Exploring TPA and Health Plan Inertia with Elizabeth Mitchell: What Plan Sponsors Need to Know.

In this Take 2 of episode 436 of Relentless Health Value, host Stacey Richter speaks with Elizabeth Mitchell, President and CEO of the Purchaser Business Group on Health, about the challenges third-party administrators (TPAs) face, the issues around hidden fees, and the problems with health plan inertia. 

They discuss how self-insured employers can find reliable TPA partners, the impact of anti-competitive contracts, and the importance of transparency in healthcare procurement. Mitchell emphasizes the need for direct contracting between employers and providers to reduce costs and improve quality. 

The episode covers the implications of the Consolidated Appropriations Act, the role of brokers, and how employers can achieve better value for their healthcare spend.

=== LINKS === 🔗  Show Notes with all mentioned links:   https://cc-lnk.com/EP436-Take2

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08:06 What is the overarching context for health plans in healthcare purchasing?

11:31 Why is it important to reestablish a connection between the people paying for care and people providing care?

13:47 What are the needs of a self-insured employer when managing employee benefits?

19:00 Is it doable for employers to set their own contracts?

21:24 Is transparency presumed?

22:39 Will the new transparency upon us actually expose wasted expense?

24:23 EP408 with Chris Deacon.

25:58 “This is not about individual bad actors. … The systems … that is not aligned.”

27:39 Are there providers who want to work directly with employers?

30:53 Why is it important that incentives need to be aligned?

32:42 EP427 with Rik Renard.

33:51 What’s missing from the conversation on changing health plans?

In Episode 484 of Relentless Health Value, host Stacey Richter talks with Dave Chase from Health Rosetta about the three most pressing questions faced by self-insured employers today. 

The discussion covers how to verify if a benefits advisor truly protects employer interests, avoiding personal liability when third-party administrator contracts have hidden conflicts, and identifying if employers are being systematically overcharged on pharmacy costs despite PBM guarantees. 

The episode emphasizes the importance of accessing comprehensive data to identify conflicts and transparency in reporting, and it highlights open source resources available to create high-performance health plans. The conversation also mentions noteworthy related episodes and cases to provide further context and insights.

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

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

06:36 What questions does a plan sponsor need to ask their consultant, EBC, or broker to ensure they are protecting the interest of the plan sponsor?

07:59 EP478 with Andreas Mang and Jon Camire.

08:49 EP453 with Claire Brockbank.

09:51 EP433 with Justin Leader.

09:53 EP436 with Elizabeth Mitchell.

11:03 How can plan sponsors avoid personal liability when their TPA has hidden conflicts of interest?

11:40 Tiara Yachts v. Blue Cross Blue Shield of Michigan lawsuit.

13:48 EP483 (Part 1) with Jonathan Baran.

14:18 EP457 with Cynthia Fisher.

16:18 The Marshall-Hickenlooper bill called the Price Tags Act.

16:50 Summer Short with Elizabeth Mitchell.

17:36 How do plan sponsors figure out if they are being overcharged for pharmacy benefits?

18:09 EP365 with Scott Haas.

20:18 EP397 with Paul Holmes.

20:22 EP465 with Chris Crawford.

20:37 EP429 with Luke Slindee, PharmD.

22:56 EP476 with Ann Lewandowski.

28:38 Where to find open-source resources to help guide plan sponsors with making better health plan decisions.

29:47 How the open-source trend is growing for health transparency.

30:48 What to look forward to at RosettaFest.

In the second part of this conversation with Jonathan Baran, CEO of Self Fund Health, the focus is on reversing the negative cycle of skyrocketing healthcare costs by shifting from buying discounts to investing in primary care and better benefit designs. 

The discussion highlights the current issues with the healthcare flywheel, driven by employers buying discounts, and offers solutions such as investing in direct primary care, incentivizing proper healthcare utilization, and improving patient navigation. 

The conversation also explores the potential for direct contracting between employers and health systems, aiming for a paradigm shift where employers, brokers, and health plans work collaboratively to improve member health and reduce costs.

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

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

05:23 Where to start in reversing the flywheel.

06:57 Why investing in primary care is pivotal to containing healthcare costs.

10:02 EP453 with Claire Brockbank.

10:04 EP452 with Cora Opsahl.

10:07 EP457 with Cynthia Fisher.

10:12 EP365 with Scott Haas.

10:13 EP465 with Chris Crawford.

10:14 EP475 with Peter Hayes.

11:11 EP468 with Matt McQuide.

11:13 EP472 with Eric Bricker, MD.

12:14 “The most expensive thing in healthcare is the pen of the primary care doctor.”

13:04 How the role of the broker has to fundamentally change.

16:16 What will the single most challenging aspect of this restructuring become?

20:20 How self-funded employers can be amazing customers in containing the rising cost flywheel in healthcare.

22:56 How do EHRs and other medical record systems play into reversing the flywheel of rising healthcare costs?

23:57 Ramy Khalil, MD’s post on interoperability.

24:59 Why is it important for employers to drive volume differently?

25:38 How Self Fund Health is helping in this regard.

In this episode Stacey Richter speaks with Jonathan Baran, CEO of Self Fund Health in a detailed exploration of what they term the 'Flywheel Downward Spiral' of American healthcare costs. The conversation delves into how electronic health records (EHR) and the incentives driving insurers, brokers, and hospital systems contribute to consistently rising healthcare premiums. 

Key points include how insurers profit from high premiums, the misleading marketing focus on discounts rather than actual costs, and the role of EHR systems in maximizing hospital profits rather than improving patient care. The episode sets the stage for a subsequent discussion on reversing these trends, aiming to align healthcare outcomes with cost reductions.

Self Fund Health, I am so pleased to tell you, as I am always so pleased to tell you, did make such a kind offer to help out Relentless Health Value financially. You and the tribe here are really, really great folks who I truly appreciate. Please support Self Fund Health if you are in Wisconsin.

This episode is sponsored by Self Fund Health.

=== LINKS === 🔗  Self Fund Health: https://selffundhealth.com

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

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

08:46 Entering the health system “flywheel” at the renewal phase.

09:46 What goes on in the renewal season that contributes to the health system “flywheel”?

12:28 Why is the standard 9% increase in healthcare costs during renewal season actually problematic?

13:22 How does the purchase of discounts contribute to the skyrocketing cost of healthcare and distract from discussing the actually underlying cost of healthcare?

16:07 EP465 with Chris Crawford.

17:01 Why do employers need to learn to buy healthcare and not insurance?

20:32 Rina Tikia’s post on self-funded plans.

23:18 Why are hospital executives incentivized to buy and own all of the primary care in a market?

26:35 How big electronic medical record systems play into this increase in healthcare costs.

28:27 Acquired podcast on one EHR system.

31:09 What needs to happen to reverse this flywheel of increasing healthcare costs?

In this bonus clip from Episode 483 of Relentless Health Value, host Stacey Richter discusses the efforts of individuals working within large healthcare organizations to improve patient outcomes despite systemic challenges. 

Guest Jonathan Baran, co-founder and CEO of Self Fund Health, highlights how incentives within the healthcare system drive behaviors that often conflict with patient and member interests. 

The discussion emphasizes the importance of not generalizing the intentions of all employees based on organizational actions and encourages a deeper understanding of underlying incentive structures to foster meaningful changes. 

Self Fund Health, I am so pleased to tell you, as I am always so pleased to tell you, did make such a kind offer to help out Relentless Health Value financially. You and the tribe here are really, really great folks who I truly appreciate. Please support Self Fund Health if you are in Wisconsin.

This episode is sponsored by Self Fund Health.

=== LINKS === 🔗  Self Fund Health:   https://selffundhealth.com

🔗  Show Notes with all mentioned links:   https://cc-lnk.com/EP483-BONUS

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

03:11 A brief background on Jonathan and Self Fund Health.

04:24 Why is it imperative that individuals stop identifying wholly with the organization that they work with?

05:48 Why is it important to be direct and call out the behavior without calling out the individual?

07:14 EP483 (Part 1) with Jonathan Baran.

In this episode, Stacey Richter talks with Dr. Stan Schwartz, co-founder of ZERO.health about the tension between mission-driven healthcare and financial incentives within the healthcare system. Highlighting examples like the Comprehensive Primary Care Initiative and other advanced primary care efforts, Schwartz shares insights on how health system economics, particularly the reliance on emergency room admissions, often undermine initiatives aimed at reducing costs and improving patient outcomes. 

The discussion delves into the role of employer-sponsored health plans as potential change agents in the healthcare system, given their significant influence over commercially insured patients, who are highly attractive to providers. Dr. Schwartz underscores the importance of aligned financial incentives and collective action among employers to drive meaningful change in healthcare.

If you would like to get a copy of the mentinoed personal integrity and “are you in healthcare for the right reasons” policy called the Guiding Principles Policy that Doug Geinzer and Amy Mecham from High Performance Providers put together.please either check your inbox for the newsletter this week that you just got when this show went live and find the link to download or sign up for the newsletter and I will include it again next week on Thursday.

=== LINKS === 🔗  Show Notes with all mentioned links:   https://cc-lnk.com/SUMS11

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08:11 What was Dr. Schwartz’s “Pelican Brief” moment?

09:09 How Dr. Schwartz’s advanced primary care structure and health information exchange beat out competing states for CMMI funding.

12:53 What did “good” look like with this advanced primary care program?

15:06 EP391 with Scott Conard, MD.

15:42 EP438 with John Lee, MD.

16:57 What got Dr. Schwartz interested in employer-sponsored healthcare?

18:46 EP419 with Andreas Mang.

18:48 EP453 with Claire Brockbank.

18:50 EP452 with Cora Opsahl. 

In this episode, Stacey Richter discusses 'Three Surprising Ways Carriers Make Lots of Money' with Preston Alexander. The episode highlights how carriers leverage financial strategies—like using premium dollars as float, intracompany eliminations, and upcoding in Medicare Advantage—to enhance their profits. 

The discussion emphasizes the importance for plan sponsors and policymakers to understand these tactics to better manage healthcare costs. Alexander advises collaborating with unbiased consultants who are experts in health plan design to navigate these complex financial dynamics effectively.

=== LINKS === 🔗  Show Notes with all mentioned links:   https://cc-lnk.com/EP482

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

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08:29 What is float, and why is it a surprising way that carriers make money?

14:01 Summer Shorts on pharma rebates with Ann Lewandowski.

14:41 Why carriers really do denials and delays of payouts.

17:34 What are intercompany eliminations, and how do they make carriers more money?

22:21 How do carrier-owned pharmacies play into this?

23:19 How are carriers creating profit off of Medicare Advantage and Medicaid Advantage markets?

27:18 How the fee-for-service price increases affect Medicare prices.

28:12 Why aren’t large insurance carriers motivated to make costs go down?

32:42 What is a potential way forward to fix the rising cost of healthcare?

33:36 As a plan sponsor, how do you address carriers making profit on your float?

35:07 EP478 with Andreas Mang and Jon Camire.

36:34 “Our economy’s not gonna survive healthcare.”

In this second take on episode host Stacey Richter speaks with Dr. Tom Lee, founder of One Medical and Galileo. The discussion centers on the survival of independent primary care practices in the current healthcare economy, the associated challenges, and the paradox of primary care. 

Topics include reducing ER visits, managing downstream specialty spend, and the imbalance between CMS and commercial carrier payments to primary care practices. 

Dr. Lee highlights the importance of 'enlightened leadership' and a 'value-focused mindset' in balancing efficient service operations with quality care. He also touches on the complexities of integrating technology and human-centered care, the importance of operational efficiency, and the challenges posed by current reimbursement models.

For a bonus sidebar conversation with Dr. Lee, click here.

=== LINKS === 🔗  Show Notes with all mentioned links:   https://cc-lnk.com/TakeTwo-EP445

✉️  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

🎤  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/ ✭ Bluesky   https://bsky.app/profile/relentleshealth.bsky.social ✭ X   https://twitter.com/relentleshealth10:30 What is the paradox of primary care?

12:47 Why is it hard to run an independent primary care practice?

13:29 What are the barriers to running an independent primary care practice?

14:09 Can you have fee for service and value?

15:53 “Value is more about a mindset.”

16:49 What hidden waste is there in a primary care practice?

18:36 What do you need to have a value-focused mindset?

20:41 Why does access precede quality?

22:40 What are the nuances of a service business that make them challenging for managers?

23:27 How do you find the balance between fee for service and value?

30:07 EP438 with John Lee, MD.

31:04 How can you invest in quality without a value-based contract?

33:09 How do you address the trade-off between fee-for-service finances and investing in value-based care?

34:26 Where is the “productive middle”?

35:18 Dr. Tom Lee’s message to payers.

38:45 Dr. Tom Lee’s message for policymakers.

This short bonus episode is a side bar conversation with Dr. Tom Lee discussing why retail clinics are struggling with Dr. Tom Lee. 

They explore the shortcomings of retail clinics in providing longitudinal primary care, despite their convenience for minor urgent care and vaccinations. 

Dr. Lee emphasizes that true primary care requires consistent, long-term patient relationships and complex management which many retail clinics fail to deliver. They also discuss the economic challenges of running such clinics and the importance of defining primary care's value proposition correctly.

=== LINKS === 🔗  Show Notes with all mentioned links:   https://cc-lnk.com/Bonus445

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

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🎤  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/ ✭ Bluesky   https://bsky.app/profile/relentleshealth.bsky.social ✭ X   https://twitter.com/relentleshealth/

01:01 Why have retail clinics failed in being longitudinal primary care destinations?

01:32 Why access is an important factor, but not the only one.

02:10 Access vs. longitudinal care.

02:47 The challenges of operating a service operation within primary care.

03:47 What is a longitudinal primary care destination and why does it matter?

04:15 How is primary care not delivering on its promise?

04:27 How is the “promise of primary care” different than an urgent care or MinuteClinic?

Recent past interviews:

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

Dr Benjamin Schwartz, Dr John Lee (Take Two: EP438), Kimberly Carleson, Ann Lewandowski (Summer Shorts), Andreas Mang and Jon Camire (EP479), Justin Leader (Take Two: EP433), Andreas Mang and Jon Camire (EP478), Stacey Richter (EP477), Charles Green (Bonus Episode), Ann Lewandowski, Peter Hayes

Balancing Mission and Margin in Healthcare: A Candid Conversation with Dr. Ben Schwartz

In this episode, host Stacey Richter engages in a deep dive with Dr. Ben Schwartz to explore the phrase 'No Margin, No Mission' and its practical implications in the healthcare industry. 

They discuss the complex relationship between profitability and mission-driven care, the challenges of value-based care, and the role of dyad leadership. The episode emphasizes the importance of transparency, regulatory measures, and trust in fostering a balance between mission and margin. Along the way, Dr. Schwartz shares insights from his new role at Commons Clinic and addresses broader systemic issues like regulatory capture and the subjective nature of defining value in healthcare.

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

✉️  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/ ✭ Bluesky   https://bsky.app/profile/relentleshealth.bsky.social ✭ X   https://twitter.com/relentleshealth/

08:50 Sister Irene Kraus and the origin of no margin, no mission.

10:01 Margin and mission versus profit and profiteering.

12:45 Stacey’s manifesto (EP400).

13:01 What is the broad mission within healthcare?

14:12 What is mission drift within healthcare?

15:54 EP474 with Yashaswini Singh, PhD.

17:26 Why do we struggle with balancing margin and mission?

20:47 EP455 with Beau Raymond, MD.

20:52 How does value vary?

23:18 EP326 with Rishi Wadhera, MD, MPP.

23:53 What needs to happen to balance margin with mission?

28:29 Why does everything come down to trust?

28:33 EP391 with Scott Conard, MD.

30:30 EP419 with Andreas Mang.

32:21 What are the “vectors of change” to create balance between mission and margin?

32:43 EP475 with Peter Hayes.