Relentless Health Value

EP531: 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.

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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.

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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.

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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.

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Why Should a Plan Sponsor Care About the 340B Charity Program? With Shawn Gremminger

How the 340B Drug Discount Program Quietly Raises Costs for Self-Insured Employers. Episode 527. Why should a self-insured employer care about the 340B charity program? That's the single question Stacey Richter puts to Shawn Gremminger, president and CEO of the National Alliance of Healthcare Purchaser Coalitions, in this episode—and his answer traces four ways the $68 billion program quietly drives up what employers and plan sponsors pay for drugs and medical care. From supercharged hospital consolidation to disappearing PBM rebates, Gremminger lays out why 340B, once treated as a niche topic, now sits squarely at the center of the drug pricing debate. WHAT YOU'LL LEARN ✅ Why 340B—now the second-largest drug purchasing program in the country at roughly $68 billion a year—matters directly to self-insured employers, not just to pharma and hospitals ✅ How 340B-driven hospital consolidation pushes up prices for all services, not just drugs, since hospital spend typically makes up 55–58% of total employer health plan costs ✅ Why 340B hospitals tend to mark up drugs even more aggressively than non-340B hospitals, and why 340B clinics disproportionately prescribe higher-priced drugs over cheaper alternatives ✅ How the Inflation Reduction Act's drug price caps are reportedly pushing some 340B entities to nonmedically switch patients toward non-IRA, higher-margin drugs ✅ Why employers lose access to PBM-negotiated rebates entirely whenever a drug is purchased through the 340B channel instead of the traditional channel ✅ Why Shawn Gremminger argues employers, purchasers, and policymakers need to stop treating 340B as a separate, carved-out issue from the broader drug pricing debate WHY THIS MATTERS Hospital spend already makes up more than half of a typical self-insured employer's healthcare costs, and 340B's distortions—inflated markups, prescribing skewed toward higher-priced drugs, and vanishing rebates—flow straight into that spend. A recent study found that for every point increase in hospital prices, non-healthcare employers respond by cutting payroll and jobs for middle-class workers. As 340B has grown from a niche $5–10 billion program into a $68 billion one, treating it as someone else's problem is no longer an option for anyone trying to understand or control drug pricing. MENTIONED IN THIS EPISODE Article: Brian Reid's Cost Curve Weekend newsletter, on pharma-hospital data-requirement lawsuits LinkedIn Post by Peter Hayes Article: "Reforming 340B to Serve the Interests of Patients, Not Institutions," by Anthony DiGiorgio, DO, MHA Article: "How a Company Makes Millions Off a Hospital Program Meant to Help the Poor," New York Times EP448 (Part 1 and Part 2) with Shawn Gremminger: Apple Podcasts | Spotify | Other Apps Study: Zack Cooper, PhD, on rising healthcare prices driving unemployment and job losses LinkedIn Post by Shawn Gremminger === 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. 01:02 What the 340B charity program does in a nutshell. 02:01 A summary of what's happening right now around the 340B charity program. 08:39 The conversation with Shawn Gremminger. 09:28 Why should you care from a patient and consumer advocate perspective? 12:09 Why we're seeing distorted pricing at 340B hospitals. 13:26 What happens when a drug is purchased through a 340B channel rather than a traditional channel. 14:50 A recap of the distortions caused by 340B. 16:19 A clarification on the IRA. 19:07 Why you shouldn't take a side in the "blame game."

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Mark Cuban and Cora Opsahl: The Truth About Pass-Through PBM Contracts and Generic Compliance Ratios

How Discount Theater and Generic Compliance Ratios Quietly Overcharge Patients and Employers. Episode 526. Mark Cuban, co-founder of Mark Cuban Cost Plus Drug Company, and Cora Opsahl, managing director of Peterson Health Analytics and former director of the 32BJ Health Fund, join Stacey Richter for an outtake from their conversation last fall (EP488) on the operational mechanics of the pharmacy supply chain. They trace how a generic compliance ratio—typically requiring pharmacies to buy at least 92% of their generics from a single primary wholesaler—pushes independent pharmacies into paying a premium that gets passed straight to patients, and how so-called pass-through PBM contracts can pay pharmacies using one pricing formula while billing employers using an entirely different one. Along the way, they walk through the classic generic imatinib example—a drug Cost Plus Drugs sells for $25 a month that a traditional PBM channel has billed at $9,000—to show why a discount off an inflated reference price is, as Cuban puts it, discount theater. WHAT YOU'LL LEARN ✅ Why pharmacies get locked into overpaying: wholesalers set a Generic Compliance Ratio requiring pharmacies to buy at least 92% of their generics from them or face chargebacks and fees that wipe out their margin ✅ The classic generic imatinib example: Cost Plus Drugs sells it for $25 a month, while the same drug billed through a traditional PBM channel has run $9,000 a month—a "discount" off a $27,000 branded Gleevec price that Mark Cuban calls discount theater ✅ How specialty tiers compound the problem: because generic imatinib gets classified on a specialty tier, patients can owe 25% coinsurance calculated off the inflated WAC price rather than the drug's real cost ✅ Why a "pass-through" PBM contract isn't simple math: Cora Opsahl explains that PBMs often reimburse pharmacies on an acquisition-cost-plus formula while billing employers a completely different AWP-minus formula for the same claim ✅ Why claims audits keep finding money owed back to the plan—and why employers are often restricted to auditing only a pre-approved sample of 250 claims ✅ Mark Cuban's advice for the next RFP: simply requiring that Cost Plus Drugs be included in the network is often enough on its own to get PBMs to offer better rebates and terms WHY THIS MATTERS As Stacey Richter puts it, where there's mystery, there's margin—and pharmacy pricing is thick with both. Generic compliance ratios, WAC-based specialty tiers, and pass-through contracts that pay pharmacies one number while billing employers another all point to the same underlying reality: so much of what gets called an expense in medicine is simply pricing failure. For plan sponsors and brokers heading into their next RFP, understanding these mechanics—rather than accepting a discount off an inflated reference price—is what it takes to move from passive price taker to informed decision maker. MENTIONED IN THIS EPISODE EP429 with Luke Slindee, PharmD: Apple Podcasts | Spotify | Other Apps EP488 with Mark Cuban and Cora Opsahl: Apple Podcasts | Spotify | Other Apps EP422 with Benjamin Jolley, PharmD: Apple Podcasts | Spotify | Other Apps EP465 with Chris Crawford: Apple Podcasts | Spotify | Other Apps EP486 with Stan Schwartz, MD: Apple Podcasts | Spotify | Other Apps === LINKS === 🔗 Show Notes with all mentioned links: Episode Page ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter 🫙 Support the podcast with a small donation to the Tip Jar 📺 Subscribe to our YouTube channel 🎤 Listen on Apple Podcasts 🎤 Listen on Spotify === CONNECT WITH THE RHV TEAM === ✭ LinkedIn ✭ Threads ✭ Bluesky ✭ X 00:00 Introduction to this episode. 03:43 An overview of today's conversation. 05:59 Today's conversation with Mark Cuban and Cora Opsahl. 07:25 Why discounts are meaningless without knowing the absolute price. 09:29 What a generic compliance ratio does. 12:28 Thinking about the demand side for employers. 15:00 The complication of a pass-through contract. 17:48 Why too much of healthcare comes down to a negotiation.

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PMPM vs FFS—The Perverse Incentives Plan Sponsors Sometimes Miss, With Cristin Dickerson, MD

Four Questions Plan Sponsors Should Ask Before Choosing PMPM or Fee-for-Service. Episode 525. This episode is a tangent that never made it into the final cut of Stacey Richter's original conversation with Cristin Dickerson, MD, founding partner of Green Imaging, a physician-led radiology network built on direct contracting for imaging. In episode 485, they discussed how imaging can run 6% to 11% of total plan sponsor spend and how direct contracting brings that down while improving access; this outtake is where they got into the harder question underneath it — whether PMPM (per member per month) capitated payments create their own new perverse incentives, potentially just as strange as the old-fashioned fee-for-service kind, depending on who's holding the risk and why. It's a natural follow-on to last week's conversation with John Quinn (EP524) on buying healthcare like a supply chain of defined "pods of care." WHAT YOU'LL LEARN ✅ Why Dr. Dickerson says fee-for-service can reduce perverse incentives compared with a PMPM subscription — Green Imaging charges no PEPM or admin fees and takes on the risk that its services simply won't be used ✅ How radiologist protocols and appropriateness guidelines let Green Imaging cut unnecessary imaging — switching a CT to an MRI, or skipping unneeded contrast — while showing 60% to 90% documented savings for employers ✅ Why not being the referring physician removes Green Imaging's financial incentive to drive up volume, which Stacey Richter identifies as the real test of whether a fee-for-service model has mitigated its own perverse incentive ✅ The four factors Stacey Richter says plan sponsors should weigh before choosing fee-for-service over PMPM: price beats the base network, the vendor (not the plan) drives its own volume and is auditable, the contract allows termination at will, and the plan's ASO contract actually permits carving out or steering to a high-value provider ✅ Why Stacey Richter argues there isn't just one "fee-for-service" — pricing you can see and verify against what you're billed is a fundamentally different model than a discount-based fee-for-service that hides the real price and can add 20% or more in revenue-cycle "hot potato" costs ✅ How this conversation builds on John Quinn's supply-chain framing from EP524: treating a bounded, clearly defined "pod of care" as something to procure competitively, regardless of which payment model is attached to it WHY THIS MATTERS Value-based care is often framed as the fix for fee-for-service's volume-driving perverse incentives, but a PMPM subscription simply moves the risk instead of eliminating it — the purchaser now pays whether or not the service is used, and different accountability failures can follow. Dr. Dickerson's model works not just because it's fee-for-service, but because it's fee-for-service structured so the vendor can't drive volume, the pricing is transparent, and the contract can be ended at any time. For self-insured employers and plan sponsors choosing how to pay for a defined pod of care, the payment model matters less than these underlying safeguards. MENTIONED IN THIS EPISODE EP485 with Cristin Dickerson, MD: Apple Podcasts | Spotify | Other Apps EP524 with John Quinn: Apple Podcasts | Spotify | Other Apps EP521 with Andrew Tsang: Apple Podcasts | Spotify | Other Apps LinkedIn Post by Ryan Kline EP482 with Preston Alexander: Apple Podcasts | Spotify | Other Apps EP445 with Tom X. Lee, 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 📺 Subscribe to our YouTube channel 🎤 Listen on Apple Podcasts 🎤 Listen on Spotify === CONNECT WITH THE RHV TEAM === ✭ LinkedIn ✭ Threads ✭ Bluesky ✭ X 00:00 Introduction to this episode. 01:15 What today's conversation entails. 06:36 The conversation with Dr. Cristin Dickerson. 07:13 In a PMPM scenario, who is taking the risk? 10:44 What mitigates the perverse incentive to drive up volume. 12:18 The other difference between PMPM and fee for service.

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Beating Provider Network Pricing Games by Thinking About Buying Healthcare Like a Manufacturer Supply Chain, With John Quinn

John Quinn, founder and CEO of Wellnecity, joins Stacey Richter in episode 524 for an outtake from their conversation last fall on rethinking how self-insured employers build their provider networks. Rather than treating the network as one big, undifferentiated system, Quinn argues employers should think like a manufacturing supply chain: break healthcare into defined "subassemblies," or pods of care — pediatric care, a cancer journey, a kidney stone episode — and direct-contract for those pods whenever the price beats the fee-for-service average. If the boundaries of the pod are clear and the price comes in lower, Quinn says, the plan and the member both win, quality being equal. WHAT YOU'LL LEARN ✅ Why Stacey Richter says the provider-network debate could fill "a 20-hour show," and why networks still have real upsides — administrative infrastructure, claims coordination, guaranteed provider payment, and broad access — even as critics like Mark Cuban ask on LinkedIn, "Why do we need networks? It is just a way for insurers to play pricing games." ✅ A real example of network rigidity: a self-insured employer identified 40 physicians who cost the plan upwards of $15 million in a single plan year while patient harm was occurring, and their ASO couldn't figure out how to remove those doctors from network under the existing contract structure ✅ How John Quinn defines a "subassembly" or "pod of care" — a bounded, definable episode like pediatric care or a cancer journey — and why purchasing that pod for less than the fee-for-service average is a win for the plan and member, assuming quality stays neutral ✅ Quinn's kidney stone example: a physician who says he can now treat a kidney stone in a 48-hour to five-day episode for roughly $2,000 to $3,000, versus the typical six weeks of pain, overuse of pain medication, and a price north of $10,000 ✅ Why Quinn frames network optimization as a manufacturing supply-chain problem — the same way an automobile gets built from subassemblies sourced from specialized providers around the globe — because it's a mental model CFOs and senior leadership at self-insured employers already trust ✅ Quinn's bottom line: "We have the tech and we've got the tools to do this at this point. We just have to get ourselves out of" the fee-for-service hangover WHY THIS MATTERS Provider networks have real tradeoffs: broad access and guaranteed payment on one side, opaque pricing and rigid contracts on the other. John Quinn's pitch to self-insured employers isn't to blow up the network model, but to layer bounded, directly contracted "pods of care" on top of it wherever a clear price beats the fee-for-service average. Framing that as supply-chain sourcing, rather than a wholesale network overhaul, gives risk-averse finance and HR leaders a model they already understand — and, Quinn argues, the technology to act on it already exists. MENTIONED IN THIS EPISODE LinkedIn Post by Mark Cuban Article: Medical Economics, "An Idea Whose Time Has Gone: Healthcare Provider Networks," by Jim Jusko, JD EP457 with Cynthia Fisher: Apple Podcasts | Spotify | Other Apps EP433 with Justin Leader: Apple Podcasts | Spotify | Other Apps EP501 with Ivana Krajcinovic, PhD: Apple Podcasts | Spotify | Other Apps EP503 with Ryan Wells; Leo Spector, MD, MBA; and Adam Stavisky: Apple Podcasts | Spotify | Other Apps EP485 with Cristin Dickerson, MD: Apple Podcasts | Spotify | Other Apps EP486 with Stan Schwartz, MD: Apple Podcasts | Spotify | Other Apps EP493 with John Quinn: Apple Podcasts | Spotify | Other Apps EP495 with Mick Connors, MD: Apple Podcasts | Spotify | Other Apps EP505 with Ahilan Sivaganesan, MD: Apple Podcasts | Spotify | Other Apps === LINKS === 🔗 Show Notes with all mentioned links: Episode Page ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter 🫙 Support the podcast with a small donation to the Tip Jar 📺 Subscribe to our YouTube channel 🎤 Listen on Apple Podcasts 🎤 Listen on Spotify === CONNECT WITH THE RHV TEAM === ✭ LinkedIn ✭ Threads ✭ Bluesky ✭ X 00:00 Introduction to this episode. 00:50 LinkedIn post by Mark Cuban. 01:16 EP457 with Cynthia Fisher. 01:20 EP433 with Justin Leader. 01:29 Medical Economics article by Jim Jusko, JD. 03:01 EP501 with Ivana Krajcinovic, PhD. 04:22 A breakdown of what's to come in today's conversation. 06:11 EP503 with Ryan Wells; Leo Spector, MD, MBA; and Adam Stavisky. 06:34 EP485 with Cristin Dickerson, MD. 06:49 EP486 with Stan Schwartz, MD. 07:07 EP493 with John Quinn. 07:57 The conversation with John Quinn. 10:06 Is calculating value realistic? 11:38 Looking at value calculation through an assembly lens. 14:54 The takeaway. 15:17 EP495 with Mick Connors, MD. 15:20 EP505 with Ahilan Sivaganesan, MD.

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The Sleeping Giants of Healthcare—Why Self-insured Employers and Clinicians Keep Missing Each Other, With Suhas Gondi, MD, MBA. EP523

Why Self-Insured Employers and Clinicians Keep Missing Each Other, With Suhas Gondi, MD. The Sleeping Giants of Healthcare: Why Employers and Clinicians Keep Missing Each Other. Episode 523. Dr. Suhas Gondi, MD, MBA, chief medical officer at Health Strategy and an attending physician at Massachusetts General Hospital, co-wrote a New England Journal of Medicine article — "A Sleeping Giant of Health Care Affordability—Self-Insured Employers" — because most clinicians, he found, have little idea a self-insured employer, not an insurance carrier, is the one actually paying for their patients' care. Talking with Stacey Richter, Dr. Gondi argues that self-insured employers and clinicians are both "sleeping giants," each holding real power over cost and access, who rarely communicate directly — leaving patients caught in the gap. WHAT YOU'LL LEARN ✅ Why Dr. Suhas Gondi and his NEJM co-author, Zirui Song, MD, PhD, wrote for clinicians who, they found, have little sense that a self-insured employer — not the carrier name on the card — actually pays for a patient's care ✅ How a GLP-1 prescription can get denied at the pharmacy counter even after a clinician verifies coverage, because the employer has quietly moved GLP-1 coverage exclusively through a single third-party prescribing and coaching vendor ✅ Why GLP-1 spending alone can push a self-insured employer's pharmacy costs up 9% to 20% in a year, and why the roughly eight-year payback period employers are counting on assumes patients stay adherent far longer than most actually do ✅ How oncology site-of-care steering — an employer declining to pay a roughly 40% premium for infusion at a hospital-owned center instead of a physician's office — can look to the patient and oncologist like a denied cancer drug ✅ Why Dr. Gondi says EHRs like Epic are built to optimize revenue for hospital-system customers, not to surface a lower-cost site of care for patients or plan sponsors ✅ Dr. Gondi's advice for closing the gap: clinicians and employers should communicate directly, especially before a coverage change lands on patients, rather than assuming direct contracting is the only fix WHY THIS MATTERS Roughly half to 60% of the US population has commercial insurance, and nearly three-quarters of large employers self-insure that coverage — yet most clinicians have no visibility into the plan-level decisions those employers make, and most employers have no channel to explain those decisions to the doctors whose patients are affected. Both sides, Dr. Gondi says, usually believe they're doing the right thing — covering the GLP-1, covering the cancer drug — and the patient still gets lost in between. Closing that gap doesn't require full direct contracting, he argues, just employers and local provider groups actually talking to each other before a coverage change lands on a patient, not after. MENTIONED IN THIS EPISODE Study: New England Journal of Medicine article, "A Sleeping Giant of Health Care Affordability—Self-Insured Employers," by Suhas Gondi, MD, MBA, and Zirui Song, MD, PhD EP406 with Lauren Vela: Apple Podcasts | Spotify | Other Apps EP519 with Lisa Rosenbaum, MD: Apple Podcasts | Spotify | Other Apps EP509 with Patrick Nelli: Apple Podcasts | Spotify | Other Apps EP494 with Sarah Emond: Apple Podcasts | Spotify | Other Apps EP501 with Ivana Krajcinovic, PhD: Apple Podcasts | Spotify | Other Apps EP468 with Matt McQuide: Apple Podcasts | Spotify | Other Apps Article: Acquired's episode on how Epic quietly powers American healthcare === LINKS === 🔗 Show Notes with all mentioned links: Episode Page ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter 🫙 Support the podcast with a small donation to the Tip Jar 📺 Subscribe to our YouTube channel 🎤 Listen on Apple Podcasts 🎤 Listen on Spotify === CONNECT WITH THE RHV TEAM === ✭ LinkedIn ✭ Threads ✭ Bluesky ✭ X 00:00 Introduction to this episode. 00:35 A big thank you. 06:22 The conversation with Dr. Suhas Gondi. 07:08 Why Dr. Suhas Gondi and his coauthor wrote their article. 09:24 Why the affordability of care and the decisions self-employers are making about coverage matter to clinicians. 12:12 What the term "sleeping giants" implies and how that reflects the reality of healthcare. 14:31 A case study. 21:24 How the patient can still get lost even when both the employer and clinician think they're doing the right thing. 22:52 An example from the oncology space. 28:47 Dr. Suhas Gondi's advice to clinicians. 30:55 The communication gap between clinicians and employers. 33:30 Why the presence of middlemen should not prevent communication between clinicians and employers.

How GoodRx Actually Makes Money: PBMs, Cash Prices, and Pharmacy Contracts, With Ge Bai, PhD, CPA (EP522)

Ask Me Anything: How Does GoodRx Actually Make Money, and Who Really Pays for the Discount? Episode 522. A listener asked Stacey Richter a deceptively simple question: how exactly does GoodRx make money? To answer it, this AMA episode revisits a 2021 conversation with Ge Bai, PhD, CPA, professor of accounting at the Johns Hopkins Carey Business School and of health policy and management at the Johns Hopkins Bloomberg School of Public Health, recently nominated to serve as Assistant Secretary at the Department of Health and Human Services (HHS). Ge Bai lays out exactly how GoodRx turns pharmacy-PBM contract dysfunction into a business, and Stacey updates listeners on what's changed—and what hasn't—in the years since. WHAT YOU'LL LEARN ✅ Why GoodRx is purely a pricing platform with no pharmacy of its own—unlike Amazon, which operates its own pharmacy ✅ How PBM contracts requiring pharmacies to offer insurers their "best price" force cash list prices artificially high, the exact dysfunction GoodRx monetizes ✅ How GoodRx's network of contracted PBMs—including Express Scripts and OptumRx—collects a per-dispense fee every time a patient uses a GoodRx card ✅ Why pharmacies lose out twice: they never collect their high list price, and they still owe a fee to the PBM that "referred" the cash-pay patient to them ✅ What's changed since 2021: a wave of new cash-pay competitors like Mark Cuban Cost Plus Drugs, GLP-1-driven cash-pay behavior, and proposed legislation targeting "Most Favored Nation" (lesser-of) clauses in PBM contracts ✅ Ge Bai's recent nomination to Assistant Secretary at HHS, building on research she has used to testify before Congress and shape healthcare policy WHY THIS MATTERS GoodRx's entire business model runs on a single structural quirk: PBM contracts require pharmacies to keep their list price higher than any insurer's negotiated rate, which pushes cash prices artificially high for anyone without a coupon. As Stacey Richter puts it, this dysfunction "is sadly pretty much the same" today as when Ge Bai first explained it in 2021, even as new cash-pay entrants and proposed "Most Favored Nation" contract restrictions start to reshape the landscape. MENTIONED IN THIS EPISODE EP520 with Stacey: Apple Podcasts | Spotify | Other Apps EP517 with Stacey: Apple Podcasts | Spotify | Other Apps EP516 with Ophelia Johnson: Apple Podcasts | Spotify | Other Apps EP439 with Luke Slindee, PharmD: Apple Podcasts | Spotify | Other Apps === LINKS === 🔗 Show Notes with all mentioned links: [Show Notes link — episode not yet live, add once published] ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter: newsletter 🫙 Support the podcast with a small donation to the Tip Jar 🎤 Listen on Apple Podcasts 🎤 Listen on Spotify 📺 Subscribe to our YouTube channel === CONNECT WITH THE RHV TEAM === ✭ LinkedIn ✭ Threads ✭ Bluesky ✭ X 00:00 Introduction to this episode. 06:22 The conversation with Ge Bai. 06:28 The difference between GoodRx and Amazon Pharmacy? 06:53 The one thing GoodRx makes money from. 07:55 How is GoodRx getting paid? 08:18 Are there middlemen in GoodRx's financial model? 09:25 How PBMs play into the GoodRx model. 10:29 Where the pharmacy fits into the deals created by GoodRx. 11:59 What's changed since this conversation with Ge Bai.

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How Revenue Cycle Management (RCM) Became an Over $200 Billion Healthcare Hot Potato, With Andrew Tsang. EP521

RCM: Why Revenue Cycle Management Is Healthcare's $200B Hot Potato, With Andrew Tsang (EP521) How Revenue Cycle Management (RCM) Became an Over $200 Billion Healthcare Hot Potato. Episode 521. Revenue cycle management (RCM) sounds like the least sexy phrase in healthcare — a back-office spreadsheet problem. It isn't. Andrew Tsang, an independent healthcare analyst and writer of the Substack Health Is Other People, with 15+ years across providers, payers, consulting, and policy, joins Stacey Richter to unpack how RCM has grown into a $200-plus-billion industry that eats roughly a third of every healthcare dollar spent — not on care, but on the fight over who pays for it. Together they trace RCM's front end, middle, and back end, and the "hot potato" that lands on whoever has the least leverage to fight back. WHAT YOU'LL LEARN ✅ How revenue cycle management (RCM) grew into a $200-plus-billion industry — Andrew Tsang puts RCM-related market cap at roughly $217 billion, and estimates roughly a third of every healthcare dollar goes to the fight over payment, not to care ✅ The three phases of RCM (front-end eligibility and prior authorization, middle clinical coding, and back-end claims adjudication and appeals) and why the "hot potato" of financial responsibility lands on whoever has the least administrative leverage — patients, independent practices, or self-funded employers ✅ Why a routine screening colonoscopy can flip to a diagnostic procedure — and an unexpected bill — the moment a polyp is found, even though the ACA mandates the screening itself be free ✅ How the prior authorization burden (physicians average roughly 39 prior auths a week) forces independent practices to compete on administrative capacity rather than clinical outcomes, accelerating consolidation into larger health systems ✅ Why self-funded employers face their own version of the hot potato through stop-loss "lasering," where a stop-loss carrier can exclude a specific high-cost employee from coverage after a catastrophic claim ✅ Why direct contracting — agreeing on price upfront — is Andrew Tsang's proposed way to opt out of the RCM hot potato game entirely WHY THIS MATTERS Revenue cycle management isn't a niche back-office function — it's a $200-plus-billion economy built on claim-by-claim fights over who pays. As Stacey Richter puts it, this isn't a story about villains; it's a story about an industry built around claim-by-claim fistfights. Whoever has the least administrative leverage in any given moment — patient, independent practice, or self-funded employer — is the one who winds up eating the cost. MENTIONED IN THIS EPISODE LinkedIn Post by Andrew Tsang, featuring his Revenue Cycle Market Landscape interactive chart EP497 with Zack Kanter: Apple Podcasts | Spotify | Other Apps EP363 with David Scheinker, PhD: Apple Podcasts | Spotify | Other Apps LinkedIn Post by Sheri Mancini, MD, FACS EP494 with Sarah Emond: Apple Podcasts | Spotify | Other Apps === LINKS === 🔗 Show Notes with all mentioned links: Episode Page ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter 🫙 Support the podcast with a small donation to the Tip Jar 📺 Subscribe to our YouTube channel 🎤 Listen on Apple Podcasts 🎤 Listen on Spotify === CONNECT WITH THE RHV TEAM === ✭ LinkedIn ✭ Threads ✭ Bluesky ✭ X 00:00 Introduction to this episode. 02:13 What revenue cycle management is. 03:22 How RCM is an endless game of hot potato. 07:10 The conversation with Andrew Tsang. 08:24 Is it actually a cycle? 08:54 How big the RCM industry actually is. 09:49 Defining revenue cycle management. 12:13 Why patients may spend more time doing revenue cycle tasks than with their doctor. 17:12 Who pays and why? 19:56 An example of RCM working within something like a colonoscopy. 22:55 The worst part about this whole revenue cycle. 24:49 How RCM affects independent doctors. 29:51 How RCM affects self-funded employers and stop-loss carriers.

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Cash-Pay Generic Drugs Are a Functioning Market in Healthcare—Policymakers Beware and Be Careful. EP520

Cash-Pay Generic Drugs and the PBM Spread Pricing Problem (EP520) Cash-pay generic drugs are one of the few corners of US healthcare where a real, functioning market already exists — which is why Stacey Richter argues policymakers need to tread carefully when trying to "fix" drug affordability. In this solo episode, Stacey explains why cash generic prices can run as low as $1 a prescription, then plays clips from four past guests — Ge Bai, PhD, CPA; Bryce Platt, PharmD; Benjamin Jolley, PharmD; and Luke Slindee, PharmD — showing how inserting a PBM extracts $41 out of every $100 spent, leaving patients paying more for the "privilege" of using their insurance. WHAT YOU'LL LEARN ✅ Why cash-pay generic drugs are one of the few genuinely functioning markets left in US healthcare, with multisource manufacturer competition keeping prices as low as $1 to $18 per prescription ✅ Why using insurance/PBM coverage makes the 20 most prescribed generics more expensive 43% of the time overall, and up to 79% of the time in the deductible phase, per Ge Bai, PhD, CPA's research in Annals of Internal Medicine ✅ How PBMs extract $41 out of every $100 spent on generic drugs that cost roughly 47 cents to manufacture, largely through the administrative overhead of risk pooling ✅ How Most Favored Nation "lesser of" clauses in PBM-pharmacy contracts punish pharmacies for lowering their cash prices, and why Luke Slindee, PharmD, argues removing that single clause could unlock a more robust cash-pay market without pulling generics from insurance entirely ✅ Why generic drug adoption has slowed from about one month to six months to reach peak uptake, which Bryce Platt, PharmD, ties to PBM formulary control rather than reduced competition or prescriber resistance ✅ Four policy ideas Stacey floats for keeping generics affordable without wrecking the underlying market: eliminating MFN clauses, funded wallets or prepaid cards, pre-funded cash-pay pharmacy relationships, and removing generics from PBM adjudication entirely WHY THIS MATTERS Generic drugs are one of the only truly functioning markets left in US healthcare, and cash prices are already low because of it. But policymakers trying to make medications more affordable often reach for the same lever — routing everything through insurance/PBM adjudication — which the data shows frequently raises what patients pay while handing PBMs a 41-cent cut of every dollar spent. As Stacey puts it, "you have to be really careful what levers you push because you can't see what they're attached to," and the wrong fix could break the one part of healthcare that's actually working. MENTIONED IN THIS EPISODE EP444 with Ann Kempski: Apple Podcasts | Spotify | Other Apps LinkedIn Post by Bryce Platt, PharmD EP495 with Mick Connors, MD: Apple Podcasts | Spotify | Other Apps EP420 with Ge Bai, PhD, CPA: Apple Podcasts | Spotify | Other Apps EP422 with Benjamin Jolley, PharmD: Apple Podcasts | Spotify | Other Apps EP517 with Stacey: Apple Podcasts | Spotify | Other Apps LinkedIn Post by Bryce Platt, PharmD EP439 with Luke Slindee, PharmD: Apple Podcasts | Spotify | Other Apps LinkedIn Post by Patrick Moore EP465 with Chris Crawford: 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 📺 Subscribe to our YouTube channel 🎤 Listen on Apple Podcasts 🎤 Listen on Spotify === CONNECT WITH THE RHV TEAM === ✭ LinkedIn ✭ Threads ✭ Bluesky ✭ X 00:00 Introduction to this episode. 03:48 Intermediaries versus functioning markets. 05:30 The use case for today's episode. 10:56 The reason why cash-pay generics are cheap right now. 11:42 The value proposition of PBMs versus cheap generics. 16:09 What risk pooling is and how it plays into all of this. 26:16 Solutions to keeping generics affordable.

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Cognitive Atrophy and Referral Incentives Breaking Primary Care, With Lisa Rosenbaum, MD (EP519)

Cognitive Atrophy and Referral Incentives Breaking Primary Care, With Lisa Rosenbaum, MD (EP519) Primary care physicians are leaving traditional practice for concierge medicine in visible numbers—and the question is whether that exodus is an unavoidable consequence of how the system is built, or something we've simply chosen not to fix. Stacey Richter talks with Dr. Lisa Rosenbaum, a cardiologist at Beth Israel Deaconess Medical Center (BIDMC) and national correspondent for the New England Journal of Medicine , who recently devoted an entire season of her NEJM podcast, Not Otherwise Specified , to the state of primary care. Together they test three forces reshaping the field—cognitive atrophy, referral incentives, and care fragmentation—against a single question: inevitable, or fixable? WHAT YOU'LL LEARN ✅ Why Dr. Lisa Rosenbaum calls the risk of "cognitive atrophy" among primary care physicians a generational threat rather than an individual one—and why she believes it is not inevitable ✅ How financial incentives that pay far more for a specialist visit than a primary care visit (roughly 5% of healthcare dollars for close to 35% of outpatient visits) structurally push referrals earlier and more often than necessary ✅ Why "relational expertise"—the judgment a doctor builds by knowing a patient over time—is, in Dr. Rosenbaum's view, primary care's real and undervalued skill set ✅ How care fragmentation, illustrated by Miriam Paramore's LinkedIn essay about her father's end-of-life care, leaves patients bouncing among specialists with no one taking ownership of the whole picture ✅ Why Dr. Rosenbaum argues that blaming everything on structural constraints "strip[s] ourselves of our own agency," and what she thinks physicians and healthcare buyers should each do about it WHY THIS MATTERS Roughly 70% of physicians are employed today, and about 5% of every healthcare dollar goes to primary care despite it covering close to 35% of all outpatient visits—numbers that, per Dr. Rosenbaum, reflect choices the system has made, not laws of nature. When primary care doctors lose the time and incentive to build relationships with patients, the system loses its quarterback, and patients end up fragmented across specialists with no one accountable for the whole picture. Dr. Rosenbaum's core argument is that none of this is inevitable, but fixing it requires both structural change and individual physicians and healthcare buyers reclaiming their own agency. MENTIONED IN THIS EPISODE EP504 with Ryan Jacobs: Apple Podcasts | Spotify | Other Apps EP473 with Kenny Cole, MD: Apple Podcasts | Spotify EP391 with Scott Conard, MD: Apple Podcasts | Spotify | Other Apps Article: "Ordinary Rural Death: My Father's End-of-Life Journey" by Miriam Paramore EP409 with Larry Bauer, MSW, MEd: 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 📺 Subscribe to our YouTube channel 🎤 Listen on Apple Podcasts 🎤 Listen on Spotify === CONNECT WITH THE RHV TEAM === ✭ LinkedIn ✭ Threads ✭ Bluesky ✭ X 00:00 Introduction to this episode. 03:47 Cognitive atrophy: what is it in terms of primary care providers? 08:56 Why Lisa Rosenbaum, MD, did an entire series on primary care. 11:32 Why physicians need to practice at the top of their license. 13:54 Why a good internist is a "quarterback." 16:23 How family medicine and procedures play into skill atrophy. 20:21 The majority versus the minority in primary care. 21:00 Is cognitive atrophy inevitable for primary care providers? 23:34 Full-spectrum clinical scope versus referrals in primary care. 25:51 The fix for too many referrals in primary care. 27:36 Why the solution is not an either/or. 30:08 Longitudinal relationships versus fragmentation. 36:07 Is this inevitable, or is this fixable? 39:02 What every listener in a position of power needs to ask themselves.

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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: 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.

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

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.

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Cash Pay From the Pharma Manufacturer Point of View, With Ophelia Johnson (EP516)

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: 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. 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.

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Self-Insured Employers: SNF Fraud or Perverse Incentives? Understaffing, Gamed STAR Ratings, and Medicare Dollars at Skilled Nursing Facilities with Michelle Cera. EP515

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 Article: 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.

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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 This is Episode 514 (EP514) of Relentless Health Value. 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 Post by Kimberly Carleson Comment by Daron Pitts 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.

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Revisiting Cunning Anticompetitive Hospital Contracts, With Brennan Bilberry - EP513

The Hospital Contract Playbook: Four Clauses That Turn Market Power Into Higher Prices 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.

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 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.

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