Relentless Health Value

Well, this episode is suddenly incredibly relevant again just with all the stuff going on with co-pay maximizers. If you’re gonna understand maximizers, though, you really have to start here. In a nutshell, this whole thing is a battle royale between co-pay cards and patient assistance programs offered by pharma companies versus co-pay accumulators and co-pay maximizers deployed by health plans and PBMs (pharmacy benefit managers). I just want to start by getting everyone grounded on a few really key points. #1: Drug abandonment is a thing. Patient goes into the pharmacy to pick up their Rx and the out of pocket is too expensive, so they leave without their drug. This can happen on the first fill, like, “Oh, wow, I guess I don’t really need that new drug my doctor just told me I should pick up.” Or it can happen downstream, like in January when, all of a sudden, a deductible kicks in. But in all cases, we have a patient getting sticker shock on the out of pocket for a med and then going without the drug … or

Thanks, shurx, for this review on iTunes entitled “Prepare to Learn.” Shurx wrote: “[RHV] provides key insight from experts that you won’t find anywhere else. It paints the picture of how our healthcare is tangled, and who benefits because of it. Whether it’s drug pricing, PBM shenanigans, hospital billing, or market trends that are challenging the status quo, this podcast is worth your time. I’ve shared many of the episodes with my pharmacy colleagues who have replied, ‘I didn’t know that’s how it worked.’ Now they do thanks to Stacey and her team.” I wanted to kick off this particular show with this review because today we are again digging into the business of hospital care in this country. That’s actually how Sanat Dixit, MD, MBA, FACS, put it on LinkedIn recently. He said some of the hospitals these days aren’t in the healthcare business; they’re in the hospital care business. And when I say some hospitals, I mean some people in decision-making roles at some hospitals. There was an opinion piece in the N

You would think that hospitals with the most money would offer the most charity care—trickle down and all of that. If my health system is big and I have lots of money and profitable commercial patients, I can stuff more dollar bills into the charitable donation balance sheet bucket, right? Except, in general, it’s a fairly solid no on that. Let’s talk about some of my takeaways from the conversation that I had with Vikas Saini, MD, and Judith Garber from the Lown Institute. During the conversation, there’s also mention of a powerhouse of a New York Times article. So, let’s circle up on but a few of the more interesting (according to me) reasons why some rich hospitals fail to offer the level of charity care that you might think they could or should: #1: Chasing commercial contracts because they are very profitable means building in areas where there are frankly not a whole lot of poor people. You see hospital chains doing this all of the time and saying at the 2023 JPM (J.P. Morgan) conference that t

Hey, thanks so much to kwebs14 for your super nice review on iTunes the other day. Kwebs wrote: [I have] learned so much, shared so many episodes with colleagues, clients … and gained so much value from regularly listening to [Relentless Health Value]. … Thank you … for providing the platform for so many that believe that we can consistently do better in healthcare. Thanks much for writing this. I think our Relentless Tribe is a unique group, and every day of every week I admire your willingness to hear some things that might be pretty hard to hear because they may hit pretty close to home. Dr. Benjamin Schwartz was talking about the podcast on LinkedIn the other day, and he said he doesn’t always agree with guests or the discussion but he always learns something and each episode stimulates and challenges his thoughts and opinions. Yes … to all of this. This is our goal in a nutshell: to help those who want to do better in healthcare to have the insight, the information, the other side of the story, the d

This week, I am with my Aventria team on-site at one of our clients. We are holding a full-day workshop to help our client figure out who all across the healthcare industry they will need to get aligned with to achieve greater success in the market and how to handle all of these inevitably conflicting interests strategically and also potentially from a messaging standpoint. I’m one of the subject matter experts who gets to pipe up during the part where we talk about all of these market dynamics, what everybody is up to, and who is going to want what so the client team can do their thing and get paid for it. Anyway, I say all this to say that this week, I am pretty darn busy but also thrilled to encore this episode with Nikhil Krishnan, founder of Out-Of-Pocket, and one of our most popular episodes in the past 12 months. My guest in this healthcare podcast is Nikhil Krishnan, who is the founder of the Out-Of-Pocket newsletter. I was talking with Nikhil, and we identified—or, more accurately, he identified—five

So, a few things to remind everybody. First of all, don’t forget EHRs (electronic health records) were purpose built originally for billing. This is no secret. People quite openly have called EHR systems glorified cash registers. If I want to be generous, maybe I would restate this to say that EHRs were designed to document patient interactions. This is what their core architecture was built to achieve. But today, there’s a lot that goes on that isn’t a traditional patient interaction. First of all, me even calling it, frankly, a patient interaction should give longtime listeners a clue where this is headed. I mean, say you’re sitting at home on your couch. I don’t know. You’re probably not considering yourself a patient. You’re considering yourself a person sitting on your couch. However, say you’re sitting on your couch and you haven’t taken your COPD maintenance therapy. Potentially that is something of clinical significance that maybe should get figured out and noted somewhere—potentially prior to the acu

On Relentless Health Value, I don’t often get into our guests’ personal histories. There are a bunch of reasons for this, which, if you buy me beer, we can talk podcast philosophy and I will tell you all about my personal, very arguable opinion here. Nevertheless, in this healthcare podcast, we are going rogue; and I am talking with Scott Conard, MD, who shares his personal story. You may ask why I decided to go this route for this particular episode, and I will tell you point blank that Dr. Conard’s experience, his narrative, is like the perfect analogue (Is analogue the right word [allegory, composite example]?). His story just sums up in a nutshell what happens when a PCP (primary care provider) does the right thing, manages to improve patient care for real, and then at some point gets sucked into the intrigue and gambits and maneuvering that is, sadly, the business of healthcare in the United States today. Before we kick in, I just want to highlight a statement that Scott Conard makes toward the end of th

If you go to the Sage Transparency dashboard Web site, you get a really graphical representation of the prices that any given hospital actually needs to charge so that they break even. You can see precisely which hospitals are operating on thin margins and which ones are not. You might be thinking, “Okay, so ... what’s the big deal about this? Why is the Sage Transparency information so meaningful? Aren’t hospitals (most of them) providing their financial statements already?” Well, let’s discuss. First of all, we have the main hospital lobbying organization coming out with press releases such as this one saying (here’s some quotes): “Hospitals have incurred serious losses …” “The vast majority of America’s hospitals [are] in serious financial jeopardy …” Combine quotes like these (and there are many) with some of the funny stuff going on in some (not all) hospital financial reporting—like counting investment losses from their venture funds, not counting endowments or their big trusts in the math, paying C-sui

For the past few shows and in a few coming up, we are circling our wagons around a theme: In healthcare in this country, there are two teams. One team is employers, taxpayers, patients … those trying to keep healthcare prices down. Then on the other team, we have those looking for healthcare prices to continue to go up, meaning, as just one example, some health systems and some hospitals. There was a New York Times article recently, and Peter Hayes wrote an interesting comment about it on LinkedIn. He wrote: “This article is troubling on so many levels and clearly demonstrates that patient health and well-being are not the top priority of many in healthcare leadership in our hospitals. Unfortunately, it is much more about patient revenue than patient health. … The non-profit status of our health facilities is a huge hidden tax and wealth transference from every taxpayer that is estimated to be about $39 billion annually.” Look, for sure, not talking about everybody in healthcare leadership here, and increasin

HRRP stands for Hospital Readmissions Reduction Program, by the way. I wanted to encore this episode with Dr. Rishi Wadhera because it’s a great representation of a common root cause reason why quality metrics sometimes don’t end well in real life. This root cause is otherwise known as Goodhart’s Law, and we dig into Goodhart’s law later on in this healthcare podcast. But the actual and ultimate impact of HRRP is also a pretty good representation of the consequences, what happens, when you create a blunt-force policy that assumes hospitals with very different circumstances are the same. Before we kick in to the episode, I asked Dr. Wadhera, my guest today as aforementioned, if there’d been any updates regarding HRRP since this show originally aired last year; and he told me that two key pieces have come out this past month in JAMA journals calling out CMS (Centers for Medicare & Medicaid Services) to move on from/retire this policy: A Decade of Observing the Hospital Readmission Reductions Program—Time to

This show was one of the most popular episodes in the past 12 months. So, here it is again for your listening pleasure. Mostly this whole episode is about the so-called “Big Three” PBMs that provide between the three of them pharmacy benefit services for 95% of insured Americans. PBM stands for pharmacy benefit manager, and the Big Three PBMs being ESI, otherwise known as Express Scripts; OptumRx, which is a part (a big profitable part) of UnitedHealth Group; and then also CVS. Yes, CVS is not just for your retail pharmacy needs; they are also a huge pharmacy benefit manager. Now, we get to the GoodRx part of our story. If you don’t know how GoodRx works, I would strongly encourage you to go back and listen to “An Expert Explains” with Dr. Ge Bai from last year (AEE13). That said, here’s the super short semi-reductive version to keep us all level set here. If you already know how GoodRx works, you can skip forward about four minutes. So, first of all, let’s all understand that GoodRx’s business model only exi

We have done three inbetweenisodes so far on healthcare stakeholder collaboration. In sum, there are two major issues that patients have with our healthcare industry, and both can only be solved for if healthcare stakeholder collaboration happens: Patients falling into care gaps and winding up with bad downstream consequences Patients not being able to afford their care This show, we are moving on to talk about an actionable solution here to the care gap problem—the very ubiquitous issue of patients with some pretty serious health issues who remain either undiagnosed or not on optimal treatment or follow-up. Our team at Aventria Health has a big success story that I would love to share relative to care gaps and how to think about solving for them at the local, regional, and national level. Spoiler alert here: What we’re talking about in this healthcare podcast, which we call our Groundswell Solution™, improved the usage of best-practice clinical guidelines for patients with end-stage liver disease by 23% na

In this healthcare podcast, I have Merrill Goozner on the show talking about his prognostications for the future of healthcare in this country and how, realistically, it could be engineered so that the healthcare industry rightsizes itself relative to our GDP. Merrill offers three glide paths to this end. Okay … so, let’s break this down some. First, Merrill talks about the full impact of huge numbers of patients/people in this country who are scared to seek medical attention. They are afraid to play the game at the end when the bill comes in the mail and they open it up having no idea what it is going to be. It’s a magical mystery guessing game of luck and chance where losers go bankrupt. This is not a victimless situation we have going on here in this country. All these deaths of despair and life expectancy going down … this is unprecedented. So now, we’re level-set on the stakes. Interestingly, Merrill plots out the aspiration for healthcare spending in exactly the same way that David Muhlestein, PhD, JD,

Here’s a big thing that Betsy Seals makes clear in this show: Big companies can be successful in Medicare Advantage (MA)—and I mean success in all of its financial glory—because they have experience and the scale and also the specialized departments who keep track of all kinds of intricacies that are rate critical to MA success. Specifically, things Betsy Seals talks about as critical success factors, for example, are having relationships with brokers and health systems and other provider organizations. She also makes it clear how much local market knowledge is necessary. A benefit design working great in one local market might be a medical trend disaster in another area with different levels of social determinants of health (SDoH) or different disease patterns, so scaling into new areas isn’t a matter of just cutting and pasting. History has shown it’s easy enough to go down in a flaming ball of unanticipated medical trend and/or OIG/DOJ scrutiny. So, this is one thing that big MA carriers can get right and

We got two new reviews this week on the podcast, which I was thrilled to see. The first was from, it turns out, Dave Chase from Health Rosetta, who wrote that “with so many people in healthcare practicing ‘innovation theater’ and bloviating versus driving real change, it’s a breath of fresh air to listen to Relentless Health Value.” Thank you so much for saying that, Dave. We try really hard to get guests who are actually doing great things such as yourself. And then there’s another review from mattiw2002, who says, “For anyone trying to stay abreast of developments in the healthcare space, there’s none better than … Relentless Health Value.” Thank you so much to the two of you who took the time to write a review—could not appreciate it more. There have been two inbetweenisodes this year where I get deep into the why behind the “why collaborate.” And when I say collaborate, what I mean is anybody in the healthcare industry working together with and for the patients that we’re supposed to be serving here. It’s

This episode was one of the most popular episodes in the past 12 months. Since it aired, there was a show with Kevin Schulman, MD (EP366), that added some context, which I would recommend, and also one with David Muhlestein, PhD, JD (EP364). Those two shows and this one are a good three-pack. And hey, here’s something new that we’re going to try out. Coming up in December, Dr. Bricker and I will host a smallish virtual chat to discuss the topics covered in this episode. It will be a conversation, not a presentation, so therefore the “why” behind the “smallish.” If you are kinda thinking this is something that you’d like to do, go to our Web site and scroll down to the “Join the Relentless Tribe.” When we get our act together, we’ll send out the details for how to sign up in a future email. I’m thinking it will be very cool to get a chance for the great people who support our show enough to actually get a weekly email to talk amongst ourselves! In this healthcare podcast, I’m speaking with Eric Bricker, MD, ab

First of all, let me thank those of you who have left a podcast review in 2022. There was one from Best Healthcare Podcast Around on Apple Podcasts the other day that thanked Relentless Health Value for being singularly responsible for providing a 400-level education in so many complex areas of healthcare, which I personally really appreciated because we aspire to be a master class in healthcare industry strategy, such that those looking to do right by patients understand the dynamics well enough to succeed. This also echoed a review from February of this year that said that Relentless Health Value distills complex healthcare issues into a highly intuitive and highly accessible narrative that helped the reviewer’s Fortune 500 company get everybody in the C-suite the understanding needed to confidently make some pretty key healthcare-related decisions. Thanks so much to those of you who left a review for taking the time. As I have said on earlier shows, we really have a Relentless Tribe here working hard to ma

If you listened to the show with Dan O’Neill (EP359), you would know this already. But let me tell you: If you’re a provider, even a provider very confident in your office’s ability to confer better patient health, you will still have a super hard time getting off the fee-for-service (FFS) hamster wheel. Why? Because it’s hard to find payer contracts out there which will reward you (the provider) for actually taking care of your patients and to be accountable for the value of healthcare that you deliver. This is a tangled web we weave because, despite some payers offering risk-based contracts, a lot of times there’s some IPA (independent physician association) or other “holder of the actual payer contract” who does not pass along these contract terms. These IPAs or health systems even sometimes just keep paying docs or provider offices FFS even if they themselves have a risk-based or capitated or value-based-of-any-kind agreement. If I actually kept track of the issues raised in the emails I receive from docs

Here’s a Milton Friedman quote: “There is one and only one social responsibility of business—to use its resources and engage in activities designed to increase its profits so long as it [that entity] stays within the rules of the game, which is to say, engages in open and free competition without deception or fraud.” Okay, so this is Friedman, Milton Friedman, pretty much the most influential advocate of free market capitalism, stating quite clearly that an entity’s greatest responsibility lies in the satisfaction of its shareholders. His nod to social responsibility or ethics of any kind comes at the end there, where he says that for free market capitalism to function, there must be open and free competition and no fraud. So, let’s compare this to what’s going on in the payer space in the healthcare industry. First off, there was just a chart in the New York Times the other day where pretty much every major payer except one got a check in a box for being accused of fraud. Interestingly, if you look in the co

The show on direct contracting with Doug Hetherington (EP367) and also the one with Katy Talento (EP350), both of these experts have said that if an employer direct contracts with a provider organization, in general, the employer gets about 20% savings over the status quo. This makes sense—just cut out the middleman with an MLR (medical loss ratio) of plus or minus about 15% and you’re at three-quarters of the way there. You might be thinking, “Well, maybe not so fast here, because then wouldn’t FFS (fee-for-service) rates go up? Is it not Slide 1 on most carriers’ sales decks how great they are at leveraging their vast buying power to negotiate discounts with hospitals?” Hmmm … if you think this, you’re about to be shook. Turns out, carriers are not so good at negotiating rates with hospitals. For more on this topic, follow Leon Wisniewski on LinkedIn. Or check out an article entitled “Hospital prices vary widely, often higher with insurance than cash, The New York Times finds.” The big concerns for employer