$135 vs $13,560: The Infusion Price Shock That Kicks Off the Episode
[00:00:00] Stacey Richter: Episode 501. "Speaking of Infusions, Do You Want To Pay $135 or Do You Want To Pay $13,560 for the Exact Same Drug?" Today I am speaking with Ivana Krajcinovic.
[00:00:36] Stacey Richter: Let us chat about today, the “inches all around us”, and also about how there is no market in healthcare all at once In this show. Today I am talking with Ivana Krajcinovic. And let me give you some examples of the inches.
Two members of a plan get infusions at a hospital. And if these two members had gone down the street to get their infusions, the total cost of the two of them would have been $1 million less. $1 million less. How many inches is a million dollars?
Or the examples Ivana Krajcinovic talks about coming up where an independent practice was charging $135 for a chemo infusion, and the hospital down the street was charging for the same exact drug, by the way the same exact infusion, $13,560. $135 versus $13,560.
We talk about affordability in this country? Members paying co-insurance off that 13k, by the way, And if you're doing the math at home, that is a 10000% markup. Or if we start from the Medicare price, it was a 40000% markup.
Then there's another example that Ivana talks about where a plan member went to a hospital and got a $90,000 bill for a series of infusions that, again, down the street would have been $185. All in. Inches much.
Why This Proves There’s No Real Healthcare Market (and Why Waiting for One Is “Magical Thinking”)
[00:01:58] Stacey Richter: So it's pretty clear why the show is part of the “Inches Are All Around Us” series. Why do I say this is part of the No Market series? Because look, functioning markets rationalize prices. That's just what they do. So if you have two places in the exact same geography and one of them is charging 500 times or whatever the other one, you don't have a market if they're both still in business a year later. Ongoing wild price variations is a big tell that there's no market to be had.
Another tell though, is that carrier networks, who are supposed to be the demands curve here, or at least that's what their marketing says, or what we are all kind of led to believe. They advertise as high value networks, right?
The fact that any given network experiences, essentially no business repercussions for spending a million dollars extra of its plan sponsors, its customers money because that's who's paying for this, the self-insured employer, or union at the end of the day, and the network, the carrier network doesn't lose business as a result. Right?
Listen to the show from last week with Dr. Jacob Asher about the carrier nonmarket and why this is the case. But bottom line, if anyone is waiting on a market to constrain prices for them, that is very magical thinking.
Where this whole thing is gonna wind up, by the way, is with my guest today, Ivana Krajcinovic, suggesting a roadmap to make a whole lot more likely that you'll pay $135 for an infusion instead of 13 grand. For more on this, do go back and listen to the show with Keith Hartman, by the way, we teed this off a couple of years ago. That was episode 369.
But in Ivana's upcoming roadmap that you're gonna hear about, just doubling down on the spoilers. If I'm gonna do something, I might as well do it well. But in that roadmap, direct contracts with indie practices will feature a starring role. I'm telling you this because if you're one of those folks that listens to like 23 minutes of any given podcast and then bails, make sure you make it to around the 30 minute mark of the show.
[00:04:36] Stacey Richter: As I have said several times already, my guest today is the incomparable Ivana Krajcinovic, the outgoing Vice President of Healthcare Delivery at UNITE HERE HEALTH.
Ivana has just retired, but she spent over three decades with her team protecting the health and the hard earned wages of 230,000 hospitality workers. She is exactly the kind of in “dangerous expert” that we love to have on the show. Someone with the wisdom about how the system actually works and the articulate willingness to talk about it.
Okay, so this conversation about the inches and the nonmarket for infusions specifically in this country, for more information, do go back and read the really excellent Bloomberg News expose by John Tozzi. It's a really good article, and you'll see everything that we talk about today in writing with all the fact checking that one would expect from Bloomberg News.
So, okay. What we'll do in this episode is first we're gonna talk about the infusion nonmarket, the inches and its implications such as an infusion costing 500 times Medicare when there are 1.5x Medicare options in the same exact health system. Sometimes I just can't, even with some of the stuff.
But another nonmarket tell, again is that carrier networks are still in business. We talk all about that. What happens next in this episode is we deconstruct the roadmap that Ivana used to fight back, which starts with no surprises, drilling into data and ends with direct contracting with independent doctors. And how that happens is by carving out utilization management so that there is site of care steerage.
So this is a conversation about fiduciary duty. It's a conversation about transparency, the power of collective action. My name is Stacey Richter. This podcast is sponsored by Aventria Health Group with an assist from Payerset. And I thank Payerset very much for the financial support.
Ivana Krajcinovic, welcome to Relentless Health Value.
[00:06:34] Ivana Krajcinovic: It is an honor and a pleasure to be here. Thank you.
Inside the Infusion Nonmarket: Wild Drug Price Variations in Real Claims Data
[00:06:37] Stacey Richter: Today we're focusing on an area of the healthcare no market that is of great interest to most every ultimate purchaser, meaning plan sponsors like self-insured, employers and unions, because it tends to be an area with a lot of high cost claimants. We're talking about infusions.
And I wanna talk today about the tells of this nonmarket. Like, if these things exist, you can rest assured that there's no market, because if there was a market, then you wouldn't see these things.
The first one that struck me, if you have wild price variations for something that is like an economist, tell number one that there's a dysfunctional or no market. Because like if you have a market, then the invisible hand tends to rationalize prices in a corridor, kind of around a given price point. Wild price variations without corresponding shifts in like fundamental supply or demands, that just indicates that a market's mechanism for determining what is a fair value is pretty completely broken.
So Ivana, if you look across the infusion nonmarket, could you help me understand what are the price variations that you have seen?
[00:07:53] Ivana Krajcinovic: When we started really drilling down and looking at our data, and this is spend on the medical side, we found multiple instances across the country of just surreal discrepancies in what we were paying for the same drug.
And many of these drugs, by the way that we looked at, are drugs that are long off patent. These aren't new blockbuster drugs that are everybody knows are expensive. And I wanna be totally clear that we looked at just the price of the drug itself, which is to say we also pay for the provider to administer it. So if it's being administered in a hospital, they're gonna charge more 'cause they have more overhead. Fine. Usually two to three times more what you would pay in a doctor's office.
So we put that aside, and we looked at just the price of the drug because we wanted to compare apples to apples.
[00:08:37] Stacey Richter: In other words, this is just the price that the hospital is charging a plan sponsor, such as a union for the drug itself.
[00:08:45] Ivana Krajcinovic: Exactly. We looked at a generic cancer drug called Oxaliplatin, and there's, there's a number of these, but that's the one that we, um, were really focused on, which has been off patent, like I said, for a long time. Medicare, because it's been off patent for so long, pays only $35 for this, you know, again, you have to control for the dosage.
If you go to a doctor's office, a little bit more, $135. But the hospitals, one of the hospitals in Chicago that we're looking at was charging $13,560.
[00:09:15] Stacey Richter: Whoa. Whoa. What? Okay, so we've got Medicare paying 34, we've got an independent clinic that maybe charges $135, so you know they're making a hundred dollars over.
And then you've got a hospital that "looks at notes", $13,000. What'd you say? $13,560?
[00:09:32] Ivana Krajcinovic: Yeah. A hundred times more than what it cost in the doctor's office.
[00:09:37] Stacey Richter: I'm speechless.
[00:09:37] Ivana Krajcinovic: Yes, we were. We were too. I mean, we thought, well, we wanna make sure it wasn't anomaly in that market. So we looked at, for instance, in Monterey, California where we watch the market very closely.
And we found, again, this patient received a series of Oxaliplatin infusions and Medicare would've paid $185 for that series; and we paid, or we were charged $90,000. So a markup of almost 500 times.
The Human Cost: Coinsurance, Medical Debt, and Wages Eaten by Hospital Markups
[00:10:03] Stacey Richter: I just wanna point out the impact here because we're talking about one of your union members. Who is an hourly worker who probably has co-insurance, I'm assuming so 10, 20%, right?
So we have a situation where the whole thing should have cost. $135 times four or whatever, right? And instead it costs $90,000. So you have a hourly worker now paying $9,000 out of pocket, $18,000.
So, you know, we talk about the affordability crisis in this country and then you see an example like this and you're like, who is surprised? I am not surprised. Let alone, obviously the balance, which the plan sponsor had to pick up.
[00:10:48] Ivana Krajcinovic: It's a really important point, and particularly because these workers at the time they're getting chemo, are often not working, so they have even less income than they would be if they were working.
In the case of in Monterey, that member had co-insurance and was responsible for 20%. That patient was paying thousands of dollars for each infusion, and in fact, in Monterey, it is not unusual for patients to reach their out-of-pocket maxes by February if they're getting chemo because the charges are so high.
When if we were paying something closer to Medicare, that member would've paid 10, 20, 30 bucks every time he had an infusion. So I think it feels like preying upon chemo patients at the time where their health is the most delicate and where they have the least amount of disposable income.
[00:11:33] Stacey Richter: We have 41% of Americans or something like this who have medical debt, this is why this this happens.
[00:11:39] Ivana Krajcinovic: The other place that it ends up costing, there is less money left over for wage increases. Any employer will tell you that they have a wage and benefit package and they wanna be competitive in the market. Hospitals, they're the biggest chunk of the spending. So this cook paid for it twice. Out of her pocket, and then the next time she's looking to get a wage increase, there's not gonna be the money there because that money went out the door to pay the hospitals.
[00:12:03] Stacey Richter: And these are real implications. Cora Opsahl was on the pod a little while ago talking about the 32BJ Union and how they were able to give $5,000 to member workers when they cut a, really, what the union did was they cut a really high priced hospital out of network.
I mean, just simply like that is how much money we're talking about from one overpriced hospital. It's certainly a zero sum game here if we consider either those dollars go to the hospital or those dollars go to higher wages.
[00:12:36] Ivana Krajcinovic: You know, hats off to Cora. I think the work that 32BJ has done, it's been very inspiring and has encouraged us to look more at our own data.
And we had, again, in the Monterey market, two patients on a chemo drug. Again, off patent, common chemotherapy drug. And we had found a local independent oncology practice that was only charging, between a hundred and 150% of Medicare.
So we looked at how much money we would save by moving just those two patients to this other setting. Same exact drug, same treatment, just in a different setting.
The savings in one year is almost a million dollars off these two patients, there are about a thousand union workers in Monterey. So basically we could have given every worker a thousand dollars more per year if we just move these two patients, just two patients to a different setting.
Or you can also think of it as every single member in that Monterey local paid an extra thousand dollars to the hospital, so that they could administer the same exact drug that was available down the street to two members.
I mean, the economics are just astounding in these cases.
Tell #2: “Lazy Networks” and the Discount Game That Lets Overpricing Persist
[00:13:43] Stacey Richter: I think this is a perfect example of, maybe I could call it our second tell, our second indication that there's no healthcare market over on the infusion side as evidenced by there's no market on the carrier side of the house.
Because lazy networks don't equal a demand curve, right? A functioning demand curve means, and you need a functioning demand curve for a market, you know, supply and demand and all that. But what a functioning demand curve means if the price is too high and it's determined that what you're getting isn't worth it, buyers find a better option, they go elsewhere.
But if we have a network that is lazy where members aren't steered and tiered to better options. Then yeah, why would any purveyor of infusions or pretty much anything lower their prices? They're gonna keep the same amount of volume. Why would they lower their prices?
[[The take two episode last week with Dr. Jacob Asher covers why the commercial carrier market slash nonmarket is so very boring and never changes because yeah, you can have a really, really lazy network and still maintain your market share if you are a carrier. It's a very neat trick, and here's how the magic happens. Listen to episode 483, by the way, with Jonathan Baran for more on this.
But bottom line, how you pull it off, how you keep your market share and have a really lazy network is to convince employers to buy discounts. Other things too, but that's a big one.
Because when purchasers buy discounts, a carrier enables a flywheel that raises prices. In fact, you wind up with what Ivana just talked about, where two patients cost a million dollars when down the street the cost would've been 500 times less. But the lazy network included both options in their network.
So yeah, here's the whole point. No market. No market that rationalizes prices. That's our tell, Number 1. But the other no market tell is if a network can be so lazy and not go out of business or significantly lose market share, this is our Number 2 tell that we have, if not, no market then a really dysfunctional one.]]
I think the points that you're bringing up here, where if you had two members who went to a different care setting, it would save the plan a million dollars, but you don't have the existing ASO network, rented network, PP, like whatever you're gonna call it. You don't have that network trying to do this math ahead of time. They're just gonna let the plan sponsor spend an extra cool million.
That also is indicative of the fact that there's no competitive pressure or whatever we're thinking we're relying on a market to do that doesn't exist.
[00:16:15] Ivana Krajcinovic: Yeah, we were kind of struck by how apathetic the networks were on this point.
Because of course, I'm obviously talking a lot about the hospitals and their responsibility here, but the networks also have a responsibility. And so we went to our network, and we said, what is going on here? And it took them forever to look into it. And once they did, they said, “Oh, well we just negotiate the discount across the book of business. So if you're getting some higher prices somewhere, you're getting some lower prices somewhere else.”
So look, I understand if the basic discount is 30%, and on some prices we're at 25 and somewhere at 35. Okay, fair enough. But when we are paying like 500 times more on some prices. Like where is the price where we're paying 500 times less plus it's of no use at all to the individual patient.
Because if it levels out, and that's a big, “if” that's not the case for the individual patient who just got stuck with the higher price.
In the Chicago case I talked about, it's even more outrageous because the hospital and the provider, they were both part of the same hospital system. Right? And they in fact, billed the network the same amount of money. But the network turned around and paid the doctor's office much less than the hospital.
So they know. They know what the price of the drug is, they are themselves paying these providers different. And then when we raise our hand, they sort of say like, “Oh, don't worry about it. It's all gonna come out even in the end.”
And, that's just not an acceptable answer. There needs to be some guardrails, right? There needs to be a corridor, and I understand that, you know, we can argue about how wide the corridor is, but it can't be hundreds of times difference on either side of those rails.
[00:17:55] Stacey Richter: And I think what you're pointing out as we hone in on lazy networks, you have to have supply and demand in a market.
And no comment on whether a market is the right way to run US healthcare. Like that's not what we're talking about here. We're talking about in 2026, the construct that whenever we talk about how we're controlling prices in the US, we say that the network is the demand curve and negotiates a lower price with the hospital.
So if you have that not actually happening then for all kinds of reasons, by the way, and if we wanna talk perverse incentives, I'll put some links of shows in the show notes where we dig in on this hard [EP483 & EP475].
[00:18:31] Ivana Krajcinovic: There's also a lot of information asymmetry generally in healthcare, but the more complex the case, the more asymmetric the information is gonna be.
People with cancer are gonna rely on what their providers recommend. They're not gonna shop around. This isn't a situation where we can expect the patient to do anything different unless we give that patient a lot of help. And I'll talk later about how we can actually do that.
[00:18:55] Stacey Richter: It would really be incumbent on the network to ensure that the care setting selected was the care setting of highest value. And I think the point that you're making is, because they're not fulfilling that role, we have these wild, unchecked price variations.
I just wanna say in case anyone's wondering how this happens, because someone might be thinking, oh ASP [average sales price] plus 6%, how is this happening? It's your lucky day. First of all, that is only pertinent to Medicare. Secondly, there's a show, episode 370 with Erik Davis and Autumn Yongchu and is entitled, "How Do Some Health Systems Manage to Charge 6x the Cost of a Specialty Pharmacy Med to Infuse It?"
So if anyone really wants the nitty gritty there, please do go back
Let me ask you something, you said before that the networks negotiate discounts as a broad stroke like hospital, we want 35% across the board, whatever it is. And so therefore, depending on what the charge master rate is, if it's wildly inflated.
But it also sounds like these things might be really easy to spot, so like once you spot them, can you just go to your network and be just like, okay, I see what you just did there fix that.
Whack-a-Mole: Spotting Overcharges, Hospital Excuses, and Transparency File Games
[00:19:55] Ivana Krajcinovic: They are easy to spot and encourage people to try to look at their medical claims. The nice thing about this type of research is that it's just about the drug. Sometimes when we're looking at comparing prices for an episode of care or a particular kind of surgery, you have to do all sorts of risk adjustment and take into account other factors.
Here, it's like the drug is the drug is the drug, right? So as long as you know what you're looking for, and we're very lucky. We use Brian Cotter from Bright Spot Insights as a consultant. I think he's a member of the tribe as well, and he knows what to look for, and so he can quickly look through our claims and see what we're paying on these, on these various drugs.
The problem that we have is what I call the Whack-a-Mole problem, is that you find one, and even if it gets corrected, there's no stopping the hospital from jacking up the price somewhere else. Right?
So the example I gave, I actually called the hospital COO, who I had met at a regulatory hearing and I said, what is going on here? Like there must be some mistake if we are paying 89,000 for a drug that Medicare would pay 185. Help me understand this. And weeks go by. They tell me that, you know, they put some consultant on the phone who reassures me that I'm only paying six to 9% above the cost and it's just not believable. Right, at a certain point.
And then, you know, John Tozzi and his article in Bloomberg last December went back and revisited all of this with the hospital and they again claim that there was some error and they've dropped the price. And when John said, well, but it's not reflected in your price transparency files, they said, well, it will be in January. Well, I looked last week at the end of January, they had actually removed this drug from the price transparency file.
So that's the game that they're playing apparently. So you really have to stay on top of it. I think ironically, this shows that we're doing something right, that they have to keep hiding the ball.
I think that we have successfully educated folks about getting surgeries in ambulatory surgery centers and getting their labs taken in independent laboratories, and so many of these hospitals are trying to find other places to make up the margin. I mean, the better players are figuring out that they have to bring down expenses, and that's how you keep your margin.
But I actually think in some ways it means that we're onto something. And if we can keep the pressure on in this field, they're gonna realize that there's not as many moles that they can pop up because we've whacked them all.
[00:22:15] Stacey Richter: There are very many, let's just say naive plan sponsors out there in the world.
I don't think anyone would dispute that. At the same time, though, your organization not naive by a long stretch. And even your folks are finding themselves exactly like you just said, it's really hard to know what's going on.
The Roadmap to Fight Back: Data —Benefit Design—Site-of-Care Steerage
[00:22:38] Ivana Krajcinovic: It is hard to know, but I think the other place where we have some power is to leave and to look for opportunities to have direct contracts, which is what we did in Monterey. We found this independent oncology practice that could provide infusions not just for cancer but for for many other illnesses as well.
So we redesigned our benefits to make it free to go to this place that people love free and then sent them to go. We also work with UM/CM vendor, utilization management case management vendor, to be able to steer and talk to our people about where they should go. So that they feel like they're, they're comfortable going and they have a medical professional helping them make that decision.
[00:23:19] Stacey Richter: We have pivoted to the advice portion of this show. So if I'm just thinking through the steps that you went through.
The first one is obviously you gotta drill into your data and you mentioned Brian Cotter, like you mentioned, the work that you're doing in your data, because you have to see that this is happening. You have to be able to figure that out.
Have we heard this before? Yes. Probably 90 times, right? Just what's going on with your data. And John Quinn, most recently just talked about it. Mark Newman [EP496] from Nomi also.
I spying who's charging a whole lot for something which could be had at equal quality elsewhere. And then moving share. If I'm just talking like an economist, over to the higher value place.
[00:23:58] Ivana Krajcinovic: The hospitals are realizing they're gonna realize they're losing business. The networks also when you have a direct contract, are losing business. Right? You know, they can even clean up their act or they're going to start losing the revenue that they have.
But I think we need more people to do that, And we need to do that in more places. It's not always easy. There is a lot of nuance to it. But like I said, the payoff in this case, you know, it's in the millions of dollars.
[00:24:21] Stacey Richter: For two members. I mean, you just gotta find two, right?
[00:24:24] Ivana Krajcinovic: Just those two. We had another example for Crohn's disease. It's not cancer, but much more common. The member was receiving a biosimilar to Remicade.
And she was going to the hospital roughly every other month getting these infusions. The hospital was charging $8,700. They increased the price 21% at the beginning of this past year in 2025 to over $10,000, and she was paying out of pocket thousands of dollars to get this infusion that she needs every two months.
We moved her to the independent practice. She has no more out-of-pocket expenses. We are now paying something closer to a hundred percent of Medicare. So just again, to make the, the point on this one patient, her last four infusions at the hospital, we paid over $38,000 where her last four at the practice were $5,000.
We can help many more people with many more things and they can have much higher wages if we can figure out how to shift people over. You know, we needed to have a system, we needed to look at the data to find her. We need to have a nurse call her, make the suggestion. We had to change the benefit design.
So I'm not gonna say that there aren't some steps here, but is doable. And I think the more people that hear about this, you know, in the Monterey market, if two or three other big payers decide to do this, I think that that is gonna put the pressure on the hospitals to change their pricing and also the networks to do a better job at negotiating the prices.
[00:25:51] Stacey Richter: If you have a network that is not constraining price variation and making, and how you do that, by the way, is you steer to higher value places. Because there has to be market incentive for anyone to do anything. Supply and demand. I've belabored this point.
If the price is really high for commensurate quality, then somehow or another that place loses business. Like that is how you put pricing pressure on an entity. They lose volume.
So if that is not happening, there is no incentive for anyone to lower their prices. So it actually takes having a functioning network and or having plan sponsors perform that job themselves.
And the point that you just made, if there are more plan sponsors in the same geography that do the same thing, now there's a market.
Direct Contracting With Independent Practices: A Win-Win at 150% of Medicare
[00:26:37] Stacey Richter: The second thing that you brought up was really thinking about doing direct contracting, maybe preferred partnerships, especially with independent doctors.
Let me ask you a question. So you go to an independent doctor organization and you say to them, “Hey, I would like to direct contract with you.” Which obviously you did. How'd that go?
[00:27:00] Ivana Krajcinovic: It was really interesting. You know, we went on site, we have a medical director she went to see for herself, you know, we had members too that were already going there. So we talked to them about what their experience had been. And we looked at their credentials and talked to other doctors. So we had done all of that.
The part that I will never forget was sitting in the room and talking to them about if we were gonna do this direct contract. And you know, you always talk about how, you'll pay claims quickly and you'll get rid of some of the bureaucracy and that will all feel good to them.
But we also talked about what percent of Medicare we would pay. And they sort of sheepishly said, well, currently we're negotiating renegotiating some of our network contracts because we're only getting between a hundred and 130% of Medicare. So we would like to suggest 150%, and it took every ounce of discipline I had not to jump across the table and kiss them for that, because the alternative in that market in Monterey at the hospital is 800% of Medicare for chemo.
So this is how out of whack this is. That provider can tell me, I want 50% more than Medicare, which is 50% more than what it should take to cover my costs, and I'm elated because that is a huge deal for us.
But they were above board about it. We quickly reached an agreement and both sides benefit from it, And you know, our members end up with quality care. So it's a win-win.
[00:28:24] Stacey Richter: You're very much underscoring. I think a really important point when we talk about hospitals, that is not a synonym for most of the time. Doctors, clinicians, even some administrators.
Like really for anyone that works there that we really just have to understand that in this country, these are large, consolidated corporatized entities. Whether they're tax exempt or not is completely irrelevant, and there might even be private equity in the mix, but generally speaking, listen to the show with Preston Alexander. Just everybody's after bonds or like whatever. So it's become very, very financialized.
If you go directly to the doctors, which I think is the point that you're making here, they're happy with a hundred and like there is win-wins here. Especially when you think you always hear that for every dollar that a healthcare organization gets paid, the clinicians get paid 20 cents or less than that, right?
Like, so it becomes very evident here that on the supply side, my heart is warmed when you get a clinical organization that is independent, that isn't surrounded by these corporatized wraparounds. That there are deals to be had, which are win-wins in which actually can make healthcare more affordable like this, that is really a bright spot.
[00:29:34] Ivana Krajcinovic: And moreover, I think in the case of this practice and probably others that are forward thinking enough to make these sort of arrangements, is that we're able to spend time talking to them, not about claims and pricing, but about how to coordinate care for our members.
They have been able to fund basically community health workers that can help our members with the sort of nonclinical issues that get in their way all the time, like transportation and paying utility bills and all the other things that cancer patients face, that get in the way of their medical treatments, right?
So that is a much better thing to be talking to a provider about is how are we making sure that our members are getting the best quality care instead of arguing about what the markup is on a drug that you can get in a number of different settings.
[00:30:19] Stacey Richter: Yeah, and we do have a conversation coming up with Health Here actually about that exact thing that if you get the buyer and the ultimate purveyor of that care, ie, the doctor organization, you put them in a room together, not disintermediated by this kind of middle layer that may have other things. Incentives, operations, afoot, right? Like it's amazing actually, the agreements that can be met.
Okay, so the second thing that you said was, think about direct contracting. Think about going directly to those, providing the care and figuring out what you can work out, because there may be a lot of very aligned needs there.
We had Dr. Stan Schwartz on the show from Zero Health also just talking about how, and you mentioned this in passing, but it's really important just that you can get rid of the member portion because the collection rate is so low.
Just like so just doing that really can be extremely beneficial to provider organizations who have turned into collection agencies as deductibles have gone up.
Carving Out UM/CM: Member Outreach That Actually Works (Language, Timing, Trust)
[00:31:15] Stacey Richter: The third thing that you mentioned in sort of rundown relative to what you have done is you said carve out UM/CM so not to rely on network provided utilization management or case management to really carve it out.
And I'm assuming you're saying that because again, just kind of wrapped up in the example with the direct contracting, you wanna make sure that you're utilization, managing and case managing to the directly contracted entities, etc, and not just within network.
[00:31:47] Ivana Krajcinovic: The networks UM/CM is beholden to the network. So how had are they gonna try?
[00:31:52] Stacey Richter: Ann Lewandowski says this all the time. She was told she was actually trying to shop as a consumer and she was told getting a lower price is no reason to go out of network.
[00:32:01] Ivana Krajcinovic: Right. And when you carve it out, and we use Health Check 360 and we've been very happy with them. You're able to sort of craft what you want for your membership.
So for instance, for our membership, it's really important to have people that speak Spanish. It's really important to have people who are gonna call after five o'clock in the evening.
You know, you have a network UM/CM nurse, they're gonna tell you, I tried reaching that person three times. What time did you call? I called at two o'clock in the afternoon. I said, well, you know they're working. Of course you didn't reach them.
Our vendor also works with us because we have our own staff that can go find members. Because they're often, they don't know who this person is that's calling them.
So we have people on the ground who can go find workers at their workplace or even at their homes or work through the union to say, “Hey, give this nurse a call back. She's gonna talk you through some of your options and how you can, you know, save some money out of pocket and still get the same quality care.”
So you just have a lot more control to shape it to what your members need. And I think that there are vendors out there that are doing this really well and who are thinking of site of care as part of what they should be paying attention to, not just whether the person is getting the right level of care otherwise.
[00:33:05] Stacey Richter: Yeah. And I think, you know, if you have the vendor that you're working directly with, they report to you.
[00:33:09] Ivana Krajcinovic: Right.
[00:33:09] Stacey Richter: They report to you. You are determining what good looks like. You're determining success criteria they're hearing directly from you. You don't have this middle layer in the middle where again, you wonder if the UM, what is their success metric.
Pushback + Public Pressure: Media, Regulators, and Changing the Community Dynamic
[00:33:23] Stacey Richter: I am also going to interpret based on the things that you're saying that a fourth part of this roadmap here is pushback. Like do not be complacent. Ask lots of questions. You see something, you say something kind of spirit.
Because throughout everything that we've just talked about, you would never have either seen what you're seeing or accomplished what you've accomplished unless you were in the thick of it kind of getting a little feisty.
[00:33:50] Ivana Krajcinovic: Absolutely. I think the union's all about pushing back and so we, as their trust fund have to kind of do the same for our members, right? It's their money. And if we see something, you know, we're not doing our fiduciary duty, we're not doing our moral duty if we don't question it.
And I really encourage more people to speak up because I think if we were all talking about this, it would be much harder for these providers to get away with it. I mean, shame on us, frankly, that they've been getting away with it as long as they have because we've let them, and I think if we start talking about it and start asking questions, it's gonna be uncomfortable for them.
It'll be uncomfortable for the networks. They'll start talking more to the hospitals. The hospitals will have to do something.
[[00:34:32] Stacey Richter: In case anyone is new around here. First of all, in no way is anyone conflating health system leadership with doctors and nurses and other clinicians, and even some administrators who work in the hospitals
We are all aware there are so many choices that are made by some health system leaders who are often three states away from the impact of their decisions. And it's not like any kind of democratic vote was taken.
In fact, the epidemic of moral injury and burnout inside health systems is because those who are working there are suffering under the same decision making framework as what Ivana is talking about here.
So I just don't want anyone to lose track of that.]]
[00:35:12] Ivana Krajcinovic: So it's talking about it just to the people you normally do business with. I think it's also trying to find other forums. Right. We talked about the, the Bloomberg piece. You know, certainly getting this stuff out in the media is helpful.
We've done a lot in California around the regulatory process set up by the Office of Healthcare Affordability, which is attempting to kind of reign in the growth of healthcare costs in California.
And when we first started talking to OCA as it's called, we thought, well, I don't know how much this is gonna help, because in Monterey, our prices are already five times Medicare. So the fact that they're gonna grow slower is cold comfort. But it was a platform and it was a way to go. And, you know, we had average members go to Sacramento and talk about what was going on in with the hospitals.
And it has really changed the dynamic in that community where I think hospitals are used to just without, you know, working very hard for it, getting a lot of love, you know, for the work that they do. And a lot of the stuff they do is really important. We wanna have good hospitals in our communities, but nobody's talking about this like dark underbelly of pricing that's going on.
And as you start to talk about it and the media starts to pay attention, so many average people have had this experience of going to a hospital and getting a bill that they didn't understand. I think it really is gonna force the hospitals to work much harder to get the status that they want in their community.
It's not just gonna be on the natch that because you're a hospital and you take care of people, you're gonna have a sterling reputation. You're gonna have to answer for the pricing that you're putting out there.
[00:36:40] Stacey Richter: For sure. And I had a two-part conversation [EP490 & EP492] with Dr. Sam. Flanders and Shane Cerrone from Kada Health about this exact point serving the community and fiscal discipline probably should go hand in hand.
And the implication, as Shane Cerrone said, there's, there's a couple of different ways to be a nonprofit. One of the ways is struggle. The other way is being completely inefficient. Right? And again, without a market, you can't tell the difference. Where there's no market, so like you spend every dollar that you're given next year, you raise your prices and you say your operating margin is low.
Final Takeaways: Collective Action, Stay “Enraged,” and Where to Learn More
[00:37:14] Stacey Richter: Ivana Krajcinovic, is there anything I neglected to ask you that you wanna mention today?
[00:37:21] Ivana Krajcinovic: I hope that people feel inspired to do something because there is something to be done here. And if it is a game of Whack-a-Mole, if we have a lot more people with mallets, we'll eventually win this game. This is an area where we can make some change, and I'm really grateful to people like you on this podcast that are spreading the word in a way that hopefully gives people the confidence to go out and do things.
We don't have that many lives in Monterey, and we were able to do something. We were really inspired by the 32BJ story. Taking on New York Presbyterian and realize when other markets, if you have a group of lives, you can do something or band together with another payer to do it, because that's the only way that we're gonna make change in healthcare I think.
[00:38:05] Stacey Richter: We just did episode 500 a couple of shows ago, and one of the themes we identified as we talk about Relentless Health Value, but really what it's gonna take to move healthcare. Just the necessity of collective action, of having a tribe working together, and I think you're very much echoing that point.
[00:38:24] Ivana Krajcinovic: I always say that you have to remember to be enraged every day doing this work. It is very easy to just get sort of inured by constantly seeing the overcharging and the things that shouldn't be happening in the market, and you just have to tap into that anger because I think that's the stuff that's gonna motivate us to make change.
[00:38:43] Stacey Richter: Normally at this point in the interview, I say, where can people go for more information? However, given that this is day one of your rest of your life, I'm sure you're gonna say somewhere else, friend.
[00:38:56] Ivana Krajcinovic: There's a lot of information on our website, uhh.org for UNITE HERE HEALTH.org, and I encourage people to go back and read the December article that John Tozzi put out in Bloomberg. There's a lot of good links in that article as well.
[00:39:10] Stacey Richter: Ivana Krajcinovic thank you so much for being on Relentless Health Value today, and thank you for your decades of work in this industry.
[00:39:20] Ivana Krajcinovic: It has been my pleasure. You know, I often listen to this podcast when I garden on the weekends, and now I'll be able to garden during the week. So I look forward to catching up on all the episodes now, while I'm out in my garden.