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  • Take Two: EP438: Is It Mission and/or Margin? With John Lee, MD

    Take Two: EP438: Is It Mission and/or Margin? With John Lee, MD
    2025/07/03
    I am so focused right now on the intersection (or lack thereof) of mission and margin, so I’m taking a second listen to this episode right now with John Lee, MD, because it is so ridiculously relevant given that I am, as stated, on a bit of a tear. For a full transcript of this episode, click here. If you enjoy this podcast, be sure to subscribe to the free weekly newsletter to be a member of the Relentless Tribe. This mission/margin bender kicked off actually, if I had to diagnose the root cause, it’s because of all of the conversations that happen after what I’m calling the trust through line episode (EP477). Because if you think about it—and I have—if we are talking about trust, what does that even mean? Like, trust to what end? And when you start distilling it down, you wind up with trust that someone is gonna do right by patients and purchasers and the actual clinicians providing the care that even if there’s a stack of Benjamins to be had by doing the wrong thing, we can trust that mission will be put over margin—or at least balanced with it in some kind of palatable way. Right? That’s a big piece of what it means to be trustworthy in healthcare. “You are what you won’t do for money.” That was a headline to a Ryan Holiday article I read recently and wrote down, because … right? Now, it’s one thing for each of us listening here to contemplate mission and margin, and that matters. But it’s quite another thing for this contemplation to happen at scale, at status quo consolidated health systems, carriers; many status quo, not transparent brokerages, PBMs (pharmacy benefit managers), TPAs (third-party administrators); status quo stakeholders across the board. But because of this, actions being taken at the organizational level may not mirror the mission/margin ratio that you or I might aspire to. So, why this episode with Dr. John Lee, you may be wondering? How did this conversation get teed up for a Take Two in the midst of this mission/margin tear that I apparently am on right now? Dr. John Lee talks about and gives some advice for individuals in a status quo, not transparent organization how to find a mission to feel good about. I would also highly recommend listening to the show with Larry Bauer, MSW, MEd. It’s a Summer Short, and it’s called “Knights, Knaves, and Pawns.” So, here’s my conversation with Dr. John Lee, and next week come back because I’m gonna continue the mission margin conversation with Ben Schwartz, MD, MBA—and it’s a really good one. So, come back next Thursday, too. Let’s say a person believes they want to do well by patients but their performance review depends on, as just one example, making care less affordable for patients. But somehow, this individual is able to conclude that what they’re doing is a net neutral or a net positive despite (in this hypothetical, let’s just say) obvious indications that it is not. In this hypothetical, there are, say, clear facts that show that what this person is up to is indisputably a problem for patients. But yet at every opportunity, this person talks about their commitment to patients, this rationalization or earmuffs don’t look, don’t see is cognitive dissonance. Cognitive dissonance is when what someone winds up doing, their actions, are in conflict with what they believe in. Now, it’s harder to engage in cognitive dissonance the closer you are to patients because you see the impact up close. Unless these at-the-bedside clinicians enjoy a robust lack of self-awareness, those who are seeing patients don’t, a lot of times, have the luxury of pretending that what is going on is good for patients when they can see with their own two eyes that it is not good for patients. The further from the exam room or the community, however, the easier it is to not acknowledge the downstream impact, if you can even figure out what that downstream impact is. Sometimes it’s legitimately difficult to connect the dots all the way down the line to the customers, members, or patients. Today I am talking with Dr. John Lee about what to do in the face of all this when working in the, as I call it, the belly of the beast—working for a large healthcare organization such as a hospital. Because hospitals sometimes (and we certainly do not want to put all hospitals in the same category—they are a wildly diverse bunch), but sometimes some people at some hospitals do some things which are not things I think they should be doing anyway. They’re fairly egregious breaches of trust, actually. But yet within that same organization, you have doctors and other clinicians or others who are working really hard to serve patients as best they can. This is the real world that we’re talking about, and the question of the day is … so, now what? When you are a person not suffering from cognitive dissonance, at least to the level of those around you, what do you do to not get, I don’t know, demoralized? And ...
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    36 分
  • EP480: Payment Integrity Meets Health System Boasts, Such as Our Rates Are 2x Medicare, With Kimberly Carleson

    EP480: Payment Integrity Meets Health System Boasts, Such as Our Rates Are 2x Medicare, With Kimberly Carleson
    2025/06/26

    Enhancing Payment Integrity in Health Systems: An In-depth Discussion with Kimberly Carleson.

    In Episode 481 of Relentless Health Value, host Stacey Richter speaks with Kimberly Carleson, CEO of US Beacon, about payment integrity within health systems. They delve into strategies some hospitals use to maximize revenue without raising rates and discuss the importance of accurate billing.

    Key takeaways include the high prevalence of billing errors, which can lead to significant overcharges for plan sponsors, often due to documentation gaps and complex coding systems. Kimberly provides actionable advice for both healthcare providers and plan sponsors on how to mitigate billing inaccuracies and enhance transparency.

    Emphasized points include the necessity of third-party claim audits, understanding legal rights under various acts, and the importance of maintaining clear communication and compliance with legal billing standards.

    === LINKS ===
    🔗 Show Notes with all mentioned links:
    https://cc-lnk.com/EP480

    ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter:
    https://relentlesshealthvalue.com/join-the-relentless-tribe

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    https://relentlesshealthvalue.com/join-the-relentless-tribe

    🎤 Listen on Apple Podcasts https://podcasts.apple.com/us/podcast/feed/id892082003?ls=1

    🎤 Listen on Spotify https://open.spotify.com/show/6UjgzI7bScDrWvZEk2f46b

    📺 Subscribe to our YouTube channel https://www.youtube.com/@RelentlessHealthValue

    === CONNECT WITH THE RHV TEAM ===
    ✭ LinkedIn https://www.linkedin.com/company/relentless-health-value/
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    08:36 What’s the magnitude of the lack of payment integrity within healthcare?

    12:11 EP285 with Dawn Cornelis.

    12:46 How is lack of coordination a main culprit of lack of payment integrity?

    13:42 How does reading the records reveal whether health plans are being overcharged?

    15:43 A real-world example of how reviewing the charges can drastically reduce your healthcare costs.

    18:32 Do you have a right to a review of your claim?

    19:37 EP370 with Erik Davis and Autumn Yongchu.

    22:08 How can contracts contradict what can legally be charged?

    23:46 EP472 with Eric Bricker, MD.

    25:04 How can hospitals update their billing to have better payment integrity?

    28:44 Advice for hospital executives and their finance teams.

    29:03 Advice for plan sponsors.
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    32 分
  • Pharma Rebates: A Few Nuances You May Not Have Thought Of, With Ann Lewandowski—Summer Shorts

    Pharma Rebates: A Few Nuances You May Not Have Thought Of, With Ann Lewandowski—Summer Shorts
    2025/06/19

    Exploring the Complexities of Pharma Rebates with Ann Lewandowski

    In this Summer Short episode of Relentless Health Value, host Stacey Richter converses again with Ann Lewandowski about the intricate dynamics of pharmaceutical rebates, or as Lewandowski prefers, post-sale concessions.

    The discussion delves into the nuances of these rebates, the impact they have on drug costs, and the hidden consequences for patients and plan sponsors.

    They highlight articles and insights by Austin Chelko and Peter Hayes, touching on how rebates can disadvantage the pursuit of lower-cost generics and biosimilars, and can obstruct pharmacogenetic testing that ensures drug efficacy and safety.

    The conversation also critiques the opacity of rebates, deemed trade secrets by pharma and PBM companies, and underscores the ethical and financial dilemmas posed by the current rebate-driven system.

    === LINKS ===
    🔗 Show Notes with all mentioned links:
    https://cc-lnk.com/EP480

    ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter:
    https://relentlesshealthvalue.com/join-the-relentless-tribe

    🫙 Support the podcast with a small donation to the Tip Jar:
    https://relentlesshealthvalue.com/join-the-relentless-tribe

    📺 Subscribe to our YouTube channel https://www.youtube.com/@RelentlessHealthValue

    🎤 Listen on Apple Podcasts https://podcasts.apple.com/us/podcast/feed/id892082003?ls=1

    🎤 Listen on Spotify https://open.spotify.com/show/6UjgzI7bScDrWvZEk2f46b

    === CONNECT WITH THE RHV TEAM ===
    ✭ LinkedIn https://www.linkedin.com/company/relentless-health-value/
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    07:24 What is a pharmaceutical rebate?

    08:15 Why are pharma rebates so opaque?

    09:52 Texas lawsuit on insulin pricing.

    10:18 Why is focusing on a singular type of concession difficult with current pharma rebate structures?

    10:50 EP397 with Paul Holmes.

    13:55 EP353 with Pramod John, PhD.

    14:29 How does pharma genomics testing affect pharma rebates?

    14:52 EP465 with Chris Crawford.

    15:52 EP426 with Nina Lathia, RPh, MSc, PhD.
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    19 分
  • EP479: What Could Go Wrong Covering High-Cost Claimants With Stop-Loss Reinsurance? With Andreas Mang and Jon Camire

    EP479: What Could Go Wrong Covering High-Cost Claimants With Stop-Loss Reinsurance? With Andreas Mang and Jon Camire
    2025/06/12

    In this second discussion with Andreas Mang and Jon Camire of Blackstone, Stacey Richter has an advanced discussion on the intricacies of stop-loss reinsurance for high-cost claimants.

    This show today, for sure, it’s for plan sponsors and anyone on or about plan sponsors; but also listen if you are serving high-cost claimants some other way. Because what you’ll learn here today is some insights relative to how plan sponsors go about making sure that they can pay you—like if you work for, for example, some clinical organization.

    There’s a, I don’t know, 101 starting point of this conversation if you need it on stop-loss, which is episode 478 from a couple of weeks ago. This show is the, let’s say, 201-level conversation that I’m having with Andreas Mang and Jon Camire about, as I said, stop-loss insurance and stop-loss insurance considerations.

    Emphasizing the importance of eligibility audits and aggregating buying power, the guests highlight best practices to avoid overpaying for coverage and ensuring comprehensive risk management.

    This episode is sponsored by Havarti Risk, which I am so thankful for. The show, Relentless Health Value, actually does cost an unexpectedly large sum of money to create and produce; so I always appreciate when somebody offers to sponsor a show or help sponsor a show.

    === LINKS ===

    🔗 Show Notes with all mentioned links:

    https://cc-lnk.com/EP479

    ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter:

    https://relentlesshealthvalue.com/join-the-relentless-tribe

    🫙 Support the podcast with a small donation to the Tip Jar:

    https://relentlesshealthvalue.com/join-the-relentless-tribe

    🎤 Listen on Apple Podcasts

    https://podcasts.apple.com/us/podcast/feed/id892082003?ls=1

    🎤 Listen on Spotify

    https://open.spotify.com/show/6UjgzI7bScDrWvZEk2f46b

    📺 Subscribe to our YouTube channel

    https://www.youtube.com/@RelentlessHealthValue

    === CONNECT WITH THE RHV TEAM ===

    ✭ LinkedIn https://www.linkedin.com/company/relentless-health-value/

    ✭ Threads https://www.threads.net/@relentlesshealthvalue/

    ✭ Bluesky https://bsky.app/profile/relentleshealth.bsky.social

    ✭ X https://twitter.com/relentleshealth/

    07:47 What are the best practices for plan sponsors to use for stop-loss coverage?

    10:11 What are the “unknown unknowns” within stop-loss coverage?

    15:25 What are some policy provisions that plan sponsors should be aware of?

    19:02 Why is it so important to do eligibility audits?

    20:41 What are some common mistakes made with stop-loss coverage among the self-insured?

    23:21 What’s a panel approach, and why is it important for negotiating stop-loss coverage?
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    27 分
  • Take Two: EP433: The Mystery of the Weekly Claims Wire, With Justin Leader

    Take Two: EP433: The Mystery of the Weekly Claims Wire, With Justin Leader
    2025/06/05

    Stacey Richter has a second take on the original episode 433 since it is so relevant right now. Stacey engages in a compelling conversation with Justin Leader, CEO of BenefitsDNA, about the opaque practices of third-party administrators (TPAs) and their impact on healthcare costs.

    They discuss the hidden fees tucked into weekly claims wires, including shared savings fees, prior authorization fees, prepayment integrity fees, pay and chase fees, and TPA adjudication fees.

    The episode emphasizes the need for transparency, understanding hidden costs, and ensuring fiduciary responsibility for self-funded employers. Additionally, Leader shares insights from a Health Affairs article and mentions ongoing legal cases that highlight the financial discrepancies in TPA practices.

    === LINKS ===

    🔗 Show Notes with all mentioned links:

    https://relentlesshealthvalue.com/episodes

    ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter:

    https://relentlesshealthvalue.com/join-the-relentless-tribe

    🫙 Support the podcast with a small donation to the Tip Jar:

    https://relentlesshealthvalue.com/join-the-relentless-tribe

    🎤 Listen on Apple Podcasts https://podcasts.apple.com/us/podcast/feed/id892082003?ls=1

    🎤 Listen on Spotify https://open.spotify.com/show/6UjgzI7bScDrWvZEk2f46b

    📺 Subscribe to our YouTube channel https://www.youtube.com/@RelentlessHealthValue

    === CONNECT WITH THE RHV TEAM ===

    ✭ LinkedIn https://www.linkedin.com/company/relentless-health-value/

    ✭ Threads https://www.threads.net/@relentlesshealthvalue/

    ✭ Bluesky https://bsky.app/profile/relentleshealth.bsky.social

    ✭ X https://twitter.com/relentleshealth/

    06:32 EP457 with Cynthia Fisher.

    06:56 How is the claims wire typically explained to a plan sponsor?

    10:49 What is the whole point of self-funding?

    10:58 Why is it so vital to understand what you’re paying for?

    11:53 What are the five “buried” items that wind up in these claims wires?

    12:12 What is a shared savings fee?

    16:14 “Rates are important, but so are your rights.”

    20:13 What’s going on with prior auth fees?

    22:44 What is prepayment integrity?

    27:29 What is pay and chase?

    28:46 EP428 with Julie Selesnick.

    30:58 What is a TPA claim review?

    33:21 EP285 with Dawn Cornelis.

    34:16 EP379 with AJ Loiacono.

    34:45 Is there medical claim spread pricing?
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    39 分
  • EP478: Stop-Loss Coverage, Part 1: How It Goes Right, and How It Can Go Horribly Wrong, With Andreas Mang and Jon Camire

    EP478: Stop-Loss Coverage, Part 1: How It Goes Right, and How It Can Go Horribly Wrong, With Andreas Mang and Jon Camire
    2025/05/29

    Host Stacey Richter discusses the intricacies of stop-loss coverage with Andreas Mang and Jon Camire from Blackstone. The episode focuses on defining stop-loss insurance and exploring its critical role in protecting self-insured employers from catastrophic financial losses.

    The conversation delves into the nuances of individual and aggregate stop-loss policies, laser claims, and the importance of selecting an experienced consultant to navigate this complex landscape. The episode is essential listening for those managing high-cost claimants and exploring self-insurance options.

    This is a two part show. The second show will cover major fails, mistakes that happen with stop-loss when somebody doesn’t understand or do everything that we talk about. So, tune back in for the next part of this conversation, in two weeks.

    Thank you to Havarti Risk for sponsoring this weeks episode.
    Havarti Risk empowers healthcare leaders like you to make smarter
    decisions that increase quality and lower cost of care.
    https://havarti-risk.com/

    === LINKS ===

    🔗 Show Notes with all mentioned links:

    https://relentlesshealthvalue.com/episodes

    ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter:

    https://relentlesshealthvalue.com/join-the-relentless-tribe

    🫙 Support the podcast with a small donation to the Tip Jar:

    https://relentlesshealthvalue.com/join-the-relentless-tribe

    🎤 Listen on Apple Podcasts

    https://podcasts.apple.com/us/podcast/feed/id892082003?ls=1

    🎤 Listen on Spotify

    https://open.spotify.com/show/6UjgzI7bScDrWvZEk2f46b

    📺 Subscribe to our YouTube channel

    https://www.youtube.com/@RelentlessHealthValue

    === CONNECT WITH THE RHV TEAM ===

    ✭ LinkedIn https://www.linkedin.com/company/relentless-health-value/

    ✭ Threads https://www.threads.net/@relentlesshealthvalue/

    ✭ Bluesky https://bsky.app/profile/relentleshealth.bsky.social

    ✭ X https://twitter.com/relentleshealth/

    07:24 What is stop-loss?

    08:27 What is reinsurance?

    09:57 EP420 with Ge Bai, PhD, CPA.

    10:10 Why has stop-loss been a barrier for smaller companies going self-insured?

    13:55 Why self-insurance needs to be a joint decision between finance and HR.

    15:38 What is aggregate versus individual within stop-loss?

    19:51 Why is it important for companies to choose the right level of stop-loss coverage?

    21:29 What is a laser claim?

    29:28 Why is it important to know what your brokers are getting paid on your stop-loss policies?
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    32 分
  • EP477: Through Line Show: What the Tribe Thinks You Need to Know About Trust or It’s Gonna Be a Problem. Also, Why You Are Smart, With Stacey Richter

    EP477: Through Line Show: What the Tribe Thinks You Need to Know About Trust or It’s Gonna Be a Problem. Also, Why You Are Smart, With Stacey Richter
    2025/05/22

    In this episode, Stacey Richter explores the impact of trust on healthcare outcomes, drawing from listener contributions and prior episodes of Relentless Health Value.

    The discussion underscores how trust or the lack thereof affects patients, clinicians, and healthcare systems. Key points include the importance of building trusted relationships, the detrimental effects of antitrust behaviors, and the broader implications for healthcare delivery.

    Stacey also highlights a bonus show featuring Charles Green on earning and maintaining trust. The episode concludes with an uplifting message about the collaborative and giving nature of the Relentless Health Value community.

    === LINKS ===

    🔗 Show Notes with all mentioned links:
    https://cc-lnk.com/EP477

    🔗 Bonus Show - Show Notes
    https://cc-lnk.com/Bonus477:

    ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter:
    https://relentlesshealthvalue.com/join-the-relentless-tribe

    🫙 Support the podcast with a small donation to the Tip Jar:
    https://relentlesshealthvalue.com/join-the-relentless-tribe

    🎤 Listen on Apple Podcasts https://podcasts.apple.com/us/podcast/feed/id892082003?ls=1

    🎤 Listen on Spotify https://open.spotify.com/show/6UjgzI7bScDrWvZEk2f46b

    📺 Subscribe to our YouTube channel https://www.youtube.com/@RelentlessHealthValue

    === CONNECT WITH THE RHV TEAM ===

    ✭ LinkedIn https://www.linkedin.com/company/relentless-health-value/

    ✭ Threads https://www.threads.net/@relentlesshealthvalue/

    ✭ Bluesky https://bsky.app/profile/relentleshealth.bsky.social

    ✭ X https://twitter.com/relentleshealth/

    00:47 What is the new, emerging through line becoming apparent in healthcare?

    01:54 Bonus Episode with Charles Green.

    02:52 What is the impact of trust in healthcare?

    02:55 EP475 with Peter Hayes.

    03:11 EP473 with Kenny Cole, MD.

    05:31 EP295 with Rebecca Etz, PhD.

    06:07 EP326 with Rishi Wadhera, MD, MPP.

    07:06 Why does trust grow through proximity, and why do providers need to integrate this into care models?

    07:59 Why antitrust is so prevalent in healthcare.

    10:00 What are two main contributors to the lack of primary care doctors?

    13:27 Why collaboration builds trust.
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    19 分
  • Bonus Add-on to EP477: How to Earn Trust, With Charles Green

    Bonus Add-on to EP477: How to Earn Trust, With Charles Green
    2025/05/22

    In this bonus add-on to episode 477 of Relentless Health Value, host Stacey Richter revisits a decade-old conversation with trust expert Charles Green, founder of Trusted Advisor Associates. Green discusses the intricacies of building and maintaining trust in healthcare, emphasizing four key trust principles: client focus, collaboration, long-term relationships, and transparency.

    The discussion highlights the challenges within the healthcare industry, compounded by conflicts of interest and transactional dynamics. Green underscores the importance of individual actions and leadership in fostering trust, advocating for empathetic listening and genuine curiosity about others as foundational behaviors.

    === LINKS ===

    🔗 Show Notes with all mentioned links:
    https://relentlesshealthvalue.com/episodes

    ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter:
    https://relentlesshealthvalue.com/join-the-relentless-tribe

    🫙 Support the podcast with a small donation to the Tip Jar:
    https://relentlesshealthvalue.com/join-the-relentless-tribe

    🎤 Listen on Apple Podcasts
    https://podcasts.apple.com/us/podcast/feed/id892082003?ls=1

    🎤 Listen on Spotify https://open.spotify.com/show/6UjgzI7bScDrWvZEk2f46b

    📺 Subscribe to our YouTube channel https://www.youtube.com/@RelentlessHealthValue

    === CONNECT WITH THE RHV TEAM ===

    ✭ LinkedIn https://www.linkedin.com/company/relentless-health-value/

    ✭ Threads https://www.threads.net/@relentlesshealthvalue/

    ✭ Bluesky https://bsky.app/profile/relentleshealth.bsky.social

    ✭ X https://twitter.com/relentleshealth/

    01:45 Four trust principles that can help you earn your clients trust and come off as more trustworthy from first impressions onward.

    04:31 Charles’s words of wisdom for rebuilding lost trust.

    05:46 Where does trusted leadership start?

    06:38 Why trust in leadership is about embodying trust in actions, not words.

    07:26 Why does personality have an outsized impact in leadership and trust?

    08:21 “If we want to improve our trust, we just simply need to work on ourselves.”

    08:56 Why listening with a sense of curiosity and respect drives reciprocal behavior and improves trust.

    09:14 What is the best technique to immediately improve your trust relationship?
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    12 分