Relentless Health Value

This episode is the very first episode that we have done that is an AMA—an Ask Me Anything—and here is our very first question. Sarah Monroe: Hi. This is Sarah Monroe in Chicago, and I'm a benefits procurement leader. And I'm curious why you think so few executives take proactive bold action in health benefits strategy given the magnitude of opportunity. 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. Stacey: Thank you, Sarah Monroe, for that question that so many probably wonder about. To help answer said question, I shanghaied the one and only Lee Lewis. And wow, is that a good choice, if I do say so myself. As just one place that Lee takes this conversation—which is also a wild spoiler alert, so earmuffs if you're opposed to such things—but coming up here, Lee tells the following gem of a C-suite anecdote, just so you know where this conversation is headed. Lee says, after an M&A (merger and acquisition), after an acquisition, they looked at the health plans; and the one employer had a $2,300 per year of less expense per employee, and the benefits were actually better. So, when they moved over the employees, they made over a quarter billion dollars of instant equity value for the acquired company that nobody had priced into the calculation. Right? Nobody had thought about this or looked into it or anything, but it was a quarter billion dollars of additional value because this one company just had managed their health benefits so much better. I don't know. That feels like the first verse of some CEO love song, right, if you ask me. But let me get organized. This conversation has three parts. The first part is what Lee calls dogmas. By the way, they are all false. You're gonna know if you're a longtime listener of the show or even a short-time listener. You're gonna know immediately that each one of these dogmas is false. But many CEOs may believe these three dogmas. And if they do, they're not gonna do anything with their health plan besides, as Lee says, stay in the herd. Right? Just like not be an outlier amongst comparable companies. In brief, those three dogmas that are all false that we talk about in the conversation that follows are: Dogma 1: Health benefits are a fixed expense. Dogma 2: Saving money hurts people. Dogma 3: Fixing healthcare is never worth the effort. It's high risk. It's high disruption. We've tried things before. They've never worked. You can definitely see how if there is a C-suite that believes any one of those three dogmas, they're not gonna do anything with their health plan anytime soon. All right … so, after we talk about the internal dogmas, Lee and I, then we talk about the potential external reasons for a lack of action by C-suites. And in brief, there are four of them. They are: 1. Circles a CEO travels in may include hanging out with health system leaders, and as I say in the show that follows, they may be drinking Kool-Aid they never realized got put in their beverage. So many shows on what C-suites at Consolidated health systems are into. Go back and listen to some of them. 2. Balance of trade: threats and promises. Balance of trade, we talk about at some length later on. So, if you don't know what that means, you're in luck. Stay tuned. 3. Personal incentives for a CEO or others offered by some of the big status quo vendors, you know, go on trips, fancy tickets, weekends at a ranch, that kind of thing. 4. CEOs may not be all that concerned about a $5,000 deductible or a higher co-pay. But a $25-an-hour employee? Yeah … a very, very different perspective. So, we go through each one of those four. And then we close out this show with Lee giving one good idea after another. Let me say he is on a roll giving advice for how, even if the CEO C-suite is extremely risk averse for a benefits team to get the show on the road, to get moving, to try new...

Look, we wonks, meaning you and me, you're listening to this, so I am on to you. But we wonks in the Relentless Tribe, we move like lightning on Relentless Health Value. We tend to cover lots of ground pretty fast. So, sometimes I like to, with great intention, sum up what's been said—really lock into the big revelations, the big points made, the through lines. 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 like to do this so that points stick in my mind and I remember them and can build on them later. I am thinking you like this, too, because actually our through line shows in the past have been pretty popular. But this, today, is not your average through line show. I am trying something new and actually playing clips of earlier episodes so that you can recall what a guest may have said exactly and specifically and also really see the ways that episodes may interlock. So, to that end, let me just get to it and tell you the four core concepts to buy or deliver the highest-value healthcare that we will cover today. Core Concept 1: Buy healthcare. And by the way, health insurance is not healthcare. Jonathan Baran talks about that, and then Cynthia Fisher, Mark Newman, and Justin Leader cover the why, which is billions of dollars. Core Concept 2: When buying said healthcare, avoid the myth of less expensive healthcare. What is the myth of less expensive healthcare? Well, there's a lot of them, actually. One myth is that low price means low quality. Wrong. Most of the time there is actually no correlation between price and quality, but sometimes less expensive is higher quality. Also, low quality can be the most expensive care irrespective of the cost. Also, the same exact healthcare service or product can cost wildly different prices. Just keep that in mind. You'll hear Elizabeth Mitchell; Sam Flanders, MD; Shane Cerone; Jerry DiMaso; Ivana Krajcinovic, PhD, talk about this, this whole idea of when buying healthcare, avoid the myth of less expensive healthcare. Core Concept 3: So, of course, at this point, direct contracting enters the building. Because direct contracting between ultimate buyers of healthcare (meaning plan sponsors like self-insured employers etc.) and the actual purveyors of healthcare (meaning clinicians) is a fairly obvious strategy if we're going to try to get high quality at a fair price. I mean, get the beginning and the end of the road together. When you do that, it not only can spotlight—and thereby help eliminate—who might be low value that's sitting in the middle of the road collecting tolls like a toll booth, but it also enables collaboration in other ways, really, between the ultimate purchasers and the ultimate deliverers of care. Because there can be conversations about integration. There can be goals and then work out issues together, right? Collaboration is the next breakthrough innovation. So, that's our Core Concept 3: Consider direct contracting or even just, you know, as a start, go talk to, if you're a self-insured employer or you're a purveyor of care, go just find somebody to have a conversation with. Go talk to each other. Just have a chat. And I might include pharmacies, actually, in that mix. It's amazing what can happen, actually, when those buying care and selling care sit in the same room. In this number three core concept, consider direct contracting, we hear again from Ivana Krajcinovic but then also from Ryan Jacobs, Adam Stavisky, and then lastly, we have a quote from Ryan Wells. Core Concept 4: When direct contracting, or otherwise purchasing healthcare, buy the highest-value healthcare. How is that for an aspirational goal? But really, what do you want a direct contract for? What do you want your partners to be accountable to deliver? And what's rolled up into all of that? What is value? What is value, right? We go there, and when I say...

So, we have a few miniseries afoot here on Relentless Health Value right now, and one of them is "The Inches That Are All Around Us"—finding the hidden fees, the hidden friction for plans and members and clinics themselves a lot of times in those inches. 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, how does transparent pricing data fit in here? Well, you can use it to find inches. They are all around us. You can see it in this data. So, we talk about self-insured employers, plan sponsors, and their perspective on this price transparency data first in the conversation that follows. And then we get into the perspective of the provider organization or the clinic. Let's take this from the top. Plan sponsors such as self-insured employers or unions can gain three very interesting and maybe underappreciated insights from this price transparency data. Not limited, of course, to these three insights, but these were the three that Jerry DiMaso talked about; and I lasered in on them with very single-minded ambition. Okay … so, here's the three insights of interest to plan sponsors. (1) Benchmarking against a plan sponsor's competitors. We often forget about this, that every self-insured employer is actually a company trying to sell something, probably with competitors. You can search for your own plan or a competitor's plan using an EIN to compare rates, specific carve-outs, and identify if there are other companies in the same industry that are receiving better pricing. Considering that paying for health benefits is often the second-biggest line item on many corporate balance sheets, I wonder how long it's going to take for some activist shareholder group to figure out that they can find evidence of avoidable overspending. Especially because of our number two insight here, which is (2) you can use this data to identify high-cost codes. Plan sponsors can pinpoint specific billing codes where they are paying way too much. And right now (maybe you are, too) but I am thinking about the examples of infusions given in the recent episode with Ivana Krajcinovic, PhD (EP501) and that Brian Cotter talks about all the time. Also Nate Walker. Plans paying a million dollars too much for some infusion. That would be a crazy thing for a corporate shareholder to figure out and bring up at some, I don't know, shareholder meeting or earnings call, right? (3) Exposing the, I'm gonna call it, "discount shell game." This data allows plan sponsors to see through stuff like gross aggregated discounts. They can verify if a TPA's, I don't know, 90% discount is actually real savings. Okay … so, what does one then do with these insights once found? Jerry DiMaso, again, my guest today in the conversation that follows, talks through these at some length; but here's the very top line. First thing a plan sponsor can do is use this information to direct TPA negotiations. Plan sponsors can get their TPA to go back to providers and negotiate better rates. I did not know that. Number two thing that a plan sponsor can do with this information: Implement service carve-outs and direct contracts. Employers can identify expensive outliers and then steer and tier and maybe direct contract with specialized providers or Centers of Excellence as a result of that knowledge. As a second bit to this, not to be underestimated, this data allows for objective calculation of savings a lot of times from, you know, direct contracts or other initiatives so that plan sponsors don't have to rely on vendors to grade their own homework, as they say. Plan sponsors can start to do their own math. And here's the last thing that we discuss in the episode that follows that a plan sponsor can do with this price data: Model alternative plan types. Right? You can analyze whether switching from a PPO to an HMO or some other alternative model would save...

Stacey Richter interviews neurosurgeon Dr. Ahilan Sivaganesan (Dr. Siva) about replacing vague healthcare "value" claims with quantified outcomes and unit-level costs, introducing his Operative Value Index (OVI). They discuss how hospitals often lack true internal episode costs and how common quality metrics miss patient-reported outcomes and appropriateness across the full care journey. Using time-driven activity-based costing (TDABC) and condition- or procedure-specific patient-reported outcomes, OVI creates a common mathematical language to compare surgeons, practices, or health systems, risk-adjust for confounders, and support steering/tiering and direct contracting for self-funded employers. Siva describes transparency via bubble charts that spur clinician behavior change without new incentives and argues this infrastructure is essential as bundled payments and risk-based arrangements expand, framing a "Yahoo vs Google" shift from fee-for-service volume to measurable value. === LINKS === 🔗 Show Notes with all mentioned links: https://cc-lnk.com/EP505 ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter: https://relentlesshealthvalue.com/join-the-relentless-tribe 🫙 Support the podcast with a small donation to the Tip Jar: https://relentlesshealthvalue.com/join-the-relentless-tribe 🎤 Listen on Apple Podcasts https://podcasts.apple.com/us/podcast/feed/id892082003?ls= 🎤 Listen on Spotify https://open.spotify.com/show/6UjgzI7bScDrWvZEk2f46b 📺 Subscribe to our YouTube channel https://www.youtube.com/@RelentlessHealthValue === CONNECT WITH THE RHV TEAM === ✭ LinkedIn https://www.linkedin.com/company/relentless-health-value/ ✭ Threads https://www.threads.net/@relentlesshealthvalue/ ✭ Bluesky https://bsky.app/profile/relentleshealth.bsky.social ✭ X https://twitter.com/relentleshealth/ 00:00 Introduction to this episode. 00:38 The goal of this episode. 01:28 What the Operative Value Index (OVI) is. 02:04 A quick episode overview. 04:23 EP434 with Benjamin Schwartz, MD, MBA. 04:44 How this episode came about. 09:24 How Dr. Siva got involved in the research around outcomes and costs. 11:51 How the value equation doesn't add up to true quality. 14:12 What measuring quality across the entire care journey means. 15:00 EP326 with Rishi Wadhera, MD, MPP. 15:08 EP295 with Rebecca Etz, PhD. 16:07 Why appropriateness is the foundation of quality. 19:08 Why practicing clinicians need to be thinking about the true costs of delivering care. 21:20 Time-driven activity-based costing (TDABC). 23:44 The two things that must be known for value-based care to succeed. 24:06 Article by Dana Prommel Strauss. 27:09 A quick summary of the conversation thus far. 30:42 The power of transparency in Dr. Siva's bubble plots. 32:39 EP449 with Marty Makary, MD, MPH. 34:05 Why these bubble plots work not just at the procedural level but at the diagnosis level, too. 36:13 EP503 with Ryan Wells; Leo Spector, MD, MBA; and Adam Stavisky. 36:21 EP501 with Ivana Krajcinovic, PhD. 36:30 EP398 with Jacob Asher, MD. 37:28 The "big blue ocean" opportunity for forward-looking providers. 38:52 Substack post by John Lee, MD. 40:37 The incredible opportunity for entities and groups that can help provide the infrastructure needed for this value index. 41:42 Essay written by Dr. Siva. 43:19 Last thoughts by Dr. Siva on TDABC and competition on value.

Why Advanced Primary Care Doesn't Scale: Conflicting Incentives, Complacency, and a 3-Step Roadmap Stacey Richter interviews Ryan Jacobs (SVP Strategy and Partnerships, Marathon Health) on why evidence-backed advanced primary care (APC)—focused on managing risk, improving outcomes, and lowering costs—still isn't widespread. They argue APC struggles to scale due to two root barriers: conflicting fiduciary duties (health systems and payers driven by volume, "heads in beds," and market-power growth, while APC keeps patients out of hospitals) and a "black box of complacency," where innovators often lose to the status quo because dominant organizations can rationally avoid investing without gaining share. Jacobs offers a three-step roadmap: perform a reality-based assessment by following the money and identifying who is financially harmed by prevention; anticipate stakeholders' math by framing value as CFOs, benefits leaders, and plan sponsors do; and proceed from strategic conclusions such as direct contracting to bypass misaligned intermediaries. === LINKS === 🔗 Show Notes with all mentioned links: https://cc-lnk.com/EP504 ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter: https://relentlesshealthvalue.com/join-the-relentless-tribe 🫙 Support the podcast with a small donation to the Tip Jar: https://relentlesshealthvalue.com/join-the-relentless-tribe 🎤 Listen on Apple Podcasts https://podcasts.apple.com/us/podcast/feed/id892082003?ls=1 🎤 Listen on Spotify https://open.spotify.com/show/6UjgzI7bScDrWvZEk2f46b 📺 Subscribe to our YouTube channel https://www.youtube.com/@RelentlessHealthValue === CONNECT WITH THE RHV TEAM === ✭ LinkedIn https://www.linkedin.com/company/relentless-health-value/ ✭ Threads https://www.threads.net/@relentlesshealthvalue/ ✭ Bluesky https://bsky.app/profile/relentleshealth.bsky.social ✭ X https://twitter.com/relentleshealth/ 00:00 A refresher on advanced primary care (APC). 02:36 Why APC isn't everywhere. 04:39 The problem of complacency in the healthcare system. 05:27 Ryan Jacobs' roadmap. 08:59 The pitfalls of advanced primary care. 09:58 What primary fiduciary responsibility means. 10:51 Growth on the payer side. 11:51 SUMS5 with Jacob Asher, MD. 12:36 EP483 (Part 1 and Part 2) with Jonathan Baran. 12:48 EP465 with Chris Crawford. 13:27 The reality of the healthcare system in the United States. 14:11 The flywheel created by the tension within the healthcare system. 15:25 EP391 with Scott Conard, MD. 15:51 The tension between APC's goals and fiduciary responsibility. 17:52 The black box of complacency. 19:25 EP436 with Elizabeth Mitchell. 20:05 What's driven most of the change in the advanced primary care space. 20:54 EP398 with Jacob Asher, MD. 21:01 What would happen if there was a functioning market in healthcare. 21:41 EP286 with John Rodis, MD, MBA. 21:52 Why complacency may be a rational move in healthcare. 22:41 EP438 with John Lee, MD. 23:22 A roadmap to success in advanced primary care. 23:55 Step 1: Follow the money. 24:50 Step 2: Someone's gonna do math. 25:17 What strategic thinking looks like as an employer. 28:34 Step 3: Proceed based on strategic conclusions. 30:20 How self-insured employers have created their own market. 31:07 The strategic decision for physicians wanting to create change. 32:25 A reiteration of the episode's discussion. 33:49 Better payment structures.

This inbetweenisode I wanna try something new for two reasons. One of them is that I need to check this episode off my to-do list because I am crushed for time. I'm going to be headed to Arizona tomorrow for the Collective Health Conference, which will have occurred three weeks ago by the time you listen to this. If you ever have an urge to time travel, start a podcast with a three-week production cycle. 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 yeah, the bigger reason, though, that I wanted to do this show in this way today, this inbetweenisode, is that sometimes after a show airs, after an episode airs, I get a big mailbag of responses from listeners like you—really good responses, actually, with many incredibly relevant points, adjacencies, additional examples, just a rounding out of the thought processes around any given episode or series of episodes. There's two Relentless Tribe members that I really want to spotlight in this inbetweenisode: Ken Wosczyna and then also Michelle Bernabe, RN. All right … starting out here with a LinkedIn post, written by Ken Wosczyna, and he writes, "The greatest strength of [Relentless Health Value] is moving from theory to practical transformation. Insight is common. Execution is rare. Healthcare doesn't lack frameworks or commentary. It lacks better decisions. In employer-sponsored healthcare, decisions about contracts, incentives, and pricing transparency aren't academic. They affect real dollars. They affect real people. [Relentless Health Value] episodes don't just spark ideas. They sharpen judgment. Better judgment leads to better contracts and smarter benefit design." And then Ken says, "That's why I listen. [That is] why I implement." I really appreciate this post that Ken Wosczyna wrote, because it actually was a point that I was trying to make about this judgment about this decision making. I was trying to make it during episode 500, but I realized afterwards that I didn't entirely succeed. And the unmade point I was trying to make but didn't is exactly what Ken wrote: that what we ultimately wind up doing or not doing all boils down to the quality of our decisions and how they all stack up to either align or not align with our values. Our whole healthcare system is really a massive aggregation of all of the decisions made by all of the humans. We need better decisions, just like Ken said. So, thank you so much to Ken Wosczyna for spotting this whole thing and getting it over the line with such eloquence. But while I'm on this topic, think about this—and I've said this in other shows, especially the one with Larry Bauer, MSW, MEd (SUMS8) about Knaves, Knights, and Pawns—the C-suite is certainly a bunch of offices filled with power; and they have the potential up there to influence how a company, a corporatized health system, a carrier, right, a lot of power to influence the kind of corporate citizen that company will be. But look, what goes on in the halls is often very different from what is written on the walls—in good and bad ways, actually. But what happens in those hallways is often a choice being made by those walking them. The actual direction of any given company is determined by the millions of decisions made by those who work at the place. There was a show with Keith Passwater and JR Clark (SUMS7) a couple of years ago. These two are actuaries, and both of them were like, look, as an actuary, you can decide to put patient affordability in your algorithm, which it's not in most cases. As an actuary, you do not have to eke out the last possible percentage point. You have more power than many think to align with values. Now, don't get me wrong, we all have lifey crappy choices to make sometimes when we are navigating staying employed with aligning to our values. But often there are ways to proceed that are better than others....

Today we are digging into something I've said probably way too often: Collaboration is the next breakthrough innovation. And I'm doubling down on this because in the current healthcare landscape, two parties that actually should be talking—like burning up the phone wires talking—are sitting on opposite ends of a very long, very crowded roadway. 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. On one end of the road, you have self-insured employers, the ultimate purchasers, plan sponsors. On the other end of the road, the specialists who actually provide the care. Status quo in the middle. We got a whole lot of traffic, let's not forget. We're talking carriers. We got ASOs (administrative services only), TPAs (third-party administrators). We got large, consolidated health system organizations, also in the middle there, often with their own interests. It is no wonder one of my guests today, Leo Spector, MD, MBA, he says these two groups—the plan sponsors and the specialists—are often like two ships passing in the night. So, today we are talking about bridging that gap, bringing the two ends of the road together, putting a gang plank betwixt the ships. We have lots of metaphors. And to have this conversation about bridging this gap, I have with me today Adam Stavisky, who has managed benefits for Walmart among other massive member populations; and he now consults with innovative purchasers. We have Dr. Leo Spector, a surgeon and CEO of OrthoCarolina. And we also have Ryan Wells, who is the founder and CEO of Health Here, which is an organization that provides the digital bridge to make sure that any direct connections don't result in an inadvertent additional pile of manual paperwork and administrative waste—because the current rails of healthcare don't really support direct contracting so well. Okay … so, this is how this conversation that follows is gonna go down. First, we dig into the complications, let's call them, when the two ends of the road start to talk to each other, right? We should be educating ourselves in the topics that we know for a fact are gonna come up that we do not want to turn into a dustup. So, let's prep for these in advance. Here are the things that we know are going to rear up whenever you get specialists and plan sponsors in a room. Here's the first one. What is quality? Who delivers quality? What is appropriate care? What is care that is of value? Right? So, we spend some time on this one because we've all been there. As we were talking about this one, though, I wanna point out Adam Stavisky, he made a beautiful point when we were level setting what is the opportunity here really as far as quality and appropriateness is concerned. In other words, what is the why to even try to figure this out. This is what he said. He said, "Traditional carrier networks have a tough time in any really informed quality conversation because they're often trapped by 'disruption analyses.'" If you have any given plan sponsor who insists that every single doctor remains in network to avoid the dreaded D word (disruption), then that plan sponsor is de facto prioritizing no disruption over patient quality and even patient safety. Because you wind up with clinicians who are practicing medicine standards of deviation differently from the best practice, and they wind up in everybody's network. But look, that challenge is actually the opportunity because when you get the ultimate purchasers and those delivering the actual care sitting around a table together, this is why collaboration is the breakthrough innovation because you can put your heads together and work it out. I mean, progress might be iterative; but if you don't try, then you'll be left with the status quo—these lazy networks where quality and price in the same network is highly variable. And I'll leave it at that. Next area of...

You know, I always kind of wondered what the hackers were doing with all of the medical data that they've managed to get their mitts on over the past, I don't know, however many years. Now, I know at least one thing. If you're a hacker, you can use your stolen medical data to not actually send wildly overpriced catheters to seniors across the country but then you bill CMS (Centers for Medicare & Medicaid Services) anyway. 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. Fast-forward, CMS pays $3.5 billion in one year for all of this DME (durable medical equipment) that didn't actually get sent. If you add wound care stuff like skin substitutes into this fraudulent mix, the cost of all of this very suspicious activity adds up to 4% of the CMS budget … 4% of the budget! I was gonna say something about the inches are all around us, but in these past few shows, we've got inches that have so many zeros. Four percent of the CMS budget, by the way, is more than all of home care or something like this. So, as just one consequence for all of us, enjoy your personal and/or corporate tax dollars going to buy some Eastern European hacker a yacht or something like that. But that's not really what I wanted to talk about today in my conversation with Brian Machut. What I wanted to talk about today with Brian—who is an actuary from Alliant Health, by the way—what I wanted to do first of all is just a little level setting where mostly Brian blows my mind with just the wildly adventurous level of grift that seems fairly glaring here. But what do I know? What I wanted to mostly talk about after that, though, is how all of this impacts shared savings, potentially, if you're an ACO (accountable care organization). And then from there, why that actually has downstream impact for plan sponsors such as self-insured employers—and it does actually have a downstream impact in multiple ways. Here's a big honkin' spoiler alert: This fraud, the 4% of the budget, it can and some of it is getting passed on in the form of higher expenses for attributed patients in ACOs with shared savings—MSSP (Medicare Shared Savings Program) and REACH (Realizing Equity, Access, and Community Health)—programs. Because these ACOs who might do the most amazing job helping Medicare help patients not cost as much. And then they get walloped in the back of the head if one of these skin substitute companies gets ahold of one of their attributed patients, covers their entire body or whatever in skin substitutes that they're charging for by the centimeter, and then the cost of that attributed patient gets high, and then the ACO misses their shared savings mark. There's another implication for ACOs that has to do with trend. Bottom line, there are several different ways that the fraud can be a detriment to providers, including independent providers who are in these ACO programs, meaning they make less money than they thought they were gonna make. And look, if you're a provider on the clinical side of the house, this obviously is a problem. But it also, for sure, impacts plan sponsors in several different ways. Let me briefly outline a few, but definitely listen to the conversation for the deep dive here. First, you want PCPs (primary care providers), especially independent PCPs, and other practices to stay in business, right? Especially as a self-insured employer. We have talked about this in multiple shows (see below). Well, to do that, you gotta have some value-based care going on. It is super hard these days for a PCP, especially an independent practice, to survive on fee for service alone, let alone rejigger their practice patterns to incorporate the data and the processes to level up outcomes and the value of care delivered. Most PCPs need a variety of value-based contracts that kind of all add up to a critical mass of dollars, a critical mass...

Let us chat about today the inches all around us and also about how there is no market in healthcare all at once in this show. Today I am talking with Ivana Krajcinovic. And let me give you some examples of the inches. Two members of a plan get infusions at a hospital. And if these two members had gone down the street to get their infusions, the total cost of the two of them would have been $1 million less … $1 million less! How many inches is a million dollars? 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. Or the examples Ivana Krajcinovic talks about coming up where an independent practice was charging $135 for a chemo infusion and the hospital down the street was charging for the same exact drug, by the way—the same exact infusion—$13,560 … $135 versus $13,560! We talk about affordability in this country? Member's paying coinsurance off that 13K, by the way. And if you're doing the math at home, that is a 10,000% markup. Or if we start from the Medicare price, it was a 40,000% markup. Then there's another example that Ivana talks about where a plan member went to a hospital and got a $90,000 bill for a series of infusions that, again, down the street would have been $185—all in. Inches much? So, it's pretty clear why the show is part of "The Inches Are All Around Us" series. Why do I say this is part of the "No Market" series? Because look, functioning markets rationalize prices. That's just what they do. So, if you have two places in the exact same geography and one of them is charging 500 times or whatever the other one, you don't have a market if they're both still in business a year later. Ongoing wild price variations is a big tell that there's no market to be had. Another tell, though, is that carrier networks, who are supposed to be the demand curve here—or at least that's what their marketing says or what we are all kind of led to believe—they advertise as high-value networks, right? The fact that any given network experiences essentially no business repercussions for spending a million dollars extra of its plan sponsors' (its customers') money—because that's who's paying for this, the self-insured employer or union, at the end of the day—and the network, the carrier network doesn't lose business as a result … Right? Listen to the show from last week with Jacob Asher, MD (Take Two: EP398) about the carrier nonmarket and why this is the case. But bottom line, if anyone is waiting on a market to constrain prices for them, that is very magical thinking. Where this whole thing is gonna wind up, by the way, is with my guest today, Ivana Krajcinovic, suggesting a roadmap to make a whole lot more likely that you'll pay $135 for an infusion instead of 13 grand. For more on this, do go back and listen to the show with Keith Hartman, RPh, by the way. We teed this off a couple of years ago. That was episode 369. But in Ivana's upcoming roadmap that you're gonna hear about (just doubling down on the spoilers—if I'm gonna do something, I might as well do it well), but in that roadmap, direct contracts with indie practices will feature a starring role. I'm telling you this because if you're one of those folks that listens to like 23 minutes of any given podcast and then bails, make sure you make it to around the 30-minute mark of the show. As I have said several times already, my guest today is the incomparable Ivana Krajcinovic, the outgoing vice president of healthcare delivery at UNITE HERE HEALTH. Ivana has just retired, but she spent over three decades with her team protecting the health and the hard-earned wages of 230,000 hospitality workers. She is exactly the kind of "dangerous expert" that we love to have on the show—someone with the wisdom about how the system actually works and the articulate willingness to talk about it. Okay … so, this conversation about the inches and the...

We have been doing a little series called "The Inches Are All Around Us," digging out waste in the $5.6 trillion healthcare sector where half an inch of waste can equal billions of dollars. I'm going to right now introduce another series that is complementary but has a slightly different focus. And we will toggle kind of back and forth between these two series coming up here for a bit. 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'm gonna call this other series our "No Market" series, as in, in general, there is no healthcare market; and that is material because anyone who is relying on a market and the invisible hand or any principle of capitalism, frankly, to constrain costs or raise quality … yeah, bad strategy. Or what did Julia Roberts tell the shopkeeper ladies in Pretty Woman? How'd she put it? "Big mistake. Big. Huge." Do not rely on a market to keep vendors in line when there is no market. Whatever you accomplish, you gotta do it yourself. But the results are there for those who pick up the baton. There's just so many success stories, so many examples of how someone cut 15% of costs and actually raised quality for their health plan members. There's so many examples of that. So, yeah, it's just one of these areas where if you don't actively not get taken advantage of, you will actively get taken advantage of. Don't kill the messenger. So, I'm doing a Take Two of the show with Jacob Asher, MD, about why the carrier market—now he's talking specifically about California, but this is not limited to California—just why the carrier market is so boring, why it never changes. It's completely stagnant. And I'm doing this—resurfacing the show from three years ago—because it is both a great follow-on and also a great prelude for episodes past and future, and also, three years later, it's still completely boring. Nothing has changed. Giant spoiler alert. But the reason the carrier market is so boring sort of fundamentally is, again, because there is no market here. What I mean is no one is competing on the strength and quality and affordability of their provider network. And while there is an obvious fetish for discounts, as has been discussed deeply in many shows but most thoroughly maybe in that episode with Jonathan Baran (EP483) about flywheels, discounts do not automatically equal lower prices. In fact, discounts plus gamed shared savings goings-on often equate to perversely higher prices paid, irrespective of what the contract says. In short, no market. Now look (and this is exciting), there are some new TPAs (third-party administrators) inching into the market, but if I'm just talking in general, this no market business is devastatingly material. Elizabeth Mitchell talked at length about this in the episode that I reprised recently (EP436). It's called "Let's Talk About TPA and Health Plan Inertia Instead of Jumbo Employer Inertia." So again, that was with Elizabeth Mitchell from the PBGH (Purchaser Business Group on Health). It was a really popular show. So, if you haven't listened to that, go back and do so. So, yeah, while the commercial payer/commercial carrier marketplace is completely boring because there is, in fact, no market to spice it up with any action whatsoever, the reasons it's boring and there's no market are, frankly, not boring. So, let me walk you through this conversation that follows with Jacob Asher, MD. First, we establish that the relative number of each carrier's commercial members in California specifically doesn't seem to change year over year. And this has been true for years, and it's still pretty much true. When you rank order carriers by member count, the song remains the same. It is Groundhog Day. Then Dr. Asher and I dissect what anybody's actually doing to cut into Kaiser's market share or try to grab share from the two big Blues plans, if anything,...

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...