Relentless Health Value™

Last time Cora Opsahl was on the show, Michelle Bernabe, RN, KAT, wrote a comment on LinkedIn I thought encapsulated the gist of it all so well. She wrote, “[Cora] first became a mentor/ally through Relentless Health Value episode 372. … It opened a doorway to a whole group of very relentless people.” 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. I want to start there because it’s a nice comment, but it’s also a call to action. Think about this and think about it not in the context of being a “stakeholder” and not in the context of being an organization but in the context of humans who work at these various organizations who, combined, comprise the bucket of companies that we lumped together using the old stakeholder word. All of these individuals are making choices every day, and all of these choices, they could be made with integrity and with the patient or member in mind … or not. In real life, right now, the overwhelming majority of members/patients in this country get their clinical care and the pleasure of paying for that care or drugs within the current ecosystem we have here in the USA. For any of us, or all of us who work within that traditional ecosystem, it is up to us to choose our own legacy here. It’s probably why you listen to this show in the first place, actually. There are so many RHV (Relentless Health Value) listeners who are pushing for patients against the riptide that is the profit motives of the organization that they work for. It’s hard. But yeah, it’s all about finding our people and supporting each other. Okay, so let’s get to the “between a rock and a hard place” portion of this discussion. Hospitals and ASOs (administrative services organizations)/carriers/TPAs (third-party administrators) often enter into or sometimes enter into what amounts to anticompetitive contracts with each other. Listen to episode 395 with Brennan Bilberry for the rundown on that one. But meanwhile, the CAA, the Consolidated Appropriations Act from 2021, holds employer plan sponsors accountable and responsible to ensure that plan assets are spent prudently, that costs paid are reasonable, and that there’s no conflict of interest (COI). This is the definition of what a fiduciary is supposed to do, by the way—prudent, reasonable, and no COI. Anticompetitive contracts between a carrier and a hospital are the very definition of COI. And when that COI results in higher, maybe unreasonable, prices and non-prudent spend, well, plan sponsors are put between a rock and a hard place if they stick with their existing vendors. Rosa Novo from Miami-Dade County Public Schools put this really succinctly on a panel at a 32BJ event recently. She said what amounts to, I have no choice but to actually do the right thing here, for many reasons, but one of them is I do not look good in orange. She said, my personal butt is on the line here. And furthermore, who do class action lawsuits make look bad when their company or CEO or CFO are personally sued over conflicted benefits? See the Wells Fargo lawsuit, J&J lawsuit, etc. It sucks that employers or plan sponsors get put into this pickle by their own vendors. And that’s what we’re talking about today. This is a conversation that starts out talking about rates (ie, prices), edges into rights (ie, plan sponsor rights), and ends up all about power. And by the way, if you’re a plan sponsor, especially in New York City, maybe doing the right thing here means hatching a plan to steer and tier in your benefit design, figuring out how to, for reals, help support the efforts of 32BJ to advantage pretty much every patient near and far. The pushback I often hear to doing something like this often involves the perception that plan members are too rich to care about reasonable prices, prudent plan spending, and COI. And yeah, to state the obvious, these same people are also...

Right out of the gate here, I wanted to thank Reimagine Care for sponsoring this episode. It’s kind of a breath of fresh air, honestly, to have someone reach out not only with an interesting pitch for a show but also with an offer to help out financially. 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. Pulling off a show like this one is not cheap, and my Aventria business partner Dave Dierk and I are happy to fund the vast majority of it. But yeah, breath of fresh air, and thanks much to the team over at Reimagine Care for their sponsorship. My one disclaimer is that I have not personally vetted the solution, but there is a white paper available where you will also find some insights from Reimagine Care’s work with Memorial Hermann Health System. So, today, Relentless Health Value listeners, we are gonna hear about doing at-home cancer care, otherwise known as integrative cancer care, otherwise known as side effect management. This is the same topic, by the way, that I ranted about being so important in episode 442. In that last episode 442, Andreas Mang from Blackstone was talking about how the most common reason for readmissions is nausea after chemotherapy. I mean, think about that. Avoidable with a capital A, expensive for everybody, and horrible for an already very, very ill person/patient. For the extent of the problem, again, please go back and listen to episode 442. But today, we’re talking about how do you think about operationalizing the “hey, let’s actually make sure cancer patients are proactively managed after they leave the four walls of the clinic.” Interestingly, helping patients get their questions answered and not show up needing emergency care or abandoning their treatment also gets high marks with nurses and doctors, which makes sense. Who wants to show up in clinic every morning dealing with a patient portal full of messages and questions, and too many patients hooked up to IVs in the ER? I don’t think the feedback of clinician teams, in other words, is insignificant, because we need to protect our clinical teams so they have the bandwidth to protect their patients. Dan Nardi, my guest today, is CEO over at Reimagine Care. Earlier, he headed up operations at Carrum Health, which I’m sure provided some great perspective. Oh, and one last point: At the present time, Reimagine Care’s clients are mostly health systems who white label this service. Also mentioned in this episode are Reimagine Care; Dave Dierk; Memorial Hermann Health System; Andreas Mang; Ethan Basch, MD; and Tom Nash. You can learn more at Reimagine Care and by following Dan on LinkedIn. Dan Nardi is the CEO of Reimagine Care, the nation’s leading provider of on-demand cancer care. With over 24 years of experience in the digital health space, Dan has a proven track record of leadership and rapid growth. Before joining Reimagine Care, he was the chief operating officer at Carrum Health, where he oversaw operations, care delivery, and growth in value-based care. Dan also played a key role in scaling Livongo from 13 employees to its IPO (initial public offering) as vice president of operations. His expertise in building high-performing teams and turning ambitious visions into reality is well recognized. Dan is an active board member and advisor for several nonprofits and industry organizations. He holds a bachelor’s degree in mathematics and a master’s in computer science from the University of Vermont. Dan lives in Boulder, Colorado. 03:38 Why is it really important to keep track of oncology patients and their side effects? 04:27 Why is cancer treatment such a complex care journey? 05:57 Are there outcome and financial issues that compound when an oncology patient is left to navigate their care journey on their own? 08:53 What is difficult in navigating cancer treatment care pathways, and what does...

Before we kick in to the show today, I just want to make two points. Here’s the first point. Together, we can do it. No one said transforming healthcare and elevating patients over profits would be easy. And it is not. It’s really, really hard. I just want to say thanks for all that you have accomplished, Relentless Health Value (RHV) tribe members. These are the things that matter to, really, our entire country, friends, family, patients, members, and in so many ways is really worth 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. Second point I want to make is to thank everybody who has left a tip in our tip jar. Some people have even left recurring donations, which, wow, my faith in humanity is restored when I see my people offering their financial support this way. I feel this way because (a) I don’t usually ask for financial support on the pod, even though it’s something that is certainly on my mind a lot, and (b) those who offer financial support, at least at this time, don’t get anything other than knowing that their help helps this podcast continue, which, again, just warms my heart. The show today is a companion, I’m gonna say, to episode 446, also with Dr. Spencer Dorn. In the first show, we didn’t talk about the impact of EHR (electronic health record) systems; and in a similar vein today, we’re not gonna talk about the impact of artificial intelligence. I’m phrasing this in this kind of odd way because that earlier conversation with Dr. Dorn was about Kranzberg’s First Law of Technology. And this one is, too, where Melvin Kranzberg says, “Don’t ascribe any given technology a label of good, bad, or even neutral.” Point being, let’s not sit around blaming or crediting a technology for downstream consequences. After all, I mean, if we’re thinking about just EHR instances, there’s EHR instances where it takes 60 clicks for a doctor to order a patient Tylenol—60 clicks! Then, same EHR system installed in a different hospital? It can take 2 clicks. Those excess 58 clicks aren’t because of the technology itself. They’re because the technology was configured poorly by humans involved in configuring the technology. And if that technology then results in burnout or moral injury or someone insisting on measuring 58 quality measures in the most labor-intensive way possible, that’s a function of how that tool is used or configured, not anything inherent in that technology itself. So, yeah … watch where those fingers are pointing. And all of this is equally relevant to artificial intelligence. As Dr. Dorn says, there’s no intrinsic property of the technology—any technology—that determines the outcome. It’s how we use it, how we implement it, how we put it into daily practice that really ultimately is the arbiter of what happens and how it impacts lives. I’d also just add even if the tech itself has some glitches or hallucinates, someone decided to use it in the current form it’s in. So … yeah. So, the first takeaway from this short show focused on artificial intelligence is gonna be the same, really, as it was in episode 446 about EHRs. Do not ascribe any given technology a label of, as I said, good, bad, or even neutral. That is, as I just said, Kranzberg’s First Law of Technology; and it applies here, too. Second major takeaway—and again, this is the same as in that earlier show about EHRs, but today we’re talking about AI—if you’re thinking about the ultimate impact of the people and the processes that have some technology in their midst (technology, again, such as AI, artificial intelligence), the ultimate impact will not be a black-and-white binary. We talk about some of these nuanced not binaries in the 10 minutes that follow, but for more, I’ve put some links below for some newsletters et cetera to check out. One last thing before we get into the show today. Speaking of AI, I asked...

Yeah, I made a meme for the show with Marilyn Bartlett. My very first meme ever. In this meme, I picture that Olympic silver medalist shooter from Turkey who showed up in a T-shirt and his hand in his pocket versus the others with all their fancy equipment that, turns out, may or may not be necessary, regardless of who might swear up and down that complexity requires even more complexity and plenty of expensive gear to shoot straight. Point being, it’s amazing what a dedicated CPA with a spreadsheet and their eye on the target can accomplish in the real world when they just do their thing and follow the dollar. 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 with that, Marilyn Bartlett has entered the chat. Marilyn Bartlett isn’t called the “Queen of Healthcare” for no good reason, and nobody is joking when they say this. She was probably the first person (or one of the first, at a minimum) to truly identify the amount of money getting sucked out of the wallets of taxpayers and employers and plan members and into the pockets of the healthcare and insurance and consulting industries. She is a through and through numbers person but also deeply cares. She is truly a senior stateswoman in our field. 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 that was going bankrupt, clearly had seen over $100 million of taxpayer money exit stage left and wind up in the bank account of their vendors. Now might be a good time to mention something that Chris Deacon wrote about: the Federal Employees Health Benefits Program. This is a $55 billion program, once again funded by taxpayers. As per an OIG (Office of the Inspector General) audit, there are no written policies or procedures over approval and payment of funds to the carriers via ACH (Automated Clearing House). Wait, what? This is just one example, along with a whole lot of other things that kind of make you go, “Hmmm … can a CPA with a spreadsheet please get in there and do your thing?” In the conversation that follows, I ask Marilyn to tell me what she did in roughly three short years to do her thing and save the state of Montana over $100 million while improving benefits of the state workers. And she tells me, short version, she created a why—that’s step one. Step two, she looked at her spreadsheets and financial analyses and...

So, I had a chance to read Dr. Marty Makary’s new book, which is called Blind Spots; and here’s why I wanted to get him to come back on Relentless Health Value and talk to you, people of the healthcare industry. It’s because of something that he said on page 127 and which I’ve been mulling over for probably years, actually. 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’s this idea of what is appropriate care and how good are we at ensuring that patients/members get said appropriate care. Lots of people are of the same minds because appropriate care has come up in the show with Ben Schwartz, MD, MBA (EP434); John Lee, MD (EP438); Spencer Dorn, MD, MPH, MHA (EP446); Tom Lee, MD (EP445). And if you want a blast from a couple of years past, the show with Bob Matthews (EP315) and, wow, I could go on … Will Shrank, MD (EP413) talking about the amount of waste from so-called inappropriate care. I mean, an estimated 21% of all medical care is potentially unnecessary. And unnecessary is, of course, one category of things that are not appropriate. This is according to a national survey of physicians: 25% of diagnostic tests, 22% of all medications, and 11% of all procedures are unnecessary/inappropriate. This is billions of wasted dollars doing stuff that shouldn’t be done, and it’s not appropriate care. But think about this: How many visions for how to fix healthcare and how to reduce waste depend upon a broad-stroke assumption that we will materially ensure that patients are getting best-practice (ie, appropriate) care? That we cut down on over-medicalization and surgeries on the back end and add appropriate preventative stuff and optimal medical therapy to the front end? Okay … great. Now let’s head out into the real world, which is what the conversation is about today with Dr. Marty Makary, this intersection between knowing the best science available and getting a critical mass of patients, getting care informed by this best science available. Because in the real world, getting patients appropriate care, getting members appropriate care could be a challenge for the following three reasons that Dr. Makary sums up in the conversation that follows. 1. Medical dogma and groupthink can lead to incorrect health recommendations that are slow to change, even in the face of new scientific evidence. There’s this cognitive dissonance. I mean, think about the whole fear of peanut allergies and, therefore, avoiding peanuts thing actually resulted in a lot of peanut allergies. There’s the C-section rates, HRTs (hormone replacement therapies), fat-free diets with margarine. Lots of examples of science learning new stuff, but the standard of care is well behind. But speaking of medical dogma, to not be dogmatic requires a degree of openness and humility. And openness and humility might be a hard thing for doctors, maybe in particular. It’s kind of the curse of experts to be overconfident in their expertise. But it’s also just a hard thing for humans to be open and have some humility. I mean, when habit becomes automatic, it also takes on a veneer of being correct and true. You know where I just read this, that habit becomes truth? In the writings of Blaise Pascal from 1670. Yes, I am a nerd, but also yes, to succeed in providing “appropriate care,” a doctor is fighting against human instinct that clearly goes back a ways. Also, Daniel Kahneman, of course, won a Nobel Prize proving this point of Blaise Pascal’s. So, yeah … there’s also that System 1 thinking, if that rings a bell. So, medical dogma and groupthink can make it difficult for patients to get appropriate care. 2. Delivering appropriate care is impacted not just by the clinical aspects of what’s going on but also business, legal, and financial incentives that creep in. Obviously, there’s incentive to treat sickness, not prevent it, in this country; and...

First of all, we got two really nice reviews lately. One is from Doug Geinzer. Hi, Doug! Doug wrote, “[Relentless Health Value is] a must listen. There are just a few podcasts that I listen to religiously [and] Relentless Health Value is one of those.” He goes on to say we have a knack for “finding the brightest of the bright and asking the right questions to unpack the reason healthcare is where it is and explore the real solutions of what we need to do to fix 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. Second review we got this month is from Mike33754, who kept it short and sweet. He said, “Great stuff. Thank you for your work!” Thank you for listening, Mike33754. As you may have heard already, because you are in the know and/or you read the email I sent because you (ahem) have chosen to subscribe to our weekly emails. That was a subliminal suggestion for those of you who aren’t subscribed to our weekly emails, by the way. Or maybe you’re in the know because you listened to Part 1 of this conversation with Shawn Gremminger. But no worries, because here’s the scoop: The scoop is, after some pondering, I decided to release this 340B extravaganza of a conversation with Shawn Gremminger in two parts. So, listen to one, listen to both, pick your poison. These shows aren’t particularly sequential. You are currently tuned in to Part 2, and you can, for sure, start here. Right now, we are going to talk about how 340B impacts employers and commercial plans and other plan sponsors. So, if all you want to hear about is the why—as in, Why do employers care about what amounts to a program that is or was supposed to be for low-income Americans and Medicaid?—you are in the right place. As just one example of the why should employers care if you are teetering on the edge of proceeding, did you know that if an employee or a member of a commercial plan gets a drug at a contract pharmacy participating in 340B, the employer does not get the rebate? The employer is gonna pay the list price for that med. Wait, what? Yeah, details follow because Shawn Gremminger is gonna get into this and many other reasons why employers or anyone in the commercial market (or taxpayers, really) should care about this, as some may call it, Medicaid program. The fact is, 340B is currently so gargantuan that it creates market distortions that bleed into the prices and possibly the quality of healthcare for everybody, all Americans. And that could really matter to employer or Taft-Hartley plan sponsors. If you have really zero idea of what 340B is beyond some program that was supposed to be safety-net hospitals buying drugs low and selling them high and then taking the dollars in the middle and using them to support underserved patient populations, that might actually be sufficient. You got the gist of it. But after you listen to this show, if you want to drill in a little deeper on the “what the what” and the history of 340B, head back and take in Part 1 of this episode 448. Shawn Gremminger gives the skinny on how the program morphed over the years into a $53 billion juggernaut and is credited (or blamed) for all kinds of healthcare market consolidation and many other weird and unusual consequences that make me admire some of the folks who are truly gold medal winners in the sport of financial engineering. Before we kick in to this fast-moving convo, I just want to point out a few interesting 340B posts and Tweets and articles. The first one is from Anthony DiGiorgio, DO, MHA, talking about the recent announcement by one 340B covered entity hospital to stand up a film studio. I guess it could be deemed an educational endeavor that may or may not be considered charity. But yeah … I, too, have questions. Then there is a new report out from Neal Masia, PhD, and Health Capital Group that found that state Medicaid spending...

So, after some pondering, I decided to release this conversation with Shawn Gremminger about 340B in two parts. So, listen to one, listen to both, pick your poison. Shawn Gremminger came up with three really important takeaways relative to 340B, which is a feat unto itself, considering how sprawling this conversation can be. So, if you came here for some concise and actionable takeaways, you have come to the right place. 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 first part you are listening to right now zeros in on Shawn’s first takeaway: whether or not the original intent, or the presumed original intent, of the 340B program has actually been met. Many do not realize that 340B began life as a caterpillar. It originally, actually, was conceived as a lowly bureaucratic fix. But over the past 15 years, it has gone into a chrysalis and emerged into a 500-pound gorilla that sits in the corner of a lot of rooms, actually—probably more than many people realize. All of that being said, when you’re done listening to this first part of the convo, you should be able to competently assess whether or not 340B does, in fact, adequately help underserved communities get better healthcare—because 340B is supposed to help safety-net healthcare providers stretch scarce resources. The second part of the show, which is a separate episode called Part 2, is how all of this impacts employers and commercial plans. And there’s two more takeaways there. So, if you already have the gist of how we got from the beginnings of 340B to where we are in 2024 already and all you want to hear about is why do employers care about what amounts to a low-income program or was purported to be a low-income program, feel free to zip over to the second show and cut to that chase. If you’re still with me for this Part 1—and I hope you are, because … wow, it’s a wild and tangled journey—here’s an outline of where this first part of the discussion is headed. So, for the sake of posterity and having this introduction transcribed in your inbox, here you go. Here’s the outline. First, Shawn describes how the program expanded over the years due to the rise of Medicaid enrollments and hospital consolidations, which leads to more hospitals that will qualify for 340B status. Hospitals and others that qualify, by the way, are called covered entities, or CEs. This expansion, and other goings-on (such as hospital systems linking many outpatient clinics to their 340B eligibility, and also for-profit contract pharmacies getting in on the game and exploiting weak patient definitions), all of this has contributed to widespread use, which some may consider misuse, of the 340B program, significantly altering the healthcare market. Today, 340B is the second-biggest drug buying program in the country, after Medicare Part D, to the tune of $53 billion running through it. After that, Shawn goes on to point out that there’s no statutory requirement for hospitals to reinvest 340B proceeds into charity care or community services. So, the program is supposed to allow hospitals to arbitrage dollars and put those arbitrage dollars into charity care, but yeah … there’s no mechanism to track what they’re doing with the money, resulting in a lack of transparency and accountability regarding the financial benefits gained from this program. And all of this wraps up with Shawn contending that while the original intent of the 340B program might have been well meaning, the current implementation raises serious questions about its effectiveness and fairness. So, significant reform is in order? Mentioned in this episode is Adam Fein, PhD, from the Drug Channels Institute, who has given some comments on 340B. And also a new report out from Neal Masia, PhD, and Health Capital Group. Shawn Gremminger, my guest today, is the relatively newly installed president of the...

In this Summer Short Episode of Relentlessly Seeking Value, host Stacey Richter discusses the hidden costs and inefficiencies of value-based care with Elizabeth Mitchell, President and CEO of the Purchaser Business Group on Health (PBGH). To read the full article and show notes which include mentioned links, visit the episode page. If you enjoy this podcast, be sure to subscribe to the free weekly newsletter to be a member of the Relentless Tribe. They uncover how value-based care, often touted as the ideal system, can be manipulated by middlemen to extract more money from plan sponsors without delivering real value to patients. Through a critical conversation involving examples and insights from various experts, they explore the disconnect between financial incentives and actual care quality in American healthcare. Elizabeth argues for for-real alternative payment models that are transparent to the employer plan sponsors. She wants prospective payments or bundled payments, and she wants them with warranties that are measurable. She wants members to get integrated whole-person care in a measurable way, which most health plans (ie, middlemen) either cannot or will not administer. Elizabeth says to achieve actual care that is of value, cooperation between employers, employees, and primary care providers is crucial (ie, direct contracts). She also says that this whole effort is really, really urgently needed given the affordability crisis affecting many Americans. There’s been just one article after another lately about how many billions and billions of dollars are getting siphoned off the top into the pockets of the middlemen and their shareholders. These are dollars partially paid for by employees and plan members. We have 48% of Americans with commercial insurance delaying or forgoing care due to cost. If you’re a self-insured employer and you’re hearing this, don’t be thinking it doesn’t impact you because your employees are highly compensated. As Deborah Williams wrote the other day, she wrote, “Co-pays have gotten high enough that even higher-income patients can’t afford them.” And she was referencing a study to that end. To read the full article and show notes which include mentioned links, visit the episode page. If you enjoy this podcast, be sure to subscribe to the free weekly newsletter to be a member of the Relentless Tribe. So, yeah … with that, here is your Summer Short with Elizabeth Mitchell. 10:36 What are members and providers actually asking for in terms of value-based care? 10:56 Why won’t most health plans administer alternative payment models? 12:17 “We do not have value in the US healthcare system.” 12:57 Why you can’t do effective primary care on a fee-for-service model. 13:30 Why have we fragmented care out? 14:39 “No one makes money in a fee-for-service system if people are healthy.” 17:27 “If we think it is not at a crisis point, we are kidding ourselves.”

My conversation today is with Will Shrank, MD. Dr. Shrank led the evaluation group at CMMI (Center for Medicare and Medicaid Innovation). He has spent time in the private sector, first at CVS Health and UPMC (University of Pittsburgh Medical Center) as chief medical officer of the health plan in Pittsburgh, and then as the chief medical officer for Humana. Now he is a venture partner at Andreessen Horowitz and doing some consulting for CMMI. To read the full article and show notes which include mentioned links, visit the episode page. If you enjoy this podcast, be sure to subscribe to the free weekly newsletter to be a member of the Relentless Tribe. We start out this conversation talking about waste in healthcare. In fact, Dr. Shrank was on a team who did a study about waste in the US healthcare system. (The article is, unfortunately, paywalled.) In that study, it says estimates suggest we have upwards of a trillion dollars of waste a year. This waste can be categorized into administrative and clinical failures. Dr. Shrank emphasizes the need for aligning incentives with higher quality care, paying for patient outcomes, and highlights the potential rising power of PCPs. The discussion covers the progress made towards value-based care, the challenges faced by the current fee-for-service model, and the future landscape of primary care and healthcare delivery. In sum, we have a waste problem in this country. Aligning incentives might be one way to curb that waste. 06:54 Can we cut healthcare waste while improving patient care? 07:33 What does “healthcare waste” consist of? 07:46 What are the six categories of “healthcare waste”? 10:23 EP363 with David Scheinker, PhD. 10:37 How much money does Dr. Shrank estimate is wasted each year in healthcare? 13:09 Where is that healthcare waste going, and why does it happen? 20:07 Uncaring by Robert Pearl, MD. 21:18 “We’ve built a backbone of extraordinary waste on a fee-for-service chassis.” 22:16 EP409 with Larry Bauer, MSW, MEd. 24:24 EP359 with Dan O’Neill. 26:02 Dr. Shrank’s warning to providers out there. 30:03 Summer Shorts 2 with Scott Conard, MD. 31:41 Why there might be a generational shift among younger providers looking to work with different models.

This encore episode is with Amy Scanlan, MD. It was, in fact, one of our most popular episodes of the past year. It is still just as relevant today in a slightly different way. It’s interesting how things which were said maybe a year ago have shades of meaning which become evident as time goes on. So, I liked this show a lot in the second listen with the advantage of time passing. To read the show notes with mentioned links and a transcript, head over to our site. If you enjoy this podcast, be sure to subscribe to the free weekly newsletter to be a member of the Relentless Tribe. Complicating fact of current life, it’s becoming increasingly obvious that in order to stand up a practice that can take advantage of value-based care payments—payments where primary care docs mainly at this time can get paid more and likely more fairly to care for patients well—you need a lot of infrastructure. You need data, you need tech, you need a team. Translation: You need money, maybe a lot of money, to invest in all of this. These are the external realities that hit anyone trying to do right by patients from every direction. But on the other hand (or maybe different fingers on the same hand), as Dr. Amy Scanlan says in this healthcare podcast, physicians are the backbone of this system. Dr. Scanlan talks in the interview today about the opportunity, and maybe the responsibility, that physicians have here for patients; but also the Eric Reinhart article comes up again about rampant physician moral injury (unpaywalled link with my compliments). Right now might be a great time to read something from Denver Sallee, MD. He wrote to me, and he wrote, “Like many physicians, I did not have much understanding of the business side of medicine, as I mistakenly thought as long as I helped take great care of patients that I was doing my job. More recently, it became apparent to me that by ceding the management of medicine to nonclinical administrators and to companies interested primarily in value extraction for the benefit of shareholders that I needed more education in order to truly help patients.” Today as aforementioned, I’m talking with Amy Scanlan, MD, who is chief medical officer of the clinically integrated network (CIN) that is the joint venture between Intermountain Health and UCHealth in Colorado. We talk about what it’s like to be in the kind of messy middle of transformation to integrate care in a clinically integrated network, trying to figure out how to help physician practices and the CIN itself navigate the external environment in a way that empowers different kinds of practices at different points in their transformation journey that empowers physicians to be in charge, and considering clinical and financial outcomes (ie, the business of healthcare). Dr. Scanlan brings up four main factors to consider when plotting strategy from here to there. Listen to the episode or read the show notes to learn about the four factors. 06:35 How is Dr. Scanlan thinking about the transformation process and the shift to value? 09:16 “It is really trying to think about, how do we help practices get there?” 11:48 “The hard part is the in-between spaces.” 13:21 EP407 with Vivek Garg, MD, MBA. 14:12 “Team-based care done badly is really just a series of handoffs.” 15:52 “We have to get to that point where the culture of collaboration is more pervasive.” 19:58 “How do we as healthcare providers step in and solve this problem?” 20:06 Why do providers have a responsibility to step in and try to fix the healthcare system? 20:22 Article (unpaywalled) by Eric Reinhart, MD, PhD. 21:51 Why do physicians need to be accountable for the cost of care as well as outcomes? 23:38 Why does physician burnout give Dr. Scanlan hope? 24:26 What is the solution to changing fee-for-service incentives? 25:43 What are some of the challenges facing changing incentives? 27:16 Why is data so important? 28:54 EP393 with David Muhlestein, PhD, JD. 30:13 “It’s...

In Episode 447, Stacey Richter interviews Ashleigh Gunter, president of Translucent Healthcare Consulting, to discuss the indispensable role of change management in healthcare transformation. They emphasize that creating an effective change strategy involves great leadership, a clear case for change, influential change champions, over-communication, and continuous measurement and celebration of successes. The conversation highlights the importance of understanding and aligning with the 'why' that drives healthcare professionals and the necessity of a multi-faceted approach beyond just implementing technological solutions like EHR systems. Visit the Episode Page to read the show notes with mentioned links. If you enjoy this podcast, be sure to subscribe to the free weekly newsletter to be a member of the Relentless Tribe. I saw a bar chart by Phil Ballentine the other day in Nikhil Krishnan’s Out-Of-Pocket newsletter that showed, in the USA, in 2024, there are 18,982 live instances of Epic. Each one of those 18,982 live instances are all different: different workflows, separate data, different ways to do the same thing. So, even if having an “Epic strategy” actually was a complete master plan to change behavior in clinic, healthcare has no “nationwide, everywhere it’s all the same, so figure out your thing once and you’re good to go” thing going on. There are 18,982 differences of opinion out there, but here’s the actual and big kahuna real reason why I’m leery. An Epic strategy is not equivalent to a change management strategy. That’s the real point that I want to make. It’s necessary, very necessary even, but not sufficient. You want to make the way as easy as possible once the “why” goes down and the case for change is made, but even if it’s one click and not your usual 14 to 60 clicks, there’s no “why” there. There’s no automatic case for change that slithers out of anybody’s API like a spontaneous miracle. I said this last week, too. Lots of things are really pretty easy. Lots of things are in Epic. Yet no one uses them. I mean, let’s talk about actually reading most of the best-practice alerts that pop up. How about consistent use of SmartSets in the majority of those 18,982 instances? Anyway, I couldn’t be more pleased to have learned a thing or two from Ashleigh Gunter about change management and how to do this whole thing right. This conversation happened actually a while ago. It’s re-edited for 2024—call it a supercut—specifically considering change management at hospitals or physician organizations. Ashleigh Gunther is president of Translucent Healthcare Consulting. She is also an expert in change management and how to align employees and staff so that an organization can move forward together. One quick spoiler before we proceed: According to Ashleigh, there’s five steps to effective change management that will ensure success: 1. Having great leadership 2. Creating a case for change. This includes the whole “why” thing. 3. Finding champions—engaging people who have to change so that they can contribute and be supportive 4. Overcommunicating 5. Measuring how things are going and also celebrating small triumphs If you continue to be interested in this topic, do go back and listen to the show with Karen Root (EP381) on shepherding innovation through a large company. Before we kick in to the show today, let me remind you, if you haven’t done so and you appreciate the show, could I ask you to please leave a rating and review on Apple Podcasts or Spotify? We haven’t had any of them this month, and it is important for the show to get found and for me and the team to stay motivated over here. While you're there, be sure to Follow the show. 09:22 How does change management go wrong in healthcare? 09:56 “Communication [of change] in and of itself isn’t change management.” 10:53 How does change management work on the provider organization side? 15:33 “You want to ensure you are educating the operational...

In Episode 446, "Hey, Let's Not Talk About EHRs," host Stacey Richter engages Dr. Spencer Dorn, vice chair and professor of medicine at the University of North Carolina, in a comprehensive discussion about the implications of healthcare technology, specifically electronic health records (EHRs). Visit the Episode Page to read the show notes with mentioned links. If you enjoy this podcast, be sure to subscribe to the free weekly newsletter to be a member of the Relentless Tribe. The conversation emphasizes the necessity of understanding technology as a tool that neither possesses inherent goodness nor badness but delivers results based on its implementation and usage. They discuss the paradoxical nature of technology in healthcare, highlighting how EHR systems can simultaneously empower and overwhelm healthcare practitioners. Dr. Dorn and Stacey delve into the effects of digital technology on patient-doctor and clinician-clinician relationships, stressing the importance of proper deployment, operational excellence, and continuous improvement to optimize healthcare outcomes. In essence, the episode sheds light on the necessity of viewing technology as a means to an end rather than an end in itself. 06:15 Breaking down Kranzberg’s Laws of Technology. 08:16 How do EHRs go right? 12:49 “EHRs empower us with information, yet they also overwhelm us with information.” 16:00 How do EHRs bring healthcare workers closer together? 19:35 The Digital Doctor by Robert Wachter. 21:33 “The whole point of healthcare is to help people live healthier, happier lives.” 22:41 How the same EHR deployed in different places can be more or less efficient. 25:51 Why the problem is not necessarily the EHR but actually operational. 28:51 How technology has also changed our expectations on timing and value.

I wanted to talk with Dr. Lee because so many RHV (Relentless Health Value) listeners are trying to figure out how to sustain primary care as a stand-alone entity when the most obvious and most common way to make enough money in primary care is to drive and maximize the dollars from downstream volume of high-priced service lines, which, if you think about it, undermines the entire point of primary care. To read the full article, show notes as well as the links mentioned visit our episode page. While there, consider signing up for our free weekly newsletter. In Episode 445 of Relentless Health Value, Stacey Richter interviews Dr. Tom Lee, founder of One Medical and Galileo, about the sustainability of standalone primary care practices in 2024. Dr. Lee also was a founder at Epocrates They discuss the paradox of primary care, the economic challenges of running an independent practice, and the importance of enlightened leadership with a value-focused mindset. Dr. Lee emphasizes innovative service operations, cutting hidden waste, and balancing human-centered care with efficient processes. The conversation explores various facets of primary care, including access, longitudinal patient care, and the role of technology. Tune in to understand how primary care can thrive amidst economic and systemic challenges. 07:02 What is the paradox of primary care? 09:19 Why is it hard to run an independent primary care practice? 10:01 What are the barriers to running an independent primary care practice? 10:41 Can you have fee for service and value? 12:25 “Value is more about a mindset.” 13:22 What hidden waste is there in a primary care practice? 15:11 What do you need to have a value-focused mindset? 17:14 Why does access precede quality? 18:20 Why have retail clinics failed in being longitudinal primary care destinations? 20:29 What is a longitudinal primary care destination and why does it matter? 23:48 What are the nuances of a service business that make them challenging for managers? 24:35 How do you find the balance between fee for service and value? 31:17 EP438 with John Lee, MD. 32:14 How can you invest in quality without a value-based contract? 34:19 How do you address the trade-off between fee-for-service finances and investing in value-based care? 35:36 Where is the “productive middle”? 36:27 Dr. Tom Lee’s message to payers. 39:55 Dr. Tom Lee’s message for policymakers.

In this encore episode of 'Relentlessly Seeking Value,' host Stacey Richter revisits a critically important conversation with ERISA attorney Paul Holmes about the complexities and hidden pitfalls in Pharmacy Benefit Manager (PBM) contracts. Aimed at CFOs and employer plan sponsors, Holmes highlights how poorly reviewed PBM contracts can lead to companies paying 30-40% over market for pharmacy benefits, discusses the potential legal exposures under the Consolidated Appropriations Act (CAA), and suggests the essential need for independent reviews. Holmes also delves into issues with Employee Benefit Consultants (EBCs) taking indirect compensation from PBMs and offers actionable advice for employers on how to mitigate these risks. To read the full article, show notes as well as the links mentioned visit our episode page. While there, consider signing up for our free weekly newsletter. 07:41 What are Paul’s usual observations when a PBM contract crosses his desk? 08:34 “If you just sign … one of their model contracts …, you’re probably gonna pay 30% to 40% above market on your drug spend.” 12:11 What is a PBM lawyer? And why is it important to find an ERISA PBM lawyer? 17:12 EP379 with AJ Loiacono. 17:40 Who is on the hook for the cost of the PBM contracts? 21:05 What’s the problem with most ERISA lawyers today? 22:56 Lawsuit about PBM contract. 27:43 What’s Paul’s advice for benefits consultants? 31:40 How much might a plan sponsor be paying their consultant versus what a consultant might be making from a PBM?

In Episode 444 of Relentless Health Value, Stacey Richter speaks with healthcare consultant Ann Kempski about two state healthcare laws with unintended consequences: the Certificate of Need (CON) and the Certificate of Public Advantage (COPA) laws. They delve into the original intentions behind these laws, the ways in which they have often failed, and their impact on the competitive landscape. The discussion also explores how CON laws have led to increased costs and market consolidation, while COPA laws have allowed potentially monopolistic mergers under state oversight. The episode sheds light on complex regulatory terrain and highlights the importance of vigilant oversight and diverse stakeholder involvement. To read the full article with the links mentioned during the epsiode and a full transcript, visit the episode page. While on the site, please consider signing up for the free weekly newsletter. 00:00 Introduction 02:08 Understanding Certificate of Need (CON) Laws 02:57 Problems with CON Laws 04:02 Exploring Certificate of Public Advantage (COPA) Laws 05:25 Guest Introduction: Ann Kempski 06:05 In Memoriam: Suzanne Delbanco 06:20 Ann remembers Suzanne Delbanco. 06:55 EP224 with Suzanne Delbanco. 07:40 What are state Certificate of Need laws? 08:44 Why are states getting rid of these CON laws? 13:26 Why CON laws are created. 15:43 EP437 with Brian Klepper, PhD. 16:09 What are the conflicts of interest and problems that arise when CON laws are created? 20:55 What happens when states get rid of these CON laws? 24:10 How are Certificate of Public Advantage laws different from CON laws? 27:58 Why does the research show that COPAs don’t usually accomplish their goals? 31:34 What encouraging current events are happening in the realm of COPA laws? 32:08 Gloria Sachdev, PharmD, of Employers’ Forum of Indiana.

To read the full show notes with links mentioned, be sure to visit our episode page and consider signing up for our free weekly newsletter. Episode 443 of Relentless Health Value pays tribute to the late Marshall Allen, an investigative journalist dedicated to exposing injustices within the American healthcare system. Hosted by Stacey Richter, the episode features Dave Chase, founder of Health Rosetta, who shares memories and insights into Marshall's tireless work in investigative reporting. The episode highlights Marshall's impact on healthcare legislation, his significant contributions to ProPublica, and his book 'Never Pay the First Bill,' which empowers patients and employers to fight back against corrupt billing practices. The episode also includes an earlier interview with Marshall, focusing on his perspective as an investigative reporter, the exploitation within the healthcare system, and the importance of patients and employers demanding transparency and fairness. The episode encourages listeners to continue Marshall's legacy by subscribing to the Marshall Health Academy and purchasing access for employees. 09:28 What’s the point of view that Marshall is coming from with his investigative reporting? 09:57 “How does this affect the people who are paying for it and the people who are undergoing the care?” 10:49 “There’s a lot of good people working within this very messed up system.” 11:03 Why are patients considered outsiders in the healthcare system? 11:45 “What’s happened in healthcare is that the stakeholders treat each other more as the customer.” 13:45 What is upcoding? 17:18 “These are schemes that have been created within the industry to increase revenue.” 17:46 “This system is not set up for the benefit of the patient.” 18:13 “On the financial side, the industry is actually oppressing the American people.” 19:14 “We have been expected to pay whatever aggregate sum is thrown at us.” 20:21 Why have patients been so passive toward this crooked healthcare system so far? 22:05 What’s the difference between making a profit and profiteering? 29:45 What are the first-order and second-order consequences of what’s happening in health care right now, and which of these consequences will actually drive change? 30:45 “When you tell the truth about what’s going on … they become so ashamed … that they change their behavior.” 32:00 “The patient … is not their most important customer.” 32:50 “The sleeping giant is the employers.”

In Episode 442 of 'Relentless Health Value,' host Stacey Richter shares an intriguing outtake from a previous episode featuring Andreas Mang, senior managing director at Blackstone, discussing the critical issue of cost management in oncology side effect treatment. The conversation delves into the inefficiencies and patient harms caused by inadequate side effect management, particularly dehydration due to chemotherapy, and the resulting financial burdens on employers, taxpayers, and patients. Stacey explores the importance of a value-based mindset in drug purchasing, integrating oncology care, and the potential financial and health benefits of better side effect management. She highlights various expert opinions and studies supporting these points, encouraging listeners to reconsider their approach to healthcare cost structures and patient care protocols. If you enjoy this podcast, be sure to subscribe to the free weekly newsletter to be a member of the Relentless Tribe. 01:12 Andreas Mang on oncology medication side effect management. 03:12 Mark Lewis, MD’s Tweet. 03:39 Celena Latham’s response. 04:22 How integrative oncology can save money and what it looks like. 04:47 EP157 with Ethan Basch, MD. 06:20 Why PBMs saving money doesn’t necessarily mean savings for employers and payers. 07:36 EP435 with Dan Mendelson. 08:20 EP372 with Cora Opsahl. 08:40 EP331 with Al Lewis. 09:50 Stacey’s second rumination. 10:19 Why having a value mindset when purchasing is a thing. 10:42 Stacey’s third rumination. 12:03 EP370 with Erik Davis and Autumn Yongchu. 13:07 Why FFS does not pay or pay adequately for side effect management. 14:31 Stacey’s final rumination. 17:08 Summarizing Stacey’s four ruminations on this topic.

To read the full article with show notes, mentioned links and a full transcript, visit relentlesshealthvalue.com In this episode, Abby Burns from Radio Advisory interviews Stacey Richter, host of the Relentless Health Value podcast, during the Raising the Bar Value Summit. They discuss the complexities of defining and creating value in healthcare, focusing on the roles of various stakeholders including patients, providers, and payers. Stacey shares insights on the challenges and tensions in the healthcare system, such as the fragmentation of care, financial toxicity, and the cultural norms that inhibit progress. The conversation also highlights practical examples and potential strategies to drive value and sustain positive changes within the industry. 03:33 Stacey’s journey and mission. 04:16 The story of Scott Conard, MD (EP391). 09:28 Why it’s important not just to drive change but to sustain it. 12:23 Heart Failure: A Case Study in Value. 14:13 EP438 with John Lee, MD. 15:07 Why patient positive value often fails instead of succeeds. 18:07 How financial toxicity has become clinical toxicity in healthcare. 19:44 How cultural norms have evolved into healthcare challenges. 23:38 The story of Mike Tuggy, MD, in Washington. 25:13 Looking at the four tensions in measuring value as continuums. 25:37 Why timeline is important in creative value in healthcare. 27:52 Finding Allies by Michael Leavitt. 28:34 What are the four ways to measure value in healthcare? 29:27 How do payers and providers collaborate to align on value metrics? 31:26 Why will proven versus experimental treatments become more important in the next few years? 34:54 Stacey’s manifesto (EP400) and values for personal integrity in healthcare. 38:55 Stacey’s parting advice. For more information, go to Radio Advisory or Aventria Health Group.

In Episode 440 of 'Relentless Health Value,' host Stacey Richter engages with David Muhlestein to explore the optimal size for a medical practice, concluding that 10 to 20 physicians supported by a capable team provide the best balance of economies of scale and community integration. The conversation transitions into the challenges large healthcare systems face, particularly the Diversification Discount. This diversification often impedes patient care and operational efficiency by misaligning values with business practices. The episode delves into the paradox of optimizing primary care while still supporting specialty care, reflecting on how organizational values impact healthcare outcomes. Muhlestein suggests implementing business units or decentralized models to realign with patient care values and efficiencies. To read the full article and show notes with links mentioned as well as a full transcript, click here. 08:12 From a business and patient/better outcomes standpoint, what does an optimal provider practice look like? 11:48 EP412 with Robert Pearl, MD. 13:06 Why isn’t the current landscape what David considers optimal? 14:53 What leads to the “crisis of autonomy”? 15:13 How do medical practices get to the phase of delegation? 17:39 EP438 with John Lee, MD. 18:55 EP437 with Brian Klepper, PhD. 20:53 EP432 with Kate Wolin, ScD. 20:55 EP421 with Jodilyn Owen. 23:48 Medicare Meet-Up podcast with Mai Pham, MD. 24:45 What metrics should boards of directors also be held accountable for? 28:48 Why is an efficiency-focused business not necessarily the best at managing population care? 31:13 What is the “diversification discount”? 32:49 Pivot podcast with Kara Swisher and Scott Galloway, MBA. 35:53 What can primary care doctors do to optimize their practices? 36:48 Why do we need to shift the mindset from “bigger” and “more”?

In Episode 439 of 'Relentlessly Seeking Value,' host Stacey Richter discusses the convoluted issues surrounding generic drug pricing with pharmacy consultant Luke Slindee. To read the full article and show notes with links mentioned as well as a full transcript, click here. They delve into the ways traditional Pharmacy Benefit Managers (PBMs) exploit the system to make immense profits, often leading patients to pay more even with insurance. The conversation explores various solutions, such as the removal of "Usual and Customary Prices" from PBM contracts, the advantages of bypassing insurance, and giving patients direct payment tools like health savings accounts. Luke Slindee, with his extensive background in pharmacy and consulting, provides valuable insights into rebalancing the generic drug market to benefit patients, pharmacies, and plan sponsors alike. Additionally, the broader implications of these dysfunctional systems on pharmacy operations and staff conditions are discussed. Love the show? Please consider signing up for our weekly newsletter. We'll send you an article covering the latest episode with show notes, mentioned links and a transcribed intro. Join the RHV Tribe. 08:12 Where do cash prices fall when pharmacies have contracts with PBMs? 08:39 What is a usual and customary price? 12:14 How is the usual and customary price affected by PBMs? 16:49 Should pharmacies be allowed to have two sets of cash prices? 17:14 Where does GoodRx fit into this because of the pharmacy/PBM dilemma? 19:06 What’s happening with Amazon and the anticompetitive contract lawsuit, and how does it relate back to pharmacy contracts with PBMs? 20:38 EP395 with Brennan Bilberry. 21:05 EP420 with Ge Bai, PhD, CPA. 23:27 Why is there a new wave of cash-only pharmacies? 24:02 EP418 with Mark Cuban and Ferrin Williams, PharmD, MBA, from Scripta. 25:41 What would allow the generic market to return to normal competitive pricing? 26:39 How does this dysfunction create a negative downstream effect?