Relentless Health Value

Only roughly 50% of new GLP-1 prescriptions were getting approved for coverage in 2023. From a plan sponsor's seat, that looks like pharmacy trend spiking 9%, 12%, even 20% year over year. From a pharma manufacturer's seat, it's half their prescriptions not getting filled. Same market, opposite problems — and that's exactly the lens this episode flips on.

In...

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 ti...

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 Circ...

Stacey Richter introduces Episode 513 of Relentless Health Value as a primer on anti-competitive hospital contracting with Brennan Bilberry of Fairmark Partners, setting up next week's interview with Matt Cantor, lead litigator in the Sutter Health antitrust class action that led to a $575 million settlement over alleged price inflation using market power.

Bilberry explains how hospital consolidation enables higher commercial rates...

What does it look like when a broker or employee benefit consultant is circling your plan like it's a gold mine? Doug Aldeen, a well-known attorney who has spent many years in the self-insured space, has seen exactly what falls all the way down to the level of legal action — and in this episode he breaks down the top categories of broker and EBC compensation arrangements that wind up costing plans millions. In one documented ...

If we want clinical teams to take on risk, we have to reckon with what that risk-taking actually incentivizes. In this episode, Stacey Richter weaves together conversations with two physicians to surface a tension she argues hasn't been said directly enough: the very mechanism we're counting on to fix healthcare — providers going at risk — has cherry picking and lemon dropping baked right into it. And the same organizat...

If someone makes more money when the patients or members they serve are worse off, call that profiteering. That's Stacey Richter's working definition heading into this conversation — and it's exactly the lens she applies to Medicare Advantage in 2026, a program she argues touches everyone, not just seniors. When big vertically integrated carriers negotiate their own Medicare Advantage rates and shift the difference to commerc...

Employer medical inflation has averaged 7.7% annually over the last 20 years — and that was in a historically low inflation environment, so the near-term number is likely closer to 8.5%. If your finance team is forecasting health benefits at CPI, you are already behind. That single number, put into an out-year model and left to compound, makes the case for bold action faster than any benefits presentation ever could.

In this ...

One company at the Health Transformation Alliance managed their health benefits well enough that when they were acquired, the acquiring company looked at the plans and found $2,300 less expense per employee — with better benefits. Moving 2,500 employees onto that plan, at a PE ratio north of 40, created over a quarter billion dollars of instant equity value that nobody had priced into the deal. Nobody had even thought to look...

Employers pay roughly $1.20 to $1.30 for every dollar of actual healthcare their members receive. In one documented California lawsuit, a carrier charged a plan $4 million for a single inpatient stay and paid the hospital $877,000 — pocketing over $2.5 million, with MultiPlan collecting another $677,000. Knowing that, what should plan sponsors actually be trying to buy?

Stacey Richter distills four core concepts for buying or...

Hospital price transparency mandates took effect in 2019. Carrier transparency mandates followed in 2022. That means plan sponsors have had access to negotiated rate data for every billing code, every provider, and every carrier in the country for years — and most still aren't using it. The rate disparities from one employer to another for the exact same service codes are, in Jerry DiMaso's words, huge.

In this episode, Stace...

Most hospitals cannot tell you the true internal cost of a single care episode. Not the medical device costs, not the personnel, not the consumables — the actual cost. And yet we operate a $5.6 trillion sector asking clinical organizations to take on risk for outcomes and costs they cannot quantify. As Dr. Siva puts it, you can never expect a physician to go at risk if they don't understand their own costs. Jumping in without...

Advanced primary care has a robust evidence base. It manages risk, improves outcomes, and lowers costs. So why isn't it everywhere? Because in a healthcare non-market where health systems drive revenue from heads in beds and profitable surgeries, the entire goal of advanced primary care — keeping patients out of hospitals — is a direct threat to some of the largest organizations in the sector. Fewer than 45% of frontlin...

Knowledge Is Fiduciary Armor — On Making Better Decisions in a Healthcare System Built on Mystery and Margin

The US healthcare system is a massive aggregation of millions of decisions made by millions of humans — actuaries, executives, benefits leaders, clinicians, and administrators. Our whole system is really what all those choices add up to. Which means better decisions, more informed decisions, decisions made with t...

One Madison hospital charges $219,000 for a surgery that Johns Hopkins — one of the best cardiac programs on earth — does for $80,000 door to door. That's Centers of Excellence 1.0. The question this episode tackles is what comes next, and how to get there without adding another layer to a road that's already too crowded.

In this episode, Stacey Richter speaks with Adam Stavisky, who managed benefits for Walmart and now...

Here is what hackers are doing with stolen medical data: billing CMS for urinary catheters at $8,000–$9,000 each — items costing $10–$50 that were never sent to the seniors billed for them. In 2023 this totaled $3.5 billion. Dr. Tara Lagu's mother had two catheters billed in her name — $18,000 — that she never received. By 2025, one DME supplier that had never billed Medicare before January 1st was on ...

Two members of a plan received infusions at a hospital. If they had gone down the street, the plan would have spent $1 million less — for the same drug. That is the infusion nonmarket in 2026.

In this episode, Stacey Richter speaks with Ivana Krajcinovic, the outgoing Vice President of Healthcare Delivery at UNITE HERE HEALTH, who spent over three decades protecting the health and wages of 230,000 hospitality workers, about w...

If you rank California's commercial health plans by member count and check back every year for 14 years, the ranking barely moves. Kaiser at the top. The big blues plans close behind. Everyone else exactly where they were. This is not a competitive market. It is a stalemate. And the stalemate has causes.

In this episode — the first installment of Relentless Health Value's "No Market" series — Stacey Richter speaks with ...

Ten years ago, Stacey Richter started Relentless Health Value because the healthcare industry felt like a Pachinko machine — you drop a program or a policy in, it bounces around a black box, and sometimes the result is the opposite of what you intended. Then she met the Relentless Tribe, who turned out to be the alchemists.

Episode 500 is not about Stacey. It is about the listeners turning this show into real decisions, real ...