Introduction and Recap of 2025 Themes
[00:00:00] Stacey Richter: Inbetweenisode. "The Relentless Health Value Themes That We Covered Throughout 2025—A Recap, Part 1.”
[00:00:26] Stacey Richter: So this is new. What I thought could be a good idea to experiment with here is instead of bringing up, I was gonna say new concepts, then I thought better of it because there's nothing new in this world.
But as I reflect on 2025, what occurs to me, there have been certain concepts, topics that have come up over and over again. But when they come up in the different episodes, we inspect them from maybe a particular point of view. What made me really curious to do though, is to start at the theme level and kind of take it from the top in that direction.
So I reviewed all of our episodes this year, a little bit of help from AI, I will admit, and pulled out the top 5 themes that seem to have come up the most this year. And what I hope to do right now is to go through at the theme level what we've talked about.
I wanted to do this for myself, to be frank, just to kind of put a capstone on the year. Then I thought, you know, maybe this will be helpful for you as well.
My name is Stacey Richter, by the way, and this episode is sponsored by Payerset and of Aventria Health Group.
And let's get to it, shall we?
Theme 1: The Critical Need for Trusted Relationships and Simplicity
[00:02:06] Stacey Richter: Here's Theme 1, the critical need for trusted relationships and simplicity. Wow, has this come up a lot this year. Just the idea that trust is the foundational element required to achieve desired clinical and financial outcomes. And the problem is that a lack of trust is pervasive across the system.
I'm gonna kind of separate the trust topic into two categories. One is the trust that's required between a clinical care team and the patient. And Dr. Kenny Cole talks about this in this clip.
[00:02:44] Dr. Kenny Cole: It is not the patient's job to comply with what we tell them to do. It is our job to earn their trust and then go on a journey with them where we help them to accomplish what matters most to them.
It's not about them complying our adhering to what we tell them to do. It's about how effective are we at communicating and building that trust and building that rapport, and then in essence, leading them on a journey where we co-produce a desired health outcome, preferentially one that matters most to the patient themselves, so that we're appealing to their intrinsic source of motivation.
[00:03:23] Stacey Richter: But then on the other side of the house, we also have the trusted relationships that really are necessary between any ultimate purchaser, like a self-insured employer, or a union and their partners such as brokers or TPAs or PBMs. And this is what Ann Lewandowski talks about in this clip, and when she says he, she's referring to something that Matt Ohrt said.
[00:03:43] Ann Lewandowski: The thing that I love that he says is have a trusted partnership. The challenge is many people think their partnership is based on trust and they're not verifying. I think that's really where, you know, we need to have this trust and verify or practice defensive plan sponsorship so that everybody is really safe.
And you do actually have that transparency that does lead to trust.
[00:04:13] Stacey Richter: If I think about how often trust came up, I did a whole show that highlights trust as a gigantic requirement for clinical and financial success.
We've got the show with Dr. Rushika Fernandopulle, the founder of Iora who really digs into the need for trusted relational, not transactional technology and models that are really built on proactive team-based care.
The show with Matt McQuide about nurse navigators really emphasized, if you remember that one, a foundational layer of trust is going to be required if anything bad happens, and now suddenly someone becomes an unexpected high cost claimant.
If you think about it, you've got a nurse navigator that the member gets used to calling when they go to the pharmacy and can't pick up their med or whatever, so that they know and trust Irene or whoever the nurse navigator happens to be. And then when that member now has a high stakes, high cost decision to make, where they go for their cancer care, or to get that first infusion, they call Irene.
Dr. Christine Hale talked about this also in a show about high cost claimants. How high cost claimant are often desperate actually for help and are very receptive to engagement but when offered by a trusted partner. And the sad thing is you can't get trust in T minus 10 seconds while waiting in the hall to get an infusion or something like that.
So the show with Matt McQuide and the one with Christine Hale, Dr. Christine Hale certainly go together.
Dr. Cristin Dickerson was on the pod talking about imaging direct contracting and how having predictable costs and making it easy and simple builds the trust factor that's necessary for member uptake.
In the podcast with Mark Cuban and Cora Opsahl called "Trust, Simplicity and a Chicken", yeah, trust and simplicity and a chicken come up multiple times.
Just doubling down on the point, if you make the process forthright, it becomes less possible for too many middlemen really driving up costs. They see 33 or something percent of healthcare spend is fraud, waste, or abuse. And a lot of that happens in this middle part. So if you've got trusted partners and you've got simplicity, you have the best chance of that not happening.
And then lastly, the show with Dr. Mick Connors, and I'm gonna talk about this in the next theme, but mission-driven focus creates trust. If you have a margin only focus, first of all, it's easy for patients to pick that up.
If someone only cares about the money, there's a vibe, right? That margin only focus leads to plummeting trust for both patients, but then also the providers themselves. And the more the providers distrust their leadership, Dr. Komal Bajaj talked about this in a show from 2024, so not covered in the scope of this, but the more that doctors and clinicians mistrust their leadership, that trickles down. That is felt.
So in sum, this whole theme of trust and the necessity of trust has come up over and over again. And as I reflect on this, and I said this during the Thanksgiving show that I did, where I handed out five baskets of thank yous, at the same time that we are recognizing the importance of trust, maybe one of the reasons why we are recognizing the importance of trust is because of the pervasive lack of trust.
And I said this in the Thanksgiving show. 2025 I have seen some of the most egregious, honestly behavior. I've been in business, my day job for 25 plus years, and I have just never seen people choosing to do things just because they can at the level that I have seen recently.
In the midst of that, what I recognize is the importance of this community, this village, this Relentless Health Value tribe. Because the more of us that band together and demand that people are trustworthy, the more that egregious untrustworthy behavior becomes an unacceptable outlier.
And if you've ever read that book, "Give and Take" by Adam Grant, who cites tons of studies, what has been found someone who's a taker and who takes without integrity in untrustworthy ways, yeah, according to Dr. Adam Grant, they get theirs eventually, and that's what I'm banking on.
So Theme 1, the critical need for trusted relationships and simplicity. Simplicity, driving trust, obviously. So that's Theme 1. Let's move on Theme 2.
Theme 2: Primary Care as an Investment, Not a Cost
[00:08:32] Stacey Richter: Primary care must be treated as an investment, not a cost. Let's listen to two quotes actually, to kick this off. The first one here is from the Jonathan Baran’s show.
[00:08:42] Jonathan Baran: The most expensive thing in healthcare is the pen of the primary care doctor. And so where and how that dollar gets managed is ultimately dependent on them.
That's why, as you said, it needs to be independent. It needs to be unconflicted, have the time to do real primary care things.
[00:08:57] Stacey Richter: And now I'm gonna play something that Nikki King said in an encore.
[00:09:01] Nikki King: You know, right now one of the major ills of the healthcare system is how much primary care has taken place in the emergency room.
When that happens, A, it's much more expensive care than it should have been in the primary care office. It's arguably not as good care.
[00:09:16] Stacey Richter: Bottom line, and I'm not gonna belabor this, this theme because we have belabored it this year, but in short, the failure to invest in unconflicted primary care leads directly to cost escalation in high cost care settings like the emergency room and hospitals.
And right, let's just talk about the impact on self-insured employers. Broken primary care is evidenced by ER spend reaching around 6% of average total plan costs. Talked about this with Al Lewis and the podcast with him, and then also I did a Through Line Show.
But many employers are recognizing that investing in primary care is a proven strategy, advanced primary care now, is a proven strategy to reduce expensive downstream care.
But we also talked this year about how some provider organizations, so inclined can, whether they realize it or not, driven by incentives, you know, sometimes things happen so slowly that you don't realize it's happening until it's happened. But there is perverse financial incentives to buy up all the primary care in a region and then pretty much gut their ability to treat patients within the primary care offices.
Because you're using those primary care offices, as you know, a funnel for expensive downstream services. And when you do that, you neglect the true medical mission of primary care and really undermine it, the lower that you reimburse for a primary care visit, the more that you are incenting or necessitating in a certain way, higher volume, but the second that you drive throughput to a 7 or 15 minute visit, what winds up happening? The x-rays are done in the emergency room, right? Like you're driving care elsewhere.
Dr. Alex Sommers has talked about this quite a bit on LinkedIn also, Dr. Ramy Khalil.
But if you're looking to refresh your memory on what you've heard about primary care this year on Relentless Health Value, I would mention the episode with Dr. Rushika Fernandopulle, who is arguing that primary care is the right starting point for health reform and certainly requires new payment models, however, to succeed.
The episode with Tom X. Lee, Dr. Tom X Lee, who's the founder of One Medical, Dr. Tom Lee really echoed some of the same exact things that Dr. Rushika Fernandopulle was talking about in the sense that doing advanced primary care where outcomes can be proven requires a different way of thinking, a different way of using data, working really holistically as a team, a well-functioning team is required.
And I also talked with Dr. Tom X. Lee about why retail clinics haven't fulfilled this mission. If you wanna go back and listen to that.
I did episode 467, the whole show all by myself that really doubles down on this concept that primary care is an investment while skyrocketing ER costs are pure evidence of the cost of not investing in primary care.
Dr. Mick Connors mentions [EP495] this too when he starts talking about how he's a pediatric emergency room doctor, and he says: “If you ask me to give one common denominator about the kids I see in the ICU, it's kids that do not have a primary care doctor. It's kids that don't have their medication. They don't know how to use their asthma inhaler.”
We also have the show with Dr. Stan Schwartz, there was a Summer Short with him that provides a real clear example of primary care programs being shut down by health system leadership.
And Dr. Scott Conard talked about this [EP391] a couple of years ago. Same exact thing. But just again, the perverse incentives that exist because successful primary care prevents profitable hospital admissions and if what you are concerned about is putting heads in beds in the hospital, then primary care that keeps heads out of beds, you don't know what to do with them, if you're a hospital leadership. You're certainly not incented at a minimum to invest too much into this.
Then we also have Part Two of the Flywheel Shows with Jonathan Baran. He talks about the importance in investing in independent, unconflicted advanced primary care to reverse the negative financial flywheel.
Again, bringing up the show with Mark Cuban and Cora Opsahl that really highlights that high deductibles, send people to expensive ERs instead of affordable primary care.
And this is something to really think about, and I'm just gonna lightly touch upon this here because this is a much bigger topic. One of the things that we have to be really careful about with cash pay, you have to have a certain amount of wherewithal from both a knowledge standpoint, but then also from a monetary standpoint or really have a primary care structure that reduces the cost and the need for wherewithal of primary care for cash pay to not as an unintended consequence, actually drive higher downstream costs for all the reasons that we just talked about when people skip primary care 'cause they don't understand why they need it or can't afford it.
And then as we've just talked about a whole bunch, people wind up in the ER. And the perfect example of this is, of course, the one I just mentioned that Dr. Mick Connors was talking about, about kids that inhaler example, you know, kids winding up in the ICU because they don't either have their asthma inhaler or they don't know how to use it. Maybe because the parent didn't understand and nobody had a primary care doctor to explain, or nobody went to a primary care doctor or spend the money on the preventative care.
Or here's just another example. There was this mother in, it was one of the west coast states, and she had a child with Type 1 diabetes and she really didn't understand the importance of insulin for this kid. So her daughter dies in the backseat of the car without insulin. The mom drove by 31 hospitals while her child was dying in the backseat, you know, arrived home or wherever and the kid was dead.
I'm speechless, but as we contemplate the importance of primary care, ensuring that our patients and members have the education or the financial incentives or, I don't know, this is a whole separate conversation, the access to primary care, it's a topic that we didn't necessarily discuss too much this year, but it certainly warrants big contemplation.
Theme 3: The Dominance of Perverse Financial Incentives and Profiteering
[00:15:19] Stacey Richter: Theme 3. The dominance of perverse financial incentives and profiteering. Yikes. This one's a doozy. And look, the entire healthcare system is fraught with misaligned incentives where someone's cost is in fact somebody else's revenue or profit. If we talk about things like no margin, no mission, what is a fair profit and what is profiteering?
And I'm gonna play something that Dr. Ben Schwartz [EP481] said.
[00:15:46] Dr. Ben Schwartz: Where do you tip over from getting paid money to deliver a service and getting paid fairly and doing something ethical versus profiteering when it goes beyond. Your mission becomes the margin and nothing else, and it becomes profiteering where you're just looking to extract as much money or value out of the system instead of creating value.
[00:16:07] Stacey Richter: And I think that quote from Dr. Ben Schwartz really feeds into, as a prelude the episode with Dr. Mick Connors, where he starts talking about like, okay, the actual definition of margin, you know, sometimes we conflate margin with revenue. That is not actually, if you think about it like an economist, that's not the definition of margin.
What margin is, it's the amount left over. After you pay for the cost of the service or the cost of goods, right? It is the profit margin, if you start thinking about it in that context. So then the question becomes what do you do with that margin? Because what you choose to do with that margin is probably the greatest predictor of how much of the mission we as individuals, organizations, and as a society, frankly, winds up delivering.
[00:16:55] Dr. Mick Connors: I mean, I know CEO salaries have grown a hundred percent in 10 years, whereas physicians have decreased. But you know, heck, I'm a pediatrician. If I was, if I wanted to be rich, this would be the last thing I would've chosen.
It's kind of some of that dummy stuff of like, oh, I'm idealistic. I want to take care of kids. I want to take kids better care. And yet you're making it so hard for me to do it. Like at some point we gotta figure out how we can get some of these dollars to flow back into the mission and get back some of the trust that we've lost if we're just focused on margin.
And I think we need that pendulum to edge back the other way.
[00:17:27] Stacey Richter: Right. Kind of embarrassing actually, I'm gonna say for myself that I never really connected these dots before. That if you say no margin, no mission in the rest of the world, outside of healthcare at least, you're not saying no revenue, no mission, you're saying no profit, no mission. That's what you're really saying. That's what those words mean.
But in healthcare where no one really knows what the margin is because no one frequently knows what the cost of goods or the services are, then yeah, no margin, no mission that you hear so often. It's this platitude embodies that whole problem in a way that the nun who said it first, I'm sure was fully unaware of, because I don't think she meant no profit margin, no mission. But maybe I'm wrong, no profit, no mission. Hmm.
But speaking of profit, Yashaswini Singh was on the podcast talking about upsides, downsides, just digging into private equity in healthcare, and this is what she says along these lines.
[00:18:24] Yashaswini Singh: The research so far shows that unsurprisingly, when PE firms invest in healthcare facilities, a lot changes practices or healthcare entities become more performance oriented, which means there's a large emphasis on driving profitability. This can be achieved by increasing the negotiated prices that entities received from commercial insurers. Increasing the volume of profitable, lucrative surgeries and procedures, cutting back on surgeries and procedures that might be critical from the patient perspective, but not so great for the bottom line.
[00:18:59] Stacey Richter: And right? This certainly impacts self-insured employers. It certainly impacts patients. All of whom get caught in this sort of self perpetuating flywheel that I talked about with Jonathan Baran, where carriers make more money when costs and premiums rise, thus incentivizing them to not control underlying costs.
Add to that stuff like the float that I talked about [EP482] with Preston Alexander, for example, ie, delaying payments because the time value of money and that impacts provider organizations that then double down on billing early and often. So it's a pretty dysfunctional environment.
If I'm just gonna tick down through the episodes where we discussed misaligned incentives and profiteering, that is created as a result, probably every single episode at some level.
But Chris Crawford talked about this, you know, in the context of PBM incentives that reward volume and high rebate yield. I talked about this again in that show where I was talking about carrier and hospital leadership who choose expedited paths to profitability that easily can devolve into profiteering, such as care denial and maximizing risk adjustment.
All these links are in the show notes, by the way.
Then we had that show with Yashaswini Singh that I just mentioned who talked about private equity's core goals, which could be high financial returns.
Dr. Ben Schwartz, who I quoted earlier, he distinguishes the difference between legitimate profit needed for sustainability, and then unethical profiteering where you've got mission drifts, and then also just using consolidation as a means to derive the market power to raise prices.
Preston Alexander, that is a great show, really revealing how carriers maximize profit again through float. But he also talks about intercompany eliminations, which means paying affiliated provider organizations, one thing that it means, paying affiliated provider organizations that the carrier owns higher rates and thereby obscuring true profit. And Preston Alexander also talks about upcoding, for example, in Medicare Advantage.
All of these things which demonstrate that carriers benefit when costs rise.
Then we have part one and part two of the flywheel shows with Jonathan Baran, where we really get into just how all of these different bits and pieces of perversity, propel just the dollars involved to get bigger and bigger.
The episode with Kevin Lyons, who at the time that we spoke, was the head of benefits for the police union in New Jersey. He had a great quote. He said, "Profit, defends, profit.” And the point that he was making was, well, he made a bunch of points, but one of them was just how much healthcare entities spend on lobbying and political contributions.
And those same legislators by the way that are receiving those dollars in lobbying and political contributions, are in fact the ones that are in charge of doing the contract and contract negotiations with those same entities that are giving them the money.
So that's a problem that just further exacerbates the flywheel. But the more money that those entities, healthcare entities have now the more money that they can spend, right? Like you can see how this goes downhill real fast.
And then lastly, the show with Dr. Connors, Dr. Mick Connors discusses, really digs in on that investor mindset. Callback to the show with Yashaswini Singh on private equity. There's just so many different ways to undermine mission.
Conclusion and Preview of Upcoming Themes
[00:22:18] Stacey Richter: Okay. So those are the first three themes of the five themes that you can find in almost every episode of Relentless Health Value. This particular year, all of the links, all of the shows that I mentioned are in fact, in the show notes.
So if I touched on anything that you wanna go back and revisit or potentially listen to for the first time. You can go over to the show notes and find everything I just said in writing all handy like.
As I said before, my name is Stacey Richter. This podcast is sponsored by Aventria Health Group. See you next week for Themes 4 and 5, and wow, they are doozies.
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