Let’s talk about provider organizations and telehealth. It’s just too common a refrain amongst provider organizations who say some combination of: Our patients and/or clinicians don’t like telehealth. Telehealth is too expensive for us to do ... unless maybe we should charge facility fees for telehealth visits. Telehealth is risky to invest in because as soon as payers start paying less than 65% of in-person visits, we’re gonna drop it anyway. These things are said despite the overwhelming popul...
Apr 07, 2022•33 min•Ep. 362
David Contorno the other day posted the life expectancy chart comparing the US to comparable countries. Spoiler alert: It’s horrifying. You see Japan; you see Switzerland, Israel, Spain, Italy … basically everybody else in a cluster of pretty darn vertical lines: increasing life expectancies year over year without much cost increase at all. And then—wow!—off to the right, all by itself, you see the USA, costing nearly double the worst of the other countries with a life expectancy that is years l...
Mar 31, 2022•32 min•Ep. 361
Before I get into the show today, let me just remind everybody about our mailing list, which you can sign up for on our Web site, relentlesshealthvalue.com . You might follow Relentless Health Value on LinkedIn or Twitter , which is a great option, for sure; but I wanted to point out that what you see there is abridged at some level. Meanwhile, if you subscribe to our mailing list directly (again, by going to our Web site, relentlesshealthvalue.com—it’s over on the right sidebar where you can si...
Mar 24, 2022•29 min•Ep. 360
Last week’s show was with Wayne Jenkins, MD, from Centivo; and we talked about how insurance design, when not done well, can lead, in a nutshell, to mental and physical health problems for employees. This is a great lead-in to the conversation in this healthcare podcast with Dan O’Neill. And before I get into why it’s a great lead-in, let me just start here—and don’t roll your eyes. What is value-based care? Consider this delineation: There’s value-based payments, and then there’s the type of ca...
Mar 17, 2022•35 min•Ep. 359
First of all, anybody who thinks that your average citizen in the United States today is unaware of the financial double jeopardy of going to a doctor, going to an emergency room, getting a procedure is sorely mistaken. Americans today are well aware of the financial risk that they are taking by seeking healthcare in this country. To illustrate this point, let me read the first couple of sentences from a New York Times best-selling book review : “The illness narrative, ending in financial ruin a...
Mar 10, 2022•34 min•Ep. 358
Here’s the biggest problem with a lot of telehealth endeavors: Someone decides that they need to be doing telehealth, for whatever reason. Maybe there’s a pandemic, for example. And the basic plan is this: Install some technology, give everyone a username and password and a link for patients, check that box, and move on to the next thing. My guest in this healthcare podcast, Liliana Petrova, has seen and talked about how, far too many times, the whole concept of telehealth is narrowed down to th...
Mar 03, 2022•35 min•Ep. 357
So … let’s start here. Mostly this whole episode is about the so-called “Big Three” PBMs that provide between the three of them pharmacy benefit services for 95% of insured Americans. PBM stands for pharmacy benefit manager, and the Big Three PBMs being ESI, otherwise known as Express Scripts; OptumRx, which is a part (a big profitable part) of United Health Group; and then also CVS. Yes, CVS is not just for your retail pharmacy needs; they are also a huge pharmacy benefit manager. Now, we get t...
Feb 24, 2022•36 min•Ep. 356
My guest in this healthcare podcast is Nikhil Krishnan, who is the founder of the Out-Of-Pocket newsletter. I was talking with Nikhil, and we identified—or, more accurately, he identified—five business models of digital health. What makes each model distinct is a few factors. If you weren’t in the healthcare industry, you’d probably expect that I’m going to say that the biggest factor a business model must hinge on must have something to do with patient outcomes or care or something that has som...
Feb 17, 2022•35 min•Ep. 355
In this healthcare podcast, we’re gonna talk about the realities of setting up a clinically integrated network, otherwise known as a CIN. If only the whole process was unicorns and rainbows, but—as you likely suspected—it’s not. Setting up a clinically integrated network is hard work, but the payoff for patients and clinicians alike can be worth fighting for. First of all, what is a clinically integrated network? It is a kind of ACO (accountable care organization). It is a legal entity that is a...
Feb 10, 2022•33 min•Ep. 354
This episode is probably a 400-level class in specialty pharmacy rebating. If you want a 45-minute conversation on rebates in all their glory, go back and listen to the conversation with Chris Sloan ( Encore! EP216 ). But if you’re still with me, what’s gonna follow is about an eight-minute overview of pharmaceutical rebating, just to make sure we’re all on the same page before we get into the show itself. So, if you know all there is to know about pharmaceutical rebating, you can jump ahead abo...
Feb 03, 2022•31 min•Ep. 353
As a country, we spend approximately $500 billion on prescription drugs. Specialty drugs account for less than 2% of prescriptions but will cost us over $250 billion (that’s in 2021)—so, 2% of prescriptions but half the spend. Specialty is the fastest-growing segment of healthcare spend and is a dominant issue that self-funded employers and other purchasers face. But let’s dig into that $250 billion being spent on specialty drugs, shall we? I have to say, personally, that if we spent $250 billio...
Jan 27, 2022•28 min•Ep. 352
In this healthcare podcast, I’m speaking with Eric Bricker, MD, about how so many entities in healthcare are getting up in other people’s business and swimming in other people’s traditional lanes. Consider last week’s show with Katy Talento, for example. She mentions employers who are not only doing their own direct contracting (ie, cutting out the traditional carriers and negotiating directly with provider organizations) but also employee benefit consultants who are working on setting up their ...
Jan 20, 2022•36 min•Ep. 351
In this healthcare podcast, I’m talking about direct contracting IRL (in real life) with Katy Talento. This is a conversation that’s more about the reality of direct contracting than the theory of direct contracting, and this was not an accident. So much of healthcare transformation is really easy to say and much harder to actually do. So … direct contracting. In the context we discuss in this episode, generally direct contracting means when an employer or their benefits consultant, more likely,...
Jan 13, 2022•36 min•Ep. 350
As one of our guests, Dr. Tony DiGioia ( EP332 ), has said, healthcare has been pushed to its limits this past year; but that doesn’t mean that nothing good has come of it. Celebrating our bright spots and using our experiences to inform future innovations is really the key to more accessible, equitable, and higher quality of care. While the timing of the celebration could, in general, be better given the latest pandemic news, as they say, there’s no time like the present. So, let’s do this thin...
Jan 06, 2022•14 min
This episode is a little bit of a thought experiment, so hang with me as I bumble my way through it and then hit me up with your comments. The plan is to do another episode in the future where some of you with thoughts share your version of your own thought experiment. Here’s the topic: The ultimate impact of telehealth—in 20 minutes or less. In my version of this thought experiment, I want to do something a little bit different (maybe) than everybody who seems to be putting up a poll on Twitter...
Dec 30, 2021•19 min
Believe me, filling in for the uncontested master of podcasts, Stacey Richter, is just a tad unnerving! My name is Dr. Steve Schutzer. I’m an orthopedic surgeon specializing in joint replacement surgery, and I think it’s fair to say that I’m more comfortable, in my own lane, doing complex surgery than doing this introduction to our encore podcast 294 entitled “Building a Center of Excellence: A Playbook for Physician Entrepreneurs,” which aired originally in October 2020. But when Stacey graciou...
Dec 23, 2021•34 min•Ep. 294
This interview with Lisa Trumble is mostly about clinically integrated networks (CINs)—what they are, how they work, how data get shared. Furthermore, we talk about hybrid CINs, meaning, for example, a virtual front door that might lead to in-person care. After that, we talk about the potential impact of direct contracting, which Lisa says could significantly change the healthcare marketplace. The hybrid talk, by the way, is toward the middle of the show; and we talk about direct contracting—tha...
Dec 16, 2021•31 min•Ep. 349
The discussion to follow is probably a 400-level class in payviders. If I just said the word payvider and you’re scratching your head wondering where you may have heard that term before, this show is probably not the best place for you to start. I’d go back and get some context by listening first to the episodes with Steve Blumberg from GuideWell ( EP304 ) and/or the one with John Moore from Chilmark ( EP172 ); and for a really retrospective lookback, check out the one episode with Dr. Kris Smit...
Dec 09, 2021•32 min•Ep. 348
I attended the STAT Summit last week and heard the heart-wrenching story told by Charles Johnson, who is the founder of 4Kira4Moms, which is a group dedicated to improving maternal health equity. Charles’s family is African American. After a planned C-section, his otherwise-healthy wife died an avoidable death because 10 hours after the clinical team was alerted that she had internal bleeding— 10 hours later —they got around to wheeling her into surgery. At that point, she had three liters of bl...
Dec 02, 2021•34 min•Ep. 347
Over the holiday season here, we’re running some of our favorite episodes from years past. This one is with Mike Schneider, who actually has taken another role since this show was recorded. Other than that, the information that Mike shares during this episode from 2020 is all good. So, let’s do this thing. Disclaimer before we get started here: This show is probably a 300-level class in pharmaceutical/PBM relations. If you are tuning in for the first time and you aren’t pretty familiar with the ...
Nov 25, 2021•30 min
In this healthcare podcast, I speak with Peter Hayes, who is president and CEO at the Healthcare Purchaser Alliance of Maine and a national presence in healthcare strategy, innovation, and a frequent keynote speaker. One thing, among many, that Peter said during our conversation struck me. He said it will take a village to fix what ails the healthcare industry in this country. There are too many interdependencies. This point obviously resonates around these parts because it’s the rationale for t...
Nov 18, 2021•36 min•Ep. 346
At the beginning of 2021, my guest in this healthcare podcast, Paul Simms, had come up with a set of predictions for 2021. Some came true; some didn’t. But I was fascinated by a bunch of things, one of them being Paul’s sort of implicit and explicit assessment of the context of these predictions. Right now, Pharma is in a weird moment: It’s a confluence of technology, consumer expectations, changes in care delivery accelerated by the pandemic, policy at the state and federal level, and the finan...
Nov 11, 2021•32 min•Ep. 345
I was on LinkedIn, and someone was saying, “Oh, there’s no real money in generic drugs. It’s not a huge issue if patients are paying 10 bucks instead of 93 cents for something. It’s not like anyone is getting rich off of that, and it’s not like patient impact here is super meaningful.” This is a pretty common refrain, actually; and from a conventional wisdom perspective, I get it, especially for those living comfortable middle- or upper-middle-class lives where an extra $9.07 for a prescription ...
Nov 04, 2021•33 min•Ep. 344
Most people who have been in the healthcare industry for a while have heard by now the metaphor about the two canoes. Provider organizations or health systems with some of their payments coming from a fee-for-service (FFS) payment model and some of them coming from value-based arrangements have the challenge of one foot in the FFS canoe and one foot in the value-based canoe. They’re probably going through a lot of metaphorical pants is the main takeaway that often comes to mind for me. But wardr...
Oct 28, 2021•30 min•Ep. 343
This episode’s conversation is about the new Consolidated Appropriations Act (CAA), the fee disclosure part of it, as well as ERISA and the fiduciary responsibility that self-insured employers are responsible to comply with under the law. Don’t worry, the first thing my guest in this healthcare podcast, Christin Deacon, does is explain these terms, what they actually mean, and how they can be a tool actually in CEOs’ or CFOs’ toolboxes to get access to the employer’s own claims data, which is a ...
Oct 21, 2021•37 min•Ep. 342
First, let’s talk about reducing administrative waste in the US healthcare system. There was a pretty famous 2019 study by Shrank et al. that estimated about 25% of the $3.6 trillion the US spends on healthcare annually is potentially wasteful. This is each person spending $2500 unnecessarily. Robert Kocher wrote a really interesting article about getting rid of administrative waste and inefficiencies, and he said that it is the “safest form of health care cost savings; virtually no one argues t...
Oct 14, 2021•33 min•Ep. 341
There’s a next generation of digital front doors being created that open up to a patient/member experience that folds in payer, provider, and employer data—plus behavioral data the patient themselves generates when they browse through content in there. Because that’s what it takes for a so-called personalized experience or patient journey to ensue. This is what I’m talking about in this healthcare podcast with Kristin Begley, PharmD. In an ideal world, you’d have, for example, a member/patient/c...
Oct 07, 2021•32 min•Ep. 340
Reference-based pricing, the way that most employee benefit consultants use the term anyway, refers to a methodology used by employers to pay providers for services. Usually we’re talking within a fee-for-service (FFS) environment here. The way it typically works ... there are different flavors, but how it typically works is this: Reference-based pricing (RBP) means that an employer starts with some reference-based price. Many times, it’s the Medicare rate. Medicare will pay X dollars for someth...
Oct 05, 2021•9 min
Let’s just start here: As a general construct, insurance carriers have every incentive for health insurance premiums to go up every year. If you’re an employer, that is a material fact. Is it counterintuitive? Maybe. Except if you’re an employer and your premiums are going up year after year, it begs the question why, every single year, the already-extravagant amount you pay continues to go up way more than the inflation rate. You’d think that if your broker and your plan administrator were so g...
Sep 30, 2021•31 min•Ep. 339
My overarching thought throughout a lot of this interview was that improving rural health will take everyone remembering to not let perfect be the enemy of the good. If I live in rural America, there’s no subspecialists. Forget about even seeing a garden-variety kind of specialist. I might have to drive hours to even get to a PCP. There are NPs (nurse practitioners) in a lot of these remote communities, but everybody’s fighting over whether to let them practice independently, even in places wher...
Sep 23, 2021•34 min•Ep. 338
