Healthcare costs keep rising, but what’s driving those increases? In this episode, Stacey Richter speaks with Dr. Vivian Ho, a health economist at Rice University and Baylor College of Medicine, to break down the real reasons behind skyrocketing commercial insurance premiums.

• Are insurance premiums rising faster than wages—and why does it matter?
• What’s the biggest driver of premium increases? (Spoiler: It’s hospital prices.)
• Are hospital price hikes justified by rising costs—or is something else at play?

Dr. Ho shares data-backed insights on hospital consolidation, executive incentives, and how health system pricing impacts self-insured employers and plan sponsors. If you’re a healthcare executive or a jumbo employer managing benefits, this episode is a must-listen.

=== LINKS ===

🔗  Show Notes with all mentioned links:https://relentlesshealthvalue.com/episodes

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=== CONNECT WITH THE RHV TEAM ===

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05:12 Are insurance premiums going up?05:59 What is the disparity between cost of insurance and wage increases?06:21 LinkedIn post by Byron Hugley.06:25 Article by Michael Strain.06:46 How much have insurance premiums gone up for employers versus employees?09:06 Chart showing the cost to insure populations of employees and families.10:17 What is causing hospital prices and insurance premiums to go up so exponentially?12:53 Article by (and tribute to) Uwe Reinhardt.13:49 EP450 with Marilyn Bartlett, CPA, CGMA, CMA, CFM.15:28 Are razor-thin operating margins for hospitals causing these rising hospital prices?16:56 Collaboration with Marilyn Bartlett and the NASHP Hospital Cost Tool.19:47 What is the explanation that hospitals give for justifying these profits?23:16 How do these hospital cost increases actually happen?27:06 Study by Zack Cooper, PhD.27:50 Who typically makes up a hospital board, and why do these motivations incentivize hospital price increases?30:12 EP418 with Mark Cuban and Ferrin Williams, PharmD, MBA.33:17 Why is it vital that change start at the board level?

The Hidden Costs of PBMs: How Aggregate Discount Guarantees Inflate Drug Prices. In episode 465 of Relentlessly Seeking Value, host Stacey Richter interviews Chris Crawford, CEO of RxSaveCard, about the inflated costs within the pharmacy benefits industry.

The discussion centers around a lawsuit involving J&J, highlighting how large PBMs can significantly overcharge for drugs that are available much cheaper through cash-pay options like Mark Cuban's Cost Plus Drugs.

Crawford explains how Aggregate Discount Guarantees, a common contracting mechanism, often fail to control spread pricing effectively and instead may lead to higher costs for plan sponsors and employees. The episode also covers how RxSaveCard can help employers and employees access these lower cash prices, circumventing the inflated costs from traditional PBMs.

=== LINKS ===

🔗  Show Notes with all mentioned links: https://cc-lnk.com/EP465

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07:12 EP365 with Scott Haas.

07:17 EP397 with Paul Holmes.

07:19 EP439 with Luke Slindee, PharmD.

07:20 EP379 with AJ Loiacono.

07:44 What is the Aggregate Discount Guarantee?

13:49 Why do the divergent list prices and the perverse incentives prevent the Aggregate Discount Guarantee from really limiting cost spread?

17:55 Why is it important for plan sponsors to check these drug cost prices, and how can employers check them?

23:56 What drives cost lower, and why does it change everything?

25:09 How does RxSaveCard work?

25:44 EP461 with Chris Crawford.

30:01 Do you need a PBM’s permission to use RxSaveCard?

30:37 How does it look for employers/employees to use the RxSaveCard?

32:39 EP356 with Ge Bai, PhD, CPA.

Emergency room costs now make up 6% of total healthcare plan spending—why? In this episode, host Stacey Richter welcomes Al Lewis to break down the data behind rising ER expenses, separating fact from fiction.

They discuss whether increased patient acuity or widespread upcoding is driving costs, the impact of the No Surprises Act, and why plan sponsors struggle to negotiate fair ER rates. Plus, Al shares actionable strategies for employers to push back against inflated charges.

If you want to understand the hidden forces behind escalating ER bills, this is a must-listen.

You can find the charts and links mentioned in the show notes in the link below.

=== LINKS ===

🔗  Show Notes with all mentioned links:  https://cc-lnk.com/EP464

✉️  Enjoy this podcast? Subscribe to the free weekly newsletter:  https://relentlesshealthvalue.com/join-the-relentless-tribe

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🎤  Listen on Apple Podcasts  https://podcasts.apple.com/us/podcast/feed/id892082003?ls=1

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00:00 Introduction

08:32 What is going on in ER visits, and how big of a deal is the total spend?

10:16 Why is the price of ER visits going up when it should be going down?

11:59 What is the major source of unexpected medical debt?

13:27 What is code creep, and why is it happening?

16:26 Why are plan sponsors unable to negotiate emergency room services?

19:22 EP415 with Rob Andrews.

25:53 Why is it important not to agree to consent when you go in to visit the ER?

27:47 EP386 with Al Lewis.

31:28 What steps can plan sponsors take to be proactive about limiting ER spending for their employees?

You can learn more at quizzify.com and by emailing [email protected]. You can also follow Al on LinkedIn.

Recent past interviews:

Click a guest’s name for their latest RHV episode!

Betsy Seals, Wendell Potter (Encore! EP384), Dr Scott Conard, Stacey Richter (INBW42), Chris Crawford, Dr Rushika Fernandopulle, Bill Sarraille, Stacey Richter (INBW41), Andreas Mang (Encore! EP419), Dr Komal Bajaj

In this episode of Relentless Health Value, host Stacey Richter engages with Betsy Seals, CEO and co-founder of Rebellis Group, to analyze the future of key Medicare Advantage policies amidst a changing political landscape. They delve into four critical areas:

1. Medicare Advantage Stars Program: Examining potential changes due to recent lawsuits and the new administration’s stance on quality measures.

2. Risk Adjustment and Government Oversight: Discussing the focus on recouping improper payments and how oversight might evolve.

3. Use of Artificial Intelligence: Considering appropriate oversight for AI applications in prior authorization processes and ensuring they benefit patient care.

4. Agent and Broker Oversight: Exploring increased scrutiny over marketing practices and the dissemination of accurate information to beneficiaries.

Betsy emphasizes the importance for Medicare Advantage plans to prioritize patient value, maintain compliance, and proactively utilize data to navigate these evolving policies. This discussion provides valuable insights for stakeholders aiming to understand the future of Medicare Advantage.

=== LINKS ===

🔗  Show Notes with all mentioned links:  

https://cc-lnk.com/EP463

✉️  Enjoy this podcast? Subscribe to the free weekly newsletter:

https://relentlesshealthvalue.com/join-the-relentless-tribe

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05:09 Will the Star Ratings program stay in this new administration?

08:08 How will the lawsuits against CMS policies play out with this new administration?

10:24 Why is it hard for Medicare Advantage plans to survive, let alone thrive?

16:22 How does AI directly impact beneficiary lives?

21:38 What’s going on now with the override payments?

27:08 How is non-collaboration going to impact Medicare beneficiaries moving forward?

31:45 Why is it important to become more technologically savvy in compliance?

In this episode, Stacey Richter explores how the demands of shareholders influence the actions of publicly traded health insurance companies with guest Wendell Potter. Drawing from Milton Friedman’s assertion that a business’s primary responsibility is to its shareholders, we examine the implications of this philosophy in the healthcare sector. The discussion highlights concerns about fraud allegations among major insurers and the lack of open competition due to market consolidation. 

We delve into the concept of the “medical loss ratio,” a key metric for investors, and how it pressures insurers to prioritize profits, often at the expense of patient care. Our guest, Wendell Potter, a former health insurance executive turned advocate for healthcare reform, provides insider insights into these dynamics. He discusses the challenges insurers face in controlling costs, the impact of rising premiums, and the broader consequences for patients and the healthcare system. This episode offers a critical look at the intersection of corporate interests and patient care, shedding light on the systemic issues that arise when profit motives drive healthcare decisions.  

All mentioned links can be found in the show notes. 

=== LINKS ===

🔗  Show Notes with all mentioned links:  https://cc-lnk.com/Encore384

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08:31 What is the medical loss metric?

11:33 “The reality is, insurers have been jacking up premiums … for a long time.”

12:48 “It’s a short-term game.”

15:39 “You’re seeing that these companies are not doing a very good job … of controlling costs because they don’t have the incentive.”

20:19 EP366 with Kevin Schulman, MD.

22:45 How do payers ensure that they’re controlling utilization?

25:53 “It’s death by a thousand cuts.”

31:51 “Just like independent practice physicians are endangered, so are community pharmacists.”

33:17 Who runs our healthcare system?

This podcast today is with Dr. Scott Conard, founder of Converging Health. You might remember him from the earlier episode (EP391). First of all, I enjoyed how it came to be. Brian Uhlig, an employee benefit consultant of some acclaim, came to me and offered to sponsor a show for someone else. Not himself. I gotta say, it’s stuff like this that warms my heart. It’s this village that we have here, this tribe of Relentless folks trying so hard to stand up for and help patients. So, thanks again to Brian Uhlig.

Right now, Dr. Conard is doing a bunch of work with Mike Adams from 7-Eleven, helping their plan members. A lot of this work is centered on and about a few pretty striking but very common insights that many plan sponsors will find in their own data. It turns out about 70%, give or take, of people who wind up costing the plan whatever the high-cost threshold is in any given plan year.

These higher-cost claimants didn’t fall out of the sky unexpectedly, 70% of them. They were actually high risk but low cost in prior years. So, the trick is to find these individuals and help them not fall into the high-risk and high-cost part of the graph. If the goal is how to best manage a population of members, a lot of that is, again, identifying high-risk patients who are currently in the low-cost zone, who, any given plan year, are gonna go out of that zone and get into the high-cost area.

So, if we’re thinking about best practices to avoid this, I’m gonna run through Dr. Conard’s list that we mostly run through in the show that follows.

Lastly, we touch a little bit in the show today on community-run primary care. This is a community paying for primary care for community members, just like they pay the fire department and the police department. There’s a town in Rhode Island doing this that Dr. Conard talks about today. In fact, Michael Fine, MD, is part of this effort in Rhode Island. 

=== LINKS ===

🔗  Show Notes with all mentioned links and articles:  https://cc-lnk.com/EP462

✉️  Enjoy this podcast? Subscribe to the free weekly newsletter: https://relentlesshealthvalue.com/join-the-relentless-tribe

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=== CONNECT WITH THE RHV TEAM ===

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07:10 How do we think about data wrongly, and how does that affect our healthcare spend in regard to population health?

09:43 What needs to be done with population health data once it’s collected.

14:48 Community in Rhode Island doing effective proactive care.

16:09 EP449 with Marty Makary, MD, MPH.

16:44 A real, successful case study.

24:08 How do we define high-cost patients?

24:14 What do we know about high-cost patients in regard to population health spend?

29:02 Why avoiding prevention in primary care only harms yourself in the future.

In this inbetweenisode Stacey Richter dives into the complexities of benefit design in American healthcare. Highlighting insights from recent episodes with Bill Sarraille (EP459) and upcoming episode with Scott Conard, MD, Richter explores the impact of cost containment measures and the moral hazard of insurance, emphasizing the importance of creating balanced and efficient benefit plans that align with plan values and avoid unintended consequences. 

She discusses the challenges and implications of high deductible health plans and copay maximizers/accumulators, urging plan sponsors to strive for pareto optimality and practical solutions. This episode is a call to carefully consider patient behavior, healthcare utilization, and the broader impacts of financial incentives in healthcare.

Going black and white or over-indexing to prevent outlier kind of stuff is probably not gonna end well. Not seeking a middle way can easily result in a solution that is possibly worse than the problem.

Moral hazard is actually a thing. There are lots of implications to patients not being able to distinguish high-value and low-value care. But if we know this, then, philosophically at least, how do we conceptualize a solve? What should we be doing? If we’re not doing black and white, what does the gray in the middle look like?

=== LINKS === 🔗  Show Notes with all mentioned links:   https://cc-lnk.com/INBW42

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🎤  Follow on Apple Podcasts  https://podcasts.apple.com/us/podcast/feed/id892082003?ls=1

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00:00 Introduction to the Rabbit Hole

04:05 Where did Stacey’s rabbit hole spiral start?

05:40 What is the moral hazard of insurance?

09:31 EP358 with Wayne Jenkins, MD.

12:49 Why isn’t moral hazard mitigated in insurance?

18:16 EP459 with Bill Sarraille.

20:51 “How do we conceptualize a solve?”

22:24 Why should we be striving for Pareto optimality?

25:20 What is the theory of second best?

This episode with Chris Crawford, CEO of RxSaveCard, is not about the when, why, or how of GLP-1s for weight loss or best-practice prescribing. This episode very, very specifically is about the how and why of the pickle plan sponsors get themselves into often enough where if they impose formulary restrictions to limit the volume of meds that they are paying for, then unit prices go up, which is a thing for GLP-1s.

And this is critical just given how the costs associated with GLP-1s for weight loss contribute to some pretty significant increases in pharmacy trend for plan sponsors who choose to cover the GLP-1s for weight loss.

Chris Crawford and Stacey Richter discuss the challenges plan sponsors face with the rising costs of GLP-1 medications for weight loss. They explore how plan sponsors’ efforts to manage pharmacy trends often result in a tradeoff: lowering unit costs by increasing volume or vice versa. Chris also introduces a potential solution leveraging the growing cash marketplace, where employers can bypass traditional PBM contracts to achieve cost savings. Tune in for actionable insights into the perverse incentives in the pharmacy supply chain and innovative ways to navigate them. (Continued below the links)

=== LINKS === 🔗  Show Notes with all mentioned links:   hhttps://cc-lnk.com/EP461

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🎤  Listen on Spotify  https://open.spotify.com/show/6UjgzI7bScDrWvZEk2f46b

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Bottom line, there are some really impactful and not frequently delved into perverse incentives at play here. And we’re gonna talk about these today. And these are really key for anybody on or about the pharmacy supply chain in the U.S. to know about. This is very actionable insight.

So, again, there’s an unfortunate tradeoff, as it stands right now, for many plan sponsors. Lower your volume and raise the unit price or vice versa.

This episode is sponsored by RxSaveCard, and a big thanks for that. I really appreciate RxSaveCard for its financial support because this episode covers a really important topic that we probably would have covered anyway over here at Relentless Health Value.

And so, RxSaveCard standing up and offering their financial support to cover it was a really nice thing to do. And I thank them for their generosity.

07:57 What are the two pieces going on with GLP-1 PBM prices and rebates for employers?

10:00 Is the cash price for these name brand drugs currently less than the rebated PBM price?

11:49 Why does the rebate for GLP-1s disappear if employers try to put restrictions on who can receive access to these drugs?

15:07 Where does RxSaveCard come in to play here?

19:55 “We exist to save people money.”

20:45 EP456 with Brian Reid.

21:16 EP356 with Ge Bai, PhD, CPA.

21:37 EP439 with Luke Slindee, PharmD.

In this Relentless Health Value episode, Dr. Rushika Fernandopulle discusses with Stacey Richter his four-prong theory of change for transforming the American healthcare system. Key topics include the necessity of new payment models, process innovation, employing a relational technology infrastructure, shifting the cultural mindset towards team-based care, and emphasizing the importance of long-term partnerships. The conversation underscores the urgent need to move away from the current status quo to ensure better health outcomes and affordable care for all Americans.

This is one of those episodes where we consider top-line strategic imperatives and key drivers. There was no better person to do this with than Rushika Fernandopulle, MD, who, in case you were unaware, was the founder of Iora Health, an advanced primary care group that was sold to One Medical and then to Amazon. 

They discusses his four-prong theory and as Stacey says, "I can’t leave well enough alone, so I plucked one more prong from our conversation and stuck it on the end." For a summary of this 5 prong approach, visit the show notes page where we also list all of the links mentioned in the episode.

=== LINKS === 🔗  Show Notes with all mentioned links:   https://cc-lnk.com/EP460

✉️  Enjoy this podcast? Subscribe to the free weekly newsletter: https://relentlesshealthvalue.com/join-the-relentless-tribe

🫙  Support the podcast with a small donation to the Tip Jar: https://relentlesshealthvalue.com/join-the-relentless-tribe

🎤  Listen on Apple Podcasts  https://podcasts.apple.com/us/podcast/feed/id892082003?ls=1

🎤  Listen on Spotify  https://open.spotify.com/show/6UjgzI7bScDrWvZEk2f46b

📺  Subscribe to our YouTube channel   https://www.youtube.com/@RelentlessHealthValue

=== CONNECT WITH THE RHV TEAM === ✭ LinkedIn   https://www.linkedin.com/company/relentless-health-value/ ✭ Threads  https://www.threads.net/@relentlesshealthvalue/ ✭ X   https://twitter.com/relentleshealth/ ✭ Bluesky   https://bsky.app/profile/relentleshealth.bsky.social

06:39 How Dr. Rushika Fernandopulle found himself where he is now.

08:06 Dr. Fernandopulle’s conversation with Kenny Cole, MD.

10:33 Why is it important to have new payment models?

12:21 EP453 with Claire Brockbank.

14:50 EP455 with Beau Raymond, MD.

16:19 Why it makes sense to change as quickly as possible.

19:55 How to be proactive and not be reactive and achieve value-based reimbursement for good care.

21:41 Why team-based care is so important for change.

23:37 Why is it important to have a different set of technology tools?

24:38 EP391 with Scott Conard, MD.

25:24 Why changing the culture is important.

27:01 “Getting doctors to do things they don’t like is a waste of time.”

33:22 “Healthcare is local.”

35:31 EP364 with David Muhlestein, PhD, JD.

35:43 Study by Zack Cooper, PhD.

36:53 EP404 with Suhas Gondi, MD, MBA.

39:04 Why long-term partnerships are the only way to make things better.

In Episode 459, host Stacey Richter speaks with healthcare attorney Bill Sarraille about co-pay maximizers and accumulators, mechanisms designed to extract maximum co-pay support dollars from pharmaceutical companies. 

They discuss the financial implications for patients, plan sponsors, and pharmacy benefit managers (PBMs), emphasizing the legal and ethical issues and potential patient harm due to high out-of-pocket costs and surprise expenses. 

Sarraille provides five key pieces of advice for plan sponsors and highlights the importance of transparency and proper utilization management to minimize patient access problems and legal risks. Listen or read the show notes on our site for the full list.

(continued below the links)

=== LINKS ===

🔗 Show Notes with all mentioned links: https://cc-lnk.com/EP459

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Co-pay maximizers and accumulators are programs designed to capture maximum co-pay assistance from phara. Maximizers spread pharma co-pay support evenly throughout the year, ensuring plan sponsors benefit while, in theory, patients face minimal costs. More on how that can go wrong in the episode.

Accumulators, however, design their plan to deplete pharma dollar support quickly, surprising patients with significant out-of-pocket expenses mid-year when they go visit the pharmacy. 

These programs usually exclude pharma assistance dollars from deductibles, potentially causing financial hardship because when pharma is paying your co-pay, those payments don't count against your deductible.

09:31 What should plan sponsors be aware of right now?

14:01 What is the justification for maximizers, and why is this at odds with the purpose of insurance?

18:05 Where does the issue of “fairness” land within cost containment?

20:00 Brian Reid’s LinkedIn post on insurance company access challenges.

21:30 What are the real legal issues presented by some of these co-pay maximizers and co-pay accumulator programs?

27:06 How are these programs creating perverse incentives?

29:28 EP450 with Marilyn Bartlett, CPA, CGMA, CMA, CFM.

32:16 “If you’re covered by the ACA, I think this is unlawful.”

32:57 What advice does Bill have in regard to these programs?

33:49 What potential litigations does Bill see coming in the near future in regard to these co-pay maximizers and co-pay accumulator programs?