The One Question to Test if a TPA Is Actually Independent, With Kimberly Carleson

Is Your TPA Truly Independent? The One Claims Audit Question to Ask, With Kimberly Carleson (EP534) The Red Flag Question That Reveals Whether a TPA Works for Your Plan or for the Network. Episode 534. What's a practical, speedy way to assess whether a TPA (third-party administrator) is truly independent and willing to protect the plan sponsor's interests, versus being captive to network contracts, carrier relationships, or other conflicts of interest? In this Ask Me Anything, Stacey Richter puts that question to Kimberly Carleson, CEO of US Beacon, one of the nation's most established independent medical and pharmacy claims compliance and integrity review firms. Her answer is a big kahuna of a tell: ask whether the TPA will let someone come in and independently review your claims — and listen closely to the response. WHAT YOU'LL LEARN ✅ The one question that quickly exposes whether a TPA is truly independent: "Can we have someone come in and independently review our claims?" ✅ Why a TPA answering "We have network contracts that restrict that" is a red flag — it means they are working for the network, not the plan ✅ What a TPA should hand over without hesitation when a plan sponsor asks for an independent claims audit: all claims data, including billed, paid, and allowed charges ✅ How blocking language in TPA and network contracts — restrictions on accessing data or contacting providers — can stop a plan from independently reviewing its own claims and payments ✅ How an "independent" TPA can still be beholden to a network, renting that network and acting the same way any BUCA would ✅ Why labels like "transparent" and "independent" aren't proof, and why due diligence matters: talk is cheap WHY THIS MATTERS Plan sponsors who go self-funded want to do their own thing and bring in their own vendors, not end up "self-funded in name only," as Jonathan Baran calls it. But irrespective of what a partner calls itself, it's still really important to validate what you hear. A TPA's willingness to let you bring in your own auditor — with access to the data and no blocking language in its network contracts — is a fast way to find out whether it works for the plan or for the network. And as Kimberly says, if you can't bring in who you want to bring in, there's something they don't want you to see. MENTIONED IN THIS EPISODE EP518 with Claire Brockbank: Apple Podcasts | Spotify | Other Apps Website: US Beacon Kimberly Carleson on LinkedIn === 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. 01:19 The conversation with Kimberly Carleson. 02:24 The one question to tell if a TPA is independent. 03:30 Breaking down the thought process behind this question. 05:59 How an independent TPA can still be beholden to a network. 06:48 Why it's so important to do due diligence.

Level-Funded Health Plan Risks: ERISA Contract Traps, Stop-Loss Gaps, and Surplus Fine Print. Episode 533. An employer with a fully insured plan told Stacey Richter his renewal this year was 69% — his broker negotiated it down to 50%, which she's not sure she'd classify as a victory. Level funding looks like a lifesaver in that spot, but as Frank Pennachio, author of The Silent Danger and a health insurance veteran with nearly 40 years of experience, explains, level funding is self-funding, with all the fiduciary risk that comes with it. Frank walks through five avoidable contract risks that level-funded plan sponsors fall into regularly, from embedded ERISA violations to stop-loss misalignment to surplus fine print. WHAT YOU'LL LEARN ✅ Why level funding is self-funding — it feels like a fully insured plan because of the flat monthly payment, but the plan sponsor carries the risks and benefits of self-funding, including fiduciary responsibility ✅ How third-party administrator (TPA) and administrative services only (ASO) agreements can embed ERISA violations the moment they're signed, and why ERISA allows personal assets to be exposed ✅ How stop-loss misalignment leaves the plan sponsor on the hook when plan promises, like eligibility for employees on approved leave, aren't reimbursed under the stop-loss contract ✅ The surplus fine print: incurred but not reported (IBNR) factors, service fees Frank has seen as high as 30%, and surplus returned as an invoice credit instead of a check ✅ Why claims data access promised up front can get signed away, and why fiduciaries must pay prudent fees — like a $50,000 charge to reprice one hospital bill ✅ Four action items: never sign a contract as is, educate the plan sponsor team, run a legit RFP, and pick a broker or EBC with experience and financial alignment WHY THIS MATTERS With renewals like 69% and 50%, there's a lot of desperation out there for a lifesaver, and level funding is being sold as one. But as Frank Pennachio quotes Thomas Sowell, "There are no solutions, there are only trade-offs," and the goal is for plan sponsors to pick the trade-offs they want rather than desperate ones. The cost increases will sting, Frank says, and they won't likely bankrupt most companies, but the risks you unknowingly assume could. MENTIONED IN THIS EPISODE Website: The Silent Danger, Frank Pennachio's book Website: The Silent Danger courses from Frank Pennachio EP478 with Andreas Mang and Jon Camire (Part 1): Apple Podcasts | Spotify | Other Apps EP479 with Andreas Mang and Jon Camire (Part 2): Apple Podcasts | Spotify | Other Apps LinkedIn Post by Kimberly Carleson LinkedIn Post by David Goldfarb on stop-loss cost trends EP512 with Doug Aldeen: Apple Podcasts | Spotify | Other Apps EP457 with Cynthia Fisher: Apple Podcasts | Spotify | Other Apps Study: Survey by Kaiser Family Foundation EP453 with Claire Brockbank: Apple Podcasts | Spotify | Other Apps EP433 with Justin Leader: 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 00:00 Introduction to this episode. 03:37 An overview of today's conversation. 04:57 What level funding is. 06:20 Why level funding is having an explosion in popularity. 08:03 What does an employer need to take into account when considering level funding? 09:36 The first risk of level funding. 12:24 The second risk of level funding. 15:01 The third risk of level funding. 19:45 The fourth risk of level funding. 21:46 The fifth risk of level funding. 24:41 Actionable strategies when considering level funding. 33:30 A summary of advice for level funding.

Emergency Department High Utilizers and Real-Time Care Coordination, With Chris Klomp (Episode 532) 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 Collective Medical, and now nominated to serve as deputy secretary of the Department of Health and Human Services (HHS), a nearly $2 trillion federal health apparatus. In this conversation, Klomp explains why emergency medicine is only 2 to 4% of total U.S. healthcare cost, so avoidable ED spend can't be more than about 0.8 to 0.9% of total spend, and why the emergency department is still the natural choke point for finding complex, high-risk patients. Listening back is a rare, candid preview of the operational philosophy which may now shape Chris Klomp's view on health policy. WHAT YOU'LL LEARN ✅ Why Klomp said in 2016 that emergency medicine is only 2 to 4% of total U.S. healthcare cost, versus about 6% for plan sponsors now ✅ How the ED works as a "clearinghouse" for physical, mental, behavioral, and social complexity, and why the goal is the right care setting, not stopping the visit (EMTALA) ✅ How a Pacific Northwest clinical group used real-time data and coordinated care plans to cut hospital readmission rates by close to 40% ✅ Klomp's four building blocks: real-time data (starting with an ADT feed, since claims data runs 90 to 180 days late), risk analytics, communication inside the EHR workflow, and community-wide collaboration ✅ How whole-person care took "Ron" from 23 ED visits in a month across seven hospitals to 3 at peak, and why 78% of ED high utilizers have physical, mental, and behavioral health comorbidities WHY THIS MATTERS With the nomination of Chris Klomp to serve as deputy secretary of HHS, all eyes are kind of on how he plans to manage a nearly $2 trillion federal health apparatus. The emergency department is a critical choke point through which complex, often high-risk patients inevitably pass. Not dealing effectively with these larger community issues costs everyone more than dealing with them effectively would cost, and if the country had done more of what Klomp describes ten years ago, it makes you wonder how things would be different now. MENTIONED IN THIS EPISODE EP467 with Stacey Richter: Apple Podcasts | Spotify | Other Apps EP495 with Mick Connors, MD: Apple Podcasts | Spotify | Other Apps EP464 with Al Lewis: Apple Podcasts | Spotify | Other Apps Study: Research from Peter Smulowitz, MD, MPH; Leah Honigman, MD; and Bruce Landon, MD, MBA EP322 with Monica Lypson, MD, MHPE: Apple Podcasts | Spotify | Other Apps EP473 with Kenny Cole, MD: Apple Podcasts | Spotify EP391 with Scott Conard, MD: Apple Podcasts | Spotify | Other Apps === LINKS === 🔗 Show Notes with all the mentioned links and article: 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. 04:38 Reducing wasteful spend in healthcare. 05:37 The percentage of total healthcare costs that goes to emergency medical spend in the U.S. 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. 24:45 The need-to-know when it comes to managing data. 28:01 Thinking about risk and imminent readmission. 30:01 Collaboration in a care plan to reduce wasteful spend. 30:53 The right data, risk analytics, communication, and community-wide collaboration. 31:11 How social determinants affect wasteful spend in the ED.

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 model. 35:59 What Handl Health is and does.

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.

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.

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.

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.

Four Questions Plan Sponsors Should Ask Before Choosing PMPM or Fee-for-Service. Episode 525. This episode is a tangent that never made it into the final cut of Stacey Richter's original conversation with Cristin Dickerson, MD, founding partner of Green Imaging, a physician-led radiology network built on direct contracting for imaging. In episode 485, they discussed how imaging can run 6% to 11% of total plan sponsor spend and how direct contracting brings that down while improving access; this outtake is where they got into the harder question underneath it — whether PMPM (per member per month) capitated payments create their own new perverse incentives, potentially just as strange as the old-fashioned fee-for-service kind, depending on who's holding the risk and why. It's a natural follow-on to last week's conversation with John Quinn (EP524) on buying healthcare like a supply chain of defined "pods of care." WHAT YOU'LL LEARN ✅ Why Dr. Dickerson says fee-for-service can reduce perverse incentives compared with a PMPM subscription — Green Imaging charges no PEPM or admin fees and takes on the risk that its services simply won't be used ✅ How radiologist protocols and appropriateness guidelines let Green Imaging cut unnecessary imaging — switching a CT to an MRI, or skipping unneeded contrast — while showing 60% to 90% documented savings for employers ✅ Why not being the referring physician removes Green Imaging's financial incentive to drive up volume, which Stacey Richter identifies as the real test of whether a fee-for-service model has mitigated its own perverse incentive ✅ The four factors Stacey Richter says plan sponsors should weigh before choosing fee-for-service over PMPM: price beats the base network, the vendor (not the plan) drives its own volume and is auditable, the contract allows termination at will, and the plan's ASO contract actually permits carving out or steering to a high-value provider ✅ Why Stacey Richter argues there isn't just one "fee-for-service" — pricing you can see and verify against what you're billed is a fundamentally different model than a discount-based fee-for-service that hides the real price and can add 20% or more in revenue-cycle "hot potato" costs ✅ How this conversation builds on John Quinn's supply-chain framing from EP524: treating a bounded, clearly defined "pod of care" as something to procure competitively, regardless of which payment model is attached to it WHY THIS MATTERS Value-based care is often framed as the fix for fee-for-service's volume-driving perverse incentives, but a PMPM subscription simply moves the risk instead of eliminating it — the purchaser now pays whether or not the service is used, and different accountability failures can follow. Dr. Dickerson's model works not just because it's fee-for-service, but because it's fee-for-service structured so the vendor can't drive volume, the pricing is transparent, and the contract can be ended at any time. For self-insured employers and plan sponsors choosing how to pay for a defined pod of care, the payment model matters less than these underlying safeguards. MENTIONED IN THIS EPISODE EP485 with Cristin Dickerson, MD: Apple Podcasts | Spotify | Other Apps EP524 with John Quinn: Apple Podcasts | Spotify | Other Apps EP521 with Andrew Tsang: Apple Podcasts | Spotify | Other Apps LinkedIn Post by Ryan Kline EP482 with Preston Alexander: Apple Podcasts | Spotify | Other Apps EP445 with Tom X. Lee, 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 📺 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. 01:15 What today's conversation entails. 06:36 The conversation with Dr. Cristin Dickerson. 07:13 In a PMPM scenario, who is taking the risk? 10:44 What mitigates the perverse incentive to drive up volume. 12:18 The other difference between PMPM and fee for service.

John Quinn, founder and CEO of Wellnecity, joins Stacey Richter in episode 524 for an outtake from their conversation last fall on rethinking how self-insured employers build their provider networks. Rather than treating the network as one big, undifferentiated system, Quinn argues employers should think like a manufacturing supply chain: break healthcare into defined "subassemblies," or pods of care — pediatric care, a cancer journey, a kidney stone episode — and direct-contract for those pods whenever the price beats the fee-for-service average. If the boundaries of the pod are clear and the price comes in lower, Quinn says, the plan and the member both win, quality being equal.  WHAT YOU'LL LEARN ✅ Why Stacey Richter says the provider-network debate could fill "a 20-hour show," and why networks still have real upsides — administrative infrastructure, claims coordination, guaranteed provider payment, and broad access — even as critics like Mark Cuban ask on LinkedIn, "Why do we need networks? It is just a way for insurers to play pricing games." ✅ A real example of network rigidity: a self-insured employer identified 40 physicians who cost the plan upwards of $15 million in a single plan year while patient harm was occurring, and their ASO couldn't figure out how to remove those doctors from network under the existing contract structure ✅ How John Quinn defines a "subassembly" or "pod of care" — a bounded, definable episode like pediatric care or a cancer journey — and why purchasing that pod for less than the fee-for-service average is a win for the plan and member, assuming quality stays neutral ✅ Quinn's kidney stone example: a physician who says he can now treat a kidney stone in a 48-hour to five-day episode for roughly $2,000 to $3,000, versus the typical six weeks of pain, overuse of pain medication, and a price north of $10,000 ✅ Why Quinn frames network optimization as a manufacturing supply-chain problem — the same way an automobile gets built from subassemblies sourced from specialized providers around the globe — because it's a mental model CFOs and senior leadership at self-insured employers already trust ✅ Quinn's bottom line: "We have the tech and we've got the tools to do this at this point. We just have to get ourselves out of" the fee-for-service hangover WHY THIS MATTERS Provider networks have real tradeoffs: broad access and guaranteed payment on one side, opaque pricing and rigid contracts on the other. John Quinn's pitch to self-insured employers isn't to blow up the network model, but to layer bounded, directly contracted "pods of care" on top of it wherever a clear price beats the fee-for-service average. Framing that as supply-chain sourcing, rather than a wholesale network overhaul, gives risk-averse finance and HR leaders a model they already understand — and, Quinn argues, the technology to act on it already exists. MENTIONED IN THIS EPISODE LinkedIn Post by Mark Cuban Article: Medical Economics, "An Idea Whose Time Has Gone: Healthcare Provider Networks," by Jim Jusko, JD EP457 with Cynthia Fisher: Apple Podcasts | Spotify | Other Apps EP433 with Justin Leader: Apple Podcasts | Spotify | Other Apps EP501 with Ivana Krajcinovic, PhD: Apple Podcasts | Spotify | Other Apps EP503 with Ryan Wells; Leo Spector, MD, MBA; and Adam Stavisky: Apple Podcasts | Spotify | Other Apps EP485 with Cristin Dickerson, MD: Apple Podcasts | Spotify | Other Apps EP486 with Stan Schwartz, MD: Apple Podcasts | Spotify | Other Apps EP493 with John Quinn: Apple Podcasts | Spotify | Other Apps EP495 with Mick Connors, MD: Apple Podcasts | Spotify | Other Apps EP505 with Ahilan Sivaganesan, 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. 00:50 LinkedIn post by Mark Cuban. 01:16 EP457 with Cynthia Fisher. 01:20 EP433 with Justin Leader. 01:29 Medical Economics article by Jim Jusko, JD. 03:01 EP501 with Ivana Krajcinovic, PhD. 04:22 A breakdown of what's to come in today's conversation. 06:11 EP503 with Ryan Wells; Leo Spector, MD, MBA; and Adam Stavisky. 06:34 EP485 with Cristin Dickerson, MD. 06:49 EP486 with Stan Schwartz, MD. 07:07 EP493 with John Quinn. 07:57 The conversation with John Quinn. 10:06 Is calculating value realistic? 11:38 Looking at value calculation through an assembly lens. 14:54 The takeaway. 15:17 EP495 with Mick Connors, MD. 15:20 EP505 with Ahilan Sivaganesan, MD.