In this second take on episode host Stacey Richter speaks with Dr. Tom Lee, founder of One Medical and Galileo. The discussion centers on the survival of independent primary care practices in the current healthcare economy, the associated challenges, and the paradox of primary care.

Topics include reducing ER visits, managing downstream specialty spend, and the imbalance between CMS and commercial carrier payments to primary care practices.

Dr. Lee highlights the importance of 'enlightened leadership' and a 'value-focused mindset' in balancing efficient service operations with quality care. He also touches on the complexities of integrating technology and human-centered care, the importance of operational efficiency, and the challenges posed by current reimbursement models.

For a bonus sidebar conversation with Dr. Lee, click here.

=== LINKS ===
🔗 Show Notes with all mentioned links:
https://cc-lnk.com/TakeTwo-EP445

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✭ X https://twitter.com/relentleshealth10:30 What is the paradox of primary care?

12:47 Why is it hard to run an independent primary care practice?

13:29 What are the barriers to running an independent primary care practice?

14:09 Can you have fee for service and value?

15:53 “Value is more about a mindset.”

16:49 What hidden waste is there in a primary care practice?

18:36 What do you need to have a value-focused mindset?

20:41 Why does access precede quality?

22:40 What are the nuances of a service business that make them challenging for managers?

23:27 How do you find the balance between fee for service and value?

30:07 EP438 with John Lee, MD.

31:04 How can you invest in quality without a value-based contract?

33:09 How do you address the trade-off between fee-for-service finances and investing in value-based care?

34:26 Where is the “productive middle”?

35:18 Dr. Tom Lee’s message to payers.

38:45 Dr. Tom Lee’s message for policymakers.

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

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

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=== CONNECT WITH THE RHV TEAM ===
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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.

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

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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.”

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

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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.

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

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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.

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:

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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

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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?

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:

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🫙 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

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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?