EP512: 3 Kinds of Broker/EBC Rent-Seeking Payment Models—A Lawyer's Perspective, With Doug Aldeen

Stacey Richter introduces Episode 513 of Relentless Health Value as a primer on anti-competitive hospital contracting with Brennan Bilberry of Fairmark Partners, setting up next week's interview with Matt Cantor, lead litigator in the Sutter Health antitrust class action that led to a $575 million settlement over alleged price inflation using market power. Bilberry explains how hospital consolidation enables higher commercial rates and outlines a four-part contracting playbook: all-or-nothing contracting requiring inclusion of all system facilities at high prices; anti-steering and anti-tiering clauses blocking lower-cost benefit designs; price gag clauses limiting disclosure of negotiated rates despite transparency rules; and pressure on ostensibly independent providers to sell or align pricing with the dominant system. The episode links these patterns to DOJ actions against OhioHealth and New York Presbyterian and emphasizes collective action, regulation, and litigation to address them. === LINKS === 🔗 Show Notes with all mentioned links: https://cc-lnk.com/EP513 ✉️ 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 Episode Setup 00:38 Why This Matters 04:41 Hospital Playbook 06:59 Consolidation Effects 11:41 All Or Nothing 15:24 Anti Steering Tiers 22:12 Price Gag Clauses 26:22 Squeezing Independents 31:15 Fixing The System 35:15 Wrap Up Sponsors

Stacey Richter interviews self-insured space attorney Doug Aldeen about how broker/employee benefit consultant (EBC) compensation arrangements lead to legal trouble and excessive plan costs.  They discuss problems with overly complex or overpriced direct compensation, then cover three problematic payment-model categories: rent-seeking solution recommendations (e.g., reference-based pricing "cost of savings," balance-billing programs, and voluntary benefits with front-loaded commissions), undisclosed vendor payments to brokers/EBCs that bias recommendations, and arrangements exploiting gray areas or weak enforcement under the Consolidated Appropriations Act (CAA), including PBM per-script payments disguised as "discounts."  Examples include an "Ohio Potato" level-funded case where broker fees depleted claims funds and a balance-billing vendor paid $2.2M to address only $94K risk. Aldeen offers a six-step roadmap: ask "why" repeatedly, calculate ROI, assess downstream risk, simplify/demystify compensation, run independent RFPs, audit claims/documents (including stop-loss gaps), ensure contract outs, and "trust but verify," especially with entrenched public entities. === LINKS === 🔗  Show Notes with all mentioned links:   https://cc-lnk.com/EP512 ✉️  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. 00:59 A caveat for the record on this episode. 02:11 The first problematic payment model discussed in this week's episode. 03:27 The second problematic payment model discussed in this week's episode. 06:16 The conversation with Doug Aldeen. 06:27 Why is reviewing broker/EBC compensation so important? 08:05 The Ohio Potato Company anecdote. 10:28 The first way brokers/EBCs might get paid. 11:45 What "cost of savings" means. 12:31 EP457 with Cynthia Fisher. 14:07 A rent-seeking solution that requires a cost-benefit analysis. 19:16 Why the broker/EBC is sometimes in the dark about vendor kickbacks. 21:46 Where the CAA is unclear. 22:23 EP508 with Lee Lewis. 22:58 EP379 with AJ Loiacono. 24:04 Actionable advice for plan sponsors. 24:57 The second piece of actionable advice for plan sponsors. 25:22 The third piece of actionable advice for plan sponsors. 26:08 Demystifying the commission structure. 27:35 Using a broker RFP from an open source. 27:54 EP484 with Dave Chase. 28:31 Why you should be auditing data and claims. 29:29 EP478 (Part 1) and EP479 (Part 2) with Andreas Mang and Jon Camire. 31:29 The importance of having an "out." 33:11 Why the broker community may be at substantial risk. 35:30 EP419 with Andreas Mang.

In this episode, Dr. Monica Lypson and Dr. Ahilan Sivaganesan join the conversation to dissect the complexities of value-based payment models and the "perverse incentives" that often follow. By examining the parallels between Medicare Advantage upcoding and sliding-scale bundled payments, Dr. Lypson and Dr. Sivaganesan provide a masterclass on the systemic friction between financial risk and clinical equity. Key Discussion Themes - The Upcoding/Downcoding Tug-of-War: An analysis of how Medicare Advantage plans and health systems navigate risk adjustment, and why current models often incentivize "grading your own homework." - The TDABC Solution: Dr. Sivaganesan explains why physicians cannot truly manage risk without Time-Driven Activity-Based Costing (TDABC) to identify condition-specific costs. - Selection Bias in Care: A deep dive into the "cherry picking" (selecting low-risk patients) and "lemon dropping" (avoiding high-risk patients) dilemmas that threaten healthcare's moral compass. - Equity vs. Efficiency: Dr. Lypson explores how value-based care can either bridge the gap for underserved populations or inadvertently widen disparities through structural barriers. - The Path Forward: Why "whole-person health"—including non-clinical factors like housing—is the ultimate cost-saver, and the necessity of neutral, third-party risk scoring. === LINKS === 🔗  Show Notes with all mentioned links:   https://cc-lnk.com/EP511 ✉️  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 Spotify  https://open.spotify.com/show/6UjgzI7bScDrWvZEk2f46b 📺  Subscribe to our YouTube channel   https://www.youtube.com/@RelentlessHealthValue 🎤  Listen on Apple Podcasts  https://podcasts.apple.com/us/podcast/feed/id892082003?ls=1 === 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. 01:53 Upcoding problems: a previously unpublished clip from EP505 with Dr. Siva. 05:22 What is the minimum requirement for physicians to go at risk? 07:22 How sliding scale bundle payments can reduce risk for physicians. 10:43 The question covered in the upcoming episode. 13:19 Is value-based care good for underserved communities? 15:01 "If you create perverse incentives, you actually might make known healthcare disparities worse … to meet the demand's value." —Dr. Lypson 16:18 "There actually might be systematic and structural ways that the healthcare system might say … we're not interested in taking care of you." —Dr. Lypson 16:51 "The incentive to have a good outcome is not there; the incentive to have another visit is there." —Dr. Lypson 17:15 EP485 with Cristin Dickerson, MD. 17:49 "The only indictment I have on the fee-for-service system is that it's gotten us to where we are right now." —Dr. Lypson 18:41 "If you don't have any connection in that system, even the provider trying to … provide a good outcome might be disconnected because the system is not in place to … connect the dots." —Dr. Lypson 19:15 EP436, EP491, and SUMS9 with Elizabeth Mitchell. 19:28 What are the must-haves for a value-based system that create the patient outcomes we need? 19:51 What is a whole health model? 22:00 EP462 (Scott Conard, MD), EP319 (Grace Terrell, MD), EP431 (Kenny Cole, MD), EP409 (Larry Bauer, MSW, MEd), and EP495 (Mick Connors, MD). 22:23 LinkedIn post by Mark Weber. 25:05 EP484 with Dave Chase. 25:31 Why we need to fix the structural issues if we want to fix health. 26:00 Why a patient's bias is the one we want in the room. 27:36 Stacey's conclusion on this week's episode.  

Medicare Advantage 2026: Stabilization, Retrenchment, and a Back-to-Basics Playbook with Betsy Seals In Episode 510, Stacey Richter interviews Medicare Advantage (MA) consultant Betsy Seals about the 2026 state of MA and its broader impact, including taxpayer value, seniors' access to care, and cost shifting to commercial employers when vertically integrated carriers negotiate MA rates while employers pay higher ASO rates.  Seals describes MA as in a stabilization/retraction phase with market exits, regulatory and administration shifts, and benefit pullbacks that can affect beneficiaries depending on whether plans cut "flashy" enrollment perks versus outcome-focused care. Her "back to basics" guidance emphasizes avoiding profiteering and compliance risks (e.g., upcoding, problematic AI-driven prior authorization), focusing on populations a plan can truly serve well (including chronic SNP strategies), and improving STARS through real health outcomes rather than box-checking.  They discuss high prior-authorization denial overturn rates on appeal, downstream provider incentives, and the need for stronger process reform and regulatory "teeth," while noting confidence in MA's long-term viability. === LINKS === 🔗  Show Notes with all mentioned links:   https://cc-lnk.com/EP510 ✉️  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 this episode. 00:43 Past episodes on profiteering: EP481 with Benjamin Schwartz, MD, MBA, and EP495 with Mick Connors, MD. 01:25 How Medicare Advantage is relevant to everyone. 06:15 A preview of today's conversation. 07:49 The "state of the state" of Medicare Advantage plans. 08:49 Video by Eric Bricker, MD, on the financial performance of the U.S. healthcare system. 09:32 Does Medicare Advantage's losses matter to the patients? 10:29 A recap of Betsy's insights so far. 11:19 The underlying strategic through line that needs to be considered. 13:04 The impact of Goodhart's Law. 14:12 What the players that are succeeding right now are doing. 14:22 The first pillar of a back-to-basics strategy: Don't get caught with your hand in the cookie jar. 16:07 EP463 with Betsy Seals. 16:50 Why short-term strategies don't work. 18:26 Stats report on prior authorizations serving the beneficiary. 19:32 EP482 with Preston Alexander. 19:38 Why prior authorization needs change. 21:28 The better strategy to use. 21:43 EP462 with Scott Conard, MD. 23:17 The second pillar of a back-to-basics strategy: Focus on the beneficiaries you actually serve well. 24:37 What it looks like to implement this focus on the beneficiaries you serve well. 25:29 How special needs plans play into this. 27:43 The third pillar of a back-to-basics strategy: Think about how STARS in clinical programs improve health. 30:04 The ethical component to implementing a Medicare Advantage program. 31:04 Betsy's advice for independent practices dealing with prior authorizations. 33:37 STAT article by Bob Herman about the effectiveness of Medicare Advantage lobbying on policy. 34:08 Betsy's final notes for all players impacted by what's currently happening.

In Episode 509 of Relentless Health Value, Stacey Richter interviews former CFO and Aligned Marketplace CEO Patrick Nelli about why executives don't take bolder action on health benefits and offers a seven-step roadmap to align finance teams with non-complacent benefit design.  Key steps include ongoing CFO-benefits engagement, forecasting medical trend accurately at 7.7%+ (two to three points above CPI) as the status-quo baseline, and presenting win-win alternatives to bend the cost curve. Nelli explains employer medical inflation drivers including Baumol's Cost Disease and cost shifting from Medicare to commercial, and argues proven strategies like independent advanced primary care can reduce unit prices, downstream utilization, and future high-cost claimants.  Additional steps cover aligning incentives with safeguards, optimizing contracting (including direct contracting), and steering/tiering via risk stratification to focus engagement on high and rising-risk members. Nelli describes Aligned Marketplace's national value-based advanced primary care and specialty marketplace. === LINKS === 🔗  Show Notes with all mentioned links:   https://cc-lnk.com/EP509 ✉️  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 this episode. 02:48 Roadmap Step 1 highlights. 03:07 Roadmap Step 2 highlights. 03:49 Roadmap Step 3 highlights. 04:15 Roadmap Step 4 highlights. 04:27 Roadmap Step 5 highlights. 04:58 Roadmap Step 6 highlights. 05:19 EP504 with Ryan Jacobs. 05:37 Roadmap Step 7 highlights. 06:28 Introduction to the conversation with Patrick Nelli. 06:36 Step 1 to Patrick's roadmap: Open the conversation. 07:57 What Patrick thinks is sometimes missing in health benefits. 09:07 What finance teams need in order to change their behaviors. 09:53 What Baumol's cost disease is. 10:58 EP341 with Gary Campbell. 11:14 EP492 with Sam Flanders, MD, and Shane Cerone. 12:18 The second item stacked against employers: Being price "takers." 13:49 The percent inflation employers should expect if they follow the status quo. 15:39 INBW46 with Stacey. 16:54 Proven strategies to bend the health benefits finance curve. 18:42 EP391 with Scott Conard, MD. 19:37 SUMS11 with Stan Schwartz, MD. 20:18 How employers and plan sponsors can bend the cost curve. 21:47 The two distinct business models that finance teams need to consider when setting up their health benefits model. 24:11 Milbank study on the role of primary care. 24:53 A quick reminder of high-cost spending within health plans. 25:00 EP466 with Vivian Ho, PhD. 25:10 EP464 with Al Lewis. 25:59 What finance teams need to hear right now to understand why disrupting their health benefits plan is worth it. 27:45 The next step when an employer recognizes that they should seek out an advanced primary care option for their members. 28:41 EP503 with Ryan Wells; Leo Spector, MD, MBA; and Adam Stavisky. 30:27 Next steps after an employer enlists an advanced primary care system and aligns values and incentives in their benefits plan. 34:26 A last word to benefit teams working with finance teams. 34:55 EP430 with Barbara Wachsman. 35:08 How Aligned Marketplace fits into this entire conversation.

Episode 508 is the first Ask Me Anything installment of Relentless Health Value, where Stacey Richter and Lee Lewis (Chief Strategy Officer and GM Medical Solutions at the Health Transformation Alliance and host of Broken Benefits) address a question from benefits procurement leader Sarah Monroe about why executives rarely take bold action on health benefits despite large opportunity.  Lewis describes three false C-suite "dogmas" that lead to "stay in the herd and keep it quiet": health benefits are a fixed expense, saving money hurts people (via cost shifting, low quality, or narrow networks), and fixing healthcare isn't worth the risk or disruption. They also discuss external deterrents including CEOs' proximity to health system leaders, "balance of trade" retaliation threats, vendor-provided personal incentives, and executives' limited empathy for deductibles/costs faced by lower-wage employees.  Lewis offers de-risking tactics (same-network TPAs, carrier-enabled vendor changes, narrow pilots, mid-year tests) and advises CEOs to encourage bold action, tie bonuses to plan performance, and staff benefits teams with diverse skills. === LINKS === 🔗  Show Notes with all mentioned links:   https://cc-lnk.com/EP508 📺  Visit Lee's YouTube Channel https://www.youtube.com/@brokenbenefits ✉️  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. 00:43 Ask Me Anything Question 1: Why don't more self-insured executives take bold action toward their benefits strategy? 03:09 A summary of the three dogmas covered in the following conversation. 05:53 A look ahead at next week's episode. 06:36 An introduction to today's guest, Lee Lewis. 08:23 Why there is an aversion to digging into health benefits for some executives. 09:43 The first dogma: Healthcare costs are fixed expenses. 09:56 The second dogma: Saving money in healthcare hurts people. 12:01 The third dogma: Fixing healthcare is never worth the effort. 12:26 How these dogmas trickle down to HR teams. 13:47 Anecdote: One company that turned down saving $50 million and why. 16:28 A quick reminder about the context behind where CEOs' mindsets are. 17:10 The kinds of employers HTA seeks out. 19:20 EP500 with Stacey. 20:03 The power of C-suites in health systems. 21:33 EP466 with Vivian Ho, PhD. 21:36 EP404 with Suhas Gondi, MD, MBA. 21:42 Why a CEO may pull the plug on health plan/health benefit improvements. 22:37 An anecdote about Lilly cancelling their health plan. 23:21 Items that CEOs need to be thinking about. 24:33 EP506 with Jerry DiMaso. 26:07 EP501 with Ivana Krajcinovic, PhD. 26:32 A summary of why CEOs should care about their health benefits costs now. 29:02 How do personal incentives play into CEOs' decisions about health benefits? 30:44 Another quick reminder about C-suites. 31:53 Why perverse incentives make it difficult for C-suites to accept change. 33:11 LinkedIn post by Patrick Moore. 33:28 Why the salary gap plays into health benefit decisions in a perverse way. 34:58 EP488 with Mark Cuban and Cora Opsahl. 36:13 Lee Lewis's advice to people in benefits who are aligned to the mission. 40:06 Lee Lewis's advice for CEOs.   Lee Lewis of @HTACOOP discusses #benefitsstrategy for #selfinsuredemployers on our #healthcarepodcast. #healthcare #podcast #financialhealth #commercialpayermarketplace #digitalhealth #healthcareleadership #healthcaretransformation #healthcareinnovation   Recent past interviews: Click a guest's name for their latest RHV episode! Stacey Richter with 15 experts (EP507); Jerry DiMaso; Dr Ahilan Sivaganesan; Ryan Jacobs; Stacey Richter (INBW46); Ryan Wells, Dr Leo Spector, and Adam Stavisky; Brian Machut; Ivana Krajcinovic  

In this episode of Relentless Health Value, Stacey Richter summarizes 4 core concepts for getting highest-value healthcare and we hear from 15 experts who weigh in on the following concepts:  (1) "Buy healthcare," not insurance, by focusing on unit prices and avoiding administrative extraction like spread pricing and layered fees, illustrated by examples from Jonathan Baran, Cynthia Fisher, Mark Newman, and Justin Leader;  (2) avoid the "myth of less expensive care," emphasizing that price often doesn't correlate with quality and that better, safer care can cost less, with support from Elizabeth Mitchell, Dr. Sam Flanders, Shane Cerone, Jerry DiMaso, and Ivana Krajcinovic, plus transparency-file rate disparities;  (3) consider direct contracting and collaboration between plan sponsors and clinicians (and pharmacies), including centers of excellence, to reduce middlemen and align incentives, with clips from Krajcinovic, Ryan Jacobs, Adam Stavisky, and Ryan Wells; and  4) buy true value—outcomes over cost—measured across the care journey and grounded in patient goals, with Dr. Mick Connors, Dr. Siva, and Dr. Kenny Cole.  === LINKS === 🔗  Show Notes with all mentioned links:   https://cc-lnk.com/EP507 ✉️  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/ Featured Experts by Core Concept Concept 1: Buy Healthcare, Not Insurance Jonathan Baran, CEO, Self Fund Health (EP483) Cynthia Fisher, founder and chairman, PatientRightsAdvocate.org; co-founder and chairman of Power to the Patients (EP457) Mark Newman, co-founder and CEO, Nomi Health (EP496) Justin Leader, founder and CEO, BenefitsDNA (EP433) Concept 2: Avoid the Myth of Less Expensive Healthcare Elizabeth Mitchell, president and CEO, Purchaser Business Group on Health (EP436) Sam Flanders, MD, senior advisor, Kada Health (EP490) Shane Cerone, CEO, Kada Health (EP492) Jerry DiMaso, co-founder and CEO, Payerset (EP506) Ivana Krajcinovic, PhD, former vice president for healthcare delivery (retired), UNITE HERE HEALTH (EP501) Concept 3: Consider Direct Contracting Ivana Krajcinovic, PhD, former vice president for healthcare delivery (retired), UNITE HERE HEALTH (EP501) Suhas Gondi, MD, MBA, chief medical officer, HealthStrategy (EP404) Ryan Jacobs, senior vice president of health plan strategy and partnerships, Marathon Health (EP504) Komal Bajaj, MD, professor of obstetrics and gynecology, Albert Einstein College of Medicine (EP458) Adam Stavisky, business advisor, Stavisky LLC (EP503) Cristin Dickerson, MD, founder and CEO, Green Imaging (EP485) Stan Schwartz, MD, chief medical officer, ZERO.health (EP486) Leo Spector, MD, MBA, CEO, OrthoCarolina (EP503) Ryan Wells, founder and CEO, Health Here (EP503) Concept 4: Buy the Highest-Value Healthcare Mick Connors, MD, pediatric emergency medicine physician, Dayton Children's Hospital (EP495) Ahilan Sivagenesan, MD, neurosurgeon, Hospital for Special Surgery; Head of Quality and Value, Mishe Health (EP505) Kenny Cole, MD, System VP, Clinical Improvement, Ochsner Health (EP473)   00:00 Introduction to this episode and guests. 01:38 The four core concepts to buy or deliver highest-value healthcare: a summary. 06:01 An exciting show announcement. 07:32 Core Concept 1: Why buy highest-value healthcare, not "best" coverage? 11:28 Core Concept 2: Will employers fall victim to the myth of inexpensive care? 13:00 Why better-quality care vs. more affordable care is a false choice. 17:09 Core Concept 3: Direct contracting. 17:58 Why demand curve matters in healthcare cost. 22:08 How Centers of Excellence play into all of this. 22:54 Core Concept 4: How do you conceive of and buy high-value healthcare? 23:48 The value equation in healthcare. 25:35 What is value? 28:20 What whole-person care looks like. 30:24 Relentless Health Value Chatbot sneak peek announcement. 32:14 Coming up: looking at the episodes ahead.

Stacey Richter interviews Jerry DiMaso, CEO of Payerset, about how hospital and carrier price transparency data (mandates beginning with hospitals in 2019 and carriers in 2022) is being used by plan sponsors and providers. For self-insured employers and unions, DiMaso highlights three key uses: benchmarking against competitors via EIN to compare negotiated rates and carve-outs, identifying high-cost billing codes, and exposing "discount shell games" by validating whether claimed discounts reflect real savings.  Employers can use the insights to guide TPA negotiations, implement service carve-outs/direct contracts and calculate objective savings, and model alternative plan types (e.g., PPO vs HMO) while maintaining access. For clinics, transparency data can level information asymmetry by enabling rate benchmarking, revealing new contracting opportunities with previously unknown carriers, and supporting rate increases by pairing price comparisons with quality/outcomes; the discussion also addresses concerns about prices rising and an emerging transparency "arms race." === LINKS === 🔗  Show Notes with all mentioned links:   https://cc-lnk.com/EP506 ✉️  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 this episode. 00:50 How does transparent pricing data fit into the "inches all around us"? 03:13 A quick overview of what plan sponsors do with these price transparency insights. 05:52 The specific ways that clinical organizations can leverage price transparency data. 08:13 How price transparency infrastructure started and how it's grown to where we are now. 09:21 What are the insights that can be gleaned from the price transparency data available? 10:01 How price transparency data is a treasure trove for self-insured employers. 11:21 How employers can utilize this transparency data. 12:31 EP472 with Eric Bricker, MD. 14:48 How employers can help TPAs negotiate. 15:18 Why employers should be thinking about carving out services. 16:11 EP503 with Ryan Wells; Leo Spector, MD, MBA; and Adam Stavisky. 16:21 Why employers need to direct contract. 17:16 LinkedIn post by Chris Deacon. 17:38 A quick summary of advice for plan sponsors. 18:04 LinkedIn post by Andrew Tsang. 18:41 LinkedIn post by Pearly Chen. 19:32 How rates get set and how small providers can see this and benefit from it. 20:55 How small providers can use rate transparency to negotiate better rates. 22:18 EP489 with Dan Greenleaf. 25:46 Have prices increased due to price transparency? 29:25 Why price transparency makes it more important to eliminate lazy networks. 29:41 EP501 with Ivana Krajcinovic, PhD. 31:10 What is the transparency arms race, and what is happening because of it? 34:39 What Payerset does.  

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.