plan or their country or their state maybe. To this end, also recall or be aware of the episode with David Scheinker, PhD (EP363). But David Scheinker in that episode gets into how much every industry pays something like 2% to administer a transaction. But in healthcare, the provider pays something like 14%, and the payer pays another 14% to submit and get paid for a claim, which is healthcare for a transaction. Don't get me wrong, it's the plan sponsors such as self-insured employers, members, and USA taxpayers who are ultimately paying for those two 14 percents. So that 28% of full-on administrative costs—most of which, we could agree, could go away and probably be better for patients, not worse—this, too, is coming out of the pockets of the ultimate purchasers of healthcare. Those costs are getting passed along. I say all this to say, to kick off this "the inches are all around us" exploration, I wanted to dig in a little more specifically into what goes on during these aforementioned transactions (ie, what this life of a claim kind of, like, looks like on the ground). I wanted to start here because, yeah, we haven't done this before; and this exploration is gonna continue into next week because we're gonna dip heavy into clearinghouses with Zack Kanter and what they do all day. And then after that, I'm talking payment integrity programs. I'm talking prepayment review programs with Mark Noel, because you know what? Employers don't wanna be bringing a knife to a gunfight. And I realized in the course of these conversations that any self-insured plan sponsor that is not doing, for real, payment integrity programs, for real, prepayment review, post-payment review. I'm getting ahead of myself, but when you listen to the show next week with Zack Kanter, you will so totally see what I mean. Today, as I mentioned earlier, I am speaking with Mark Newman, who is the CEO and founder of Nomi Health. Nomi aims to simplify the act of buying and paying for healthcare for self-insured employers. Look 'em up if that sounds intriguing. I also do need to thank Nomi Health for so generously offering to donate to RHV to cover the expenses of producing this episode. So, thank you so much to Nomi Health. Okay, lastly here, just to set the basic framework for this conversation that follows, Mark gets into two main revelations, reasons that kind of sit behind all a large part of the waste and friction in healthcare transactions. Again, otherwise known as a claim getting paid. And these two reasons are data isn't data isn't...

What I thought could be a good idea to experiment with here at the end of the year or the beginning of the year is to dissect shows from 2025 and distill out the major themes that have come up repeatedly and in different contexts throughout the year. Our big five takeaways, maybe, is another way to put it. For a full transcript of this episode, click here. If you enjoy this podcast, be sure to subscribe to the free weekly newsletter to be a member of the Relentless Tribe. Last week, we covered takeaway Themes 1 through 3; and today we're gonna cover 4 and 5. Themes 4 and 5, by the way, are a lack of transparency and data access, which allows for wild overspending and undermines fiduciary duty. So that's Theme 4. Theme 5 is this: the need to shift purchasing from discounts/volume to value. Here's another apparent theme that we won't cover today, but I'm gonna ask you to think about it as I have. This theme comes from a one-star review that someone took the time to pen on Spotify the other day, and this is the review. Headline: "The Rich Get Richer." And here's the review: "An echo chamber for CEOs and other out of touch executives that care about money and no care or making healthcare a sustainable career choice for providers." I left in the typos just to avoid misinterpreting them, but I'm throwing this in here into the ring for context. If your average "provider"—which is interesting, just right outta the gate that they labeled themselves a "provider," given how many dislike that term and feel it is a term assigned by out-of-touch execs for the purposes of undervaluing clinical education—so, question mark … who actually wrote this? But if any given clinician is so far out of the loop that they do not understand the topics that we talk about on Relentless Health Value and also the impact a CEO having the experience and the integrity to do the right thing by patients or members, how much that trickles up or down to doing the right thing by "providers," then, yeah … that's a big deal in and of itself. Interested in your perspectives. This episode is sponsored by Payerset and Aventria Health Group. Payerset is a price transparency company with a mission to create fair and equitable healthcare for everyone. Love that. Payerset empowers healthcare organizations, employers, and patients with the most complete set of healthcare price transparency data. They benchmark every negotiated rate and claim and deliver the insights needed for smarter contract negotiations and a more transparent healthcare system. So, now let's cover the remaining two themes. So, yeah … that's your subliminal message to potentially sign up for the email newsletter should you wish to have all of this and more in your inbox on a weekly basis. And, by the way, the fact that we manage one email a week is a gold star for us, so certainly don't worry about spam. You and me both do not have time for that extravagance. Enough runway. Let's get to it. Theme 4: Lack of transparency and data access allows for wild overspending and undermines fiduciary duty. A continuing lack of transparency regarding pricing, costs, quality, and vendor compensation prevents accountability. It enables conflicts of interest. It enables, as Mick Connors, MD (EP495) and I talked about with Sarah Emond, it enables us to not pay for value or not understand what value is in a really tangible way, which is a problem in and of itself. Is this getting better? Yeah, and when I say is it getting better, I mean, is there more transparency now regarding pricing and costs and vendor compensation? For sure. Listen to the show with Elizabeth Mitchell (EP491) about the PBGH (Purchaser Business Group on Health) data demonstration project, but we have your status quo TPAs (third-party administrators), PBMs (pharmacy benefit managers), and brokers who, often enough and as their standard course of doing business, will still withhold essential claims data, creating these data hostage...

So, this is new. What I thought could be a good idea to experiment with here is instead of bringing up, I was gonna say, new concepts, then I thought better of it because there's nothing new in this world. But as I reflect on 2025, what occurs to me, there have been certain concepts, topics that have come up over and over again. But when they come up in the different episodes, we inspect them from maybe a particular point of view. What made me really curious to do, though, is to start at the theme level and kind of take it from the top in that direction. For a full transcript of this episode, click here. If you enjoy this podcast, be sure to subscribe to the free weekly newsletter to be a member of the Relentless Tribe. So, I reviewed all of our episodes this year (a little bit of help from AI, I will admit) and pulled out the top five themes that seem to have come up the most this year. And what I hope to do right now is to go through at the theme level what we've talked about. I wanted to do this for myself, to be frank, just to kind of put a capstone on the year. Then I thought, you know, maybe this will be helpful for you as well. Payerset is a price transparency company with a mission to create fair and equitable healthcare for everyone. Love that. Payerset empowers healthcare organizations, employers, and patients with the most complete set of healthcare price transparency data. They benchmark every negotiated rate and claim and deliver the insights needed for smarter contract negotiations and a more transparent healthcare system. This episode is sponsored by Payerset and Aventria Health Group. And let's get to it, shall we? Here's Theme 1: the critical need for trusted relationships and simplicity. Wow, has this come up a lot this year. Just the idea that trust is the foundational element required to achieve desired clinical and financial outcomes. And the problem is that a lack of trust is pervasive across the system. I'm gonna kind of separate the trust topic into two categories. One is the trust that's required between a clinical care team and the patient. And Kenny Cole, MD (EP473) talks about this in this clip. Dr. Kenny Cole: It is not the patient's job to comply with what we tell them to do. It is our job to earn their trust and then go on a journey with them where we help them to accomplish what matters most to them. It's not about them complying or adhering to what we tell them to do. It's about how effective are we at communicating and building that trust and building that rapport and then, in essence, leading them on a journey where we co-produce a desired health outcome, preferentially one that matters most to the patient themselves, so that we're appealing to their intrinsic source of motivation. Stacey: But then on the other side of the house, we also have the trusted relationships that really are necessary between any ultimate purchaser, like a self-insured employer or a union, and their partners, such as brokers or TPAs (third-party administrators) or PBMs (pharmacy benefit managers). And this is what Ann Lewandowski (EP476) talks about in this clip, and when she says he, she's referring to something that Matt Ohrt said. Ann Lewandowski: The thing that I love that he says is have a trusted partnership. The challenge is, many people think their partnership is based on trust; and they're not verifying. I think that's really where, you know, we need to have this trust and verify or practice defensive plan sponsorship so that everybody is really safe. And you do actually have that transparency that does lead to trust. Stacey: If I think about how often trust came up, I did a whole show that highlights trust as a gigantic requirement for clinical and financial success. We've got the show (EP460) with Rushika Fernandopulle, MD, the founder of Iora, who really digs into the need for trusted relational, not transactional, technology and models that are really built on proactive team-based...

Marilyn Bartlett is the real deal. I saw Marilyn get a lifetime achievement award last year at RosettaFest from Dave Chase, and then I actually had the pleasure of getting up on the stage with her and heard that round of applause. But it takes guts to push for fiscal discipline and put patients over profits. So, thank you so much to Marilyn for showing us how to get started fixing healthcare and for creating really true health value. For a full transcript of this episode, click here. If you enjoy this podcast, be sure to subscribe to the free weekly newsletter to be a member of the Relentless Tribe. And that's why I'm encoring the show from last year. It's a great one. It's inspiring to revisit. Plus, as just one more reason for this encore, I saw a post from Katy Talento on LinkedIn the other day; and it was about health system pricing transparency. But Katy referenced the NASHP (National Academy for State Health Policy) pricing tool, which is under Marilyn's leadership; and the NASHP tool can be used as a starting point for hospital negotiations. We've had tons of shows about direct contracting, so this is really relevant. But I wanted to mention that version 5 of the NASHP tool will be out January 2026, so make a note to check it out. And with that, here is my conversation with Marilyn Bartlett. Prepare to be inspired. Yeah, I made a meme for the show with Marilyn Bartlett. My very first meme ever. 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. Let's start from the beginning here. But you'll have to listen to the interview that follows for the end. And most of Marilyn's really sage advice and words of inspiration for any of you, for all of us, trying really hard to fix healthcare and, any day of the week, taking two steps forward and/or five steps back. It's what Mike Tyson was talking about when he said, "Everybody has a plan until [you] get punched in the face." And yeah, I'd say pretty confidently that everyone in the Relentless Health Value tribe trying to fix healthcare has been there at some point or another. So, here's where I begin the conversation with Marilyn Bartlett today: One day in 2014 or 2015, Marilyn was minding her own business as a CFO at a regional TPA (third-party administrator) firm about ready to retire when the state of Montana reached out. They asked if she would consider being the plan administrator for the state employee health plan, which was, turned out, headed for bankruptcy. Marilyn took the job, and she took the state health plan from $9 million in the hole—they were in debt $9 million—to $112 million to the good. Well, meanwhile, plan members got better benefits. Think about that: $9 million in the hole to $112 million in the good. In fact, the plan had so much money in 2018 when Marilyn left that the state took some of it to pay for other things in the budget. This is truly mind blowing. I mean, get a CPA with their eye on the ball, and this is the difference that is possible to be made in a state health plan. It also just needs to be said that this same state plan, the one...

Relentless Health Value tribe, in this conversation that follows with Dr. Mick Connors, I had a barnstormer of a revelation—one I have never heard anyone talk about before … like, ever. It's a major fundamental bottom line, though, about the U.S. healthcare system—an insight that, once you see it, you kind of can't unsee it. For a full transcript of this episode, click here. If you enjoy this podcast, be sure to subscribe to the free weekly newsletter to be a member of the Relentless Tribe. And don't get me wrong, why this revelation is true, why it is, in fact, the case will shock no one. But yeah, we'll get to that after I drag out the suspense just a little bit longer. Okay … so, we, the Relentless Health Value tribe, are committed to fixing healthcare and putting patients over profits. We want to find a way forward to manage a $4.9 trillion sector such that we raise the value of services delivered—meaning reduce or at least hold costs static while the outcomes or the health gains or whatever you wanna call what the patient gets from the spend is realized. The typical formula is outcomes divided by cost equals value. Okay … so, let's think about how we measure cost or what we know about cost. And then let's think about how we measure outcomes or what we know about outcomes. And I'm picturing Willy Wonka right now, the Gene Wilder version, when he says, "So much time, so little to see. Oh, wait a minute. Strike that. Reverse it." Here's the deal: In American healthcare, we currently measure costs at a macro aggregate level. Most of the time, no one knows what it costs to deliver any given individual service. There is no or little effort at unit cost accounting. Steve Schutzer, MD, talked about this in an episode (EP294) a few years ago. So, that's half of this revelation and undeniably a problem, one of which many of you are probably fully aware of already but just right. Like, if you are running any other business and you encounter, like, any of the sharks from Shark Tank and you cannot tell them the unit cost accounting—like, you don't know what your cost of goods are—the financial discipline buzzer is gonna be going off like a fire alarm. But again, I could probably fit around my kitchen table—and I'm exaggerating for dramatic effect, of course, but I might not be far off—like, I could fit around my kitchen table the number of folks who probably could tell me with any degree of fidelity what the cost of service and cost of goods are for spine surgery or pick any other procedure. But if we can't, we essentially have no financial discipline on the cost side because if it's unclear what the unit cost of anything is, that is a requirement for fiscal discipline. So, therefore, you can't have it if you don't have one of the biggest rate criticals. All right, so now let's flip over to the quality side. We track quality, and sometimes we even use the term patient outcomes in this context, but we track it to the tenth of a percentage point using extremely specific, narrow (for example, HEDIS) measures like A1C or BP control. But on this side of the house, what do patients actually want? They want whole-person health. They want better community health, better population health. But at these rollups (whole-person health, better community health, better population health), these things are measured by very few, at least with teeth. Kenny Cole, MD, talked about this actually in the episode (EP431) with him. Health gains arise when all of the risk factors are reduced in tandem, not just one of them. And along those lines, if you listen to patients complain about the health system, once they move on from the cost of their latest doctor visit, you will next hear a long story about how some catastrophe is afoot because their cardiologist won't talk to the ortho guy who said he can't do the procedure until the blood thinners are whatever, and then they can't get the Rx for their inhaler. That is not whole-person care. And...

I was out drinking martinis with Cora Opsahl, director of 32BJ Health Fund, and Cora said, "Look, most plan sponsors' biggest expense is health system spend, hospital spend." I know this is an unexpected start to an episode about pharmaceutical pricing and value featuring Sarah Emond, CEO of ICER (Institute for Clinical and Economic Review). But yeah, 50% of most plan sponsors' spend these days goes to health systems. Fifty percent! One half! For a full transcript of this episode, click here. If you enjoy this podcast, be sure to subscribe to the free weekly newsletter to be a member of the Relentless Tribe. So, if a patient who is adherent to a drug and that drug keeps that patient out of the hospital, why do I want to make a patient have excessive skin in the game to get that drug, which everybody knows at this point this "skin in the game" can cause said patient to not be adherent in many cases, cost being a very big reason patients give for not taking medications as prescribed. So then we have this not adherent patient who winds up in the hospital, via the ER often enough. The core issue here that surfaced, bottom line—and I'm not sure if this was in spite of the martinis or as a result of them—but while hospital spend is the largest health expense, high-value drugs that prevent hospitalization often face patient cost sharing and access restrictions, which leads to poor patient adherence and ultimately higher system cost potentially. So then Cora and I spent the next half hour debating when the statement is empirically true and when it's not. And you know what it all boils down to? What's the value of the drug? Do we even know what that means to start? But if it's determined that the drug is relatively high value, then the plan desperately should want to do everything possible to keep that patient on that medication, and cost sharing is a huge barrier to adherence. Today, as I said, I'm speaking with Sarah Emond, CEO over at ICER, and we get into all of this in the conversation that follows. In fact, most of the conversation that follows explores the tensions that exist in the current way that we sell and buy pharmaceutical products. I'm just gonna sum up these tensions in a list here at the top of this show. There's six of them that Sarah Emond and I discussed today by my counting, and each of these we explore in some depth. So, here's the list. Tension 1: The value of any given drug (in other words, what is the fair price for that drug considering the health gains that it delivers) versus the total cost to the plan for the total population taking that drug. GLP-1s have entered the chat. GLP-1s (by ICER's analysis, at least) are super high-value drugs that also can bankrupt plans due to the number of folks who may benefit from taking the drug. Definitely a tense tension to kick off our list here. Tension 2: The list or net price of a drug versus patient access and affordability. Again, this can be tense in an area of much misalignment. You can have a great well-priced drug with huge patient affordability and access challenges because drug net price and coinsurance amounts often have nothing to do with each other. Tension 3: Lifetime value of a drug versus a 3-, 2.5-year, whatever time horizon that many plan sponsor actuaries use in their value assessment. We discussed this today, but there's a Summer Short (SUMS7) on actuarial value horizons with Keith Passwater and JR Clark if you wanna dig in on this further. Tension 4: The tension between the societal value of a drug or even the patient's perceived value of a drug versus what an employer plan sponsor might perceive as the value. What is the formula used to determine value? What's in and what's out? So, that's a bigger conversation just beyond the time horizon for what's included in this calculation. Tension 5: Exacerbating the what's included in the value contemplation beyond just what you include in there is the tension between what is...

Not gonna give much of an introduction here because this is a short bonus level set, but I did just wanna call everyone's attention to the "arms race" created by our status quo purchasing and selling of many things, pharmaceuticals included. For a full transcript of this episode, click here. If you enjoy this podcast, be sure to subscribe to the free weekly newsletter to be a member of the Relentless Tribe. For example, raise the list price of a drug to maximize rebates, because the higher the list, the bigger the discount you can give, which then exacerbates patient affordability because coinsurance is often based on list price. But then Pharma starts offering co-pay cards, which messes up the whole PBM (pharmacy benefit manager) plan to drive patients to their highest-rebate products (ie, the most profitable products). So then maximizers and accumulators enter the chat, and prior auths ramp up because plans start having to raise premiums after enough 340B drugs with high lists and no rebates, and then there's no cost containment and raise deductibles and around and around we go. Meanwhile, is this drug fundamentally worth the list price or even the net price? Is it an effective drug? What's the right price to be paying for this drug? Should be the operative question, right? Just like what's the quality and appropriateness of any medical service? Maybe we should just quit it and just pay for value. And with that, let me introduce Sarah Emond, CEO of ICER (Institute for Clinical and Economic Review), and I will let Sarah tell the rest of the story. Also mentioned in this episode are Institute for Clinical and Economic Review (ICER); Cora Opsahl; 32 BJ Health Fund; Payerset; Aventria Health Group; Dea Belazi, PharmD, MPH; and Tom Nash. For a list of healthcare industry acronyms and terms that may be unfamiliar to you, click here. You can learn more at ICER.org and follow Sarah on LinkedIn. Sarah K. Emond, MPP, is president and chief executive officer of the Institute for Clinical and Economic Review (ICER), a leading nonprofit health policy research organization, with 25 years of experience in the business and policy of healthcare. She joined ICER in 2009 as its first chief operating officer and third employee and has worked to grow the organization's approach, scope, and impact over the years. Prior to joining ICER, Sarah spent time as a communications consultant, with six years in the corporate communications and investor relations department at a commercial-stage biopharmaceutical company and several years with a healthcare communications firm. Sarah began her healthcare career in clinical research at Beth Israel Deaconess Medical Center in Boston. A graduate of the Heller School for Social Policy and Management at Brandeis University, Sarah holds a Master of Public Policy degree with a concentration in health policy. Sarah also received a bachelor's degree in biological sciences from Smith College. Sarah speaks frequently at national conferences on the topics of prescription drug pricing policy, comparative effectiveness research, and value-based healthcare. 02:28 What is ICER? 02:47 What does the Institute for Clinical and Economic Review do? 05:09 The importance of still showing up, even when others don't understand or disagree. 06:51 EP293 ("Game Theory Gone Wild") with Dea Belazi, PharmD, MPH. 09:04 Why it's important to think about population health and how our choices impact affordability for everyone. You can learn more at ICER.org and follow Sarah on LinkedIn. @sarahkemond discusses #ICER and the status quo of #pharmaceuticaldrug #pricing on our #healthcarepodcast. #healthcare #podcast #financialhealth #patientoutcomes #primarycare #digitalhealth #healthcareleadership #healthcaretransformation #healthcareinnovation Recent past interviews: Click a guest's name for their latest RHV episode! Stacey Richter (INBW43), Olivia Ross (Take Two: EP240), John Quinn, Dr Sam Flanders and...

This episode is gonna drop on Thanksgiving, but whenever you are listening, I'd like to suggest taking this moment to be grateful. Everybody has someone to be thankful for: colleagues, our mentors, our cheerleaders, our support system, our community, our strategic alliance partners. For a full transcript of this episode, 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 will take a village to transform healthcare. Also, just to level set, you are listening to a Thanksgiving show; and the term "demand curve" is going to come up. Just locking in our wonky bona fides, which definitely says as much about you as it does about me … just saying. But yeah, it's on or about Thanksgiving. So, consider who is on your own list to thank right about now in your world. The older I get, the more I am realizing just how important it is to give thanks and be grateful. And so, this year (because just keeping it orderly), I have devised my top five baskets of thank yous to hand out Relentless Health Value style. Not sure what that means exactly. We like our top fives around here. First basket of thank yous goes to … I'd like to thank everyone in our big tent of healthcare transformation who does not succumb to the narcissism of small differences. I did a whole episode on the narcissism of small differences a year ago (INBW39), so please go back and listen to that if you are so intrigued. But in short, in every fundamental way, if I agree with somebody—like I'm 99% in agreement with another person or even 80% in agreement—then our discussion about the 1% or the 20% where we're a little misaligned can and should be respectful and in context. There's way more agreement than disagreement. I'm reminded of what Winston Churchill said one time. He said, "The only thing worse than fighting with your allies is fighting without them." So, I wanna thank everyone who retains directional alignment and remembers the conversation is about a relatively small disagreement that could be around the edges. Some of you folks do this so beautifully on LinkedIn or otherwise, and there are so many of you who are so good at engaging in really positive ways that furthers everyone's understanding. This is so important because we need collective action. We need collaboration. I heard recently someone say effective collaboration will be the next breakthrough innovation, and I could not agree more. In fact, as I'm thinking about this, I do believe I said that myself five years ago on at least one show (INBW37), which I have linked here as evidence. But it will inarguably take a village to do pretty much anything in healthcare, which is why the "It will take a village" is the third prong from my manifesto/personal charter (EP399, EP400) that I look at every single day because it's on a Post-it note taped to my wall at this point because the Post-it glue sticky stuff is long gone. So, I had to tape it. So, in sum, thank you to all of you with the self-awareness and the abundant mindset who are reflective and inclusive in ways that I truly admire and really try to emulate. Rob Marty: Hi, this is Rob Marty, and I'll be the first to admit that working in healthcare can be stressful. I have my good days, and I have days where I feel like our broken healthcare system is here to stay. On bad days, I find hope by listening to the Relentless Health podcast, and I feel as if Stacey is speaking directly to me when she reminds us we are all part of a tribe. We are not alone in our pursuit of high-quality, cost-effective, accessible, and inclusive healthcare. Stacey: And this civility and big tent and self-awareness really, really matters … to me, at least. As I've said to any number of you, right now, at this moment, I have honestly not seen in my 25-year career in healthcare more downright just—I'm gonna call it flat out—meanness in business. Downright whatever you can take, just take it if...

This OG of directly contracted high-value networks or Centers of Excellence networks came up, name dropped and everything in the episode with Elizabeth Mitchell from PBGH, the Purchaser Business Group on Health, from two weeks ago. That was episode 491. So, welcome to this deep cut episode with Olivia Ross from way back, pre-pandemic times. For a full transcript of this episode, 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 high-value network—its official name is the Employers Centers of Excellence Network, or ECEN—and it really came up in a meaningful way in that Elizabeth Mitchell episode, and it came up for two reasons. (1) Because the work in that recent PBGH data demonstration project—and again, listen to the show with Elizabeth Mitchell for more on that if you didn't already—but here's the bottom line, whether you did or you didn't. The PBGH demonstration project now gives plan sponsors like self-insured employers, with currently available transparency data and claims data, you can see the quality, price, and safety of any given service; and you can compare that price, quality, and safety with other hospitals. Having this information enables any given self-insured employer or other plan sponsor to create a high-value network or Centers of Excellence network. They can do this all by themselves. They can create a high-value network all by themselves. So, there's that, and that is a really, really big sea change. (2) ECEN was, again, as I just said, a direct contracted network. And you know what Elizabeth Mitchell said during that recent show, episode 491? She said it's now confirmed that direct contracts between employers and clinical organizations perform way better than anything that most other third parties have negotiated. I liked how Jeff Hogan summed this all up. It's a great post. But Jeff wrote, "Direct contracts have more measurable value than generic blunt instrument networks. Direct contracts serve the specific interests of the specific group. They also give unique care delivery organizations the opportunity to align their specific services with unique populations without the involvement of confiscatory middlemen." And, yeah, this is really good news for all you unconfiscatory TPAs and others out there. This is really an opportunity to prove differentiation from those who enjoy the arbitrage maybe a little too lavishly. And maybe lavishly is a really great word here, actually, because it's allegedly and apparently (as per more than one person who would certainly know) self-insured employers pay on average about 30% more in their claims wire for a service than whoever provided said service got paid. There's 30% added onto the top. And look, I am certainly not saying that, you know, administrators shouldn't be paid or anything like that. Nobody should be working for free. The only problem here is when this 30% is not being disclosed, and it's often not. Brokers are in this arbitrage mix as well, of course—the not transparent ones, I mean, plus others. I saw Andrew Tsang's graphic that showed 27 streams of payment coming out of the middle between plan sponsors paying and a clinician getting paid. Okay … so, this directly contracted ECEN movie actually does have a sad ending, just FYI. The ECEN high-value network that we talked about in the pod that follows? It was ultimately dismantled. Why was it dismantled? I don't know. It did happen right around the time that the independent and really capable TPA who was administering this whole thing and doing great member engagement also, this TPA was bought out by a larger firm. Maybe the timing was coincidental, though. One last point before I roll tape. TPA obviously stands for third-party administrator. ASO stands for administrative services only. I've been hearing more than once lately that the right way to proceed, in the future, is for employers to negotiate...

Hello, all you great people trying to figure out how to do right by patients. Welcome to it. I was and am always extremely curious if any of what we talk about over here on Relentless Health Value has, in any way, percolated over to your average employer CEO—the ones who do not listen to this show, I mean. For a full transcript of this episode, 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 is what I try to figure out during my conversation upcoming here with John Quinn from Wellnecity today, and I score some advice to boot for employers in the face of any of these revelations that they may have. That's what's gonna go down today, and this whole endeavor is a decent plan, if I do say so myself, because John Quinn chats up a lot of employer CEOs. He's certainly got a bit of a catbird seat there. So, taking it from the top, I wanted to see how clued in these employer C-suites might be to a fundamental myth, which, if employer folks don't realize it is in fact a myth, it means that a whole lot of transformational power is going nowhere fast. And this myth is the mother of all myths: the "there is a market in healthcare" myth. We've been on a tear about this for three episodes now, at least as it relates to hospitals and health systems. I'm gonna refer everybody to LinkedIn because Luke Trocchio put up a, I don't know what you call it, a reel, highlighting something that Shane Cerone said in episode 490. And then I'm gonna tell you why whatever CEOs at self-insured employers are thinking here makes all the difference in the world. But what Shane said is this, "The myth is that we have a functioning marketplace, and we don't." Shane continues, "What I mean by [there is no actual healthcare market], as somebody who's been a CEO of multiple hospitals and health systems, hospitals don't compete on price for patients. It … doesn't work that way. And so, we don't really have a normal market incentive to reduce cost or, in this case, the price of services in order to remain competitive." Now look, and this isn't rocket science, but it needs to be said out loud. The reason there is no healthcare market largely is because self-insured employers have not insisted upon there being one. Is that fair? I don't know. And whether or not it's fair is irrelevant to this point. Self-insured employers pay for healthcare for, like, 160 million Americans. They are largely the demand curve. They are the demand side of any market that exists. Because you know something that doesn't our market make? You can't ask the supply side to create demand elasticity. You can't get a seller to get a buyer to buy or not buy at some price point. That would be like a comedy skit. Except in this case, you know, patients die or go bankrupt because they can't afford care. So, it's not really all that funny. But if in this country we are depending on health system prices being constrained by a market, and then you don't have a buyer who doesn't buy when the price is higher than the buyer wants to pay or a buyer who doesn't buy unsafe stuff or low-quality goods or services, you're gonna get sky-high prices. Welcome to it right now. Also, if there's no competition, again, no market. But competition a lot of times doesn't surface if there's no point in starting up a business because there's no demand for lower prices or higher-quality care. I mean, if no one cares if you have lower prices or higher quality, then how are you gonna attract patient volume or steal market share, right? Like, unless you're really good at marketing, I guess, or have accumulated market power. I'll say this again. If our whole, the whole healthcare sector pricing structure is built on the myth that there is a market and then there's no market and employers aren't filling for whatever reason, the vital demand side role that they have to play for there to be a market, then, right … hello, 37%...

Here's something that one of my guests today, Shane Cerone, says coming up here pretty quick. Shane Cerone and Dr. Sam Flanders are my return guests. Shane says, "We created a management model for our health system that was focused on surviving at 150% of Medicare. [Normally] there's a lot of layers of inefficiency in healthcare and in our health systems. Some of them can absolutely be reduced without any significant impact [to quality]." For a full transcript of this episode, click here. If you enjoy this podcast, be sure to subscribe to the free weekly newsletter to be a member of the Relentless Tribe. So, while this show today focuses on solutions for health systems, it's inside information also that is really relevant to plan sponsors as well as others. So, here we go. You'll like this. It's actionable. Two weeks ago, just reviewing real quick here, Shane Cerone and Dr. Sam Flanders from Kada Health talked with me (EP490) about the problems that any given solution needs to solve for at any given health system. So, this solution show is, or really should be, really timely because there really should be urgency now amongst health systems to solve inefficiency problems and solve them fast. Two reasons for the need to speed: (a) The myths that enable some of these problems to proliferate are being dismantled (these myths), and more people realize that they are well and truly myths. Listen to that show from two weeks ago where we get into these myths in detail. But also (b) is per the show last week with Elizabeth Mitchell from PBGH, the Purchaser Business Group on Health. Elizabeth Mitchell talks about what the newly complete PBGH transparency demonstration project accomplished, and it's a done deal, folks. None of this is theoretical. Elizabeth Mitchell says, what this project does, this transparency demonstration project does, first of all, it tells plan sponsors how much a health service costs. Second of all, it tells the plan sponsor how much the range for that service is. So, are they paying a fair price or not? If a member goes to one facility and it's literally five times more than the facility across the street with the same quality, that is really important information for a plan sponsor trying to effectively manage their plan, reduce costs, and improve access to high-quality providers. And you know what else now becomes possible? Plan sponsors creating their own high-value networks becomes possible. Plan sponsors creating their own centers of excellence networks becomes possible. Plan sponsors who steer and tier away from low-quality but really high-priced health systems becomes possible. And it won't matter how many billboards that health system puts on the highway. The value of the service is transparent, and I'm saying all this with the intent of protecting from financial harm patients, plan sponsors. But I'm also saying this again on behalf of those individuals who work at health systems who are trying to grab a foothold to do the right thing. And further, my intent here is to actually help hospitals because there are health systems out there who have margins that are bigger than Amazon's. Their charity care at the same time comes in at 2% or 3% of their revenues, which is abysmal. And it's very weird and sad when senior leaders cry poor when they underpay clinicians and then raise prices that are harmful to the very community that they claim to serve. Maybe some of these insights will help anybody so inclined to fix that. And look, I get that now is a crappy time given Medicaid and what's up with the ACA markets. But honestly, never let a good crisis go to waste. So, maybe this is actually the perfect time to embark on some of the solutions discussed today. If I wanna open the "let's get real" drawer, though, if you want to know why many health systems will not actually do any of this that we're talking about today, listen to the shows with Suhas Gondi, MD, MBA (EP404); the show with Vivian Ho,...

Today, back on the pod, we have Elizabeth Mitchell, CEO of PBGH, the Purchaser Business Group on Health. Elizabeth Mitchell is talking about the why, as in why did PBGH embark on a big cost and quality safety transparency data demonstration project that they just finished up? They did said project, by the way, with Milliman, Embold, and it was funded by Peterson. For a full transcript of this episode, 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 episode is a little longer than usual, and I did consider breaking it into two. But the thoughts that Elizabeth Mitchell shares are so vitally intertwined and the impact of all of this is big enough that, yeah, if you don't get through this whole show in one sitting, do come back and listen to the rest of it later on. Make your own part 2. Okay, so on the show today, first of all, we start out by diving right into the why. Why do this demonstration project, and why do I call it a game changer? Well, simple, really. The second I saw the data showing the real price of any given healthcare service, along with its quality and safety scores for clinical organizations, and down to the individual NPIs (National Provider Identifiers) actually, I had eyebrows glued to my hairline. Turns out (ruining the suspense, I guess), those big-brand health systems with the flashiest billboards and sports sponsorships, not always the highest quality. This isn't speculation. It's right in the scores. There is zero correlation between price and quality. Zero. So look, this insight and ability to see prices, quality, and safety all together now done by PBGH for its large employer members—who spend, by the way, over $350 billion (that's with a "b") a year on healthcare, thus representing a very, very profitable gang of customers for many in the healthcare industry—this whole thing has big game-changing energy for these employers themselves but also game-changing ripples that extend into the businesses of other stakeholders as well. Again, let's consider a few of these. What's the game-changing impact on consultants and TPAs (third-party administrators)? I'd say this project opens up opportunities for good unconflicted consultants and indie TPAs who know their stuff inside and out. Because now employers have the wherewithal to deduce who the good consultants and TPAs are, which has been hard heretofore (check this post by Bryce Platt, PharmD). That's great news. Still speaking of the impact on TPAs and consultants—but this time ones probably not listening right now—in the middle of the episode, Elizabeth Mitchell talks about TPAs and consultants getting called into their client's corporate boardroom to explain themselves after some of the results from this demo project were released to PBGH members. Awkward. When the client knows more about the prices they're paying and the quality and safety they're getting, then they're a longtime consultant or TPA or ASO (which means administrative services only) vendor, all of whom are supposed to be the experts. It becomes real clear, real fast that discounts are irrelevant and anybody selling discounts is gonna not look so good, even if they buy everyone in the HR department box seats to see Disney on Ice, which is just another point to ponder. Speaking of getting called onto the carpet, Elizabeth Mitchell, again, my guest today, says during the early part of the conversation that follows, she says, "One of the other things that [our PBGH transparency] project demonstrated was that [for these jumbo employers] the directly contracted arrangements [the direct contracts] were higher value than anything negotiated by the TPAs." Oh, snap! Elizabeth said that right after I said that I've been hearing more and more that TPAs (ie, third-party administrators) hired by self-insured employers to administer their health plan benefits, I've heard multiple times in the past several...

Here’s a quote: “The reality is you can have razor-thin hospital margins if you are good at just spending all the money that is given to you.” Shane Cerone says this coming up and throw hot, right? Razor-thin hospital margins may be due to high costs or some problematic market condition or uncompensated care. Or razor-thin operating margins could also transpire because you’re just really inclined to spend every dollar you’re given. For a full transcript of this episode, click here. If you enjoy this podcast, be sure to subscribe to the free weekly newsletter to be a member of the Relentless Tribe. Kind of shines a new light on the nonprofit word, right? Anyway, after Shane Cerone raises his eyebrows at the razor-thin hospital margin cliché at this point, then he continues, “And I think that’s what goes on without a competitive healthcare marketplace. It’s impossible to separate those things.” Meaning is it some problem associated with providing care in a community, or is it too much money gassing up the private jet? “It’s impossible to separate [these] things and understand what’s really possible.” Yep. That’s something that one of my guests today, Shane Cerone, will say in about T minus 19 minutes or something. So, spoiler alert. Now, let me start from the beginning. What happens when there is a market, an actual market, for any good or service? Well, prices are rationalized, supply and demand curves meet at an equilibrium point, and the invisible hand knocks sellers and buyers into line. Abracadabra. We have fair prices. If I continue down memory lane to our freshman Econ 101 microeconomics class (just in case it was that 8:00 a.m. and any of us slept through it), those aforementioned supply and demand curves, for them to do their equilibrium thing, these curves require a series of transactions that “trial and error” themselves into that aforementioned equilibrium fair for buyers and sellers price. Transactions was the key word there. In other words, a market is the sum or whatever the average of its transactions, right? It’s like a group of crows is called a murder, a herd of cows. Well, a group of transactions is called a market. Now what is required for a transaction to be an actual transaction? Let’s see. Oh, here’s a start. Both the buyer and the seller must be aware of the price at the time of the transaction as one fundamental rate critical. And this is not just textbook economics that I’m talking about right now. It’s also contract law. And yeah, anyone who has spent five minutes at this rodeo, you listening, you have immediately cottoned on to the fact that this is already not going well for anyone planning to argue that there is, in fact, a healthcare market in the United States, because does anyone even know the price that they are buying or selling at for any given healthcare transaction prior to agreeing to buy or sell? Status quo carriers and TPAs (third-party administrators) have entered the chat. But if you don’t have transactions with transparent cost or quality of the goods purchased, then yeah, real tough to have competition, which is another market rate critical that is dependent on there being, for reals, transactions. Real hard to shop for quality when you don’t know what the quality is. We often talk about this topic from the standpoint of the buyer here at Relentless Health Value. Listen to the shows with Kevin Lyons (EP487, Part 1), Jonathan Baran (EP483, Part 1), Wayne Jenkins, MD (EP358). Today, though, we’re gonna talk about this from the point of view of the health system. How does a non-market affect health systems? I’m thinking now about something John Rodis, MD, MBA, talked about in episode 286 that I repeat in the show that follows. Short version: Dr. Rodis was CEO of a hospital that threw their backs into improving quality and safety, and they got zero volume, zero demands for their efforts—no increase in demand—nor were they able to negotiate higher carrier rates. So,...

Ben Schwartz, MD, MBA, wrote an article recently, and yeah, he makes a really compelling point. Dr. Schwartz wrote, “Ultimately, the most successful care models are those that create value inherently. The goal isn’t simply cost arbitrage; it’s creating a sustainable system that makes value attainable. Care delivery innovation is about more than optimizing for VC [venture capital] returns or maximizing operational efficiency.” For a full transcript of this episode, click here. If you enjoy this podcast, be sure to subscribe to the free weekly newsletter to be a member of the Relentless Tribe. That mention of value and how to achieve it for real—like, actually create a care model that delivers value inherently—is a great segue to introduce the show this week. It’s a continuation of our mission/margin theme, and this week, we’re talking about the margin part of the “no margin, no mission” cliché. So, taking this from the top, last week—and go back and listen to that show if you have not yet (and you can listen to both of these parts in no particular order; you do you)—but last week, we talked mission. That part about value and creating value inherently? The tie-in here to mission and margin could be a value equation, really. Like, mission divided by margin is how you calculate the value delivered (less carrier spread), but that’s a whole other show with Cynthia Fisher (EP457). So, let me introduce my guest this week, who was also my guest last week: Dan Greenleaf, CEO of Duly, which is a multispecialty group in Chicago. So, last week Dan and I talked mission, as I said; but today we’re talking margin, which is, again, gonna be the denominator of so many value equations. Last week in that mission show, quick review (or spoiler alert, depending on the order in which you may be listening to these shows), but last week, Dan Greenleaf broke mission, Duly’s mission, into four quadrants. The four quadrants of mission being affordability, access, consumer experience, and quality. In this conversation today, the margin conversation, Dan Greenleaf emphasizes that achieving these four quadrants reduces friction for patients and clinicians that leads to not only better care outcomes but also financial sustainability (ie, margin). Margin can therefore be a function of mission. And again, as Dr. Ben Schwartz put it, “Ultimately, the most successful care models are those that create value inherently.” So, here we go. To be noted with one big fat fluorescent highlighter marker, a big part of this mission that comes up over and over again last week, it’s about making prices reasonable and predictable and transparent for patients. Financial toxicity is a thing. Financial toxicity not only is clinical toxicity when so many people are delaying needed care. And look, I don’t often quote Marjorie Taylor Greene, but recently she was in the New York Times and was quoted as saying, “The cost of health care is killing people.” This is what we should be focusing on. I just read the other day that one-third of adults in this country are currently delaying or forgoing care due to cost. One-third! Not one-third of low income or something like that. One-third of adults in this country are delaying or forgoing care due to fear of cost. In today’s world, affordability and price transparency is part of what customer experience means—not just, like, lemon water in the waiting room. This is what struck me the most about the conversation from last week. But wait. Does affordable for patients spell trouble when it comes to the margin part of the operation? Will an affordability mission wreak havoc on margin? Is this business model doomed? Is there even a successful care model that creates value inherently that is sustainable? Such a good question, which is why I ask it to Dan Greenleaf right out of the gate. So, just to sum this all up in the conversation that follows, Dan Greenleaf gets into the challenges and the strategies involved in balancing...

This show today is a continuation of our mission/margin series because I wanted to drag into my investigation here what clinical organizations are up to, especially ones that have brought in professional capital, as they say. For a full transcript of this episode, click here. If you enjoy this podcast, be sure to subscribe to the free weekly newsletter to be a member of the Relentless Tribe. Before I kick in here, let me just remind everyone of a few themes that we have been poking in the eyeballs in the past few months over here at Relentless Health Value. First, patients cannot afford care. Listen to the show with Mark Cuban and Cora Opsahl (EP488) mentioning middle-class wage stagnation. Listen to the show with Merrill Goozner (EP388). Listen to the show with Wayne Jenkins, MD (EP358). It is a crapshoot to get medical care these days. Roll the dice and hope you don’t get a bankrupting bill at the end. There’s no transparency (or very little) for patients. No accountability or interest from many. Not all but many take no responsibility for their financial impact on their patients or members. And look, I am in no way speaking for the vast majority of doctors or nurses or pharmacists or PAs or even really good administrators or anybody else involved in clinical care. In fact, if you listen to the show with Komal Bajaj, MD (EP458) about how many clinicians do not actually trust their leadership will do right by patients or even the clinicians themselves, then yeah. This is undeniably the broad stroke of this industry we all work in. Many take no responsibility for their financial impact on their patients or members. That is the first theme. Here’s the second theme. It’s this motto: If you can take it, take as much as you can get. And throwing no shade, but let’s just get real about that. Right now, healthcare is an industry just like any other industry. And when I say industry, I mean the tax-exempt so-called nonprofits as much as anybody else. Said another way, corporate healthcare leaders, just like any other business leaders, have every incentive to see prices go up. That is just the way commerce works. Listen to the show with Jonathan Baran (EP483, Part 1), the ones with Kevin Lyons (EP487, Part 1 and Part 2). But what is different than most other commerce endeavors when it comes to healthcare, and Shane Cerone from Kada says this in an upcoming episode, he says, “We don’t have a broken healthcare market. In many parts of the country, there is no healthcare market. The market does not exist.” And thus prices can go up like rocket ships, because self-insured employers—and also public plan sponsors a lot of times, like state health plans—are, on the whole, just such unsophisticated buyers, price elasticity is, like, nonexistent. No matter how high the price, plan sponsors still contract for who’s ever in the network; and they and their members ante up and pay the price. Many good and maybe not-so-good reasons for this (not getting into them), but net net, the result is a nonmarket. Anyone who wants to debate my corporate healthcare entities or big consolidated healthcare entities act just like any other corporate entity, read the recent Substack by Preston Alexander. It’s about hospitals raising capital with bonds. Preston Alexander wrote, “The financial design of the system has turned what should be a largely altruistic service, one designed for public good and societal benefit, and forced it to act like a financial institution.” And so, with those bonds, welcome Wall Street. What do Wall Street bankers think about patient care and access and community health? Oh, they don’t think about those things at all. Municipal bond returns, baby. That’s it. Bonds are an investment where people who invest in them, returns are expected, just like shareholders who want their dividends. Preston Alexander wrote, “Most larger health systems carry billions (that was a ‘b’ back there) in bond liabilities.” It costs money to...