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  • Take Two: EP445: What Does It Take for an Indie Primary Care Practice to Survive Right Now? With Tom X. Lee, MD

    Take Two: EP445: What Does It Take for an Indie Primary Care Practice to Survive Right Now? With Tom X. Lee, MD
    2025/07/17
    Let’s take a second listen to this interview with Dr. Tom Lee that originally aired last summer but listen to it this time within the context first of how primary care can or should reduce ER visits and also downstream specialty spend et cetera, which is one of the through lines that I, along with you lot, have been exploring a lot this past year. 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. And much of this conversation is about how primary care can survive in these unfavorable times where CMS (Centers for Medicare & Medicaid Services) and commercial carriers complain about the rates that they have to pay consolidated entities with market power, consolidated health systems, but then they actively underpay indie practices. That is very illogical, I’d say, at a fundamental level. It’s not tricky math. Do not force out of business your potential best partners and then wonder why you have so few of them left. Dan O’Neill was talking about this on LinkedIn the other day. So, that is one context to kind of listen to: How does primary care survive? But then also listen to this show in the context of my latest tear, which is this mission versus margin tear. Some of the same themes come up as in the show with, for example, Ben Schwartz, MD, MBA, from last week (EP481). How do you ensure that if you want to achieve scale, and you can only achieve scale when you take professional capital from private equity or VCs (venture capital) or even a consolidated health system with a venture fund or an innovation studio, how do you take their money but not wind up with some board member sitting at the conference room table talking about a mission like, you know, Jeff Bezos’s where he said, “My mission is other people’s margin”? How do you tow that line? Rushika Fernandopulle, MD, talked about this a little bit, too—that you need money to scale but, once you get money, it’s easy for mission to get kicked off the bus. Today I am talking with Tom X. Lee, MD, who has a long history in primary care. He founded One Medical and then also, most recently, Galileo. Dr. Lee also was a founder at Epocrates (tossing that in for context). I wanted to talk with Dr. Lee because so many RHV (Relentless Health Value) listeners are trying to figure out how to sustain primary care as a stand-alone entity when most primary care docs these days are employees of health systems. And that makes sense because these days, the most obvious and most common way to make enough money in primary care is to drive and maximize the dollars from downstream volume of high-priced service lines, which, if you think about it, undermines the entire point of primary care but is also a really good motivation for a consolidated health system to purchase all of the primary care docs in the area. I’m starting to call this the paradox of primary care because when you begin seeing the promise of primary care have to erode if you’re gonna stay in the business of primary care, then yeah, it’s sort of a paradox. Said another way, if you do primary care really well and use evidence-based preventative care to curb the need for excess specialty care (ie, you reduce specialty revenue through primary care), now you’re asking specialty (high-profit health system service lines, that is) to not only make less money but use the remaining money to pay for primary care, which is the entity that is reducing its revenue. So, again, I am hereby coining the term the paradox of primary care to express the conundrum for why a consolidated entity that knows where its bread is buttered is going to do much, if anything, to empower primary care with the technology and the staff and the time, which, if it goes well, is going to cannibalize its own major source of revenue. Meanwhile, if you choose not to participate in this paradox within the context of a consolidated entity, it’s kinda hard to stand up a pure play primary care practice. And I’ve heard this so many times, most recently from Paul Buehrens, MD, who said, he wrote on LinkedIn, “My own primary care clinic lasted independent from 1946-2017, and when costs were rising faster than reimbursement with no alternatives available, we sought out purchase by our hospital, giving up on trying to stay independent. … Consolidation is not driven by bad actors nor by quality nor volume savings, but by the bizarre economics of healthcare as a highly regulated but hardly rational market.” I simply don’t get why knowing as much as we know about the importance of primary care, CMS and others continue to follow RUC (Relative Value Scale Update Committee) guidance on PCP (primary care provider) rates. How much power must be wielded by the AMA (American Medical Association) or the AHA (American Hospital Association) or who knows? I don’t know the half of it, admittedly. Listen to episode ...
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    46 分
  • Bonus Add-on to Take Two: EP445: Dr. Tom Lee Talks About Why Retail Clinics Are Not Doing So Well, in His Opinion

    Bonus Add-on to Take Two: EP445: Dr. Tom Lee Talks About Why Retail Clinics Are Not Doing So Well, in His Opinion
    2025/07/17
    I clipped out this five-minute sort of sidebar conversation with Tom X. Lee, MD, when I was speaking with him last summer that I thought you might be interested in listening to by itself, because it is a bit of a, like I said, a sort of a tangent. 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. And again, given all of the conversations that we’ve been having lately about trust and mission and margin, I think the points that Dr. Tom Lee makes in the conversation are all the more relevant. Also mentioned in this episode are Galileo and Tom Nash. You can learn more at Galileo and follow Dr. Lee on LinkedIn. Tom X. Lee, MD, is the CEO and visionary behind Galileo—a data-driven, multispecialty care model designed to improve quality and reduce total cost of care. Operating across 50 states and partnered with large employers and health plans, Galileo is one of the fastest-growing innovators in care delivery. Prior to Galileo, Tom helped build One Medical into the leading, independent primary care system in the country. And previously, he helped launch Epocrates, the #1 mobile app used by clinicians at the point of care. Tom is a board-certified internist who completed training at Harvard’s Brigham and Women’s Hospital. He received his bachelor’s degree from Yale University, an MD from the University of Washington School of Medicine, and an MBA from Stanford University’s Graduate School of Business. 01:01 Why have retail clinics failed in being longitudinal primary care destinations? 01:32 Why access is an important factor, but not the only one. 02:10 Access vs. longitudinal care. 02:47 The challenges of operating a service operation within primary care. 03:47 What is a longitudinal primary care destination and why does it matter? 04:15 How is primary care not delivering on its promise? 04:27 How is the “promise of primary care” different than an urgent care or MinuteClinic? You can learn more at Galileo and follow Dr. Lee on LinkedIn. Tom X. Lee of @galileomedical discusses #retailclinics on our #healthcarepodcast. #healthcare #podcast #financialhealth #patientoutcomes #primarycare #digitalhealth #healthcareleadership #healthcaretransformation #healthcareinnovation Recent past interviews: Click a guest’s name for their latest RHV episode! Dr Benjamin Schwartz, Dr John Lee (Take Two: EP438), Kimberly Carleson, Ann Lewandowski (Summer Shorts), Andreas Mang and Jon Camire (EP479), Justin Leader (Take Two: EP433), Andreas Mang and Jon Camire (EP478), Stacey Richter (EP477), Charles Green (Bonus Episode), Ann Lewandowski, Peter Hayes
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    7 分
  • EP481: Seriously, IRL, What Does “No Margin, No Mission” Even Mean? With Benjamin Schwartz, MD, MBA

    EP481: Seriously, IRL, What Does “No Margin, No Mission” Even Mean? With Benjamin Schwartz, MD, MBA
    2025/07/10

    Balancing Mission and Margin in Healthcare: A Candid Conversation with Dr. Ben Schwartz

    In this episode, host Stacey Richter engages in a deep dive with Dr. Ben Schwartz to explore the phrase 'No Margin, No Mission' and its practical implications in the healthcare industry.

    They discuss the complex relationship between profitability and mission-driven care, the challenges of value-based care, and the role of dyad leadership. The episode emphasizes the importance of transparency, regulatory measures, and trust in fostering a balance between mission and margin. Along the way, Dr. Schwartz shares insights from his new role at Commons Clinic and addresses broader systemic issues like regulatory capture and the subjective nature of defining value in healthcare.

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

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    08:50 Sister Irene Kraus and the origin of no margin, no mission.

    10:01 Margin and mission versus profit and profiteering.

    12:45 Stacey’s manifesto (EP400).

    13:01 What is the broad mission within healthcare?

    14:12 What is mission drift within healthcare?

    15:54 EP474 with Yashaswini Singh, PhD.

    17:26 Why do we struggle with balancing margin and mission?

    20:47 EP455 with Beau Raymond, MD.

    20:52 How does value vary?

    23:18 EP326 with Rishi Wadhera, MD, MPP.

    23:53 What needs to happen to balance margin with mission?

    28:29 Why does everything come down to trust?

    28:33 EP391 with Scott Conard, MD.

    30:30 EP419 with Andreas Mang.

    32:21 What are the “vectors of change” to create balance between mission and margin?

    32:43 EP475 with Peter Hayes.
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    34 分
  • 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

    In this Take Two episode of Relentless Health Value, host Stacey Richter reflects on her conversation with Dr. John Lee to explore the challenging intersection between mission and margin in healthcare.

    They discuss the nuances of cognitive dissonance faced by healthcare professionals, particularly when organizational priorities conflict with patient care. Dr. Lee shares insights on finding a sense of mission within the constraints of the current healthcare system, emphasizing the importance of incremental improvements, team-based care, and peer support.

    The conversation also highlights real-world examples of systemic issues and practical advice on how individuals can contribute to meaningful change without feeling demoralized. This episode is part of an ongoing series addressing critical topics in healthcare, and listeners are encouraged to tune in next week for further discussions.

    === 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:
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    🎤 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


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    08:05 What is cognitive dissonance relative to the healthcare industry?

    09:23 What are the systems that start to bear down on individuals within the healthcare system?

    10:15 EP391 with Scott Conard, MD.

    10:53 EP415 with Rob Andrews.

    11:50 EP326 with Rishi Wadhera, MD, MPP.

    12:27 “The system has almost gamed them.”

    15:44 How can alignment still be achieved in the face of cognitive dissonance?

    17:12 EP431 with Kenny Cole, MD.

    20:43 Why does it take more than one person to solve the dysfunction in the healthcare system?

    23:01 What are some little changes that can help change the cognitive dissonance in healthcare?

    24:57 Why is a hierarchical healthcare structure not necessarily beneficial?

    27:12 The RaDonda Vaught story.

    34:30 “Be happy in the small things.”
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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

    🫙 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 ===
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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 ===
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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: Part 2. What Could Go Wrong Covering High-Cost Claimants With Stop-Loss Reinsurance?

    EP479: Part 2. What Could Go Wrong Covering High-Cost Claimants With Stop-Loss Reinsurance?
    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

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    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/

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    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