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. There are better decisions that could be made. There are incremental ways to move the needle, to change the vector just slightly. And how that happens, again, is all about better decisions, more informed decisions, more thoughtful decisions to remove the reflex, I guess. What are the inputs for these good decisions? Right, all the reasons that Ken Wosczyna talked about for listening to Relentless Health Value—to get the information that is necessary to sharpen judgment. Let me tick through a couple of rate criticals here. You can't fix what you can't see. So yes, transparency. And speaking of transparency, here's some news you can use: show coming up with Jerry DiMaso from Payerset, and they have something I was unaware of. There is now the transparency data where you can see … say, like, you're an airline. What all the other airlines, assuming everybody is self-insured, what everybody else is paying for the same service, you can see that in their transparency data file. I did not realize this was afoot. Listen to the show coming up with Jerry DiMaso in a couple of weeks because … fiduciary much? Not to plan members here, although there's also that, but to shareholders. If I'm a shareholder and I get ahold of this data and I find out that this company just paid, say, a million dollars too much for some infusion, or if the company had steered down the street to the indie practice, I'd have an extra million dollars on my balance sheet. And that is a real example, actually. And if you wanna hear the whole story, listen to the show with Ivana Krajcinovic, PhD (EP501) about the, what she calls, surreal price variations for infusions in the same exact geographies. So, I'm basically saying that this is not change in the couch cushions that we're talking about here. Site of care differentials have a lot of zeros that shareholders, if they get transparency data files, they will be able to see the caliber of the decisions being made relative to the second biggest line item on most companies' expense sheet. Many companies pay more for healthcare, providing benefits than they do for steel or coffee beans or etc. So, I can imagine if I was a big shareholder, this is something I would be looking into. I could say so much more on this topic, but I think I'll save it for the episode with Jerry DiMaso in a couple of weeks. But yeah, here's the point. You can't make good decisions without transparently available information, and there is more and more transparently available information. So, you can't fix what you can't see, can't make good decisions. So, that's the Point 1 about making better decisions. But also, you can't fix what you don't understand. And I think this is the second sort of underlying point that Ken is making, in which I have heard also from others. Because look, what you might see is an onion that looks, I don't know, really simple from the outside, right? Like, oh, here's a price. We're good. But then you start peeling layer after layer after layer, and the healthcare industry at this point is so financialized, there's so much regulatory capture, there's so much vertical integration with money getting intercompany eliminated—which is just a fancy way of saying it just got disappeared—that unless you really know the right questions to ask, you'll think what you are being shown is transparency. And you think it might look good, except it's not. You just got arbitraged. I'm thinking about the most recent episode with Eric Bricker, MD (EP472), where we talk about how health systems can use these carrier stop-loss contracts. So, not the stop-loss contracts that employers buy. There's these carrier stop-loss contracts. And if such a contract is procured, it would enable a health system to show, this is just one example, a negotiated rate of like $140,000 for a CABG (coronary artery bypass graft) to be able to show that their negotiated average across the board, their average discount, is 240% of Medicare or something. But then somehow or another, they're, on average, charging like $800,000 for a CABG, not $140K. Way over 240% of Medicare, right? How does that happen? Listen to that show. Here's another example. A PBM (pharmacy benefit manager) says they don't have spread prices or something. There's no spread. But then you find out that they're paying the pharmacies that they happen to own a higher amount than they're paying the ones that they don't own. And also, the pharmacies that they do own are very, very preferred. So, most of the volume is being dispensed at the pharmacies that the PBM owns. And when you see this, what is going on there? Oh, right … now they can, potentially, reclassify spread as pharmacy profit. Or here's another thing you can do with spread. You can pay a consultant (oh, sorry, not pay a consultant), give a consultant a discount of $7 an Rx or something. And now again, it's not spread anymore. It's a discount on book of business. Is that reportable? I don't know. You tell me. I have no idea. This stuff matters. There was a comment by Craig Herndon that I thought was really interesting. He writes, "There is no headline when someone starts stretching doses. No dashboard alert when an EOB shifts real cash flow to the family. It just happens quietly, in the background of a benefits design that looked reasonable in a boardroom. … But when it changes behavior at the kitchen table, that is a different kind of signal. For self-funded employers, the real question is not whether the design is technically compliant. [It's] whether it reflects the kind of risk [they're] actually willing to place on their own people." I'm also gonna drop a seed here right now because I wanna do a show on this coming up. Disruption. What does that word even mean anymore? Think about this, and this is a half-baked idea right now but it's in the oven. Heads up. There are so many folks out there very afraid of noise and the dreaded D word: disruption.
