Relentless Health Value

Recently on Relentless Health Value, we’ve been tinkering around with a few recurring themes—recurring through lines—that are just true about American healthcare these days. In this episode of Relentless Health Value, host Stacey Richter speaks with Dr. Christine Hale about high cost claimants and the implications for healthcare plans in 2025 and beyond. They discuss the importance of trust in patient care, the financial incentives behind patient steering, and the critical role of timely and comprehensive data analysis. Dr. Hale emphasizes the need for an integrated approach to medical and pharmacy claims data to avoid expensive consequences and improve patient outcomes. She also shares strategies for plan sponsors to effectively manage high cost claimants through evidence-based care, appropriate treatment settings, and creative problem-solving, while underlining the importance of patient engagement and satisfaction. Don't miss next week's episode with Dr. Eric Bricker for a deeper dive into these topics. === 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/ 05:22 What is a high-cost claimant, and how is the definition changing? 07:42 Why buy-and-bill pharmaceuticals can be so costly for plan sponsors. 10:19 What are plan sponsors getting wrong about this situation? 11:28 What do you need as an employer to understand your plan data fully? 13:41 EP462 with Scott Conard, MD. 17:35 What are plan sponsors currently doing that they should not being doing? 19:54 Why starting small is important. 23:02 EP468 with Matt McQuide. 25:37 What are the steps employers should take to improve their high-cost claimant spend? 31:02 EP371 with Erik Davis and Autumn Yongchu. 33:46 EP467 with Stacey. Recent past interviews: Click a guest’s name for their latest RHV episode! Nikki King, James Gelfand (Part 2), James Gelfand (Part 1), Matt McQuide, Stacey Richter (EP467), Vivian Ho, Chris Crawford (EP465), Al Lewis, Betsy Seals, Wendell Potter (Encore! EP384), Dr Scott Conard

In this episode, host Stacey Richter revisits a conversation with Nikki King, CEO of Alliance Health Centers, discussing the critical issues facing rural hospitals and healthcare systems. They delve into the impacts of Medicaid cuts, the financial struggles of rural hospitals reliant on commercial insurance, and potential solutions like freestanding emergency rooms, telehealth, and the expanded roles of nurse practitioners.  The conversation also covers the complexities of maternity care and mental health services in rural areas, emphasizing the urgent need for systemic reforms to ensure equitable access to healthcare. === LINKS === 🔗  Show Notes with all mentioned links:   https://cc-lnk.com/EP470 ✉️  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/ ✭ Threads  https://www.threads.net/@relentlesshealthvalue/ ✭ Bluesky   https://bsky.app/profile/relentleshealth.bsky.social ✭ X   https://twitter.com/relentleshealth/ 08:14 How dire is the rural hospital situation right now? 08:33 How could freestanding ERs be a potential solution for rural hospitals? 09:56 Advice from CHQPR: Rural hospitals should not be forced to eliminate inpatient care. 11:22 Why is broadband a roadblock to telehealth as a solution for rural health access? 14:52 What are other potential rural health access solutions? 15:37 The “hot potato” of nurse practitioners in the healthcare world. 16:34 “The number of residencies for physicians each year is not increasing, but the population … is increasing.” 20:28 EP312 with Douglas Eby, MD, MPH, CPE, of the Nuka System of Care. 22:00 What’s the issue with maternity care in rural America? 24:09 “As healthcare becomes more and more specialized, [the] ability to treat high-risk cases is better, but access gets worse.” 27:57 How is mental health care affected in rural communities? 28:29 “Rural communities are trying very hard to hang on to what they have.” 29:52 “When you look at the one market plan that’s available in a rural community, you probably can’t afford it.” 31:37 What’s the single biggest challenge to moving to a model that incentivizes keeping people healthy? 32:32 “The easiest low-hanging fruit … is having national Medicaid and have that put under the same hood as Medicare.”

James Gelfand, President and CEO of the ERISA Industry Committee, discusses the evolving landscape of healthcare policies. He highlights the potential impact of Medicare site-neutral payments on hospital consolidation and the necessity for plan sponsors to adapt. Gelfand also sheds light on proposed HSA reforms, which aim to expand preventive care options for employees. The conversation addresses the challenges of high-deductible plans and emphasizes the importance of transparency and competition, aiming to lower overall healthcare costs.

In part 1 of this two part episode, Stacey Richter speaks with James Gelfand, President and CEO of the ERISA Industry Committee (ERIC), about the potential effects of proposed Medicaid cuts on plan sponsors and their members.  They explore ways plan sponsors can prepare for the changes, including Medicaid's four major areas of possible cuts: reducing waste, fraud, and abuse; implementing work requirements; reeling in provider taxes; and addressing the 'Cornhusker Kickback' from the ACA.  The conversation also delves into how state governments and hospitals might respond to these cuts and suggests actions for plan sponsors to mitigate potential impacts. The episode is part one of a two-part series, with the second episode covering Medicare site neutral payments and HSA reforms. === 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/   05:22 What’s happening with Medicaid cuts? 06:47 What are the four main things congress is actually looking at in cutting Medicaid? 09:12 What is the Cornhusker Kickback? 16:46 What should plan sponsors be doing right now to prepare for these potential Medicaid cuts? 20:04 What’s going to happen to hospitals with these proposed Medicaid cuts? 20:48 EP464 with Al Lewis. 23:41 How does hospital consolidation affect the potential future with these Medicaid cuts?

In a thought-provoking discussion, Matt McQuide, CEO of Synergy Healthcare, dives into misconceptions about member engagement in the healthcare industry. He debunks the myth that individuals who struggle with health don't care, spotlighting the importance of trust and relationships. Matt outlines three major misassumptions and emphasizes the crucial role of employers in guiding employees through their health journeys. The conversation is packed with real-life examples and practical strategies for enhancing member engagement and improving health outcomes.

In this solo episode of 'Relentless Health Value,' host Stacey Richter dives into the intricate relationship between increased emergency room (ER) visits and the lack of access to effective primary care. Discussing insights from recent episodes featuring experts like Matt McQuide, Dr. Christine Hale, and others, Stacey explores how inadequate primary care leads to skyrocketing ER costs, which now account for 6% of total healthcare spending.  Key points include the systemic issues driving this trend, the incentives misalignments within hospitals and insurance carriers, and the importance of establishing trust and relationships in primary care. The episode also discusses perspectives from healthcare professionals and thought leaders on potential solutions to realign healthcare incentives and improve patient outcomes. === LINKS === 🔗  Show Notes with all mentioned links:  https://cc-lnk.com/EP467 ✉️  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/ 02:16 Connecting the dots between the last six shows. 05:34 EP466 with Vivian Ho, PhD. 05:53 EP463 with Betsy Seals. 05:56 EP384 with Wendell Potter. 14:38 Where does the primary care through line connect to carriers? 17:13 Health Affairs study showing ER cost increases. 19:19 Kevin O’Leary’s Health Tech Nerds newsletter. 19:40 EP407 with Vivek Garg, MD, MBA. 20:47 How are hospital board directors affecting hospital price increases and why? 21:49 Upcoming episode with Matt McQuide. Also mentioned in this episode are Matt McQuide; Christine Hale, MD, MBA; Kenny Cole, MD; Al Lewis; John Lee, MD; Rushika Fernandopulle, MD; Scott Conard, MD; Vivian Ho, PhD; Betsy Seals; Wendell Potter; Tim Denman; François de Brantes, MBA; Jeff Charles Goldsmith, PhD; Mick Connors, MD; Primary Care for All Americans; Rob Andrews; Alex Sommers, MD, ABEM, DipABLM; Ann Lewandowski; Steve Schutzer, MD; Sergei Polevikov, ABD, MBA, MS, MA 🇮🇱🇺🇦; Kevin O’Leary; Health Tech Nerds; Vivek Garg, MD, MBA; Suhas Gondi, MD, MBA; 

Healthcare costs keep rising, but what’s driving those increases? In this episode, Stacey Richter speaks with Dr. Vivian Ho, a health economist at Rice University and Baylor College of Medicine, to break down the real reasons behind skyrocketing commercial insurance premiums. Are insurance premiums rising faster than wages—and why does it matter? What’s the biggest driver of premium increases? (Spoiler: It’s hospital prices.) Are hospital price hikes justified by rising costs—or is something else at play? Dr. Ho shares data-backed insights on hospital consolidation, executive incentives, and how health system pricing impacts self-insured employers and plan sponsors. If you’re a healthcare executive or a jumbo employer managing benefits, this episode is a must-listen. === 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 Podcastshttps://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/ ✭ Bluesky   https://bsky.app/profile/relentleshealth.bsky.social ✭ Threads  https://www.threads.net/@relentlesshealthvalue/ ✭ X   https://twitter.com/relentleshealth/ 05:12 Are insurance premiums going up?05:59 What is the disparity between cost of insurance and wage increases?06:21 LinkedIn post by Byron Hugley.06:25 Article by Michael Strain.06:46 How much have insurance premiums gone up for employers versus employees?09:06 Chart showing the cost to insure populations of employees and families.10:17 What is causing hospital prices and insurance premiums to go up so exponentially?12:53 Article by (and tribute to) Uwe Reinhardt.13:49 EP450 with Marilyn Bartlett, CPA, CGMA, CMA, CFM.15:28 Are razor-thin operating margins for hospitals causing these rising hospital prices?16:56 Collaboration with Marilyn Bartlett and the NASHP Hospital Cost Tool.19:47 What is the explanation that hospitals give for justifying these profits?23:16 How do these hospital cost increases actually happen?27:06 Study by Zack Cooper, PhD.27:50 Who typically makes up a hospital board, and why do these motivations incentivize hospital price increases?30:12 EP418 with Mark Cuban and Ferrin Williams, PharmD, MBA.33:17 Why is it vital that change start at the board level?

Chris Crawford, CEO of RxSaveCard, dives into the murky waters of pharmacy benefits and inflated drug prices. He shines a spotlight on the hidden costs imposed by large Pharmacy Benefit Managers (PBMs) and discusses a significant lawsuit involving J&J. Crawford explains how aggregate discount guarantees often lead to higher prices for consumers, while cash-pay options can offer real savings. The conversation encourages transparency in drug pricing and highlights innovative tools that help both employers and employees navigate the complex pharmaceutical landscape.

Al Lewis, CEO and founder of Quizify, dives into the staggering rise of emergency room costs, which now account for 6% of total healthcare plan spending. He discusses whether patient acuity or upcoding is to blame for these increases. Al also tackles the impact of the No Surprises Act and the difficulties plan sponsors face in negotiating fair ER rates. With actionable strategies for employers, he sheds light on how to combat inflated charges in the healthcare system.

Betsy Seals, CEO and co-founder of Rebellis Group, dives into the evolving landscape of Medicare Advantage policies. She examines the potential shifts in the Medicare Advantage Stars Program due to lawsuits and the new administration's guidelines. There's an engaging discussion about risk adjustment practices, AI's role in prior authorization, and increased scrutiny on agent marketing tactics. Betsy stresses that Medicare Advantage plans must focus on patient value and innovative data use to navigate these changes effectively.