Inbetweenisode Setup
[00:00:00] Stacey Richter: Inbetweenisode. Relentless Tribe Goings-On With Insights to Outwit the Hot Mess of the Non-Healthcare Market.
This Inbetweenisode, I wanna try something new, for two reasons. One of them is that I need to check this episode off my to-do list because I'm crushed for time. I'm going to be headed to Arizona tomorrow for the Collective Health Conference, which will have occurred three weeks ago by the time you listen to this. If you ever have an urge to time travel, start a podcast with a three week production cycle.
But yeah. The bigger reason though, that I wanted to do this show in this way today, this Inbetweenisode, is that sometimes after a show airs, after an episode airs, I get a big mailbag of responses from listeners like you.
Really good responses actually with many incredibly relevant points, adjacencies, additional examples, just a rounding out of the thought processes around any given episode or series of episodes.
There's two Relentless Tribe members that I really want to spotlight in this Inbetweenisode, Ken Wosczyna, and then also Michelle Bernabe.
Ken's LinkedIn Praises
[00:01:28] Stacey Richter: All right, starting out here with a LinkedIn post, written by Ken Wosczyna, and he writes, "The greatest strength of Relentless Health Value is moving from theory to practical transformation. Insight is common, execution is rare. Healthcare doesn't lack frameworks or commentary. It lacks better decisions. In employer-sponsored healthcare, decisions about contracts, incentives and pricing transparency aren't academic. They affect real dollars. They affect real people. Relentless Health Value episodes don't just spark ideas. They sharpen judgment."
"Better judgment leads to better contracts and smarter benefits design." And then Ken says, "That's why I listen. That is why I implement."
I really appreciate this post that Ken Wosczyna wrote, because it actually was a point that I was trying to make about this judgment, about this decision making. I was trying to make it during episode 500, but I realized afterwards that I didn't entirely succeed.
And the unmade point I was trying to make but didn't is exactly what Ken wrote, that what we ultimately wind up doing or not doing, all boils down to the quality of our decisions and how they all stack up to either align or not align with our values. Our whole healthcare system is really a massive aggregation of all of the decisions made by all of the humans. We need better decisions, just like Ken said.
So thank you so much to Ken Wosczyna for spotting this whole thing and getting it over the line with such eloquence.
Decisions Shape Systems
[00:03:01] Stacey Richter: But while I'm on this topic, think about this. And I've said this in other shows, especially the one with Larry Bauer link in the show notes about Knaves, Knight, and Pawns.
The C-Suite is certainly a bunch of offices filled with power, and they have the potential up there to influence how a company, a corporatized health system, a carrier, right, a lot of power to influence the kind of corporate citizen that company will be.
But look, what goes on in the halls is often very different from what is written on the walls in good and bad ways, actually. But what happens in those hallways is often a choice being made by those walking them. The actual direction of any given company is determined by the millions of decisions made by those who work at the place.
There was a show with Keith Passwater and JR Clark a couple of years ago. These two are actuaries and both of them were like, look, as an actuary, you can decide to put patient affordability in your algorithm, which it's not in most cases. As an actuary, you do not have to eke out the last possible percentage point. You have more power than many think to align with values.
Now, don't get me wrong, we all have lifey crappy choices to make sometimes when we are navigating, staying employed with aligning to our values. But often there are ways to proceed that are better than others. There are better decisions that could be made. There are incremental ways to move the needle, to change the vector just slightly. And how that happens again, is all about better decisions. More informed decisions, more thoughtful decisions to remove the reflex, I guess.
What are the inputs for these good decisions, right? All the reasons that Ken Wosczyna talked about for listening to Relentless Health Value--to get the information that is necessary to sharpen judgment.
Transparency and Data
[00:04:50] Stacey Richter: Let me tick through a couple of rate criticals here. A, you can't fix what you can't see. So yes, transparency. And speaking of transparency, here's some news you can use, show coming up with Jerry DiMaso from Payerset, and they have something I was unaware of.
There is now the transparency data where you can see, say like you're an airline. What all the other airlines, assuming everybody is self-insured, what everybody else is paying for the same service, you can see that in their transparency data file. I did not realize this was afoot. Listen to the show, coming up with Jerry DiMaso in a couple of weeks because fiduciary much? Not to plan members here, although there's also that, but to shareholders.
If I'm a shareholder and I get ahold of this data and I find out that this company just paid say a million dollars too much for some infusion, or if the company had steered down the street to the indie practice, I'd have an extra million dollars on my balance sheet. And that is a real example actually. And if you wanna hear the whole story, listen to the show with Ivana Krajcinovic about the, what she calls surreal price variations for infusions in the same exact geographies.
So I'm basically saying that this is not change in the couch cushions that we're talking about here. Site of care differentials have a lot of zeros that shareholders, if they get transparency data files they will be able to see the caliber of the decisions being made relative to the second biggest line item on most companies expense sheet. Many companies pay more for healthcare, providing benefits than they do for steel or coffee beans or etc.
So I can imagine if I was a big shareholder, this is something I would be looking into. I could say so much more on this topic, but I think I'll save it for the episode with Jerry DiMaso in a couple of weeks.
But yeah, here's the point. You can't make good decisions without transparently available information and there is more and more transparently available information. So you can't fix what you can't see, can't make good decisions. So that's the Point 1 about making better decisions.
Peeling the Onion
[00:06:56] Stacey Richter: But also you can't fix what you don't understand. And I think this is the second sort of underlying point that Ken is making, in which I have heard also from others.
Because look, what you might see is an onion that looks, I don't know, really simple from the outside, right? Like, oh, here's a price. We're good. But then you start peeling layer after layer after layer, and the healthcare industry at this point is so financialized, there's so much regulatory capture.
There's so much vertical integration with money getting intercompany eliminated, which is just a fancy way of saying it just got disappeared, that unless you really know the right questions to ask, you'll think what you are being shown is transparency. And you think it might look good, except it's not. You just got arbitraged.
I'm thinking about the most recent episode with Dr. Eric Bricker (EP472), where we talk about how health systems can use these carrier stop-loss contracts. So not the stop loss contracts that employers buy. There's these carrier stop loss contracts.
And if such a contract is procured, it would enable a health system to show, this is just one example, a negotiated rate of like $140,000 for a CABG to be able to show that their negotiated average across the board, their average discount is 240% of Medicare or something.
But then somehow or another, they're on average charging like $800,000 for a CABG, not 140k. Way over 240% of Medicare. Right? How does that happen? Listen to that show.
Here's another example. A PBM says they don't have spread prices or something. There's no spread, but then you find out that they're paying the pharmacies that they happen to own a higher amount than they're paying the ones that they don't own.
And also the pharmacies that they do own are very, very preferred. So most of the volume is being dispensed at the pharmacies that the PBM owns. And when you see this, what is going on there? Oh, right now they can, potentially, reclassify spread as pharmacy profit.
Or, here's another thing you can do with spread. You can pay a consultant, oh, sorry, not pay a consultant, give a consultant a discount of $7 an Rx or something. And now again, it's not spread anymore. It's a discount on book of business. Is that reportable? I don't know. You tell me. I have no idea.
This stuff matters. There was a comment by Craig Herndon that I thought was really interesting. He writes, "There is no headline when someone starts stretching doses. No dashboard alert when an EOB shifts real cash flow to the family. It just happens quietly in the background of a benefits design that looked reasonable in a boardroom. But when it changes behavior at the kitchen table, that is a different kind of signal. For self-funded employers the real question is not whether the design is technically compliant, it's whether it reflects the kind of risk they're actually willing to place on their own people".
Rethinking Disruption
[00:10:32] Stacey Richter: I'm also gonna drop a seed here right now because I wanna do a show on this coming up. Disruption. What does that word even mean anymore? Think about this, and this is a half-baked idea right now, but it's in the oven. Heads up. There are so many folks out there very afraid of noise and the dreaded D word, disruption.
But I'm starting to feel like I could credibly argue by trying so hard to avoid disruption and problems with access, that we actually create disruption and problems with access. Like if a significant portion of folks on any given plan who actually get sick, don't have access and find themselves functionally, uninsured and or bankrupt, that's pretty disruptive.
If we don't spend for advanced primary care or steer and tier, if we choose not to do those things and stick with the status quo plan with a, “lazy network” where it's a crapshoot whether any given member will find themselves in a financial pickle, right? Or maybe they'll wind up going to the obstetrician with a 75% C-section rate for healthy patients who's still in network because we don't wanna kick them outta network because then it'll be disruptive, right? You get my drift.
Maybe it's time we rethink what the disruption word means, so stay tuned. I'm on it. If you have thoughts, hit me up.
I guess at this point, all I'm saying is that as we contemplate what decisions we wanna make, if we're considering disruption as a reason to not do something, we shouldn't consider that the baseline here is not already disruptive.
So just again, when we start peeling back this onion layer after layer to make really good decisions, again, you not only have to have information transparent that you can get your hands on, but also the knowledge to power the decisions that are being made and to realize when something might be transparent, but kind of have this spidey sense that there's something underneath there to start poking away at and asking more questions about.
Michelle's Hero Journey
[00:12:22] Stacey Richter: I'm going to read something that Michelle Bernabe wrote. She actually wrote the most beautiful LinkedIn post right after episode 500. There's a link in the show notes, but here's the gist of it. And again, I'm bringing this up because it so eloquently expresses. Why you're here and how all of this rolls up to having the knowledge and understanding to make better decisions to sharpen our judgment.
And I'm kind of also gonna read this to you because I think sometimes in the just day-to-day, whack-a-mole enraging environment where you take one step forward and six steps back and it feels very daunting. This is also all about you and why you should really take stock in your progress and the things that you've accomplished and the power that you actually have and you should trust yourself to have it.
This is what Michelle Bernabe wrote. She wrote, "Catherine Connors, who was the executive at the Walt Disney Company, responsible for turning the princess story from rescue to power. Catherine talks about this idea of descent and return. It means going into the deep with intention and attention. Staying in deep relationship to the world around you, and then coming back with the truth".
And Michelle wrote: "As I listened to the 500th episode, I realized this is literally what Relentless Health Value does episode after episode. We all together, we descend into the belly of the healthcare system. We follow the thread of a question into the incentives, into the unintended consequences. It is making sense of this very strange world in real time. There's a form of storytelling that creates the path as we go, and when the shows wrap up, we come back with something that unlocks creative potential for the Relentless Tribe for you listening. It supercharges whatever you are building. It gets you back in touch with your own agency and with your own power."
Then Michelle wrote, "Catherine gave me the language for the pattern that Stacey", hey, that's me, "is walking and talking. The Tribe is ever expanding and they're on their own hero's journey." You are on your own hero's journey, and Michelle writes, "That gives me hope in a field that sometimes feels so dark."
Thank you, Michelle, for so eloquently stating that, and I hope also you listening feel the power of those words there because they're really all about you.
So this is why what Ken and Michelle were saying is just so important. Knowledge isn't just power. It's really fiduciary armor in a health system built on mystery and margin, right?
You lot who tune in every week or often enough, it's a half hour or so a week that will fine tune ultimately your pattern recognition engine that allows you to catch a whiff of what you just know is gonna turn into a problem.
So again, be really, really proud friends. Be really proud because by putting in the half hour or whatever, and listening every week, you're building this instinct to dig in, to ask the awkward questions, to protect your members from predatory pricing and also patients.
There's a lot of doctors, nurses, other clinicians and administrators who listen to the show too, and can do this from the other side. Be proud. You're not just spotting trouble, you're the ones who are really fixing the pipes, or at a minimum polishing up your mallet to play a decent game of Whack-a-Mole.
It's just, it's so hard because the moles just keep popping up but at least you're doing your best you can to smack them. So yeah, thanks for being here.
Someone told me the other day that people who listen to this show are a skeptical and hard to reach audience, and I took that as a huge compliment. Honestly, you really should be skeptical.
Direct Contracting Ahead
[00:15:56] Stacey Richter: Speaking of good decisions, what they may entail lately, we've got some shows coming up all about direct contracting as one example of good decisions that some people are making. Listen to the show last week because if you direct contract, it's a lot harder to get arbitraged. You know the price the provider is getting paid. If you get charged more than that, well at least whoever is taking your money has to work a little bit harder to hide it.
And interestingly, this came up in the show about direct contracting last week. And if you didn't listen to it, this is a takeaway I had. You know what you call a group of direct contracts, not a herd, a herd of direct contracts or a parliament or a murder. You call a group of direct contracts, a Center of Excellence network.
Right? I just never thought about that before. Currently, we're at version three of what a Center of Excellence model could look like, so yeah, definitely go back and listen to that show with Ryan Wells from Health Here, Adam Stavisky, formerly of Walmart, and Dr. Leo Specter, CEO of OrthoCarolina.
It's a conversation full of things that made me go, huh, oh. We also have several shows coming up on advanced primary care and the trust and relationships and why there. So stay tuned.
Michelle's Episode Map
[00:17:05] Stacey Richter: Now I wanna take a left turn, so I hope your seatbelt is fastened because I wanna discuss this website/app that Michelle Bernabe put together for Relentless Health Value. It's something to behold.
Michelle wrote, "In other life updates. I taught myself to Vibe Code this weekend." And then she puts this link. It's an interactive map of the Relentless Health Value universe. Every single episode, every single guest, every theme for the past 10 years.
One of the tabs in the app tracks the number of times words are said as a trend from 2014 until today. It's both revealing and a little depressing honestly. Clearly, we've been hammering away at the same mines for, you know, a decade.
The top words in 2014 that continue to be the top words today are: market, consolidation, transparency. PBM, and rebate are also right up there. But wait, there's more.
AI Claude and Donations
[00:18:08] Stacey Richter: So then Tom Nash, our producer, starts edging in. He starts edging in and asking a whole lot of questions about this app that Michelle made Tom's fascinated. So then Michelle sends over a $50 donation for Relentless Health Value to get our own Claude account, which. You people are simply the best. And by the way, also, this $50 donation came in at the exact same time as a donation from Kimberly Carleson, you people, wow. Please go back and listen to the show with Kimberly Carleson, by the way, it continues to be wildly popular.
But anyway, AI, Claude. So Michelle is going back and forth with Tom and she mentions that there is an anonymous futurist philanthropist. Where if you're doing good things and you send over your Claude receipt and your Bitcoin wallet, this person will donate $250 of Bitcoin to fund your futurist pursuits.
I was sus as all hell, don't get me wrong. But Tom Nash was like, we have $8 in our Bitcoin wallet if they're gonna steal it, God bless 'em. Anyway, much to my shock and awe. We just got a $250 donation from the futurist, Michelle Bernabe wrote. "Damn. The fact that this chapter ends with a regenerative minded futurist from a subculture Signal chat, Bitcoining RHV's Claude subscription costs, that has exceeded all expectations, and it's a reality I'm grateful to be part of till the next episode.
Wrap Up and Sponsors
[00:19:20] Stacey Richter: So, yeah, till the next episode. See you next week.
This podcast is sponsored by Aventria Health Group with an assist from Payerset, and I thank Payerset very much for the financial support. If you haven't visited their website or visited it lately, you should go over there and check it out.