Relentless Health Value

Stacey Richter
  • 4.9 (242)
  • Medicine
  • Updated 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. How Do You Explain the Difference Between an ASO Vendor and a TPA? With Claire Brockbank. Episode 518

    4d ago

    How Do You Explain the Difference Between an ASO Vendor and a TPA? With Claire Brockbank. Episode 518

    The ASO vs. TPA Decision That Quietly Costs Self-Funded Employers More What's the real difference between an ASO and a TPA — and why does it matter that self-insured employers working with an ASO pay, by one referenced estimate, about 4.7% more than the insured book of business for the same care? In this Ask Me Anything, Stacey Richter puts a listener question from Dr. Alex Sommers, MD, ABEM, DipABLM, president of Astia Health, to Claire Brockbank, newly appointed director of the 32BJ Health Fund, who breaks down how ASO and TPA models diverge on ownership, networks, and incentives.  WHAT YOU'LL LEARN ✅ How an ASO (administrative services only) arrangement differs structurally from a TPA (third-party administrator) — in Claire Brockbank's words, an ASO is essentially "a TPA that's owned by one of the big insurance carriers" ✅ Why bringing your own network, doing carve-outs, or direct contracting is typically much easier with a TPA than with an ASO, since an ASO's network comes bundled in ✅ How ASO incentive structures can lead carriers to charge self-funded employers more to offset thinner margins on their insured book — and why a study referenced by Luke Prettol found self-insured ASO clients pay roughly 4.7% more on average ✅ Why many TPAs, as newer market entrants built around technology, can move faster on things like claims-audit integrations than legacy carrier systems that can take up to 18 months to implement changes ✅ A real-world example of how network rigidity under an ASO made it difficult for one employer to remove 40 identified unsafe physicians from its network ✅ Why reading a TPA contract carefully still matters, since aligned incentives are a structural possibility with a TPA, not a guarantee WHY THIS MATTERS ASO and TPA are routinely used interchangeably across the industry, but as Claire Brockbank lays out, the distinction isn't just terminology — it's what determines how much actual control a self-funded employer has over its own health plan. An ASO bundles in the carrier's network and legacy systems, often with built-in incentive misalignments that can show up as higher costs than the insured book of business pays. A TPA leaves more room to bring your own network, negotiate direct contracts, and move quickly when something needs to change. For any plan sponsor sorting out vendor options, knowing which model is actually on the table is foundational to getting the rights, rates, and flexibility they're after. MENTIONED IN THIS EPISODE Post by Luke Prettol EP453 with Claire Brockbank: Apple Podcasts | Spotify | Other Apps EP498 with Mark Noel: Apple Podcasts | Spotify | Other Apps === LINKS === 🔗 Show Notes with all mentioned links: [Episode 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. 00:38 Dr. Alex Sommers' question. 04:05 Claire's answer to what differentiates a TPA and an ASO vendor. 04:25 What an ASO vendor is. 04:57 What a TPA is. 06:52 The pros and cons to choosing an ASO as a carrier. 09:05 The pros and cons to TPAs.

    14 min
  2. Prior Authorizations & Pharma Rebate Contracts — How Financial Motives Keep Generics Off Formularies (EP517)

    Jun 24

    Prior Authorizations & Pharma Rebate Contracts — How Financial Motives Keep Generics Off Formularies (EP517)

    The PBM Rebate Math That Turns Prior Auths Into a Pharma Negotiating Tool What if a prior authorization has less to do with your medical need than with how big a rebate check a PBM is collecting on a competing drug? In this solo deep dive — a direct follow-up to last week's conversation with Ophelia Johnson on GLP-1s and cash pay (EP516 link below) — host Stacey Richter walks through a "Brand Darling" vs. "Brand 2" case study showing how PBM/GPO rebate contracting and the Inflation Reduction Act's pressure on list prices can turn prior auths and step therapy into negotiating leverage rather than clinical guardrails. She also breaks down the GoodRx reverse-auction mechanic and why a growing number of pharma manufacturers are responding to rebate-driven formulary exclusion by going cash-pay direct to patients. WHAT YOU'LL LEARN ✅ How PBM/GPO rebate contracts create a "rebate cliff" that locks new or lower-cost drugs out of formulary, regardless of price or clinical efficacy ✅ Why prior authorizations and step therapy are often used as a financial negotiating lever to extract bigger rebates from a dominant "Brand Darling," rather than as a clinical-necessity check ✅ How the Inflation Reduction Act's list-price pressure is collapsing the rebate spread that funds the current PBM contracting model ✅ Why cash-pay and direct-to-patient strategies are becoming a more attractive option for pharma brands excluded from preferred formulary tiers ✅ How GoodRx's reverse-auction model actually generates its advertised cash prices, and how GoodRx profits from sponsored placement, copay-card integration, and data sales ✅ Why copay accumulators and maximizers can erase the value of a manufacturer's copay card even when a patient does get coverage WHY THIS MATTERS For self-insured employers and plan sponsors footing the bill, this episode is a reminder that a prior authorization or a formulary tier placement may be a financial calculation between a PBM and a manufacturer first, and a clinical determination second. Because coinsurance is calculated off an inflated list price, the same rebate-cliff dynamics that lock a lower-cost drug out of formulary can also push more cost directly onto plan members. And as the Inflation Reduction Act squeezes the rebate spread that funds this model, cash-pay and direct-to-patient strategies are emerging as an alternative worth watching — even though, as Stacey notes, the usual PBM players are often still involved behind the scenes. MENTIONED IN THIS EPISODE EP516 with Ophelia Johnson: Apple Podcasts | Spotify | Other Apps Post by Robyn Tikia AEE13 with Ge Bai, PhD, CPA: 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. 03:53 What needs to be true, no matter what your pharma brand is. 04:20 Why a PBM picks a brand "darling." 05:10 A message to PBM sales teams. 09:43 Clarifying a point about formulary decision making. 14:34 When might a cash-pay strategy start to look rational for a pharma brand? 16:25 Cash pay versus formulary from the patient perspective. 19:50 How PBMs feel about brands going cash pay. 20:56 Why GoodRx is allowed to sell non-formulary Rxs at cash prices on PBMs. 23:51 A clarification of points on GoodRx. 26:19 A point to ponder about discount coupons.

    27 min
  3. Cash Pay From the Pharma Manufacturer Point of View, With Ophelia Johnson

    Jun 17

    Cash Pay From the Pharma Manufacturer Point of View, With Ophelia Johnson

    Only about half of new GLP-1 prescriptions got approved for coverage in 2023 — a gap Ophelia Johnson says is why pharma manufacturers started building cash-pay and direct-to-employer channels instead of waiting on PBMs. Johnson, who built new channels for the manufacturer behind the GLP-1 boom and now runs e-fi.works, walks Stacey Richter through how the money moves with GoodRx and telehealth, including the buydown math behind a $500 list-price drug becoming a $100 cash price. This is Episode 516 (EP516) of Relentless Health Value. WHAT YOU'LL LEARN ✅ Why IRA maximum fair price pressure, PBM reform lawsuits, and roughly 50% of new GLP-1 prescriptions going unapproved for coverage in 2023 pushed manufacturers to build cash-pay channels ✅ The buydown math behind cash pay: a manufacturer pays savings-coupon providers like GoodRx a flat fee instead of a PBM rebate to bring a $500 list-price drug down to a $100 cash price ✅ How telehealth and white-label or manufacturer-owned pharmacies add a second cash-pay channel, with new shipping and supply-chain costs once the PBM is cut out ✅ Why "direct-to-employer" GLP-1 deals are a misnomer — PBM exclusivity clauses bar manufacturers from selling straight to employers, routing them through third-party transparent administrators ✅ Ophelia Johnson's advice to plan sponsors: shift formulary conversations from rebate yields toward auditable medication abandonment rates and total cost of care WHY THIS MATTERS Stacey Richter's follow-the-dollar lens usually points at employers and patients as the ultimate purchasers — but the incentives driving pharma manufacturers matter just as much for collaboration to work. Legislative pressure on rebates, PBM reform litigation, and a GLP-1 boom that left half of new prescriptions unfilled in 2023 are pushing manufacturers toward cash-pay and direct-to-employer models that bypass PBM rebates entirely. That changes formulary math for plan sponsors and raises the stakes on gross-to-net accuracy for manufacturers. As Richter puts it, fair profit versus profiteering comes down to making more money when a patient does worse. MENTIONED IN THIS EPISODE Post by David Alderman Post by Ann Lewandowski Post by Madelaine Feldman, MD Post by Bryce Platt, PharmD AEE13 with Ge Bai, PhD, CPA: Apple Podcasts | Spotify | Other Apps EP439 with Luke Slindee, PharmD: Apple Podcasts | Spotify | Other Apps EP426 with Nina Lathia, RPh, MSc, PhD: 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. 08:07 The conversation with Ophelia Johnson. 08:14 What is cash pay? 08:59 Why is this a thing and how did we get here? 12:28 The different ways that a patient could go about receiving and paying for their drug. 13:22 What's going on behind the scenes between GoodRx and the pharma manufacturer. 17:02 What dispense fees are and how they work. 17:41 A sidenote about next week's episode. 20:03 A sidenote about the pharma manufacturer POV. 21:44 The pharma supply chain in telehealth. 25:27 Why claims validation has never been more important. 28:19 Where do employers fit in all of this? 32:45 Where does it make sense to consider these alternative business models in lieu of the risks? 35:04 Why mapping the incentives is important. 38:42 Ophelia's advice to pharma manufacturers. 40:41 Ophelia's advice to plan sponsors. 42:46 More of Ophelia's advice to payers.

    44 min
  4. Self-Insured Employers: SNF Fraud or Perverse Incentives? Understaffing, Gamed STAR Ratings, and Medicare Dollars at Skilled Nursing Facilities with Michelle Cera

    Jun 10

    Self-Insured Employers: SNF Fraud or Perverse Incentives? Understaffing, Gamed STAR Ratings, and Medicare Dollars at Skilled Nursing Facilities with Michelle Cera

    Is it fraud — or is it just a perverse incentive? That question sits at the center of Hunterbrook Media's latest investigation into skilled nursing facilities (SNFs), and the answer, as Stacey Richter puts it, matters to self-insured employers and anyone else paying for healthcare. In this episode, Stacey speaks with Michelle Cera, PhD, investigative reporter at Hunterbrook Media, whose investigation — triggered by a tip from an overwhelmed elder abuse attorney — uncovered a pattern of systematic understaffing, self-reported CMS STAR rating manipulation, executive bonuses tied to expense-cutting, and related-party financial engineering that funnels Medicare and Medicaid dollars straight back to corporate, while the most vulnerable patients pay with their health and their lives. WHAT YOU'LL LEARN ✅ How for-profit SNF chains systematically recruit the sickest patients to maximize Medicare and Medicaid reimbursement, then staff below what those patients actually need — keeping the difference as profit and, in some cases, doubling executive bonuses in a single year ✅ How Hunterbrook analyzed millions of publicly available CMS data points across roughly 14,000 skilled nursing facilities, applying a UCSF-developed expected-hours formula tied to patient acuity, to quantify the gap between staffing hours billed and care hours actually provided ✅ Why CMS STAR ratings — the primary tool consumers use to choose nursing homes for loved ones — are largely informed by self-reported, unaudited facility data, and how former employees described manipulation of those ratings as rampant ✅ How related-party transactions allow SNF chains to route Medicare and Medicaid dollars through owned subsidiaries for goods and services like pharmacy, equipment, and insurance — with CMS flagging the overcharges as disallowed costs but lacking any mechanism to recoup them ✅ How a 2024 CMS final rule establishing a federal minimum of 3.48 HPRD (hours per resident day) and a 24/7 on-site registered nurse requirement was ultimately rescinded after industry lobbying — and what that rescission reveals about regulatory capture in the SNF sector ✅ Four concrete policy fixes: codify federal minimum staffing hours adjusted for patient acuity, strengthen reporting standards and auditing so no quality metric is entirely self-reported, create a recoupment mechanism for flagged related-party overcharges, and reform STAR ratings so consumers can distinguish independently verified data from self-reported data WHY THIS MATTERS Right now, Stacey argues, we are endlessly trying to keep up with thousands of profit-extracting geniuses and creating mazes of complexity to regulate actors who have no societal construct keeping them in check. The SNF sector is a case study in what happens when there is no agreed-upon definition of harm — when perverse incentives are just incentives. These are taxpayer, employer, and patient co-insurance dollars potentially going into someone's pocket while a patient is simultaneously being hurt. The 65-plus population is growing, the market is expanding, and — as Hunterbrook's research shows — the model that works from a profit perspective is to take sicker patients, cut the highest-paid staff first, and grade your own homework so no one notices. That playbook, once proven, spreads fast. MENTIONED IN THIS EPISODE EP511 with Dr. Siva and Monica Lypson, MD, MHPE: Apple Podcasts | Spotify | Other Apps EP509 with Patrick Nelli: Apple Podcasts | Spotify | Other Apps Hunterbrook Media's full SNF investigation Study: University of Pennsylvania analysis on repealing the CMS minimum staffing rule EP482 with Preston Alexander: 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. 00:40 Fixing the root cause problems with the American healthcare system. 01:50 Today's root problem topic. 05:12 Introducing today's guest and her latest investigation. 07:43 The conversation with Michelle Cera, PhD. 08:35 How Hunterbrook Media's latest investigation into skilled nursing facilities got started. 13:20 How inadequate staffing creates neglect in SNFs. 14:03 Connecting the dots between staffing and resident needs. 15:33 Why skilled nursing facility chains are extremely profitable to the detriment of patients. 17:15 How star ratings on CMS can be skewed in the favor of these SNF chains. 21:56 The perverse incentives playbook. 23:20 An example of how executive bonuses are tied to perverse incentives. 27:53 How lobbying walked back the CMS minimum staffing regulation for SNFs. 29:05 Another note in the perverse incentives playbook. 30:59 How much of these chain SNFs' funding is from taxpayer dollars. 33:16 Another perverse incentive: overpaying sister companies. 35:07 Why CMS can flag overcharging, but they don't have a cost recoup structure. 38:10 The case to be made about how current business dealings within SNFs is fraudulent. 39:30 How to fix the perverse incentives happening in skilled nursing facilities.

    43 min
  5. Successfully Suing a Health System for Their Anticompetitive Contracts and Also Collecting Damages for Plan Sponsors and Members, With Matt Cantor. EP514

    Jun 3

    Successfully Suing a Health System for Their Anticompetitive Contracts and Also Collecting Damages for Plan Sponsors and Members, With Matt Cantor. EP514

    How the Sutter Health Antitrust Case Opened the Door for Employers and Members to Recover Hospital Overcharge Damages What happens when a self-insured employer or health plan member finally says enough is enough and takes a consolidated hospital system to court over anticompetitive contracting practices? That's exactly what antitrust attorney Matthew Cantor did — and after 13 years of litigation, three trips to the Ninth Circuit Court of Appeals, and a first trial, he and his team secured a landmark $228.5 million settlement in Sidibe v. Sutter Health. In this episode, Stacey Richter speaks with Matthew Cantor, JD, founding partner of Shinder Cantor Lerner LLP, about one of the most significant antitrust victories in healthcare history — and what it means for self-insured employers, plan sponsors, and everyday members who have been paying inflated premiums because of hospital market power. WHAT YOU'LL LEARN ✅ How all-or-nothing clauses and anti-steering/anti-tiering provisions allow dominant hospital systems to lock up local geographies and block members from accessing lower-cost, higher-quality care ✅ Why holding large, consolidated health systems legally accountable is so difficult — including the halo effect, the FTC's lack of jurisdiction over nonprofits, and the challenges of unsympathetic witnesses ✅ How Sidibe v. Sutter Health established a groundbreaking precedent allowing indirect purchasers — employers and plan members paying inflated premiums — to recover damages from hospital overcharges ✅ Why the DOJ is already pursuing similar anti-steering litigation against health systems like OhioHealth and NewYork-Presbyterian ✅ Four concrete options for employers ready to stop being passive price takers: federal legislation, state legislation, engaging the DOJ and state attorneys general, and direct litigation WHY THIS MATTERS Hospital charges make up roughly 50% of underlying medical costs, which in turn represent 80–85% of health insurance premiums. When consolidated systems operate in local markets with little competition, everyone — employers and members alike — pays more. Sidibe v. Sutter Health shows that accountability is possible. MENTIONED IN THIS EPISODE EP512 with Doug Aldeen: Apple Podcasts | Spotify | Other Apps EP452 with Cora Opsahl: Apple Podcasts | Spotify | Other Apps EP458 with Komal Bajaj, MD: Apple Podcasts | Spotify | Other Apps EP466 with Vivian Ho, PhD: Apple Podcasts | Spotify | Other Apps EP513 with Brennan Bilberry: Apple Podcasts | Spotify | Other Apps   LinkedIn Post by Kimberly Carleson LinkedIn Comment by Daron Pitts LinkedIn Comment by Thomas Frangione EP501 with Ivana Krajcinovic, PhD: Apple Podcasts | Spotify | Other Apps EP436 with Elizabeth Mitchell: Apple Podcasts | Spotify | Other Apps EP491 with Elizabeth Mitchell: Apple Podcasts | Spotify | Other Apps EP509 with Patrick Nelli: 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 TIMESTAMPS 00:00 Introduction to this episode. 04:26 Why does the halo effect make it difficult to hold hospitals accountable? 06:16 Why the case around this episode matters. 09:31 The conversation with Matt Cantor. 09:36 The brief background of how we got here. 10:55 The Sutter litigation: an overview. 12:57 Local geography versus local market. 17:50 Why litigation? 23:50 Why are these cases so difficult? 27:36 What Matt Cantor thinks will be the future of litigation against these hospital systems. 28:11 Why Sutter? 31:21 What led to the ultimate victory in the Sutter case. 37:52 What is possible for employers now? 40:54 Antitrust enforcers that employers should consider. 41:49 The greatest challenge in fighting healthcare costs and medical spend.

    44 min
  6. Revisiting Cunning Anticompetitive Hospital Contracts, With Brennan Bilberry - EP513

    May 27

    Revisiting Cunning Anticompetitive Hospital Contracts, With Brennan Bilberry - EP513

    The Hospital Contract Playbook: Four Clauses That Turn Market Power Into Higher Prices. Episode 513. Across the country, hospital systems have used their growing market power to write four specific contract terms into their deals with insurers — terms that all but guarantee higher prices for employers, unions, and patients, regardless of quality or competition nearby. In this episode, Stacey Richter speaks with Brennan Bilberry, founding partner of Fairmark Partners, an antitrust law firm that has sued multiple dominant hospital systems, about exactly how those four contract terms work, clause by clause, and why they set the stage for the litigation explored in next week's episode with Matt Cantor. WHAT YOU'LL LEARN ✅ How all-or-nothing contracting forces insurers and employers to accept every facility in a hospital system's network — including overpriced urban hospitals — just to get access to a single must-have rural facility, a tactic central to Sutter Health's $575 million antitrust settlement in one of two cases brought against it ✅ How anti-steering and anti-tiering clauses block health plans from directing members to lower-cost, equal-quality care — illustrated by a market where a C-section costs $44,000 at one hospital and $21,000 two miles away, and by the government's case against Atrium Health in North Carolina ✅ How price gag clauses prevent insurers and TPAs from telling self-funded employers what they're actually paying for care, even after recent transparency rules — including a case where North Carolina's state treasurer received hundreds of redacted pages when he requested UNC Healthcare's prices ✅ How dominant hospital systems squeeze nominally independent physician practices into charging hospital-level prices without ever buying them outright — in one North Texas market, this drove prices up $100 million in a single year ✅ Why these four contract terms reinforce each other — block steering and a plan can't build narrow networks; restrict independent providers and there's nowhere cheaper left to steer to — making each successive workaround harder for plan sponsors to use WHY THIS MATTERS From 1998 to 2015 there were 1,500 hospital mergers, and the pace has only accelerated since — today, most physicians no longer own the practices where they work. Anticompetitive contract terms are what let that consolidation translate directly into higher prices for employers and patients. Understanding the playbook clause by clause, as laid out here, is the first step toward fighting it. MENTIONED IN THIS EPISODE EP373 with Cora Opsahl: Apple Podcasts | Spotify | Other Apps EP452 with Cora Opsahl: Apple Podcasts | Spotify | Other Apps Post by Tricia Schildhouse EP249 with Dale Folwell: Apple Podcasts | Spotify | Other Apps EP391 with Scott Conard, MD: Apple Podcasts | Spotify | Other Apps EP389 with Mike Thompson: Apple Podcasts | Spotify | Other Apps EP390 with Gloria Sachdev, PharmD, and Chris Skisak, PhD: 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 TIMESTAMPS 00:00 Introduction to this episode. 06:55 The conversation with Brennan Bilberry. 06:59 What happens after a hospital consolidates? 08:05 What an anticompetitive system looks like when a hospital consolidates. 11:12 Some anticompetitive "tricks" that hospitals employ. 13:13 Example: the Sutter case in northern California. 15:36 What to do if you're forced to engage in an all-or-nothing contract with a hospital system. 19:17 Example: the Atrium case in North Carolina. 22:12 Explaining price gag clauses. 23:48 How legacy gag clauses are designed to prevent scrutiny in litigation. 26:21 How hospital restrictions on other providers create an anticompetitive environment.

    36 min
  7. 3 Kinds of Broker/EBC Rent-Seeking Payment Models—A Lawyer's Perspective, With Doug Aldeen. EP512

    May 27

    3 Kinds of Broker/EBC Rent-Seeking Payment Models—A Lawyer's Perspective, With Doug Aldeen. EP512

    A Lawyer's Field Guide to Rent-Seeking Broker and EBC Payment Models. Epsiode 512. Brokers and employee benefit consultants often get compensated in ways health plans never fully see — and even when the dollars are technically disclosed, the math can hide an enormous overcharge. In this episode, Stacey Richter speaks with Doug Aldeen, JD, an ERISA healthcare attorney who has spent decades in the self-funded space, about the legal danger zones where broker and EBC payment models go wrong: rent-seeking solution recommendations, undisclosed vendor payments, and front-loaded voluntary-benefits commissions — and the practical roadmap any plan sponsor can use to catch them before they cost millions. WHAT YOU'LL LEARN ✅ How a level-funded plan's broker was paid more than $2 million in fees while the plan itself ended up roughly $600,000 in deficit — a cautionary tale Stacey and Doug call the Ohio Potato Company story ✅ How reference-based pricing vendors using a "cost of savings" fee model can be incentivized by rising hospital prices — illustrated by a $10,000 CT scan repriced to $1,000, netting the vendor $1,800 on a $9,000 "savings," on top of underlying facility markups that can run as high as 17,000% ✅ How a balance-billing vendor collected $2.2 million in fees over three plan years to protect against just $94,320 in disputed claims — even in a state where the hospital had no legal authority to balance bill in the first place ✅ Why voluntary benefits commissions, often front-loaded at 70% to 90% in the first year, can make a product more profitable for the broker than useful for members ✅ A practical roadmap for plan sponsors to catch rent-seeking arrangements before they cost millions: ask why repeatedly, demystify the commission structure, run an independent broker RFP, audit plan and stop-loss documents for gaps, and build a real contract "out" WHY THIS MATTERS Self-funded employers often assume their broker or EBC's incentives are aligned with the plan's. But when compensation is tied to cost-of-savings formulas, undisclosed vendor relationships, or front-loaded commissions, the incentive can quietly flip — rewarding higher healthcare prices and unnecessary point solutions instead of genuine savings. Knowing where to look, and which questions to ask, is what separates a fiduciary from a rent-seeking target. MENTIONED IN THIS EPISODE EP457 with Cynthia Fisher: Apple Podcasts | Spotify | Other Apps EP508 with Lee Lewis: Apple Podcasts | Spotify | Other Apps EP379 with AJ Loiacono: Apple Podcasts | Spotify | Other Apps EP484 with Dave Chase: Apple Podcasts | Spotify | Other Apps 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 EP419 with Andreas Mang: 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 TIMESTAMPS 00:00 Introduction to this episode. 00:59 A caveat for the record on this episode. 02:11 The first problematic payment model discussed in this week's episode. 03:27 The second problematic payment model discussed in this week's episode. 06:16 The conversation with Doug Aldeen. 06:27 Why is reviewing broker/EBC compensation so important? 08:05 The Ohio Potato Company anecdote. 10:28 The first way brokers/EBCs might get paid. 11:45 What "cost of savings" means. 14:07 A rent-seeking solution that requires a cost-benefit analysis. 19:16 Why the broker/EBC is sometimes in the dark about vendor kickbacks. 21:46 Where the CAA is unclear. 24:04 Actionable advice for plan sponsors. 24:57 The second piece of actionable advice for plan sponsors. 25:22 The third piece of actionable advice for plan sponsors. 26:08 Demystifying the commission structure. 27:35 Using a broker RFP from an open source. 28:31 Why you should be auditing data and claims. 31:29 The importance of having an "out." 33:11 Why the broker community may be at substantial risk.

    37 min
  8. The Perverse Incentive Trap Hidden Inside Value-Based Care — and What to Do About It. EP512

    May 14

    The Perverse Incentive Trap Hidden Inside Value-Based Care — and What to Do About It. EP512

    When Risk-Based Payment Becomes Its Own Upcoding Arms Race. Episode 511 Medicare Advantage plans get paid more for sicker patients, which is why upcoding became a problem — and now health systems are upcoding visit complexity right back, with MA plans automatically downcoding in response. In this episode, Stacey Richter plays an unpublished clip from her conversation with Ahilan Sivaganesan, MD (Dr. Siva), a neurosurgeon and head of quality and value at Mishe Health, on why physicians must understand their own costs before taking on financial risk, then revisits an earlier conversation with Monica Lypson, MD, MHPE, vice dean for medical education at Columbia University Irving Medical Center, on whether handing health systems that same risk-based incentive could end up worsening the very disparities value-based care is meant to fix. WHAT YOU'LL LEARN ✅ Why Medicare Advantage plans' incentive to upcode patient complexity is now mirrored by health systems upcoding visit complexity — triggering automatic downcoding wars between MA plans and providers ✅ Why physicians can't responsibly go at risk for outcomes and costs without first understanding their own costs through time-driven activity-based costing — without it, Dr. Siva says, you're "jumping blind into an abyss," straight toward cherry-picking and lemon-dropping patients ✅ How sliding-scale bundled payments, calibrated to patient and procedure complexity rather than a flat lump sum, could let practices take on bundled risk without being punished for treating sicker patients ✅ Why handing health systems a sliding-scale risk adjustment framework risks recreating the same upcoding incentives that plagued Medicare Advantage, just one level up the chain ✅ How perverse incentives baked into value-based and risk-based contracting can worsen existing healthcare disparities when systems are structurally rewarded for avoiding complex or costly patients WHY THIS MATTERS Risk-based and value-based payment models are often framed as the fix for fee-for-service's worst incentives. But if the underlying cost data and risk-adjustment frameworks aren't built carefully, the same gaming that plagued Medicare Advantage — and fee-for-service before it — can simply move up the chain to health systems and physician practices, with disparities in care quietly bearing the cost. MENTIONED IN THIS EPISODE EP505 with Ahilan Sivaganesan, MD: Apple Podcasts | Spotify | Other Apps EP485 with Cristin Dickerson, MD: Apple Podcasts | Spotify | Other Apps EP436 with Elizabeth Mitchell: Apple Podcasts | Spotify | Other Apps EP491 with Elizabeth Mitchell: Apple Podcasts | Spotify | Other Apps SUMS9 with Elizabeth Mitchell: Apple Podcasts | Spotify | Other Apps EP462 with Scott Conard, MD: Apple Podcasts | Spotify | Other Apps EP319 with Grace Terrell, MD: Apple Podcasts | Spotify | Other Apps EP431 with Kenny Cole, MD: Apple Podcasts | Spotify | Other Apps EP409 with Larry Bauer, MSW, MEd: Apple Podcasts | Spotify | Other Apps EP495 with Mick Connors, MD: Apple Podcasts | Spotify | Other Apps LinkedIn Post by Mark Weber EP484 with Dave Chase: 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 TIMESTAMPS 00:00 Introduction to this episode. 05:22 What is the minimum requirement for physicians to go at risk? 07:22 How sliding scale bundle payments can reduce risk for physicians. 10:43 The question covered in the upcoming episode. 13:19 Is value-based care good for underserved communities? 15:01 "If you create perverse incentives, you actually might make known healthcare disparities worse … to meet the demand's value." —Dr. Lypson 16:18 "There actually might be systematic and structural ways that the healthcare system might say … we're not interested in taking care of you." —Dr. Lypson 16:51 "The incentive to have a good outcome is not there; the incentive to have another visit is there." —Dr. Lypson 17:49 "The only indictment I have on the fee-for-service system is that it's gotten us to where we are right now." —Dr. Lypson 18:41 "If you don't have any connection in that system, even the provider trying to … provide a good outcome might be disconnected because the system is not in place to … connect the dots." —Dr. Lypson 19:28 What are the must-haves for a value-based system that create the patient outcomes we need? 19:51 What is a whole health model? 25:31 Why we need to fix the structural issues if we want to fix health. 26:00 Why a patient's bias is the one we want in the room. 27:36 Stacey's conclusion on this week's episode.

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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
    650
  • Rating
    Clean
  • Copyright
    ©BD Bridges LLC, All Rights Reserved.
  • Show Website
    Relentless Health Value

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