Relentless Health Value

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&mdas...

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 Publ...

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+ ye...

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 gu...

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 Medi...

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 Healt...

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 ...

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

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 aft...

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 p...

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 zo...

When Risk-Based Payment Becomes Its Own Upcoding Arms Race

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 In this episode, Stacey Richter plays an unpublished clip from her conversation with Ahilan Sivaganesan, MD (Dr.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

The Line Between Fair Profit and Profiteering in Medicare Advantage

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 integrated carriers...

The 7.7% Wake-Up Call: A Roadmap to Align Finance Teams With Benefit Design, With Patrick Nelli (EP509)

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 usi...

Why Self-Insured CEOs Won't Take Bold Action on Health Benefits, With Lee Lewis (EP508)

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 ...

4 Core Concepts to Buy or Deliver the Highest-Value Healthcare, A Review With 15 Experts (EP507)

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

Stacey Richter pulls together clips from 15 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 automatica...

Price Transparency Data: How Employers, Shareholders, and Clinics Use It, With Jerry DiMaso (EP506)

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...

Time-Driven Costing and the Operative Value Index for Surgical Care, With Ahilan Sivaganesan, MD (EP505)

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 wit...