Introduction and Overview
[00:00:00] Stacey Richter: Inbetweenisode. "Extremely Actionable Themes That We Covered Throughout 2025." So this is Themes 4 and 5, and also a recap of a one star review.
Themes Recap and Introduction to New Themes
[00:00:27] Stacey Richter: What I thought could be a good idea to experiment with here at the end of the year or the beginning of the year, is to dissect shows from 2025 and distill out the major themes that have come up repeatedly and in different contexts throughout the year. Our big five takeaways maybe is another way to put it.
Last week we covered takeaway Themes 1 through 3, and today we're gonna cover 4 and 5. Themes 4 and 5, by the way, are a lack of transparency and data access, which allows for wild overspending and undermines fiduciary duty. So that's Theme 4. Theme 5 is this, the need to shift purchasing from discounts/volume to value.
Here's another apparent theme that we won't cover today, but I'm gonna ask you to think about it as I have. This theme comes from a one star review that someone took the time to pen on Spotify the other day, and this is the review.
Headline. "The Rich Get Richer". And here's the review. "An echo chamber for CEOs and other out of touch executives that care about money and no care or making healthcare a sustainable career choice for providers." I left in the typos just to avoid misinterpreting them, but I'm throwing this in here into the ring for context.
If your average "provider", which is interesting, just right outta the gate that they labeled themselves a "provider", given how many dislike that term and feel, it is a term assigned by out of touch execs for the purposes of undervaluing clinical education. So question mark who actually wrote this.
But if any given clinician is so far out of the loop that they do not understand the topics that we talk about on Relentless Health Value and also the impact a CEO having the experience and the integrity to do the right thing by patients or members, how much that trickles up or down to doing the right thing by “providers”, then yeah, that's a big deal in and of itself. Interested in your perspectives.
My name is Stacey Richter, by the way, and this episode is sponsored by Payerset and of Aventria Health Group.
[00:02:59] Stacey Richter: So now let's cover the remaining two themes.
So yeah, that's your subliminal message to potentially sign up for the email newsletter should you wish to have all of this and more in your inbox on a weekly basis. And by the way, the fact that we manage one email a week is a gold star for us, so certainly don't worry about spam. You and me both do not have time for that extravagance.
Enough runway. Let's get to it.
Theme 4: Lack of Transparency and Data Access
[00:03:40] Stacey Richter: Theme 4: lack of transparency and data access allows for wild overspending and undermines fiduciary duty. A continuing, lack of transparency regarding pricing costs, quality, and vendor compensation prevents accountability.
It enables conflicts of interest. It enables, as Dr. Mick Connors and I talked about with Sarah Emund, it enables us to not pay for value or not understand what value is in a really tangible way, which is a problem in and of itself.
Is this getting better? Yeah, and when I say is it getting better, I mean, is there more transparency now regarding pricing and costs and vendor compensation? For sure. Listen to the show with Elizabeth Mitchell about the PBGH (Purchaser Business Group on Health) data demonstration project, but we have your status quo TPAs, PBMs, and brokers who often enough, and as their standard course of doing business, will still withhold essential claims data creating these data hostage situations that guests have talked about this year, which exposes self-insured employers to wild overspending and also fiduciary legal risk.
Here's Elizabeth Mitchell and this quote that I'm about to play is from the Take Two with her this year.
[00:04:46] Elizabeth Mitchell: Jumbo self-insured employers are spending their own money and their employees money on healthcare services. Our members spend over $350 billion a year on healthcare services and people's health is not improving.
All of those dollars seem to be getting lost in the system, and it is particularly ironic because that money is also not going to providers in the way that our members would like. They're very much aligned with providers, particularly primary care providers and mental health providers, and yet there is some disconnect between the amount they are paying and the amount the providers are getting.
You would be amazed at how resistant many of the plans are to doing what employers ask them to do. Even it's sharing data effectively or things that employers know are the right thing for their employees and to effectively manage their plan. It is remarkably challenging.
In a market, someone gives you a bad bid. You don't take it. You don't buy it. Here's the challenges. One, there's been no transparency and they have not been able to get their data to actually even evaluate the performance. One of the changes within the CAA, it absolutely clarifies that employers are entitled to the data they need to evaluate cost and quality.
But then the other problem, there are not any alternatives. If all of the plans are doing the same thing, where are they supposed to go? I think that there are some new market entrants, but right now, if you are looking for a big health plan administrator, there's not, not a lot of options for something really different.
[00:06:33] Stacey Richter: All of this hinders informed purchasing decisions and it also hinders trying to buy value. And I know we're using a lot of acronyms and kind of jargon right now, but this has so much impact, this whole thing on patients and members and that cannot be understated.
The overwhelming complexity and non-transparency regarding cost creates intense financial stress and anxiety for plan members. It forces a percentage into bankruptcy. As we all know, the biggest reason for bankruptcy in this country is medical debt. Get sick, lose your health and your money. It's so efficient. Peter Hayes mentioned this in an episode with him that there's a new vector of change that has not been present before, which is why he is predicting a tipping point finally coming.
He says it's a combination of new legislation that has increased transparency. Still have a ways to go, but yeah, there's a lot more transparency than there was before. Plus legal risk for plan sponsors given the CAA plus that transparency. Plus, and this is the new one, public outrage as he terms it.
So yeah, we might be at a moment that will become a movement, but in the meantime, we have patients and members fearing unexpected costs. John Quinn talked about this [EP493] some. Members and patients are aware now that they could be struck by unexpected costs. So they fear going and getting care despite the fact that they may be paying huge premiums in order to have an air quote, access to said care.
But there is a recognition that even those with so-called good insurance may have so much fear that they delay or abandon necessary, and turns out high value care, such as seeking treatment for suspicious moles or chest pain, or getting their asthma inhaler, which thus worsens long-term health outcomes and evil spirals start to develop here.
Also, there's such an awareness of hidden facility fees or markups that consolidated health systems and provider organizations, which means that patients pay substantially more for the same service than they would at an independent clinic. Again, just raising the both fear and public outrage as a result.
A lack of transparency and data access allows for wild overspending, overcharging, and undermines fiduciary decision making. We've talked about this so often on many shows this year. Obviously, otherwise it wouldn't be a theme.
Other shows where this theme has come up we have the show with Christine Hale, episode 471 on high cost claimants.
Dr. Christine Hale highlights the critical problem of siloed or insufficient claims data relative to high cost claimants and that prevents plan sponsors from verifying if high cost treatments are appropriate or cost effective or frankly in the optimal setting.
Then we had Justin Leader, and this was a Take Two. Justin talked about "The Mystery of the Weekly Claims Wire". And this show is really dedicated to, I'm gonna say exposing how TPAs, some of them, hide fees and engage in spread pricing which is possible because of that mystery. You know, where there's mystery, there's margin and all that, but the show really and Justin stresses that obtaining transparent data is really vital.
Then we had a banger of a show, episode 480 with Kimberly Carleson and she was talking about payment integrity, but it really underscored that plan sponsors have a legal right under the CAA and ERISA to itemize bills and contracts so that they can audit and verify claims accuracy.
Up to 80% of hospital bills may contain errors like duplicate billing, upcoding charging for non-billable items, which often results in wildly excessive charges paid for by the plan sponsor, but also often enough at least passed on to the member.
Then Dave Chase in episode 484, he talks about the data hostage situation that I mentioned earlier and the lack of compensation disclosure as warning signs for untrustworthy benefits advisors. So just all of this back to the theme, a lack of transparency and data access allows for wild overspending, overcharging, and undermines fiduciary decision making. So you can see how all these shows are aligned to this theme.
Then we had 487 with Kevin Lyons, who describes how organizations leverage in “proprietary” or also in “trade secret” claims to avoid disclosure and that forces purchasers to use detective skills to find hidden costs and conflicts of interest. And considering that Kevin Lyons was talking about the State of New Jersey and there was recently a false claims lawsuit that the state health plan carrier in New Jersey just lost and had to pay a hundred million dollars in fines for overcharging.
You can see why with the trade secret fronting here, there is a lot of money that sits behind those proprietary trade secrets, which plan sponsors and those actually paying the bills do have a right to see.
And then I also wanna mention the shows with Vivian Ho from earlier this year, and Dan Greenleaf [EP489] who talk about this whole concept from the standpoint of, I'm gonna say the hospital system or provider organization.
If it's unclear how much a hospital or provider organization is charging for something, then there's ample opportunity for there to be carrier markups, number one, and spread pricing. Sure, which, by the way, is estimated to be about 30% that plan sponsors are paying on top of the hospital or provider charges.
Right. But how would you know that if you don't know how much the hospital or provider organization is actually charging? If all you see is the amount that hits the claims wire, you don't know how the money is getting divvied up and how much the doctors and nurses or actual clinicians doing the service are getting paid out of the money that you are paying. And again, usually it's estimated to be about 30% added to the top there.
But there's another issue here that is big consolidated health systems raising prices way higher than inflation, way higher also than raises that doctors and nurses are getting. So a lot of times the second somebody starts complaining about high hospital prices, someone points to nurses, for example, and that math doesn't add up.
So not understanding what the underlying charges are can kind of cut both ways, because while it leaves carriers able to take 30% off the top, it also removes or doesn't spotlight the culpability here to some of these consolidated health systems that are raising prices at the rate and level that they are raising prices and then pointing to carriers as the culprit.
And not saying that they aren't in the mix, but let's just say there's a lot of culpability to go around. But then what happens, which is a miss, is that it leaves actionable opportunities on the table to negotiate, for example, with hospitals or recognize where some of these excess dollars are coming from.
And then lastly, this is a different take on transparency, but it is also kind of interesting. There's also the transparency around ownership transparency, and this is really relevant for policymakers, but also for any ultimate purchaser as well. Yashaswini Singh talked about this in episode 474 about private equity, and what she emphasizes is that there's a lack of ownership transparency, as I just said, especially when it comes to private equity owned provider organizations. And that prevents policymakers and really physicians a lot of times from fully understanding the forces driving practices and also costs.
So consider this a wrap on theme number four, which is a lack of transparency and data access allows for wild overspending/overcharging and undermines fiduciary duty.
Let's move on to theme number 5.
Theme 5: Shifting Purchasing to Value
[00:14:09] Stacey Richter: Theme number five is the need to shift purchasing from buying discounts or volume to buying value. This industry really to transform has got to transition away from flawed purchasing methods, such as buying discounts off of inflated list prices, which only perpetuates the cost increasing flywheels.
Stop doing that and instead, purchase actual care based on demonstrably high value and outcomes. The imperative for plan sponsors to stop buying based on, you know “discounts off inflated list prices”, and instead focus on mastering unit cost and directly purchasing high-value healthcare services.
Here's Mark Cuban on this topic.
[00:14:52] Mark Cuban: It’s a core competency to understand their benefits at all. And even though it's the second largest line item, expense line item after payroll, as Core knows very well, it's hard to dig in. I was just as much of an idiot with the Mavericks and my other companies. I had no idea I was getting ripped off.
But for our employees and their families now, as Cora knows, we're doing all direct contracting, all direct contracting. And slowly but surely, we're adding more and more providers. We're up to like 8,800 providers in our network right now, and so we're getting there.
But what we tell them and the reason they're willing to give us their cash price or something close to it. Sometimes we work off of Medicare as a reference. We tell them, A, we're gonna pay you cash upfront. B, there is no employee deductible. You know it is compensation for our employees one way or the other, and their families, right? You can pay it upfront, pay it via healthcare, whatever it may be, and so you're not taking that collection risk.
You're getting paid the full amount, and we'll do all of the preauths in advance. By the time it gets to you, it's already been approved and you take no preauthorization denial or preauthorization or denial risk. And they're like, no credit risk, no underpay risk, no preauth risk, where do I sign up?
[00:16:09] Stacey Richter: Thinking about one star provider guy, when employers shift purchasing to value, they can compensate high value providers more. Upfront. Which helps eliminate provider organization risk and reduces the need for costly administrative debt collection efforts, again, which is just gonna create a virtuous flywheel resulting in lower overall prices for patient, member, and any ultimate purchaser.
And then here's from Sarah Emond [EP494].
[00:16:35] Sarah Emond: Well, and that's part of where I have observed that sometimes the rebate model gets in the way of paying for value because your market dominance or your market position can have more to do with how much of a discount you are offering or not. And the ultimate goal of the negotiators to get a big rebate, to get a big discount.
That is not necessarily the same thing as paying for value. And one of the things that we have been talking about for years, and we're still looking for a purchaser who wants to do this, which is pay for value. Waive pretty much most prior auth and eliminate cost sharing.
Because if you are paying a value-based price as the ultimate payer, why would you have cost sharing? You are not trying to get the patient to do something different with their choice of medicine with their doctor.
So if we had a system that had full transparency into the value-based price and all of the payers were paying that value-based price, we actually wouldn't need rebates. We would just have a formulary.
Imagine what it could do for patients with rheumatoid arthritis. There are a lot of drugs approved for rheumatoid arthritis. If you don't respond to some of the older drugs like methotrexate, your choice of which drug you get has to do with the negotiation between the manufacturer and the PBM. It doesn't have anything to do with what's the best choice for you as a patient.
If we paid a value-based price for every rheumatoid arthritis drug that doctor could prescribe whatever drug was best for you. We're just far away from that reality, but I still wanna put it out there as a different choice we could make that again, would work towards deescalating this arms race.
[00:18:21] Stacey Richter: So, right, like a lot of these themes, we've covered this one deeply. This whole idea of bringing big demand curve energy.
If there is not a demand curve, there's no market. If purchasers, such as self-insured employers or otherwise, do not not buy healthcare services from entities that are too expensive or who have crappy quality, what incentive, what market incentive does anyone have to lower prices or improve quality.
If nobody cares and is just gonna buy it whenever, whatever, then anybody on the supply side who spends any amount of money or effort to get more efficient or raise quality will not result in, again, improved market share or any increase in revenue, which is the incentive of a market.
Now look, are markets the correct way to run healthcare in this country? Not the point at all. The point is containing healthcare costs in this country right now in 2025 the whole way that the industry is structured, the whole way incentives work, etc, is dependent upon there being a market. And there isn't a market without a demands curve. There isn't a market, in other words. There will never be a market again without a demand curve.
And self-insured employers right now provide and pay for care for 160 million Americans, meaning self-insured employers have one really big job here. It's an important job. Be an elastic demand curve.
This comes up so often this past year, and this really matters again for members and patients because shifting purchasing toward value and outcomes, it creates opportunities to lower members costs. Remove financial barriers to necessary care. Improve the consistency and predictability of care delivery. It also has a great opportunity to increase outcomes because if you're buying value, outcomes are part of the mix in a way that's simply reducing costs even doesn't take into account, and that can go horribly wrong, which is probably a whole other topic.
How can you go about this? Direct contracting is one example. So plan sponsors can offer members access to high quality care. This could be for imaging or surgery at $0 out of pocket. Discussed this with Dr. Cristin Dickerson on a show, and also Dr. Stan Schwartz [EP486], among others.
Other shows where this theme has come up big time is the two part show, episode 483 with Jonathan Baran that defines discounts which by the way includes rebates and shared savings with the solution being reject discounts, focus on mastering unit cost, investing in primary care, redesigning benefits to buy actual healthcare, not insurance.
Then also the show 488 with Mark Cuban and Cora Opsahl that the earlier quote was from.
We also have episode 492 with Dr. Sam Flanders and Shane Cerone. They're talking about this from the hospital system perspective, and they really provide a call to action for employers to insist health systems submit pricing, and also create competition which ultimately is going to drive high quality care at significantly reduced unit costs. But also provide rewards for those organizations who are able to do this well. Which generally speaking physicians and other clinicians appreciate.
We also have episode 493 (with John Quinn, who advises c-suites on their need to review healthcare as a supply chain to be managed and must move absolutely, again, past buying discounts and focusing on steering members to lower cost, high quality alternatives.
We also have the show with Sarah Emond that the earlier quote was from.
So that is Theme 5, which again is the need to shift purchasing from buying discounts or buying volume to buying value.
Additional Timely Ideas and Conclusion
[00:21:58] Stacey Richter: Okay, so lastly, I might have missed a few shows that did in fact touch on one or more of these themes, these through lines, which were just so everywhere, everything, and occasionally all at once. But we did have a few shows that dug in on other very timely ideas, such as the shows [EP469, Part 1 and Part 2] with James Gelfand on the impact of some of the legislation currently ongoing and its impact on Medicaid and HSAs and other policy changes which affect self-insured employers.
And also we talked stop-loss coverage [EP478], which is a big deal with Andreas Mang and Jon Camire, or we did a show on Medicare Advantage Trends earlier this year with Betsy Seals. So all this stuff is interrelated for sure.