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  • Slaying the Three-Headed Monster of Health Plan Networks, With Evan Anderson

    Slaying the Three-Headed Monster of Health Plan Networks, With Evan Anderson
    2026/09/30
    Discount Illusions, Billing Errors, and Site-of-Care Markups: A Carrier Network Primer for Employers with Evan Anderson of Handl Health. Episode 531. Whatever the plan was at the very beginning, the big status quo carrier networks have evolved into what Stacey Richter calls a three-headed monster: the contractual illusion of discounts, payment integrity nobody with skin in the game is allowed to check, and wild site-of-care price swings inside the very same network. Stacey talks with Evan Anderson of Handl Health, where he works on product strategy, general strategy, and operations, about how fee-for-service networks got here and what self-insured employers, brokers, and TPAs can do around the edges right now. Consider it a primer — a survey of the general map of the landscape, with breadcrumbs to many past episodes for anyone ready to take a deep dive. WHAT YOU'LL LEARN ✅ Why a discount off a chargemaster price is "an optical illusion" — including the 2023 Health Affairs finding that at roughly half of hospitals, the discounted cash price is lower than the insurer-negotiated rate ✅ How old mainframe adjudication systems, obtuse contracts, and double-digit billing error rates make payment integrity nearly impossible to verify — because where there's mystery, there's margin ✅ How site-of-care differentials drive runaway spend, from hospital multipliers as high as 13X to $135 vs. $13,560 for the exact same infusion drug — both in-network ✅ Why switching carrier networks, even with your own claims file and transparency data, is a shrinking lever as prices regress toward the mean ✅ Three around-the-edges moves: direct contracting for advanced primary care and Centers of Excellence, steerage and tiering that include site-of-care tiers, and bundled episodes of care aggregated into alternative health plans ✅ How the broker/EBC role is shifting from network shopper to plan orchestrator WHY THIS MATTERS These networks are, lest we forget, built on a fee-for-service model that structurally aligns incentives in ways that are a lot of times misaligned with members and plan sponsors. As Evan puts it, cut one head off and the body grows it back — that body being decades of opacity (gag clauses were only banned by the CAA in 2021) and intermediaries paid in ways indifferent or positively correlated to higher spend. For plan sponsors facing extreme increases, knowing the real price, the quality, and what was actually billed is how you start chipping away at the status quo. MENTIONED IN THIS EPISODE EP505 with Ahilan Sivaganesan, MD: Apple Podcasts | Spotify | Other Apps EP434 with Benjamin Schwartz, MD, MBA: Apple Podcasts | Spotify | Other Apps Website: Handl Health Handl Health on LinkedIn Evan Anderson on LinkedIn Article: Katy Talento, ND, ScM, on a post-network world LinkedIn Post by Mark Cuban LinkedIn Post by Craig Gottwals Study: Health Affairs, hospital cash prices vs. negotiated prices EP482 with Preston Alexander: Apple Podcasts | Spotify | Other Apps EP480 with Kimberly Carleson: Apple Podcasts | Spotify | Other Apps EP521 with Andrew Tsang: Apple Podcasts | Spotify | Other Apps Article: Jim Jusko, JD, on healthcare provider networks (Medical Economics) EP529 with Eric Bricker, MD: Apple Podcasts | Spotify | Other Apps EP501 with Ivana Krajcinovic, PhD: Apple Podcasts | Spotify | Other Apps EP472 with Eric Bricker, MD: Apple Podcasts | Spotify | Other Apps EP398 with Jacob Asher, MD: Apple Podcasts | Spotify | Other Apps LinkedIn Post by Mike Hopkins EP528 with Yashaswini Singh, PhD: Apple Podcasts | Spotify | Other Apps LinkedIn Comment by Lori Smith Guliano LinkedIn Comment by Patrick Nelli EP509 with Patrick Nelli: Apple Podcasts | Spotify | Other Apps EP504 with Ryan Jacobs: Apple Podcasts | Spotify | Other Apps EP530 with Jake Velie and Keith Hartman, RPh: Apple Podcasts | Spotify | Other Apps EP523 with Suhas Gondi, MD, MBA: Apple Podcasts | Spotify | Other Apps EP503 with Ryan Wells; Leo Spector, MD, MBA; and Adam Stavisky: Apple Podcasts | Spotify | Other Apps EP294 with Steve Schutzer, MD: Apple Podcasts | Spotify | Other Apps === LINKS === 🔗 Show Notes with all mentioned links ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter 🫙 Support the podcast with a small donation to the Tip Jar 🎤 Follow us on Apple Podcasts 🎤 Follow us on Spotify 📺 Subscribe to our YouTube channel === CONNECT WITH THE RHV TEAM === ✭ LinkedIn ✭ Threads ✭ Bluesky ✭ X 00:00 Introduction to this episode. 02:21 An overview of today's conversation. 06:31 The conversation with Evan Anderson. 06:40 What is a network? 08:15 The reality of contracts and care networks. 13:19 The contractual illusion of discounts. 21:17 What does a good solution look like right now? 24:35 How incentivizing providers can open opportunities. 26:44 How COE and steerage architecture plays into this. 34:02 The different role of the broker and EBC in this ...
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    38 分
  • EP533: Level Funding Is Self-funding: 5 Avoidable Contract Risks, With Frank Pennachio

    EP533: Level Funding Is Self-funding: 5 Avoidable Contract Risks, With Frank Pennachio
    2026/10/14
    Hello, all you Relentless Tribe members. Thanks for hanging with me today to talk about a bunch of things. One of them being what exactly are level-funded plans, and what are the upsides, and then what are the risks? Because here's the thing. I was talking to an employer the other day, an employer with a fully funded insured plan; and he told me his renewal this year: 69% … 69%! 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. Now, their broker managed to negotiate that increase down to 50%. I'm not entirely sure if I'd classify that as a victory. So, when Frank Pennachio says in the conversation with him that I'm gonna have today that there's a lot of desperation out there for a lifesaver for these plan sponsors, for employers out there, for just a way forward that may just even preserve the employer's ability to continue to provide coverage; to not actively be working insanely hard to try to replace the humans with, like, AI that doesn't need insurance; or to, like, offshore labor to a country, literally any other country, because any other country is going to have more affordable healthcare, like, at a certain point, one more double-digit increase, one more 50% increase becomes a really big corporate decision. So, right, we talk a lot about self-funding on Relentless Health Value because it can be a very empowering way to go if a plan sponsor chooses to embrace the entirety of the potential upsides while mitigating the inherent risks of becoming a fiduciary and, as Elizabeth Mitchell has said, running a small insurance business off the side of their desks. That's what you're doing when you become self-insured. Someone in the company is running a small insurance business off the side of their desk. What would be a problem for anyone to hear, though, is a message that self-funding or becoming a self-insured employer is, like, some kind of homogenous broad stroke. Like, all of these employer-sponsored insurance companies that have gotten stood up are the same or maybe even similar, kind of forgetting that there are many, many different flavors or models of self-insurance. So, coming up here, Frank Pennachio, my guest today, quotes economist Thomas Sowell, who famously said that in healthcare, "There are no solutions. There are only trade-offs." And you can see why, because all of this adds up to a key point: how plan sponsors can make intentional and intelligent decisions, trade-offs, pick which trade-off they want rather than desperate ones. So, right, my guest today is Frank Pennachio, who is the author of the book The Silent Danger. Frank brings nearly 40 years of experience in the health insurance industry. He started his career on the P&C (property casualty) side before evolving into employee benefits, owning an agency, consulting, and training with agencies and plan sponsors nationwide. Frank also has a couple of courses available on his Web site, so certainly do check them out. In the conversation coming up here, Frank walks us through the hidden contract risks that level-funded plan sponsors fall into regularly; and then we get into the critical takeaways to help plan sponsors, their advisors, navigate these waters with eyes wide open. If you are an employer considering, for example, level funding or trying to figure out other ways to be self-funded or an advisor or a policymaker or anybody thinking hard about healthcare affordability and where the dollars spent by taxpayers, members, and health plans are going, this episode is your essential field guide. This is Relentless Health Value. I want to first of all thank Frank for generously offering to sponsor the costs of producing this episode, which was really kind of him. That was a really nice gesture. Also, thanks to our founding sponsor, Aventria Health Group. And with that, here is my conversation with Frank Pennachio. Also mentioned in this episode are Elizabeth Mitchell; Aventria Health Group; Andreas Mang; Jon Camire; Kimberly Carleson; Justin Leader; Lori Guliano; David Goldfarb; Doug Aldeen; Cynthia Fisher; Claire Brockbank; Stan Schwartz, MD; and ZERO.health. For a list of healthcare industry acronyms and terms that may be unfamiliar to you, click here. You can learn more at thesilentdanger.com and by following Frank on LinkedIn. Frank Pennachio is a nationally recognized authority on fiduciary risk, ERISA compliance, and the governance of self-funded health plans. With more than four decades in the insurance and risk management industry, Frank has built a reputation for challenging conventional thinking and exposing hidden liabilities that often go undetected in employer-sponsored benefit programs. Frank is known for connecting silos that traditionally operate independently: employee benefits and property & casualty. Frank is the author of The Silent Danger, a book focused on the overlooked ...
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    37 分
  • EP532: Why Avoidable ER Visits Aren't the Real Cost Problem: Revisiting Our 2016 Interview With HHS Nominee Chris Klomp

    EP532: Why Avoidable ER Visits Aren't the Real Cost Problem: Revisiting Our 2016 Interview With HHS Nominee Chris Klomp
    2026/10/07
    Today we are dipping into the archives for an essential replay from 2016, one decade ago, featuring Chris Klomp back when he served as CEO of a company called Collective Medical. With the nomination of Chris Klomp to serve as deputy secretary of the Department of Health and Human Services (HHS), all eyes are kind of on how he plans to manage a nearly $2 trillion federal health apparatus. 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. Hey, turns out I have a semi-decent track record for finding the folks who are going to make a difference or who are making a difference and bringing them to you, Relentless Health Value tribe. Or it could be that—what do they say?—twice a day a blind squirrel finds a nut. I could edit out that metaphorical mess I just made, but I'm not going to so you can fully appreciate the work that our editor, Tom Nash, has cut out for him. Okay … so, a decade ago, Chris Klomp, as a CEO, was focused on one of the most stubborn bottlenecks in healthcare: frequent emergency department visits and systematic lack of care coordination therein. In this conversation that follows, in this earlier episode, he broke down how real-time insights and aligned incentives can prevent avoidable hospital utilization. Listening back today provides a kind of rare, candid preview of the operational philosophy which may now shape Chris Klomp's view on health policy. Now, you might consider this a very, very short introduction 'cause I'm wrapping up here. But never fear. Instead of chewing your ear off at the top of the show, like I normally do, I'm gonna spread my commentary inside the conversation with Chris Klomp that follows, just to kinda keep everything in context. Also, speaking of changes around here, we are experimenting with a new way to start the show that kinda jumps right in instead of trying to figure out a, like, one-sentence title for the entirety of the episode. Maybe I'm just terrible at titles (which might be fair enough), but it also seems like the main point or summary or takeaway of any given show, it only sorta starts to come out when the episode hits you lot, you Relentless Tribe, you listeners. You go on LinkedIn and pull out and parse and respond, and then all of a sudden, I wish the episode had a different name or a different title based on the sometimes really crystal-clear reflections and insights that I read or hear about later on and after the dust settles. So, if you have thoughts on this—seems like a big deal to us, but maybe it's not a big deal to you—if you have any thoughts, do share. This is Relentless Health Value. Thank you so much to Aventria Health Group, which is our founding sponsor. Thank you also so much to our series underwriter in 2026, Payerset. And I just wanna let you know that Payerset just posted about 129,000 self-funded employers' allowed amounts on their Web site for free. So, do go over to Payerset's Web site if you wanna check that out. Also, thank you very much to Patient Rights Advocate for a really, really nice donation this year. It's so important to helping keep this show on the air. Again, this is the show from 2016 with Chris Klomp. Also mentioned in this episode are Tom Nash; Arielle Bose; Aventria Health Group; Payerset; Patient Rights Advocate; Collective Medical Technologies; Mick Connors, MD; Al Lewis; Peter Smulowitz, MD, MPH; Leah Honigman, MD; Bruce Landon, MD, MBA; John Lee, MD; Monica Lypson, MD, MHPE; Kenny Cole, MD; Scott Conard, MD; and Jerry DiMaso. For a list of healthcare industry acronyms and terms that may be unfamiliar to you, click here. Chris Klomp is the chief counselor at the U.S. Department of Health and Human Services. He has driven healthcare reform at state and federal levels, focusing on value-based care and interoperability. He built Collective Medical; has co-founded, advised, and served on the board of many innovative start-ups and on the Utah Digital Health Services Commission; and worked at Bain Capital and Bain & Company. Chris holds a bachelor of arts degree with honors in economics and English from Brigham Young University and an MBA from Stanford. 00:00 Introduction to this episode. 04:38 Reducing wasteful spend in healthcare. 05:37 The percentage of total healthcare costs that goes to emergency medical spend in the U.S. 06:07 EP467 with Stacey. 07:09 Why ED spending is low-hanging fruit. 08:17 How EDs operate as choke points. 09:14 Impacting what happens in the emergency department. 17:34 What happens when a patient enters the ED. 20:57 Why it's important to have data available to everyone who might touch the patient. 23:44 EP495 with Mick Connors, MD. 23:51 EP464 with Al Lewis. 23:58 Research from Peter Smulowitz, MD, MPH; Leah Honigman, MD; and Bruce Landon, MD, MBA. 24:45 The need-to-know when it comes to managing data. 28:01 Thinking about risk and imminent ...
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    37 分
  • The Sleeping Giants of Healthcare—Why Self-insured Employers and Clinicians Keep Missing Each Other, With Suhas Gondi, MD, MBA. EP523

    The Sleeping Giants of Healthcare—Why Self-insured Employers and Clinicians Keep Missing Each Other, With Suhas Gondi, MD, MBA. EP523
    2026/08/05
    Why Self-Insured Employers and Clinicians Keep Missing Each Other, With Suhas Gondi, MD. The Sleeping Giants of Healthcare: Why Employers and Clinicians Keep Missing Each Other. Episode 523. Dr. Suhas Gondi, MD, MBA, chief medical officer at Health Strategy and an attending physician at Massachusetts General Hospital, co-wrote a New England Journal of Medicine article — "A Sleeping Giant of Health Care Affordability—Self-Insured Employers" — because most clinicians, he found, have little idea a self-insured employer, not an insurance carrier, is the one actually paying for their patients' care. Talking with Stacey Richter, Dr. Gondi argues that self-insured employers and clinicians are both "sleeping giants," each holding real power over cost and access, who rarely communicate directly — leaving patients caught in the gap. WHAT YOU'LL LEARN ✅ Why Dr. Suhas Gondi and his NEJM co-author, Zirui Song, MD, PhD, wrote for clinicians who, they found, have little sense that a self-insured employer — not the carrier name on the card — actually pays for a patient's care ✅ How a GLP-1 prescription can get denied at the pharmacy counter even after a clinician verifies coverage, because the employer has quietly moved GLP-1 coverage exclusively through a single third-party prescribing and coaching vendor ✅ Why GLP-1 spending alone can push a self-insured employer's pharmacy costs up 9% to 20% in a year, and why the roughly eight-year payback period employers are counting on assumes patients stay adherent far longer than most actually do ✅ How oncology site-of-care steering — an employer declining to pay a roughly 40% premium for infusion at a hospital-owned center instead of a physician's office — can look to the patient and oncologist like a denied cancer drug ✅ Why Dr. Gondi says EHRs like Epic are built to optimize revenue for hospital-system customers, not to surface a lower-cost site of care for patients or plan sponsors ✅ Dr. Gondi's advice for closing the gap: clinicians and employers should communicate directly, especially before a coverage change lands on patients, rather than assuming direct contracting is the only fix WHY THIS MATTERS Roughly half to 60% of the US population has commercial insurance, and nearly three-quarters of large employers self-insure that coverage — yet most clinicians have no visibility into the plan-level decisions those employers make, and most employers have no channel to explain those decisions to the doctors whose patients are affected. Both sides, Dr. Gondi says, usually believe they're doing the right thing — covering the GLP-1, covering the cancer drug — and the patient still gets lost in between. Closing that gap doesn't require full direct contracting, he argues, just employers and local provider groups actually talking to each other before a coverage change lands on a patient, not after. MENTIONED IN THIS EPISODE Study: New England Journal of Medicine article, "A Sleeping Giant of Health Care Affordability—Self-Insured Employers," by Suhas Gondi, MD, MBA, and Zirui Song, MD, PhD EP406 with Lauren Vela: Apple Podcasts | Spotify | Other Apps EP519 with Lisa Rosenbaum, MD: Apple Podcasts | Spotify | Other Apps EP509 with Patrick Nelli: Apple Podcasts | Spotify | Other Apps EP494 with Sarah Emond: Apple Podcasts | Spotify | Other Apps EP501 with Ivana Krajcinovic, PhD: Apple Podcasts | Spotify | Other Apps EP468 with Matt McQuide: Apple Podcasts | Spotify | Other Apps Article: Acquired's episode on how Epic quietly powers American healthcare === LINKS === 🔗 Show Notes with all mentioned links: Episode Page ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter 🫙 Support the podcast with a small donation to the Tip Jar 📺 Subscribe to our YouTube channel 🎤 Listen on Apple Podcasts 🎤 Listen on Spotify === CONNECT WITH THE RHV TEAM === ✭ LinkedIn ✭ Threads ✭ Bluesky ✭ X 00:00 Introduction to this episode. 00:35 A big thank you. 06:22 The conversation with Dr. Suhas Gondi. 07:08 Why Dr. Suhas Gondi and his coauthor wrote their article. 09:24 Why the affordability of care and the decisions self-employers are making about coverage matter to clinicians. 12:12 What the term "sleeping giants" implies and how that reflects the reality of healthcare. 14:31 A case study. 21:24 How the patient can still get lost even when both the employer and clinician think they're doing the right thing. 22:52 An example from the oncology space. 28:47 Dr. Suhas Gondi's advice to clinicians. 30:55 The communication gap between clinicians and employers. 33:30 Why the presence of middlemen should not prevent communication between clinicians and employers.
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    35 分
  • Mark Cuban and Cora Opsahl: The Truth About Pass-Through PBM Contracts and Generic Compliance Ratios

    Mark Cuban and Cora Opsahl: The Truth About Pass-Through PBM Contracts and Generic Compliance Ratios
    2026/08/26
    How Discount Theater and Generic Compliance Ratios Quietly Overcharge Patients and Employers. Episode 526. Mark Cuban, co-founder of Mark Cuban Cost Plus Drug Company, and Cora Opsahl, managing director of Peterson Health Analytics and former director of the 32BJ Health Fund, join Stacey Richter for an outtake from their conversation last fall (EP488) on the operational mechanics of the pharmacy supply chain. They trace how a generic compliance ratio—typically requiring pharmacies to buy at least 92% of their generics from a single primary wholesaler—pushes independent pharmacies into paying a premium that gets passed straight to patients, and how so-called pass-through PBM contracts can pay pharmacies using one pricing formula while billing employers using an entirely different one. Along the way, they walk through the classic generic imatinib example—a drug Cost Plus Drugs sells for $25 a month that a traditional PBM channel has billed at $9,000—to show why a discount off an inflated reference price is, as Cuban puts it, discount theater. WHAT YOU'LL LEARN ✅ Why pharmacies get locked into overpaying: wholesalers set a Generic Compliance Ratio requiring pharmacies to buy at least 92% of their generics from them or face chargebacks and fees that wipe out their margin ✅ The classic generic imatinib example: Cost Plus Drugs sells it for $25 a month, while the same drug billed through a traditional PBM channel has run $9,000 a month—a "discount" off a $27,000 branded Gleevec price that Mark Cuban calls discount theater ✅ How specialty tiers compound the problem: because generic imatinib gets classified on a specialty tier, patients can owe 25% coinsurance calculated off the inflated WAC price rather than the drug's real cost ✅ Why a "pass-through" PBM contract isn't simple math: Cora Opsahl explains that PBMs often reimburse pharmacies on an acquisition-cost-plus formula while billing employers a completely different AWP-minus formula for the same claim ✅ Why claims audits keep finding money owed back to the plan—and why employers are often restricted to auditing only a pre-approved sample of 250 claims ✅ Mark Cuban's advice for the next RFP: simply requiring that Cost Plus Drugs be included in the network is often enough on its own to get PBMs to offer better rebates and terms WHY THIS MATTERS As Stacey Richter puts it, where there's mystery, there's margin—and pharmacy pricing is thick with both. Generic compliance ratios, WAC-based specialty tiers, and pass-through contracts that pay pharmacies one number while billing employers another all point to the same underlying reality: so much of what gets called an expense in medicine is simply pricing failure. For plan sponsors and brokers heading into their next RFP, understanding these mechanics—rather than accepting a discount off an inflated reference price—is what it takes to move from passive price taker to informed decision maker. MENTIONED IN THIS EPISODE EP429 with Luke Slindee, PharmD: Apple Podcasts | Spotify | Other Apps EP488 with Mark Cuban and Cora Opsahl: Apple Podcasts | Spotify | Other Apps EP422 with Benjamin Jolley, PharmD: Apple Podcasts | Spotify | Other Apps EP465 with Chris Crawford: Apple Podcasts | Spotify | Other Apps EP486 with Stan Schwartz, MD: Apple Podcasts | Spotify | Other Apps === LINKS === 🔗 Show Notes with all mentioned links: Episode Page ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter 🫙 Support the podcast with a small donation to the Tip Jar 📺 Subscribe to our YouTube channel 🎤 Listen on Apple Podcasts 🎤 Listen on Spotify === CONNECT WITH THE RHV TEAM === ✭ LinkedIn ✭ Threads ✭ Bluesky ✭ X 00:00 Introduction to this episode. 03:43 An overview of today's conversation. 05:59 Today's conversation with Mark Cuban and Cora Opsahl. 07:25 Why discounts are meaningless without knowing the absolute price. 09:29 What a generic compliance ratio does. 12:28 Thinking about the demand side for employers. 15:00 The complication of a pass-through contract. 17:48 Why too much of healthcare comes down to a negotiation.
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    20 分
  • Private Equity in Primary Care: What the Data Actually Shows, With Yashaswini Singh, PhD. Episode 528.

    Private Equity in Primary Care: What the Data Actually Shows, With Yashaswini Singh, PhD. Episode 528.
    2026/09/09
    Private Equity in Primary Care: Just Another Inflationary Business Model? What Does the Data Actually Show, With Yashaswini Singh, PhD (EP528) Private equity has been buying up primary care practices for years, promising the capital that chronically underfunded clinicians badly need. But does the money actually make care better? Yashaswini Singh, PhD, MPA, the Thomas J. and Alice M. Tisch Assistant Professor of Health Services, Policy, and Practice at Brown University, has spent years studying that question — and her newest research, published in Health Affairs and JAMA Health Forum, finds PE-affiliated primary care physicians negotiate prices 8% to 10% higher than independent doctors, while patient outcomes barely budge. WHAT YOU'LL LEARN ✅ Why negotiated prices for PE-affiliated primary care physicians run 8% to 10% higher than independent doctors — and why hospital-affiliated physicians still command the highest prices of all ✅ How a national study of roughly 200 PE-acquired primary care practices found a 20% increase in preventive services, including the Medicare Annual Wellness Visit, with no evidence of low-value care ✅ Why "cognitive atrophy" — deskilling from rigid, box-checking visits — isn't inevitable under PE ownership, but why the "best case scenario" often isn't what's actually happening ✅ How opaque common ownership — the same investors owning primary care, GI, orthopedic, and oncology practices — can create hidden referral incentives current data can't detect ✅ Why site-of-care payment arbitrage — a hospital-owned MRI can cost double or triple an independent one — drives referral-machine incentives regardless of who owns the practice ✅ Why PE's promise to reduce fragmentation through consolidation has instead produced physician turnover that undermines the patient-doctor relationship WHY THIS MATTERS Primary care clinicians are chronically underpaid, and private equity promises the capital to fix that. But Dr. Singh's research shows a real tradeoff: costs rise 8% to 10% while quality barely moves. Whether professional capital builds sustainable, whole-person care or becomes, as Stacey puts it, corporate arbitrage in a different Halloween costume depends on realigning payment incentives around outcomes rather than throughput — something no ownership model, PE included, is yet built to do. MENTIONED IN THIS EPISODE EP519 with Lisa Rosenbaum, MD: Apple Podcasts | Spotify | Other Apps LinkedIn Post by Yashaswini Singh, PhD EP474 with Yashaswini Singh, PhD: Apple Podcasts | Spotify | Other Apps Study: "Private Equity Acquisitions in Primary Care" (Health Affairs) Study: "Private Equity Acquisition in Primary Care and Avoidable Hospitalizations" (JAMA Health Forum) LinkedIn Comment by Andrea DeSantis, DO, FAAFP EP521 with Andrew Tsang: Apple Podcasts | Spotify | Other Apps EP523 with Suhas Gondi, MD, MBA: Apple Podcasts | Spotify | Other Apps === LINKS === 🔗 Show Notes with all mentioned links: Show Notes ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter 🫙 Support the podcast with a small donation to the Tip Jar 🎤 Follow us on Apple Podcasts 🎤 Follow us on Spotify 📺 Subscribe to our YouTube channel === CONNECT WITH THE RHV TEAM === ✭ LinkedIn ✭ Threads ✭ Bluesky ✭ X 00:00 Introduction to this episode. 04:16 The three categories covered in today's episode. 05:36 The conversation with Dr. Singh. 07:02 Findings these private equity studies have found about primary care. 12:00 Does private equity make cognitive atrophy inevitable? 14:49 In PE-backed, single-specialty primary care, is it easier for PCPs to have full-spectrum clinical scope? 17:14 Why perverse financial incentives cause problems but aren't necessarily an inevitability. 22:17 Fragmentation and private equity in primary care. 25:46 Indie primary care versus PE-backed primary care versus hospital system–backed primary care. 32:22 What Dr. Singh is thinking about and looking to solve for next. 34:30 Inspiring physician-led work and a reason for hope.
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    39 分
  • How Stark Law, Stipends, and Noncompetes Drive Hospital Consolidation, With Eric Bricker, MD

    How Stark Law, Stipends, and Noncompetes Drive Hospital Consolidation, With Eric Bricker, MD
    2026/09/16
    The Chain Reactions Wrecking Healthcare Affordability: Facility Fees, Stark Law, and Noncompetes. Episode 529. Why do hospital facility fees keep pace with inflation while professional fees fall behind—and how did a law meant to stop kickbacks end up fueling a stipend economy instead? Stacey Richter talks with Eric Bricker, MD, founder of AHealthcareZ and former co-founder and chief medical officer of Compass Professional Health Services, about two action/reaction chains reshaping healthcare affordability: the facility-versus-professional-fee gap, and the Stark Law's unintended stipend economy driving hospital consolidation. Along the way: a $48,126 hospital charge for the same appendectomy that pays a surgeon $609, the AMA's $300 million CPT-code business, and how Tryon Medical Group in Charlotte, North Carolina, won back 90% of its patients by leaving its hospital employer. WHAT YOU'LL LEARN ✅ How separate physician "professional fee" and hospital "facility fee" billing streams have diverged so far that Medicare pays a surgeon $609 for an appendectomy while the hospital's published charge for it runs $48,126 ✅ Why the Stark Law's ban on hospitals paying physicians for referrals gave rise to "stipends"—flat annual payments that can range from $1 million to $50 million depending on hospital size, and how physician consolidation in fields like anesthesiology has pushed those stipends higher ✅ How "site unneutral" payment gaps incentivize hospitals to buy independent physician practices and shift services like echocardiograms into hospital settings to capture higher fees for identical care ✅ Why noncompete clauses trap physicians in incentive structures misaligned with patient care—and how Tryon Medical Group in Charlotte, North Carolina, sued to leave its hospital employer and kept over 90% of its patients ✅ Why self-insured employers (covering roughly 60% of Americans) and physicians organizing beyond fragmented specialty lines are healthcare's "two sleeping giants" ✅ Practical alternatives already in use: employer direct contracting, direct primary care subscriptions, and fixed-fee specialty models like the LA urology group paid on subscription for prostate cancer care WHY THIS MATTERS These two chain reactions—the facility-versus-professional-fee gap, and a well-intentioned law that quietly created a stipend economy—aren't abstract policy trivia. Together they drive the hospital consolidation and site unneutral payment schemes squeezing employers, taxpayers, and patients alike. As Stacey frames it, understanding how these action/reaction chains work is what it takes to reverse their direction toward more affordable, higher-quality care. The fix isn't waiting on Washington: it's employers and physicians—healthcare's two sleeping giants—using their leverage, whether through direct contracting, ending noncompetes, or simply voting with their feet. MENTIONED IN THIS EPISODE Dr. Eric Bricker's YouTube Channel and his site AhealthcareZ.com EP519 with Lisa Rosenbaum, MD: Apple Podcasts | Spotify | Other Apps LinkedIn Post by Payerset Instagram Reels by Elisabeth Potter, MD, on the AMA: Video 1, Video 2 Instagram Post by Graham Walker, MD EP437 with Brian Klepper, PhD: Apple Podcasts | Spotify | Other Apps EP472 with Eric Bricker, MD: Apple Podcasts | Spotify | Other Apps EP523 with Suhas Gondi, MD, MBA: Apple Podcasts | Spotify | Other Apps Article: AMA CPT Editorial Panel workgroups and committees EP524 with John Quinn: Apple Podcasts | Spotify | Other Apps EP525 with Cristin Dickerson, MD: Apple Podcasts | Spotify | Other Apps === LINKS === 🔗 Show Notes with all mentioned links: Show Notes ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter 🫙 Support the podcast with a small donation to the Tip Jar 🎤 Follow us on Apple Podcasts 🎤 Follow us on Spotify 📺 Subscribe to our YouTube channel === CONNECT WITH THE RHV TEAM === ✭ LinkedIn ✭ Threads ✭ Bluesky ✭ X 00:00 Introduction to this episode. 01:34 An overview of today's episode. 03:37 The conversation with Dr. Eric Bricker. 03:59 The first action/reaction chain. 07:03 How AHA's success in lobbying plays into its ability to outpace inflation. 14:48 The second action/reaction chain. 21:57 How all of this impacts the patient. 28:24 Purchasers as a sleeping giant. 29:36 Physicians as the second sleeping giant. 31:26 Site-neutral payments: who wants them, who doesn't. 33:33 Dr. Bricker's advice.
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    39 分
  • A Wildly Underappreciated Point: Overpaying for Infusions Means Overpaying for Stop-Loss Coverage, With Jake Velie and Keith Hartman, RPh

    A Wildly Underappreciated Point: Overpaying for Infusions Means Overpaying for Stop-Loss Coverage, With Jake Velie and Keith Hartman, RPh
    2026/09/23
    The Hidden Link Between Expensive Infusions and Rising Stop-Loss Renewal Premiums. Episode 530. When an infusion claim lands on a self-insured plan's high-cost claims report, it's tempting to treat the price tag as fixed — but the exact same infusion drug can cost 10 times more depending on where a member receives it, and every expensive claim that breaches a stop-loss attachment point can push next year's premium higher or get that member's claim lasered off coverage entirely. In this episode, Stacey Richter talks with Jake Velie, founder, chairman, and CEO of National Integrative Health (NIH), and Keith Hartman, RPh, NIH's chief strategy officer, about the direct — not dotted — line between overpaying for infusions and overpaying for stop-loss coverage, and the four pillars plan sponsors need to actually pull off site-of-care optimization. WHAT YOU'LL LEARN ✅ Why there's a direct, not dotted, line between expensive infusion claims and rising stop-loss renewal premiums — and how breaching an attachment point can get a claim lasered off coverage ✅ How the opacity of J-codes and Q-codes on the medical benefit hides how much margin is built into an infusion's billed cost, unlike the more visible pharmacy-benefit claims data ✅ Why the exact same infusion drug can cost 10 times more depending on where a member receives it ✅ The four pillars of a real site-of-care optimization program: deep clinical oversight, proactive pre-cert intervention, plan design and financial incentives, and member/influencer engagement ✅ Why a vague "denied" fax in the pre-cert process leaves prescribing clinicians in the dark and can sabotage a site-of-care redirect before it starts ✅ How home infusion can be used as a site-of-care option even when an anticompetitive hospital contract otherwise restricts steering WHY THIS MATTERS Stop-loss coverage is usually a self-insured plan's single biggest expense, yet Stacey Richter points out that the typical reaction to an expensive infusion claim is to treat it like an unalterable fate. The same infusion can cost 10 times more depending on where a member gets it, and every claim that breaches a stop-loss attachment point pushes premiums higher or risks getting the claim excluded from coverage. As medical and pharmacy trend keeps climbing, knowing how to steer members toward lower-cost, clinically appropriate sites of care is becoming a core skill for plan sponsors — not knowing how is turning into a problematic knowledge gap. MENTIONED IN THIS EPISODE EP529 with Eric Bricker, MD: Apple Podcasts | Spotify | Other Apps EP370 with Erik Davis and Autumn Yongchu: Apple Podcasts | Spotify | Other Apps EP468 with Matt McQuide: Apple Podcasts | Spotify | Other Apps Website: National Integrative Health EP501 with Ivana Krajcinovic, PhD: Apple Podcasts | Spotify | Other Apps EP508 with Lee Lewis: Apple Podcasts | Spotify | Other Apps EP480 with Kimberly Carleson: Apple Podcasts | Spotify | Other Apps EP523 with Suhas Gondi, MD, MBA: Apple Podcasts | Spotify | Other Apps EP472 with Eric Bricker, MD: Apple Podcasts | Spotify | Other Apps === LINKS === 🔗 Show Notes with all mentioned links: Show Notes ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter 🫙 Support the podcast with a small donation to the Tip Jar 🎤 Follow us on Apple Podcasts 🎤 Follow us on Spotify 📺 Subscribe to our YouTube channel === CONNECT WITH THE RHV TEAM === ✭ LinkedIn ✭ Threads ✭ Bluesky ✭ X 00:00 Introduction to this episode. 02:42 An overview of today's conversation. 05:50 The critical pillars plan sponsors underestimate. 07:44 Today's conversation with Keith and Jake. 10:08 Connecting the dots between infusion therapy costs and stop-loss coverage. 13:44 Why stop-loss carriers are starting cost-containment initiatives themselves. 17:36 The things many plans miss. 18:40 Why some plans miss or underestimate extensive clinical capabilities. 20:39 What does "good" look like, relative to a clinical team? 23:10 What do plan sponsors need to ensure further care fragmentation? 27:05 Why plan design and member financial alignment are so important. 29:44 Why is it important for plan sponsors to have a member and influencer engagement engine? 32:58 What about anti-competitive contracts and ASO resistance? 35:15 What National Integrative Health does. 36:22 Where you can go to learn more about National Integrative Health.
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