EP505: The Death of the "What Is Value" Guessing Game for Clinical and Plan Decision-Makers Ready to Move On, With Ahilan Sivaganesan, MD

Stacey Richter interviews neurosurgeon Dr. Ahilan Sivaganesan (Dr. Siva) about replacing vague healthcare "value" claims with quantified outcomes and unit-level costs, introducing his Operative Value Index (OVI). They discuss how hospitals often lack true internal episode costs and how common quality metrics miss patient-reported outcomes and appropriateness across the full care journey.  Using time-driven activity-based costing (TDABC) and condition- or procedure-specific patient-reported outcomes, OVI creates a common mathematical language to compare surgeons, practices, or health systems, risk-adjust for confounders, and support steering/tiering and direct contracting for self-funded employers.   Siva describes transparency via bubble charts that spur clinician behavior change without new incentives and argues this infrastructure is essential as bundled payments and risk-based arrangements expand, framing a "Yahoo vs Google" shift from fee-for-service volume to measurable value.  === LINKS === 🔗  Show Notes with all mentioned links:   https://cc-lnk.com/EP505 ✉️  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= 🎤  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/ 00:00 Introduction to this episode. 00:38 The goal of this episode. 01:28 What the Operative Value Index (OVI) is. 02:04 A quick episode overview. 04:23 EP434 with Benjamin Schwartz, MD, MBA. 04:44 How this episode came about. 09:24 How Dr. Siva got involved in the research around outcomes and costs. 11:51 How the value equation doesn't add up to true quality. 14:12 What measuring quality across the entire care journey means. 15:00 EP326 with Rishi Wadhera, MD, MPP. 15:08 EP295 with Rebecca Etz, PhD. 16:07 Why appropriateness is the foundation of quality. 19:08 Why practicing clinicians need to be thinking about the true costs of delivering care. 21:20 Time-driven activity-based costing (TDABC). 23:44 The two things that must be known for value-based care to succeed. 24:06 Article by Dana Prommel Strauss. 27:09 A quick summary of the conversation thus far. 30:42 The power of transparency in Dr. Siva's bubble plots. 32:39 EP449 with Marty Makary, MD, MPH. 34:05 Why these bubble plots work not just at the procedural level but at the diagnosis level, too. 36:13 EP503 with Ryan Wells; Leo Spector, MD, MBA; and Adam Stavisky. 36:21 EP501 with Ivana Krajcinovic, PhD. 36:30 EP398 with Jacob Asher, MD. 37:28 The "big blue ocean" opportunity for forward-looking providers. 38:52 Substack post by John Lee, MD. 40:37 The incredible opportunity for entities and groups that can help provide the infrastructure needed for this value index. 41:42 Essay written by Dr. Siva. 43:19 Last thoughts by Dr. Siva on TDABC and competition on value. 

Why Advanced Primary Care Doesn't Scale: Conflicting Incentives, Complacency, and a 3-Step Roadmap Stacey Richter interviews Ryan Jacobs (SVP Strategy and Partnerships, Marathon Health) on why evidence-backed advanced primary care (APC)—focused on managing risk, improving outcomes, and lowering costs—still isn't widespread.  They argue APC struggles to scale due to two root barriers: conflicting fiduciary duties (health systems and payers driven by volume, "heads in beds," and market-power growth, while APC keeps patients out of hospitals) and a "black box of complacency," where innovators often lose to the status quo because dominant organizations can rationally avoid investing without gaining share.  Jacobs offers a three-step roadmap: perform a reality-based assessment by following the money and identifying who is financially harmed by prevention; anticipate stakeholders' math by framing value as CFOs, benefits leaders, and plan sponsors do; and proceed from strategic conclusions such as direct contracting to bypass misaligned intermediaries.  === LINKS === 🔗  Show Notes with all mentioned links:   https://cc-lnk.com/EP504 ✉️  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/   00:00 A refresher on advanced primary care (APC). 02:36 Why APC isn't everywhere. 04:39 The problem of complacency in the healthcare system. 05:27 Ryan Jacobs' roadmap. 08:59 The pitfalls of advanced primary care. 09:58 What primary fiduciary responsibility means. 10:51 Growth on the payer side. 11:51 SUMS5 with Jacob Asher, MD. 12:36 EP483 (Part 1 and Part 2) with Jonathan Baran. 12:48 EP465 with Chris Crawford. 13:27 The reality of the healthcare system in the United States. 14:11 The flywheel created by the tension within the healthcare system. 15:25 EP391 with Scott Conard, MD. 15:51 The tension between APC's goals and fiduciary responsibility. 17:52 The black box of complacency. 19:25 EP436 with Elizabeth Mitchell. 20:05 What's driven most of the change in the advanced primary care space. 20:54 EP398 with Jacob Asher, MD. 21:01 What would happen if there was a functioning market in healthcare. 21:41 EP286 with John Rodis, MD, MBA. 21:52 Why complacency may be a rational move in healthcare. 22:41 EP438 with John Lee, MD. 23:22 A roadmap to success in advanced primary care. 23:55 Step 1: Follow the money. 24:50 Step 2: Someone's gonna do math. 25:17 What strategic thinking looks like as an employer. 28:34 Step 3: Proceed based on strategic conclusions. 30:20 How self-insured employers have created their own market. 31:07 The strategic decision for physicians wanting to create change. 32:25 A reiteration of the episode's discussion. 33:49 Better payment structures.

In this Inbetweenisode, Stacey shares listener feedback and reflects on making better decisions in employer-sponsored healthcare, spotlighting LinkedIn posts by Ken Wosczyna and Michelle Bernabe.  Ken argues Relentless Health Value moves from theory to practical transformation by sharpening judgment, which Stacey ties to how millions of workplace decisions shape the healthcare system and how actuaries and executives can align choices with values.  Stacey emphasizes that good decisions require both transparency and understanding, previewing an upcoming episode with Jerry DiMaso about using transparency files to compare what peer companies pay, and citing examples of misleading "transparency" through complex contracting and financialization (e.g., CABG pricing and PBM tactics).  She also questions what "disruption" means when the status quo already harms access. Stacey highlights direct contracting, Centers of Excellence, and upcoming advanced primary care episodes. === LINKS === 🔗  Show Notes with all mentioned links:   https://cc-lnk.com/INBW46 ✉️  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/   00:00 Introduction: trying something new with this inbetweenisode. 01:29 "Insight is common. Execution is rare.": a LinkedIn post from Ken Wosczyna. 03:02 SUMS8 with Larry Bauer, MSW, MEd. 03:08 The power of the C-suite versus the decision power of workers. 03:45 SUMS7 with Keith Passwater and JR Clark. 04:00 The power of actuaries to align with values. 04:50 Rate criticals for fixing the nonexistent healthcare market. 05:50 EP501 with Ivana Krajcinovic, PhD. 06:56 Why you can't fix what you don't understand. 07:46 EP472 with Eric Bricker, MD. 09:27 A comment from Craig Herndon. 10:44 Why avoiding disruption and problems with access can create disruption and problems with access. 12:22 A LinkedIn post from Michelle Bernabe. 12:26 EP500 with Stacey. 15:56 Looking ahead: topics future episodes will be covering. 16:07 EP503 with Ryan Wells; Leo Spector, MD, MBA; and Adam Stavisky. 17:08 A Web site/app for Relentless Health Value episodes. 18:24 EP480 with Kimberly Carleson. 19:22 Check out this episode's sponsor.  

Episode 503 of Relentless Health Value features Stacey Richter with Adam Stavisky, Dr. Leo Spector (OrthoCarolina), and Ryan Wells (Health Here) discussing how self-insured employers and specialists rarely connect directly due to intermediaries and fee-for-service "rails."  They outline three common pitfalls when bridging this gap: defining and measuring quality and appropriateness (limits of claims data and missing patient-reported outcomes), achieving scale across geographies and specialties, and ensuring benefit design and incentives so members actually use direct-contracting programs. The conversation frames the evolution of Centers of Excellence from 1.0 (travel to brand-name hospitals) to 2.0 (more local but administratively manual) to 3.0 (new infrastructure enabling direct, efficient contracting).  Health Here is described as a digital bridge to support payment and communication pathways and reduce administrative waste. === LINKS === 🔗  Show Notes with all mentioned links:   https://cc-lnk.com/EP503 ✉️  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/ 00:00 Introduction. 00:32 Collaboration as the next breakthrough innovation. 02:24 A summary of the upcoming conversation. 05:45 A summary of where we are and what the future looks like. 06:24 A relevant post from Jonathan Baran. 08:12 The conversation with Ryan Wells, Dr. Leo Spector, and Adam Stavisky: collaboration from the standpoint of a specialist. 12:22 The pitfalls of data accuracy and defining what quality means from the POV of a self-insured employer. 15:36 Defining quality and data accuracy from the POV of a physician. 15:57 How do you measure outcomes when assessing quality and looking at the available data? 21:45 EP294 with Steve Schutzer, MD. 22:06 Scale and operationalization: How do we do it? 27:00 Shout-out to OrthoForum. 29:58 Take Two: EP398 with Jacob Asher, MD. 30:13 EP501 with Ivana Krajcinovic, PhD. 30:30 How things could be better. 33:29 One last complication and how to structure benefit design to align incentives. 35:33 What an "anti-cricket" program looks like. 37:24 EP308 with Mark Fendrick, MD. 37:34 How do we operationalize benefit design and aligned incentives? 39:39 What we're seeing today in Centers of Excellence 2.0. 41:47 What Adam wants to make clear in all of this.

Episode 502 features Stacey's conversation with Brian Machut (Alliant Health) on how widespread Medicare fee-for-service fraud is inflating costs and undermining ACO shared savings in MSSP and ACO REACH. ACOs uncovered major urinary catheter fraud in 2023 tied to codes A4352/A4353, totaling about $3.5B, with some beneficiaries billed for items never received (including a case shared by Dr. Tara Lagu).  CMS created a "SAHS" (significant, anomalous, highly suspect) process to remove certain suspect costs, but benchmark effects can unevenly impact ACOs; catheter fraud is still projected at $3–$3.5B in 2025. The episode also highlights rapidly growing "skin substitute" spending projected at $13–$15B in 2025; CMS did not classify 2024 skin substitute costs as SAHS, leaving them in ACO performance calculations.  Machut explains this fraud and missed CMS trend projections can reduce provider earnings, discourage participation in value-based care, and potentially drive cost shifting into higher commercial rates—affecting plan sponsors such as self-insured employers. === LINKS === 🔗  Show Notes with all mentioned links:   https://cc-lnk.com/EP502 ✉️  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/ 00:00 One way hackers are using medical data to commit Medicare fraud. 01:49 What today's conversation with Brian Machut entails. 02:16 The downstream impact that this Medicare fraud can have. 03:30 A brief outline of how plan sponsors can be affected by this Medicare fraud. 06:38 What does a value-based actuary do? 08:04 The conversation with Brian Machut: What caused his team to look into DME costs and uncover Medicare fraud? 08:46 How much did this fraud scheme cost organizations in 2023? 09:57 How this data was tracked down and uncovered. 11:13 How fee-for-service ACOs work, and why this Medicare fraud affected the ACOs' shared savings. 12:46 The two codes that were the target of this fraud. 15:13 Across the U.S., how much money in 2023 did this fraud, waste, and abuse cost, and what was done about it? 16:14 The framework that was created to combat this fraud spend. 17:49 Why the CMS decision to pull those expenditures negatively affected some ACOs. 20:17 Where things stand now with this catheter fraud. 21:33 Why this fraud is still able to happen. 22:19 Is this a use case for prior authorizations? 23:49 How this Medicare fraud affects self-insured employers and what they should keep in mind. 25:12 What is the correlation to employee affordability? 27:08 A cost that dwarfs the catheter Medicare fraud. 28:21 A brief summary of skin substitutes. 29:32 What SAHS means, and how CMS uses it to calculate an ACO's shared savings. 31:21 Why CMS chose not to classify skin substitutes as SAHS. 33:26 Why this fraud affects ACOs' prospective trend pricing risk. 36:40 Why these fraud cases make participating in ACO programs less appealing to provider organizations. 38:28 Medicare Advantage Advance Notice for 2027.

Episode 501 of Relentless Health Value features Stacey Richter interviewing Ivana Krajcinovic, outgoing Vice President of Healthcare Delivery at Unite Here Health, about extreme and persistent price variation for medical infusions as evidence of a "no market" in healthcare. They cite examples where the same chemotherapy drug (Oxaliplatin), long off patent, cost Medicare about $35 (or $185 for a series), an independent practice about $135, but a hospital in Chicago charged $13,560 and a hospital in Monterey billed $90,000 for a series—markups described as up to nearly 500x and far beyond Medicare.  The discussion highlights how these prices create major member affordability problems through co-insurance and reduce funds available for wages, with one Monterey analysis showing nearly $1 million in annual savings by moving just two patients to an independent oncology practice.  They argue that functioning markets would rationalize prices and that carrier networks often fail as a demand curve, showing apathy and relying on broad "discount" negotiations even when prices differ by hundreds of times, including cases within the same health system.  Krajcinovic describes a roadmap to fight back: drill into claims data, push back on providers and networks, use benefit design to steer site of care, carve out utilization management and case management to support member navigation, and pursue direct contracts with independent practices. They also discuss the "whack-a-mole" dynamic of hospital pricing and the value of collective action, media attention and regulatory forums such as California's Office of Health Care Affordability. === LINKS === 🔗  Show Notes with all mentioned links:   https://bit.ly/Episode501 ✉️  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 📺  Subscribe to our YouTube channel   https://www.youtube.com/@RelentlessHealthValue 🎤  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/ 00:00 $135 vs $13,560: How infusion drug prices play into the "Inches All Around Us" series. 02:02 How infusion drug pricing fits into the "No Market" series. 03:19 A roadmap and more episodes on this topic. 04:36 Introducing this week's expert, Ivana Krajcinovic, PhD. 05:10 A must-read Bloomberg News article on infusion pricing. 05:33 An overview of what to expect from this episode. 06:54 The first tell of the infusion nonmarket. 07:41 The price variations that Ivana has seen in the infusion nonmarket. 11:39 How hospital spend affects wage increases affects patients and employees twice over. 12:04 EP373 with Cora Opsahl. 13:43 The second tell of the infusion nonmarket. 14:33 Take Two: EP398 with Jacob Asher, MD. 14:55 EP483 with Jonathan Baran. 16:15 Why networks are apathetic to this pricing discrepancy. 17:55 The factors that play into the nonmarket issue of infusion drug pricing variations. 18:26 EP475 with Peter Hayes. 19:18 EP370 with Erik Davis and Autumn Yongchu. 19:45 Are pricing discrepancies easy to spot? 22:38 Where we have power in a nonmarket situation. 23:22 A recap of the advice in the show so far. 23:39 EP493 with John Quinn. 23:41 EP496 with Mark Newman. 25:51 How you place pricing pressure on an entity. 28:47 EP482 with Preston Alexander. 29:34 How an improved market creates time for better care coordination. 30:52 EP486 with Stan Schwartz, MD. 33:23 The fourth part of the roadmap. 36:41 EP492 and EP490 with Sam Flanders, MD, and Shane Cerone. 36:49 Why serving the community and being fiscally responsible should go hand in hand. 38:05 EP500 with Stacey.

The Non-Market Reality of Healthcare Carrier Marketplaces with Dr. Jacob Asher. In this episode of Relentlessly Seeking Value, host Stacey Richter introduces the 'No Market' series focused on the healthcare sector's lack of competitive market dynamics, which affects cost and quality.  The episode features a conversation with Dr. Jacob Asher, who has extensive experience as a Chief Medical Officer at major healthcare plans. They discuss the stagnant nature of commercial carrier marketplaces, particularly in California, and the various factors contributing to this stasis, including employer inertia, the influence of employee benefit consultants, and the strategic focus of carriers on Medicare Advantage over commercial business.  They also explore how carriers' dependence on existing provider networks and contractual negotiations based on member volumes contribute to a lack of meaningful competition. The episode highlights the challenges faced by plans attempting to innovate or differentiate on quality and the systemic issues that perpetuate the current equilibrium. === LINKS === 🔗  Show Notes with all mentioned links:   https://cc-lnk.com/Take2-EP398 ✉️  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/ 00:00 Introduction to the episode. 00:42 The "No Market" series. 01:51 Why is the carrier market boring? 04:26 A breakdown of what follows. 05:48 Six reasons why a marketplace doesn't actually exist. 10:04 Upcoming episodes in the "No Market" series. 10:41 The conversation with Dr. Jacob Asher. 11:01 What is the competitive picture of California's health plans? 11:03 Understanding the California health plan market. 12:28 What the competitive landscape looks like to get market share in California. 12:55 Challenges in market competition. 13:14 What are micro markets and market drivers? 15:14 How brokers and consultants shape the marketplace. 15:49 Why is it difficult to take market share? 16:56 Who was Dr. Asher pitching to and why? 18:56 How is Kaiser's position in the marketplace unique? 19:29 Did employers ever buy plans for quality? 23:23 What does this look like from the payer perspective? 27:42 What improvements have there been to engagement in health plans? 29:47 Have plans gotten better at communicating with employers? 31:19 Why is it hard to compare the Kaiser world to the non-Kaiser world? 31:19 Dr. Asher's final thoughts and reflections. 33:40 EP390 with Gloria Sachdev, PharmD, and Chris Skisak, PhD.  

In the milestone Episode 500 of the 'Relentless Health Value' podcast, Stacey Richter reflects on the significant influence and community formed around the platform. Initiated by a conversation with Cora Opsahl, the episode transforms into a heartfelt ode to the listeners — healthcare entrepreneurs, executives, and change-makers, whom Stacey refers to as 'the tribe.' Featured contributions from several listeners highlight themes such as moving from theory to practical transformation, the power of collective momentum, and 'unplugging from the Matrix' of opaque healthcare practices.  Notable testimonials underline how the podcast has guided real-world decisions, fostered community connections, and provided actionable insights that have tangibly influenced the healthcare sector. The episode concludes with gratitude for the tribe's effort toward transforming the healthcare system and a forward-looking encouragement to remain relentless in their mission. === LINKS === 🔗  Show Notes with all mentioned links:   https://cc-lnk.com/EP500 ✉️  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/ 00:00 Introduction and episode 500 announcement. 00:22 The origin of episode 500. 01:49 The LinkedIn post and its impact. 02:43 Celebrating the Relentless Health Tribe. 07:55 Clip from Michelle Bernabe and how EP373 gave her a framework to model off of and understand that the failures in healthcare weren't personal failures. 10:08 Theme 1: Moving From Theory to Practical Transformation. 10:38 Clip from Ken Wosczyna and the episodes that have led to consistently good decisions in his work. 11:27 The Tipping Point by Malcolm Gladwell. 12:55 Examples of tribe members changing and improving their corner of healthcare after being inspired by RHV episodes. 13:54 Clip from Mark Weber. 14:54 Clip from Alex Sommers, MD, and how EP391 and EP462 changed his work 16:13 Clip from John Lee, MD, and how RHV helped him realize that "gaming the system" can also be used for good. 18:42 Theme 2: The Power of the Tribe and Collective Momentum. 19:28 Clip from Justin Leader. 21:45 Why being a "good villager" is so important to the overall outcome of healthcare. 23:22 Clip from Cristin Dickerson, MD, and how she draws inspiration from various RHV episodes. 25:21 Clip from Andrew Gordon. 27:39 Theme 3: Unplugging From the Matrix of Healthcare Opacity. 28:32 Clip from Andrew Tsang. 29:29 RHV episodes that cover better value out of health benefits. 32:15 Clip from Sergei Polevikov. 34:11 What tech needs to do in order for healthcare to succeed and improve. 35:06 Clip from Bryce Platt, PharmD. 36:01 More RHV episodes on unplugging from pricing opacity.

In this episode of Relentless Health Value, host Stacey Richter talks with Dr. Jay Kimmel, an orthopedic surgeon and co-founder of Upswing Health, about the significant costs associated with musculoskeletal (MSK) injuries and conditions for self-insured employers and other plan sponsors.  They explore how a large portion of MSK-related expenses are for low-acuity injuries that often heal on their own without the need for emergency room visits or unnecessary treatments. Dr. Kimmel discusses the importance of addressing the 'white space'—the critical initial moments when a patient decides whether or not to seek emergency care.  He emphasizes the value of immediate access to knowledgeable professionals to help guide these decisions and prevent avoidable high-cost care. They also touch on historical practices where physicians would consult each other informally, suggesting that modern solutions like Upswing Health can replicate those beneficial spontaneous interactions to improve patient care and reduce costs. === LINKS === 🔗  Show Notes with all mentioned links:   https://cc-lnk.com/EP499 🔗  Visit Upswing Health:  https://upswinghealth.com ✉️  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/ 07:49 EP472 with Eric Bricker, MD, on high-cost claimants. 08:01 What is the "white space" in MSK spend? 10:43 Statistics on Connecticut's spending on plan members with low-acuity MSK injuries. 13:30 How back pain also easily transitions from a low-acuity issue to a high-acuity problem. 15:11 How plan sponsors can detect their white space downstream spend. 16:58 EP464 with Al Lewis. 17:02 EP470 with Nikki King, DHA. 18:15 Why where patients start their journey often dictates where they wind up and how costly that medical pathway is. 20:48 Where PCPs fit into this MSK spend issue. 25:26 EP468 with Matt McQuide. 25:34 EP471 with Christine Hale, MD, MBA. 25:39 Why access is key.  

In Episode 498, host Stacey Richter converses with Mark Noel of ClaimInsight about the critical aspects of payment integrity within self-insured employers and plan sponsors, focusing on the arms race with revenue cycle management (RCM).  The discussion reveals three main insights: the substantial impact of small claim errors, the inherent flaws and conflicts within prepayment analysis by TPAs, and the problematic financial incentives influencing claim processing. Noel emphasizes the importance of prepayment integrity for both plan savings and protecting members, underscoring the need for meticulous oversight and proactive management in payment processes. === LINKS === 🔗  Show Notes with all mentioned links:   https://cc-lnk.com/EP498 ✉️  Enjoy this podcast? Subscribe to the free weekly newsletter: https://relentlesshealthvalue.com/join-the-relentless-tribe ✉️  Visit ClaimInsight https://www.claiminsight.com/ 🫙  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/ 06:03 How millions of dollars can be recovered per year from smaller claims under $500. 07:46 EP486 with Stan Schwartz, MD. 09:10 How to get to payment integrity prepayment. 11:20 How payment processing efficiency is necessary to payment integrity. 13:59 How TPAs fit into the claims payment process and how they can add to payment integrity. 15:59 LinkedIn post from Chris Deacon. 16:50 EP433 with Justin Leader. 17:04 LinkedIn post from Justin Leader. 17:10 How shared savings incentives can be perverse incentives. 23:05 How employers are doing retrospective reviews. 24:29 How employers should be negotiating their TPA contracts. 25:41 EP285 with Dawn Cornelis. 25:43 EP480 with Kimberly Carleson. 27:40 Why it's imperative that payment integrity vendors are up-to-date on all policies. 30:00 EP497 with Zack Kanter. 31:13 What should self-insured employers do to assess their payment integrity?