Relentless Health Value

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.

In this episode, Stacey Richter explores how the demands of shareholders influence the actions of publicly traded health insurance companies with guest Wendell Potter. Drawing from Milton Friedman’s assertion that a business’s primary responsibility is to its shareholders, we examine the implications of this philosophy in the healthcare sector. The discussion highlights concerns about fraud allegations among major insurers and the lack of open competition due to market consolidation.  We delve into the concept of the “medical loss ratio,” a key metric for investors, and how it pressures insurers to prioritize profits, often at the expense of patient care. Our guest, Wendell Potter, a former health insurance executive turned advocate for healthcare reform, provides insider insights into these dynamics. He discusses the challenges insurers face in controlling costs, the impact of rising premiums, and the broader consequences for patients and the healthcare system. This episode offers a critical look at the intersection of corporate interests and patient care, shedding light on the systemic issues that arise when profit motives drive healthcare decisions.   All mentioned links can be found in the show notes.  === LINKS === 🔗  Show Notes with all mentioned links:  https://cc-lnk.com/Encore384 ✉️  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/ ✭ Bluesky   https://bsky.app/profile/relentleshealth.bsky.social ✭ Threads  https://www.threads.net/@relentlesshealthvalue/ ✭ X   https://twitter.com/relentleshealth/   08:31 What is the medical loss metric? 11:33 “The reality is, insurers have been jacking up premiums … for a long time.” 12:48 “It’s a short-term game.” 15:39 “You’re seeing that these companies are not doing a very good job … of controlling costs because they don’t have the incentive.” 20:19 EP366 with Kevin Schulman, MD. 22:45 How do payers ensure that they’re controlling utilization? 25:53 “It’s death by a thousand cuts.” 31:51 “Just like independent practice physicians are endangered, so are community pharmacists.” 33:17 Who runs our healthcare system?

Dr. Scott Conard, founder of Converging Health, dives into the intricacies of population health management. He highlights that 70% of high-cost patients were previously high-risk yet low-cost, emphasizing the importance of early identification. Discussions revolve around aligning healthcare benefits with community needs for better access and proactive health management. Conard advocates for a holistic view of health, using comprehensive data to create a 'whole person risk score', illustrating that effective management can reduce costs while enhancing patient outcomes.

Stacey Richter dives into the intricacies of healthcare benefit design, spotlighting the challenges posed by moral hazard. She emphasizes the need for balanced benefit plans that encourage high-value care while preventing unintended consequences. Discussions revolve around high deductible health plans and how financial incentives impact patient behavior. Richter questions the binary approach to solutions, urging a nuanced understanding of healthcare utilization and the importance of Pareto optimality in resource allocation.

In this conversation, Chris Crawford, CEO of RxSaveCard, delves into the complex world of GLP-1 medications and the financial dilemmas faced by plan sponsors. He discusses how trying to limit medication volume can paradoxically lead to higher unit costs. Chris explores innovative solutions in the burgeoning cash marketplace, allowing employers to bypass traditional PBM contracts for better pricing. Tune in for insights on navigating pharmacy trends and leveraging alternative strategies to manage healthcare costs effectively.