Relentless Health Value

Stacey Richter
  • 4.9 (250)
  • Medicine
  • Weekly

Welcome to Relentless Health Value, the podcast for those working in the belly of the beast to fix our fundamentally broken healthcare system. If you are a self-insured employer, plan sponsor, benefits consultant, clinician, a C-suite executive or anyone in the business of healthcare tired of the "transformational theater" and marketing fluff, you have found your tribe. The U.S. healthcare system isn't a rational market; it's a game of Pachinko where perverse incentives reign, and as we always say, where there's mystery, there's margin. Hosted by Stacey Richter, we relentlessly hunt down the administrative "inches" of waste and expose the hidden fees draining the $5.6 trillion healthcare sector. We transform wonky healthcare theory into ruthlessly practical, actionable insights. Whether it's demanding radical transparency, navigating complex PBM contracts, or buying actual healthcare instead of illusory discounts, our mandate is simple: If it results in a net positive for patients, we do it. Join the Relentless Health Value Tribe to equip yourself with the fiduciary armor needed to outwit the status quo, demand accountability, and drive real change.

  1. 1d ago

    When Patient Experience Means Parking and Pianos, Plan Sponsors Pay for Hotels, Not Outcomes—What to Measure Instead, With Robyn Leone

    Plan Sponsors Need Outcomes, Not Valet Parking: Build the Patient Journey in Three Buildings. Episode 535. Is your patient experience strategy a piano in the lobby, or is it the right diagnosis, the right treatment, and a price the patient can afford? Robyn Leone, Chief Experience Officer at ZERO.Health, joins Stacey Richter to architect the patient journey as three buildings: access and navigation before care, delivery and care coordination during care, and transparent, accountable billing after. Stacey's bottom line: good intentions, clinician empathy, and customer service cannot overcome a bad structural design. WHAT YOU'LL LEARN ✅ Why Robyn Leone defines patient experience as the right diagnosis at the right time, the right treatment, and care the patient can afford — not espresso machines, pianos, and valet parking ✅ The three-buildings framework: access and navigation, delivery and care coordination, and transparent billing with accountable settlement ✅ Why advanced primary care is the front door of building two, and how its absence shows up for employers as high ER rates, high specialist costs, and duplicate services ✅ How surprise bills (expecting $50, getting $900) and slow carrier payment push clinicians to demand upfront payment ✅ Four questions for plan sponsors: primary care spend, chronic condition utilization, what is paid for high-volume services like MRIs, CT scans, MSK procedures, and specialty infusions, and the gap between what was paid and what the provider received ✅ Why clinicians weighing direct contracting should ask vendors for median days to payment, not target days WHY THIS MATTERS Healthcare is slightly obsessed with the real estate kind of architecture, with lots of marble and waterfalls and fancy art, while patient experience measures end up better suited to a hotel than a hospital. Patient experience is a direct operational consequence of the architecture underpinning the patient journey, and plan sponsors get what they pay for, intentionally or otherwise. Direct contracts, steering and tiering, and measurable advanced primary care set the default to the right diagnosis and the right treatment at a fair price. === LINKS === 🔗 Show Notes with all mentioned links 🔗 ZERO.health ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter 🫙 Support the podcast with a small donation to the Tip Jar 🎤 Follow us on Apple Podcasts 🎤 Follow us on Spotify 📺 Subscribe to our YouTube channel 💬 Connect with us: LinkedIn ✭ Threads ✭ Bluesky ✭ X MENTIONED IN THIS EPISODE Robyn Leone on LinkedIn EP532 with Chris Klomp: Apple Podcasts | Spotify | Other Apps EP482 with Preston Alexander: Apple Podcasts | Spotify | Other Apps EP466 with Vivian Ho, PhD: Apple Podcasts | Spotify | Other Apps EP492 with Sam Flanders, MD, and Shane Cerone: Apple Podcasts | Spotify | Other Apps EP404 with Suhas Gondi, MD, MBA: Apple Podcasts | Spotify | Other Apps EP467 with Stacey Richter: Apple Podcasts | Spotify | Other Apps EP464 with Al Lewis: Apple Podcasts | Spotify | Other Apps EP525 with Cristin Dickerson, MD: Apple Podcasts | Spotify | Other Apps EP521 with Andrew Tsang: Apple Podcasts | Spotify | Other Apps EP501 with Ivana Krajcinovic, PhD: Apple Podcasts | Spotify | Other Apps EP524 with John Quinn: Apple Podcasts | Spotify | Other Apps EP486 with Stan Schwartz, MD: Apple Podcasts | Spotify | Other Apps   00:00 Introduction to this episode. 03:10 What the measure of patient experience should be. 04:19 A summary of today's discussion. 06:24 The conversation with Robyn Leone. 07:23 The danger in focusing on atmospheric improvements in regard to the patient experience. 09:38 How to think about measuring health outcomes in regard to the patient experience. 10:57 The three parties that need to be aligned. 16:10 What needs to happen from a patient perspective. 21:25 What happens to patient experience in relation to billing. 28:03 Where plan sponsors should start when thinking about measuring patient experience. 35:47 How ZERO.health works in all of this.

    When Patient Experience Means Parking and Pianos, Plan Sponsors Pay for Hotels, Not Outcomes—What to Measure Instead, With Robyn Leone

  2. Oct 21

    The One Question to Test if a TPA Is Actually Independent, With Kimberly Carleson

    Is Your TPA Truly Independent? The One Claims Audit Question to Ask, With Kimberly Carleson (EP534) The Red Flag Question That Reveals Whether a TPA Works for Your Plan or for the Network. Episode 534. What's a practical, speedy way to assess whether a TPA (third-party administrator) is truly independent and willing to protect the plan sponsor's interests, versus being captive to network contracts, carrier relationships, or other conflicts of interest? In this Ask Me Anything, Stacey Richter puts that question to Kimberly Carleson, CEO of US Beacon, one of the nation's most established independent medical and pharmacy claims compliance and integrity review firms. Her answer is a big kahuna of a tell: ask whether the TPA will let someone come in and independently review your claims — and listen closely to the response. WHAT YOU'LL LEARN ✅ The one question that quickly exposes whether a TPA is truly independent: "Can we have someone come in and independently review our claims?" ✅ Why a TPA answering "We have network contracts that restrict that" is a red flag — it means they are working for the network, not the plan ✅ What a TPA should hand over without hesitation when a plan sponsor asks for an independent claims audit: all claims data, including billed, paid, and allowed charges ✅ How blocking language in TPA and network contracts — restrictions on accessing data or contacting providers — can stop a plan from independently reviewing its own claims and payments ✅ How an "independent" TPA can still be beholden to a network, renting that network and acting the same way any BUCA would ✅ Why labels like "transparent" and "independent" aren't proof, and why due diligence matters: talk is cheap WHY THIS MATTERS Plan sponsors who go self-funded want to do their own thing and bring in their own vendors, not end up "self-funded in name only," as Jonathan Baran calls it. But irrespective of what a partner calls itself, it's still really important to validate what you hear. A TPA's willingness to let you bring in your own auditor — with access to the data and no blocking language in its network contracts — is a fast way to find out whether it works for the plan or for the network. And as Kimberly says, if you can't bring in who you want to bring in, there's something they don't want you to see. MENTIONED IN THIS EPISODE EP518 with Claire Brockbank: Apple Podcasts | Spotify | Other Apps Website: US Beacon Kimberly Carleson on LinkedIn === LINKS === 🔗 Show Notes with all mentioned links: Show Notes ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter 🫙 Support the podcast with a small donation to the Tip Jar 🎤 Follow us on Apple Podcasts 🎤 Follow us on Spotify 📺 Subscribe to our YouTube channel === CONNECT WITH THE RHV TEAM === ✭ LinkedIn ✭ Threads ✭ Bluesky ✭ X 00:00 Introduction to this episode. 01:19 The conversation with Kimberly Carleson. 02:24 The one question to tell if a TPA is independent. 03:30 Breaking down the thought process behind this question. 05:59 How an independent TPA can still be beholden to a network. 06:48 Why it's so important to do due diligence.

    The One Question to Test if a TPA Is Actually Independent, With Kimberly Carleson

  3. Oct 14

    Level Funding Is Self-funding: 5 Avoidable Contract Risks, With Frank Pennachio

    Level-Funded Health Plan Risks: ERISA Contract Traps, Stop-Loss Gaps, and Surplus Fine Print. Episode 533. An employer with a fully insured plan told Stacey Richter his renewal this year was 69% — his broker negotiated it down to 50%, which she's not sure she'd classify as a victory. Level funding looks like a lifesaver in that spot, but as Frank Pennachio, author of The Silent Danger and a health insurance veteran with nearly 40 years of experience, explains, level funding is self-funding, with all the fiduciary risk that comes with it. Frank walks through five avoidable contract risks that level-funded plan sponsors fall into regularly, from embedded ERISA violations to stop-loss misalignment to surplus fine print. WHAT YOU'LL LEARN ✅ Why level funding is self-funding — it feels like a fully insured plan because of the flat monthly payment, but the plan sponsor carries the risks and benefits of self-funding, including fiduciary responsibility ✅ How third-party administrator (TPA) and administrative services only (ASO) agreements can embed ERISA violations the moment they're signed, and why ERISA allows personal assets to be exposed ✅ How stop-loss misalignment leaves the plan sponsor on the hook when plan promises, like eligibility for employees on approved leave, aren't reimbursed under the stop-loss contract ✅ The surplus fine print: incurred but not reported (IBNR) factors, service fees Frank has seen as high as 30%, and surplus returned as an invoice credit instead of a check ✅ Why claims data access promised up front can get signed away, and why fiduciaries must pay prudent fees — like a $50,000 charge to reprice one hospital bill ✅ Four action items: never sign a contract as is, educate the plan sponsor team, run a legit RFP, and pick a broker or EBC with experience and financial alignment WHY THIS MATTERS With renewals like 69% and 50%, there's a lot of desperation out there for a lifesaver, and level funding is being sold as one. But as Frank Pennachio quotes Thomas Sowell, "There are no solutions, there are only trade-offs," and the goal is for plan sponsors to pick the trade-offs they want rather than desperate ones. The cost increases will sting, Frank says, and they won't likely bankrupt most companies, but the risks you unknowingly assume could. MENTIONED IN THIS EPISODE Website: The Silent Danger, Frank Pennachio's book Website: The Silent Danger courses from Frank Pennachio EP478 with Andreas Mang and Jon Camire (Part 1): Apple Podcasts | Spotify | Other Apps EP479 with Andreas Mang and Jon Camire (Part 2): Apple Podcasts | Spotify | Other Apps LinkedIn Post by Kimberly Carleson LinkedIn Post by David Goldfarb on stop-loss cost trends EP512 with Doug Aldeen: Apple Podcasts | Spotify | Other Apps EP457 with Cynthia Fisher: Apple Podcasts | Spotify | Other Apps Study: Survey by Kaiser Family Foundation EP453 with Claire Brockbank: Apple Podcasts | Spotify | Other Apps EP433 with Justin Leader: Apple Podcasts | Spotify | Other Apps === LINKS === 🔗 Show Notes with all mentioned links ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter 🫙 Support the podcast with a small donation to the Tip Jar 🎤 Follow us on Apple Podcasts 🎤 Follow us on Spotify 📺 Subscribe to our YouTube channel === CONNECT WITH THE RHV TEAM === ✭ LinkedIn ✭ Threads ✭ Bluesky 00:00 Introduction to this episode. 03:37 An overview of today's conversation. 04:57 What level funding is. 06:20 Why level funding is having an explosion in popularity. 08:03 What does an employer need to take into account when considering level funding? 09:36 The first risk of level funding. 12:24 The second risk of level funding. 15:01 The third risk of level funding. 19:45 The fourth risk of level funding. 21:46 The fifth risk of level funding. 24:41 Actionable strategies when considering level funding. 33:30 A summary of advice for level funding.

    Level Funding Is Self-funding: 5 Avoidable Contract Risks, With Frank Pennachio

  4. Oct 7

    Why Avoidable ER Visits Aren't the Real Cost Problem: Revisiting Our Interview With HHS Nominee Chris Klomp

    Emergency Department High Utilizers and Real-Time Care Coordination, With Chris Klomp (Episode 532) Today we are dipping into the archives for an essential replay from 2016, one decade ago, featuring Chris Klomp back when he served as CEO of Collective Medical, and now nominated to serve as deputy secretary of the Department of Health and Human Services (HHS), a nearly $2 trillion federal health apparatus. In this conversation, Klomp explains why emergency medicine is only 2 to 4% of total U.S. healthcare cost, so avoidable ED spend can't be more than about 0.8 to 0.9% of total spend, and why the emergency department is still the natural choke point for finding complex, high-risk patients. Listening back is a rare, candid preview of the operational philosophy which may now shape Chris Klomp's view on health policy. WHAT YOU'LL LEARN ✅ Why Klomp said in 2016 that emergency medicine is only 2 to 4% of total U.S. healthcare cost, versus about 6% for plan sponsors now ✅ How the ED works as a "clearinghouse" for physical, mental, behavioral, and social complexity, and why the goal is the right care setting, not stopping the visit (EMTALA) ✅ How a Pacific Northwest clinical group used real-time data and coordinated care plans to cut hospital readmission rates by close to 40% ✅ Klomp's four building blocks: real-time data (starting with an ADT feed, since claims data runs 90 to 180 days late), risk analytics, communication inside the EHR workflow, and community-wide collaboration ✅ How whole-person care took "Ron" from 23 ED visits in a month across seven hospitals to 3 at peak, and why 78% of ED high utilizers have physical, mental, and behavioral health comorbidities WHY THIS MATTERS With the nomination of Chris Klomp to serve as deputy secretary of HHS, all eyes are kind of on how he plans to manage a nearly $2 trillion federal health apparatus. The emergency department is a critical choke point through which complex, often high-risk patients inevitably pass. Not dealing effectively with these larger community issues costs everyone more than dealing with them effectively would cost, and if the country had done more of what Klomp describes ten years ago, it makes you wonder how things would be different now. MENTIONED IN THIS EPISODE EP467 with Stacey Richter: Apple Podcasts | Spotify | Other Apps EP495 with Mick Connors, MD: Apple Podcasts | Spotify | Other Apps EP464 with Al Lewis: Apple Podcasts | Spotify | Other Apps Study: Research from Peter Smulowitz, MD, MPH; Leah Honigman, MD; and Bruce Landon, MD, MBA EP322 with Monica Lypson, MD, MHPE: Apple Podcasts | Spotify | Other Apps EP473 with Kenny Cole, MD: Apple Podcasts | Spotify EP391 with Scott Conard, MD: Apple Podcasts | Spotify | Other Apps === LINKS === 🔗 Show Notes with all the mentioned links and article: Show Notes ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter 🫙 Support the podcast with a small donation to the Tip Jar 🎤 Follow us on Apple Podcasts 🎤 Follow us on Spotify 📺 Subscribe to our YouTube channel === CONNECT WITH THE RHV TEAM === ✭ LinkedIn ✭ Threads ✭ Bluesky ✭ X 00:00 Introduction to this episode. 04:38 Reducing wasteful spend in healthcare. 05:37 The percentage of total healthcare costs that goes to emergency medical spend in the U.S. 07:09 Why ED spending is low-hanging fruit. 08:17 How EDs operate as choke points. 09:14 Impacting what happens in the emergency department. 17:34 What happens when a patient enters the ED. 20:57 Why it's important to have data available to everyone who might touch the patient. 24:45 The need-to-know when it comes to managing data. 28:01 Thinking about risk and imminent readmission. 30:01 Collaboration in a care plan to reduce wasteful spend. 30:53 The right data, risk analytics, communication, and community-wide collaboration. 31:11 How social determinants affect wasteful spend in the ED.

    Why Avoidable ER Visits Aren't the Real Cost Problem: Revisiting Our Interview With HHS Nominee Chris Klomp

  5. Sep 30

    Slaying the Three-Headed Monster of Health Plan Networks, With Evan Anderson

    Discount Illusions, Billing Errors, and Site-of-Care Markups: A Carrier Network Primer for Employers with Evan Anderson of Handl Health. Episode 531. Whatever the plan was at the very beginning, the big status quo carrier networks have evolved into what Stacey Richter calls a three-headed monster: the contractual illusion of discounts, payment integrity nobody with skin in the game is allowed to check, and wild site-of-care price swings inside the very same network. Stacey talks with Evan Anderson of Handl Health, where he works on product strategy, general strategy, and operations, about how fee-for-service networks got here and what self-insured employers, brokers, and TPAs can do around the edges right now. Consider it a primer — a survey of the general map of the landscape, with breadcrumbs to many past episodes for anyone ready to take a deep dive. WHAT YOU'LL LEARN ✅ Why a discount off a chargemaster price is "an optical illusion" — including the 2023 Health Affairs finding that at roughly half of hospitals, the discounted cash price is lower than the insurer-negotiated rate ✅ How old mainframe adjudication systems, obtuse contracts, and double-digit billing error rates make payment integrity nearly impossible to verify — because where there's mystery, there's margin ✅ How site-of-care differentials drive runaway spend, from hospital multipliers as high as 13X to $135 vs. $13,560 for the exact same infusion drug — both in-network ✅ Why switching carrier networks, even with your own claims file and transparency data, is a shrinking lever as prices regress toward the mean ✅ Three around-the-edges moves: direct contracting for advanced primary care and Centers of Excellence, steerage and tiering that include site-of-care tiers, and bundled episodes of care aggregated into alternative health plans ✅ How the broker/EBC role is shifting from network shopper to plan orchestrator WHY THIS MATTERS These networks are, lest we forget, built on a fee-for-service model that structurally aligns incentives in ways that are a lot of times misaligned with members and plan sponsors. As Evan puts it, cut one head off and the body grows it back — that body being decades of opacity (gag clauses were only banned by the CAA in 2021) and intermediaries paid in ways indifferent or positively correlated to higher spend. For plan sponsors facing extreme increases, knowing the real price, the quality, and what was actually billed is how you start chipping away at the status quo. MENTIONED IN THIS EPISODE EP505 with Ahilan Sivaganesan, MD: Apple Podcasts | Spotify | Other Apps EP434 with Benjamin Schwartz, MD, MBA: Apple Podcasts | Spotify | Other Apps Website: Handl Health Handl Health on LinkedIn Evan Anderson on LinkedIn Article: Katy Talento, ND, ScM, on a post-network world LinkedIn Post by Mark Cuban LinkedIn Post by Craig Gottwals Study: Health Affairs, hospital cash prices vs. negotiated prices EP482 with Preston Alexander: Apple Podcasts | Spotify | Other Apps EP480 with Kimberly Carleson: Apple Podcasts | Spotify | Other Apps EP521 with Andrew Tsang: Apple Podcasts | Spotify | Other Apps Article: Jim Jusko, JD, on healthcare provider networks (Medical Economics) EP529 with Eric Bricker, MD: Apple Podcasts | Spotify | Other Apps EP501 with Ivana Krajcinovic, PhD: Apple Podcasts | Spotify | Other Apps EP472 with Eric Bricker, MD: Apple Podcasts | Spotify | Other Apps EP398 with Jacob Asher, MD: Apple Podcasts | Spotify | Other Apps LinkedIn Post by Mike Hopkins EP528 with Yashaswini Singh, PhD: Apple Podcasts | Spotify | Other Apps LinkedIn Comment by Lori Smith Guliano LinkedIn Comment by Patrick Nelli EP509 with Patrick Nelli: Apple Podcasts | Spotify | Other Apps EP504 with Ryan Jacobs: Apple Podcasts | Spotify | Other Apps EP530 with Jake Velie and Keith Hartman, RPh: Apple Podcasts | Spotify | Other Apps EP523 with Suhas Gondi, MD, MBA: Apple Podcasts | Spotify | Other Apps EP503 with Ryan Wells; Leo Spector, MD, MBA; and Adam Stavisky: Apple Podcasts | Spotify | Other Apps EP294 with Steve Schutzer, MD: Apple Podcasts | Spotify | Other Apps === LINKS === 🔗 Show Notes with all mentioned links ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter 🫙 Support the podcast with a small donation to the Tip Jar 🎤 Follow us on Apple Podcasts 🎤 Follow us on Spotify 📺 Subscribe to our YouTube channel === CONNECT WITH THE RHV TEAM === ✭ LinkedIn ✭ Threads ✭ Bluesky ✭ X 00:00 Introduction to this episode. 02:21 An overview of today's conversation. 06:31 The conversation with Evan Anderson. 06:40 What is a network? 08:15 The reality of contracts and care networks. 13:19 The contractual illusion of discounts. 21:17 What does a good solution look like right now? 24:35 How incentivizing providers can open opportunities. 26:44 How COE and steerage architecture plays into this. 34:02 The different role of the broker and EBC in this model. 35:59 What Handl Health is and does.

    Slaying the Three-Headed Monster of Health Plan Networks, With Evan Anderson

  6. Sep 23

    A Wildly Underappreciated Point: Overpaying for Infusions Means Overpaying for Stop-Loss Coverage, With Jake Velie and Keith Hartman, RPh

    The Hidden Link Between Expensive Infusions and Rising Stop-Loss Renewal Premiums. Episode 530. When an infusion claim lands on a self-insured plan's high-cost claims report, it's tempting to treat the price tag as fixed — but the exact same infusion drug can cost 10 times more depending on where a member receives it, and every expensive claim that breaches a stop-loss attachment point can push next year's premium higher or get that member's claim lasered off coverage entirely. In this episode, Stacey Richter talks with Jake Velie, founder, chairman, and CEO of National Integrative Health (NIH), and Keith Hartman, RPh, NIH's chief strategy officer, about the direct — not dotted — line between overpaying for infusions and overpaying for stop-loss coverage, and the four pillars plan sponsors need to actually pull off site-of-care optimization. WHAT YOU'LL LEARN ✅ Why there's a direct, not dotted, line between expensive infusion claims and rising stop-loss renewal premiums — and how breaching an attachment point can get a claim lasered off coverage ✅ How the opacity of J-codes and Q-codes on the medical benefit hides how much margin is built into an infusion's billed cost, unlike the more visible pharmacy-benefit claims data ✅ Why the exact same infusion drug can cost 10 times more depending on where a member receives it ✅ The four pillars of a real site-of-care optimization program: deep clinical oversight, proactive pre-cert intervention, plan design and financial incentives, and member/influencer engagement ✅ Why a vague "denied" fax in the pre-cert process leaves prescribing clinicians in the dark and can sabotage a site-of-care redirect before it starts ✅ How home infusion can be used as a site-of-care option even when an anticompetitive hospital contract otherwise restricts steering WHY THIS MATTERS Stop-loss coverage is usually a self-insured plan's single biggest expense, yet Stacey Richter points out that the typical reaction to an expensive infusion claim is to treat it like an unalterable fate. The same infusion can cost 10 times more depending on where a member gets it, and every claim that breaches a stop-loss attachment point pushes premiums higher or risks getting the claim excluded from coverage. As medical and pharmacy trend keeps climbing, knowing how to steer members toward lower-cost, clinically appropriate sites of care is becoming a core skill for plan sponsors — not knowing how is turning into a problematic knowledge gap. MENTIONED IN THIS EPISODE EP529 with Eric Bricker, MD: Apple Podcasts | Spotify | Other Apps EP370 with Erik Davis and Autumn Yongchu: Apple Podcasts | Spotify | Other Apps EP468 with Matt McQuide: Apple Podcasts | Spotify | Other Apps Website: National Integrative Health EP501 with Ivana Krajcinovic, PhD: Apple Podcasts | Spotify | Other Apps EP508 with Lee Lewis: Apple Podcasts | Spotify | Other Apps EP480 with Kimberly Carleson: Apple Podcasts | Spotify | Other Apps EP523 with Suhas Gondi, MD, MBA: Apple Podcasts | Spotify | Other Apps EP472 with Eric Bricker, MD: Apple Podcasts | Spotify | Other Apps === LINKS === 🔗 Show Notes with all mentioned links: Show Notes ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter 🫙 Support the podcast with a small donation to the Tip Jar 🎤 Follow us on Apple Podcasts 🎤 Follow us on Spotify 📺 Subscribe to our YouTube channel === CONNECT WITH THE RHV TEAM === ✭ LinkedIn ✭ Threads ✭ Bluesky ✭ X 00:00 Introduction to this episode. 02:42 An overview of today's conversation. 05:50 The critical pillars plan sponsors underestimate. 07:44 Today's conversation with Keith and Jake. 10:08 Connecting the dots between infusion therapy costs and stop-loss coverage. 13:44 Why stop-loss carriers are starting cost-containment initiatives themselves. 17:36 The things many plans miss. 18:40 Why some plans miss or underestimate extensive clinical capabilities. 20:39 What does "good" look like, relative to a clinical team? 23:10 What do plan sponsors need to ensure further care fragmentation? 27:05 Why plan design and member financial alignment are so important. 29:44 Why is it important for plan sponsors to have a member and influencer engagement engine? 32:58 What about anti-competitive contracts and ASO resistance? 35:15 What National Integrative Health does. 36:22 Where you can go to learn more about National Integrative Health.

    A Wildly Underappreciated Point: Overpaying for Infusions Means Overpaying for Stop-Loss Coverage, With Jake Velie and Keith Hartman, RPh

  7. Sep 16

    How Stark Law, Stipends, and Noncompetes Drive Hospital Consolidation, With Eric Bricker, MD

    The Chain Reactions Wrecking Healthcare Affordability: Facility Fees, Stark Law, and Noncompetes. Episode 529. Why do hospital facility fees keep pace with inflation while professional fees fall behind—and how did a law meant to stop kickbacks end up fueling a stipend economy instead? Stacey Richter talks with Eric Bricker, MD, founder of AHealthcareZ and former co-founder and chief medical officer of Compass Professional Health Services, about two action/reaction chains reshaping healthcare affordability: the facility-versus-professional-fee gap, and the Stark Law's unintended stipend economy driving hospital consolidation. Along the way: a $48,126 hospital charge for the same appendectomy that pays a surgeon $609, the AMA's $300 million CPT-code business, and how Tryon Medical Group in Charlotte, North Carolina, won back 90% of its patients by leaving its hospital employer. WHAT YOU'LL LEARN ✅ How separate physician "professional fee" and hospital "facility fee" billing streams have diverged so far that Medicare pays a surgeon $609 for an appendectomy while the hospital's published charge for it runs $48,126 ✅ Why the Stark Law's ban on hospitals paying physicians for referrals gave rise to "stipends"—flat annual payments that can range from $1 million to $50 million depending on hospital size, and how physician consolidation in fields like anesthesiology has pushed those stipends higher ✅ How "site unneutral" payment gaps incentivize hospitals to buy independent physician practices and shift services like echocardiograms into hospital settings to capture higher fees for identical care ✅ Why noncompete clauses trap physicians in incentive structures misaligned with patient care—and how Tryon Medical Group in Charlotte, North Carolina, sued to leave its hospital employer and kept over 90% of its patients ✅ Why self-insured employers (covering roughly 60% of Americans) and physicians organizing beyond fragmented specialty lines are healthcare's "two sleeping giants" ✅ Practical alternatives already in use: employer direct contracting, direct primary care subscriptions, and fixed-fee specialty models like the LA urology group paid on subscription for prostate cancer care WHY THIS MATTERS These two chain reactions—the facility-versus-professional-fee gap, and a well-intentioned law that quietly created a stipend economy—aren't abstract policy trivia. Together they drive the hospital consolidation and site unneutral payment schemes squeezing employers, taxpayers, and patients alike. As Stacey frames it, understanding how these action/reaction chains work is what it takes to reverse their direction toward more affordable, higher-quality care. The fix isn't waiting on Washington: it's employers and physicians—healthcare's two sleeping giants—using their leverage, whether through direct contracting, ending noncompetes, or simply voting with their feet. MENTIONED IN THIS EPISODE Dr. Eric Bricker's YouTube Channel  and his site AhealthcareZ.com EP519 with Lisa Rosenbaum, MD:  Apple Podcasts | Spotify | Other Apps LinkedIn Post by Payerset Instagram Reels by Elisabeth Potter, MD, on the AMA: Video 1, Video 2 Instagram Post by Graham Walker, MD EP437 with Brian Klepper, PhD: Apple Podcasts | Spotify | Other Apps EP472 with Eric Bricker, MD: Apple Podcasts | Spotify | Other Apps EP523 with Suhas Gondi, MD, MBA: Apple Podcasts | Spotify | Other Apps Article: AMA CPT Editorial Panel workgroups and committees EP524 with John Quinn: Apple Podcasts | Spotify | Other Apps EP525 with Cristin Dickerson, MD: Apple Podcasts | Spotify | Other Apps === LINKS === 🔗 Show Notes with all mentioned links: Show Notes ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter 🫙 Support the podcast with a small donation to the Tip Jar 🎤 Follow us on Apple Podcasts 🎤 Follow us on Spotify 📺 Subscribe to our YouTube channel === CONNECT WITH THE RHV TEAM === ✭ LinkedIn ✭ Threads ✭ Bluesky ✭ X 00:00 Introduction to this episode. 01:34 An overview of today's episode. 03:37 The conversation with Dr. Eric Bricker. 03:59 The first action/reaction chain. 07:03 How AHA's success in lobbying plays into its ability to outpace inflation. 14:48 The second action/reaction chain. 21:57 How all of this impacts the patient. 28:24 Purchasers as a sleeping giant. 29:36 Physicians as the second sleeping giant. 31:26 Site-neutral payments: who wants them, who doesn't. 33:33 Dr. Bricker's advice.

    How Stark Law, Stipends, and Noncompetes Drive Hospital Consolidation, With Eric Bricker, MD

  8. Sep 9

    Private Equity in Primary Care: What the Data Actually Shows, With Yashaswini Singh, PhD. Episode 528.

    Private Equity in Primary Care: Just Another Inflationary Business Model? What Does the Data Actually Show, With Yashaswini Singh, PhD (EP528) Private equity has been buying up primary care practices for years, promising the capital that chronically underfunded clinicians badly need. But does the money actually make care better? Yashaswini Singh, PhD, MPA, the Thomas J. and Alice M. Tisch Assistant Professor of Health Services, Policy, and Practice at Brown University, has spent years studying that question — and her newest research, published in Health Affairs and JAMA Health Forum, finds PE-affiliated primary care physicians negotiate prices 8% to 10% higher than independent doctors, while patient outcomes barely budge. WHAT YOU'LL LEARN ✅ Why negotiated prices for PE-affiliated primary care physicians run 8% to 10% higher than independent doctors — and why hospital-affiliated physicians still command the highest prices of all ✅ How a national study of roughly 200 PE-acquired primary care practices found a 20% increase in preventive services, including the Medicare Annual Wellness Visit, with no evidence of low-value care ✅ Why "cognitive atrophy" — deskilling from rigid, box-checking visits — isn't inevitable under PE ownership, but why the "best case scenario" often isn't what's actually happening ✅ How opaque common ownership — the same investors owning primary care, GI, orthopedic, and oncology practices — can create hidden referral incentives current data can't detect ✅ Why site-of-care payment arbitrage — a hospital-owned MRI can cost double or triple an independent one — drives referral-machine incentives regardless of who owns the practice ✅ Why PE's promise to reduce fragmentation through consolidation has instead produced physician turnover that undermines the patient-doctor relationship WHY THIS MATTERS Primary care clinicians are chronically underpaid, and private equity promises the capital to fix that. But Dr. Singh's research shows a real tradeoff: costs rise 8% to 10% while quality barely moves. Whether professional capital builds sustainable, whole-person care or becomes, as Stacey puts it, corporate arbitrage in a different Halloween costume depends on realigning payment incentives around outcomes rather than throughput — something no ownership model, PE included, is yet built to do. MENTIONED IN THIS EPISODE EP519 with Lisa Rosenbaum, MD: Apple Podcasts | Spotify | Other Apps LinkedIn Post by Yashaswini Singh, PhD EP474 with Yashaswini Singh, PhD: Apple Podcasts | Spotify | Other Apps Study: "Private Equity Acquisitions in Primary Care" (Health Affairs) Study: "Private Equity Acquisition in Primary Care and Avoidable Hospitalizations" (JAMA Health Forum) LinkedIn Comment by Andrea DeSantis, DO, FAAFP EP521 with Andrew Tsang: Apple Podcasts | Spotify | Other Apps EP523 with Suhas Gondi, MD, MBA: Apple Podcasts | Spotify | Other Apps === LINKS === 🔗 Show Notes with all mentioned links: Show Notes ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter 🫙 Support the podcast with a small donation to the Tip Jar 🎤 Follow us on Apple Podcasts 🎤 Follow us on Spotify 📺 Subscribe to our YouTube channel === CONNECT WITH THE RHV TEAM === ✭ LinkedIn ✭ Threads ✭ Bluesky ✭ X 00:00 Introduction to this episode. 04:16 The three categories covered in today's episode. 05:36 The conversation with Dr. Singh. 07:02 Findings these private equity studies have found about primary care. 12:00 Does private equity make cognitive atrophy inevitable? 14:49 In PE-backed, single-specialty primary care, is it easier for PCPs to have full-spectrum clinical scope? 17:14 Why perverse financial incentives cause problems but aren't necessarily an inevitability. 22:17 Fragmentation and private equity in primary care. 25:46 Indie primary care versus PE-backed primary care versus hospital system–backed primary care. 32:22 What Dr. Singh is thinking about and looking to solve for next. 34:30 Inspiring physician-led work and a reason for hope.

    Private Equity in Primary Care: What the Data Actually Shows, With Yashaswini Singh, PhD. Episode 528.
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About

Welcome to Relentless Health Value, the podcast for those working in the belly of the beast to fix our fundamentally broken healthcare system. If you are a self-insured employer, plan sponsor, benefits consultant, clinician, a C-suite executive or anyone in the business of healthcare tired of the "transformational theater" and marketing fluff, you have found your tribe. The U.S. healthcare system isn't a rational market; it's a game of Pachinko where perverse incentives reign, and as we always say, where there's mystery, there's margin. Hosted by Stacey Richter, we relentlessly hunt down the administrative "inches" of waste and expose the hidden fees draining the $5.6 trillion healthcare sector. We transform wonky healthcare theory into ruthlessly practical, actionable insights. Whether it's demanding radical transparency, navigating complex PBM contracts, or buying actual healthcare instead of illusory discounts, our mandate is simple: If it results in a net positive for patients, we do it. Join the Relentless Health Value Tribe to equip yourself with the fiduciary armor needed to outwit the status quo, demand accountability, and drive real change.

Information

  • Creator
    Stacey Richter
  • Years Active
    2014 - 2026
  • Episodes
    400
  • Rating
    Clean
  • Copyright
    ©BD Bridges LLC, All Rights Reserved.
  • Show Website
    Relentless Health Value

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