Relentless Health Value

The PBM Rebate Math That Turns Prior Auths Into a Pharma Negotiating Tool

What if a prior authorization has less to do with your medical need than with how big a rebate check a PBM is collecting on a competing drug? In this solo deep dive — a direct follow-up to last week's conversation with Ophelia Johnson on GLP-1s and cash pay (EP516 link below) — host Stacey Richter walks through a "Brand...

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 behin...

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...

The Hospital Contract Playbook: Four Clauses That Turn Market Power Into Higher Prices. Episode 513.

Across the country, hospital systems have used their growing market power to write four specific contract terms into their deals with insurers — terms that all but guarantee higher prices for employers, unions, and patients, regardless of quality or competition nearby. In this episode, Stacey Richter speaks with Brennan Bilber...

A Lawyer's Field Guide to Rent-Seeking Broker and EBC Payment Models. Epsiode 512.

Brokers and employee benefit consultants often get compensated in ways health plans never fully see — and even when the dollars are technically disclosed, the math can hide an enormous overcharge. In this episode, Stacey Richter speaks with Doug Aldeen, JD, an ERISA healthcare attorney who has spent decades in the self-funded space, about the l...

When Risk-Based Payment Becomes Its Own Upcoding Arms Race. Episode 511

Medicare Advantage plans get paid more for sicker patients, which is why upcoding became a problem — and now health systems are upcoding visit complexity right back, with MA plans automatically downcoding in response. In this episode, Stacey Richter plays an unpublished clip from her conversation with Ahilan Sivaganesan, MD (Dr. Siva), a neurosurgeon...

The Line Between Fair Profit and Profiteering in Medicare Advantage. Episode 510

There's a simple test for telling a fair profit from profiteering in Medicare Advantage: does the carrier make more money when the patients it serves are worse off? In this episode, Stacey Richter talks with Betsy Seals, co-founder of Rebellis Group and a Medicare Advantage consultant making her third appearance on the show, about how vertically integr...

The Seven-Step Roadmap That Gets CFOs to Stop Being Passive Price Takers on Health Benefits. Episode 509.

As a companion to last week's CEO-focused episode, Stacey Richter talks with Patrick Nelli — CEO of Aligned Marketplace and a former CFO himself — about how to bring finance teams into health benefits strategy using their own language. Patrick lays out a seven-step roadmap, starting with forecasting healthcare trend...

The Three False Dogmas Keeping CEOs From Fixing Their Health Plan. Episode 508.

In the show's first-ever Ask Me Anything episode, Stacey Richter puts a listener's question to Lee Lewis, chief strategy officer and GM medical solutions at the Health Transformation Alliance: why do so few self-insured CEOs take bold action on their health benefits strategy? Lee walks through three false dogmas, four external pressures, and the C-suite...

Buy Healthcare, Not Insurance: A Through-Line Review of the Four Concepts Behind High-Value Care. Episode 507.

Stacey Richter pulls together clips from 14 past guests to lay out the four core concepts for buying or delivering the highest-value healthcare: buy healthcare (not just insurance), avoid the myth that less expensive automatically means lower quality, consider direct contracting between plan sponsors and clinicians, and ma...

The Price Transparency Arms Race: What Self-Insured Employers and Clinics Can Both Do With the Data. Episode 506.

Health price transparency data isn't just a compliance exercise anymore — it's becoming a competitive weapon for plan sponsors, shareholders, and clinics alike. Stacey Richter talks with Jerry DiMaso, co-founder and CEO of Payerset, about how self-insured employers can use hospital and carrier transparency files t...

Time-Driven Costing and the Operative Value Index for Surgical Care, With Ahilan Sivaganesan, MD. Why "Value Equals Outcomes Over Cost" Doesn't Work Until You Can Actually Measure Both. Episode 505.

What if the only way to know who's delivering high-value surgical care is to actually calculate it, instead of guessing? Stacey Richter talks with Ahilan Sivaganesan, MD—known as Dr. Siva—a practicing neurosurgeon ...

Why Evidence-Backed Primary Care Still Can't Scale, and a 3-Step Roadmap to Get Around It. Episode 504.

Why isn't advanced primary care (APC) everywhere, if the evidence for it is this strong? Stacey Richter talks with Ryan Jacobs, SVP of Strategy and Partnerships at Marathon Health, about the two root causes blocking APC from scaling—conflicting fiduciary duties and what Jacobs calls "the black box of complacency"—and ...

Listener Insights on Better Decisions, Price Transparency, and PBM Spread Pricing Tricks. Why "Insight Is Common, Execution Is Rare" Is the Whole Game in Fixing Healthcare. Episode INBW46.

In this inbetweenisode, Stacey Richter spotlights two Relentless Tribe members whose LinkedIn posts crystallized something she'd been trying to say all season: that healthcare doesn't lack frameworks or commentary, it lacks better decisions....

Direct-to-Employer Specialty Care and Centers of Excellence 3.0, With Ryan Wells, Leo Spector, MD, and Adam Stavisky Why Self-Insured Employers and Specialists Need to Start Talking Directly Instead of Through a Lazy Middle. Episode 503.

Self-insured employers and the specialists who actually deliver care sit on opposite ends of a long, crowded road—with carriers, ASOs, TPAs, and consolidated health systems clogging up t...

Why $3.5 Billion in Fake Catheters and an Even Bigger Skin Substitute Grift End Up Costing Self-Insured Employers Too. Episode 502.

Hackers are using stolen medical data to bill CMS for catheters and other durable medical equipment that patients never actually received—and that's just one piece of a fraud scheme that adds up to 4% of the entire CMS budget. Stacey Richter talks with Brian Machut, a value-based actuary at Allia...

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 ...