Relentless Health Value

In this episode, host Stacey Richter talks with healthcare entrepreneur Cynthia Fisher about medical spread pricing and the case for contract transparency. Fisher explains how hidden fees and spread pricing by middlemen lead to substantial overcharges for employers and patients in the U.S. healthcare system — and lays out real numbers to prove it. In one example she cites, a self-insured employer paid $4 million for a claim; the provider was paid $876,000. The conversation covers recent lawsuits (including the one against Cigna) that expose these practices, the legislative progress being made on price transparency, and how transparency can ultimately transform the industry. Insights are also shared from industry experts who have been previous guests, including Chris Deacon, Justin Leader, and Andreas Mang.

WHAT YOU'LL LEARN

✅ What medical spread pricing actually is, and why it isn't "change in the couch cushions" the way PBM spread pricing adds up to billions of dollars

✅ The real numbers behind one claim: an employer paid $4 million, and only $876,000 of that made it to the provider

✅ What the lawsuit against Cigna reveals about how carriers are learning to replicate PBM-style spread pricing tactics

✅ Why American competitiveness is affected by how much employers spend on healthcare, and why transparency addresses the root cause rather than a symptom

✅ What's happening across the country to empower price transparency in healthcare, and how employers can use existing laws to demand accountability

WHY THIS MATTERS

"This is a thing now, medical spread." Just as PBM spread pricing quietly added up to billions of dollars, medical spread pricing is doing the same thing on the medical claims side — hiding in plain sight inside contracts that employers signed without full visibility into the numbers. Contract transparency isn't a nice-to-have; it's the mechanism by which employers and unions can hold carriers and providers accountable for what they're actually being charged.

MENTIONED IN THIS EPISODE

EP419 with Andreas Mang: Apple Podcasts | Spotify | Other Apps

EP452 with Cora Opsahl: Apple Podcasts | Spotify | Other Apps

EP453 with Claire Brockbank: Apple Podcasts | Spotify | Other Apps

EP433 with Justin Leader: Apple Podcasts | Spotify | Other Apps

=== LINKS ===

🔗 Show Notes with all mentioned links: Episode Page

✉️ Enjoy this podcast? Subscribe to the free weekly newsletter

🫙 Support the podcast with a small donation to the Tip Jar

=== CONNECT WITH THE RHV TEAM ===

✭ LinkedIn ✭ Threads ✭ X ✭ Bluesky

00:00 Introduction.

09:03 What is the goal of PatientRightsAdvocate.org?

10:28 Is American competitiveness being affected by healthcare spend?

13:47 Why is transparency a root cause to healthcare costs?

15:11 What's going on across the country to empower transparency in healthcare?

19:31 "I think people are fed up."

21:22 The Cigna lawsuit in California.

26:36 How do employers navigate contracts against anti-steering?

In this special Thanksgiving episode, Stacey Richter discusses the significance of being "givers" in healthcare, advocating for collaboration over transactional relationships to deliver real value to patients. She thanks listeners who left a tip in the tip jar, offered a monthly contribution, wrote a review, or interacted with the show's posts on LinkedIn — naming several by name — and reflects on how these interactions are exactly how podcasts and publications like this one are able to continue. She touches on the challenges and necessary shifts in healthcare market dynamics, emphasizing that true value is determined through bi-directional conversations between providers and end users, like patients and plan sponsors, and closes with a call to action for listeners to reflect on their own support networks.

WHAT YOU'LL LEARN

✅ Why Stacey argues that "giving" — not transacting — is what actually determines who gets invited on podcasts, quoted by reporters, or featured in publications

✅ What it means to bring a giver mindset to healthcare relationships, and why collaboration beats transactional relationships when it comes to delivering real value to patients

✅ Why true value in healthcare is only knowable through bi-directional conversations between providers and end users like patients and plan sponsors

✅ Why plan sponsors specifically need to be part of the giving and collaboration equation, not just providers and vendors

✅ Why "it will take a village" isn't just a sentiment — it's the operating assumption behind any collective effort to transform healthcare

WHY THIS MATTERS

"It is this gang — the Relentless Tribe that listens to this show — it is you who will transform healthcare." The thank-you episode makes explicit what the show argues implicitly all year: healthcare change isn't delivered by any single actor, but by a network of givers — guests, listeners, tipsters, and reviewers — who collaborate rather than transact. Being a giver isn't altruism for its own sake; per Adam Grant's research on the subject, it's also how trust, and therefore influence, actually gets built.

MENTIONED IN THIS EPISODE

Encore! EP415 with Rob Andrews: Apple Podcasts | Spotify | Other Apps

Summer Shorts 8 with Larry Bauer, MSW, MEd: Apple Podcasts | Spotify | Other Apps

INBW39 with Stacey Richter: Apple Podcasts | Spotify | Other Apps

EP399 with Stacey Richter: Apple Podcasts | Spotify | Other Apps

EP400 with Stacey Richter: Apple Podcasts | Spotify | Other Apps

=== LINKS ===

🔗 Show Notes with all mentioned links: Episode Page

🔗 Healthcare Industry Acronyms and Terms

✉️ Enjoy this podcast? Subscribe to the free weekly newsletter

🫙 Support the podcast with a small donation to the Tip Jar

📺 Subscribe to our YouTube channel

🎤 Listen on Apple Podcasts

🎤 Listen on Spotify

=== CONNECT WITH THE RHV TEAM ===

✭ LinkedIn ✭ Threads ✭ Bluesky ✭ X

00:00 Introduction.

01:33 How do you calculate the number of people you've helped?

02:46 Why is giving so important within healthcare?

03:16 Interview with Adam Grant.

05:47 How can you be a better giver?

07:50 Who is in charge of the bidirectional conversation of value?

11:35 Why is collaboration so important to value and being a giver?

12:58 Why is it important that plan sponsors are a part of all this giving and collaboration?

In this encore episode, Mark Cuban discusses his insights and experiences disrupting the healthcare and pharmacy benefits landscape with Stacey Richter. This show was one of the most popular episodes of the past year, and it's also extremely relevant right now given all of the PBM (pharmacy benefit manager) goings-on, as well as ongoing litigation like the J&J lawsuit. Joined by Ferrin Williams from Scripta, Cuban stresses the importance for CEOs and CFOs of self-insured companies to get actively involved in their healthcare plans to avoid overpaying. The conversation tackles the opaque practices of PBMs, the financialized nature of the healthcare industry, and introduces Mark Cuban's Cost Plus Drugs model, which aims for transparency and cost reduction. Key topics also include the potential legal implications for employers, the importance of trust in healthcare transactions, and the real-world savings achievable with greater involvement and transparency in healthcare management.

WHAT YOU'LL LEARN

✅ Why Mark Cuban says "if you can't convince them, confuse them and hide it" is the actual operating principle behind opaque PBM rebate practices

✅ What Mark Cuban found when he personally dug into his own company's benefit program as a self-insured employer

✅ How Cost Plus Drugs aims to bring transparency and cost reduction to a financialized pharmaceutical supply chain

✅ Why rebates are going away without it changing PBM earnings, and what that reveals about where the real money is made

✅ Why CEOs and CFOs of self-insured companies specifically — not just HR or benefits teams — need to get personally involved to avoid overpaying

WHY THIS MATTERS

"When you think it through, you start to realize that money is being spent primarily by your sickest employees." That reframing is the crux of Mark Cuban and Ferrin Williams's argument: self-insured employers are already paying for their sickest employees' care whether they engage or not, so the only real choice is whether they engage with enough transparency to actually manage that spend well.

=== LINKS ===

🔗 Show Notes with all mentioned links: Episode Page

🔗 Healthcare Industry Acronyms and Terms

✉️ Enjoy this podcast? Subscribe to the free weekly newsletter

🫙 Support the podcast with a small donation to the Tip Jar

📺 Subscribe to our YouTube channel

🎤 Listen on Apple Podcasts

🎤 Listen on Spotify

=== CONNECT WITH THE RHV TEAM ===

✭ LinkedIn ✭ Threads ✭ Bluesky ✭ X

00:00 Introduction.

06:29 What was Mark Cuban's own journey as a self-insured employer with Cost Plus Drug Company?

07:44 What did Mark find when he decided to go through and look through his company's benefit program?

09:12 "When you think it through, you start to realize that money is being spent primarily by your sickest employees." —Mark

10:02 How do you get CEOs and CFOs of self-insured employers to realize that their sickest employees are the ones subsidizing their checks?

13:00 What is the role of insurance in healthcare?

14:30 "If you can't convince them, confuse them and hide it." —Mark

15:24 The reality behind getting a rebate check.

16:21 Why are rebates going away, and why isn't that changing PBM earnings?

19:05 How do you get CEOs and CFOs to dig into their benefits plan?

20:59 Does morally abhorrent move the needle?

21:33 "What we're trying to do is just simplify the [healthcare] industry." —Mark

24:19 What's been changing in consumer behavior?

25:04 "Transparency is a huge part of building that trust." —Ferrin

25:19 Why CEOs and CFOs really have the power to change healthcare.

32:29 What are Cost Plus Drugs' plans to expand?

39:21 Where is the future of the prescription drug market going?

42:09 What will happen to the prescription drug market in 10 to 20 years?

48:40 The wake-up call self-insured employers should be acknowledging now.

52:02 Where is the real change in the healthcare industry going to come from?

In this episode, Stacey Richter speaks with Rob Andrews, CEO of the Health Transformation Alliance (HTA) and former Congressman, about the strategic steps jumbo employers can take to achieve improved health outcomes while reducing cost. They delve into the importance of using data to discern effective practices, negotiate contracts, and hold intermediaries accountable. The discussion highlights maternal health as a critical area of focus, with successful interventions shown to reduce NICU admissions and overall healthcare costs. Andrews emphasizes the role of self-insured employers in driving systemic changes that align financial incentives with health outcomes. Getting better health for the 160 million Americans covered by commercial insurance, in Andrews's view, is all about rates, rights, and power.

WHAT YOU'LL LEARN

✅ What strategic steps jumbo employers can take to improve health outcomes while reducing total cost of care

✅ Why using data to identify effective practices, negotiate contracts, and hold intermediaries accountable is central to the Health Transformation Alliance's approach

✅ Why maternal health is a critical area of focus, and how successful interventions have been shown to reduce NICU admissions and overall healthcare costs

✅ Why self-insured employers have a unique role in driving systemic change that aligns financial incentives with actual health outcomes

✅ Rob Andrews's framing for the 160 million Americans covered by commercial insurance: it all comes down to rates, rights, and power

WHY THIS MATTERS

"Strategy's not what people say; it's what they do." Rob Andrews's blueprint for jumbo employers isn't a philosophy — it's an operational discipline built on data, contract leverage, and accountability. Getting better health outcomes for the 160 million Americans on commercial insurance, per Andrews, comes down to three things: rates, rights, and power.

=== LINKS ===

🔗 Show Notes with all mentioned links: Episode Page

🔗 Healthcare Industry Acronyms and Terms

✉️ Enjoy this podcast? Subscribe to the free weekly newsletter

🫙 Support the podcast with a small donation to the Tip Jar

📺 Subscribe to our YouTube channel

🎤 Listen on Apple Podcasts

🎤 Listen on Spotify

=== CONNECT WITH THE RHV TEAM ===

✭ LinkedIn ✭ Threads ✭ Bluesky ✭ X

00:00 Introduction.

07:34 How did Rob get to his current role?

09:08 The problem of maternal health and mortality rate, and how self-insured employers wind up directly and indirectly paying for this.

10:27 Why economic consequences move the needle, and why sometimes they don't.

12:26 Why the best way to address costs isn't to re-shift costs but to address them directly.

13:22 Why compensation that isn't dependent on outcomes is a problem.

16:23 "Strategy's not what people say; it's what they do."

18:21 How do you operationalize saving money with better outcomes?

26:26 How do employers turn conflict into collaboration?

28:20 What is the win-win-win structure among employers, payers, and providers in Rob's eyes?

30:53 To whom should the task of risk adjustment fall?

34:43 "Better contracts do improve outcomes."

In this comprehensive episode, host Stacey Richter sits down with Brian Reid to discuss pivotal aspects for the pharmaceutical industry. Key topics include understanding product value from the perspectives of plan sponsors, patients, and society, and the significance of benefit design in improving patient affordability. The discussion delves into the complexities of drug pricing, the roles of Pharmacy Benefit Managers (PBMs) and brokers, and the impact of healthcare consolidation on costs. Reid emphasizes the importance of transparent communication among stakeholders, the detrimental effects of cost containment strategies, and the necessity of considering policy and reputational impacts. Throughout the conversation, examples such as the Hepatitis C drug illustrate the broader implications on drug access and affordability. Listeners are provided with critical insights into how pharmaceutical companies can better engage with ultimate purchasers to ensure patients receive necessary, cost-effective treatment.

WHAT YOU'LL LEARN

✅ How to think about "value" in pharma from the perspectives of plan sponsors, patients, and society all at once

✅ Why benefit design plays such a significant role in patient affordability, and what the Kaiser Employer Health Benefits Survey reveals about it

✅ Why pharma needs to showcase its value even when PBMs are often "locked in" at the moment of a formulary decision

✅ Why Brian is celebrating companies that put their prices directly in their press releases

✅ Why hospital monopoly behavior and healthcare consolidation are just as relevant to pharma's affordability conversation as PBM contracting is

WHY THIS MATTERS

Reid's core argument: pharma has an obligation to explain its value — not just claim it — to plan sponsors, patients, and society simultaneously. Transparent communication among stakeholders, not just clever positioning, is what actually improves patient access to necessary, cost-effective drugs, as the Hepatitis C example discussed in the show makes clear.

MENTIONED IN THIS EPISODE

EP300 with Bruce Rector, MD: Apple Podcasts | Spotify | Other Apps

EP448 (Part 1) with Shawn Gremminger: Apple Podcasts | Spotify | Other Apps

EP426 with Nina Lathia, RPh, MSc, PhD: Apple Podcasts | Spotify | Other Apps

EP370 with Erik Davis and Autumn Yongchu: Apple Podcasts | Spotify | Other Apps

=== LINKS ===

🔗 Show Notes with all mentioned links: Episode Page

🔗 Healthcare Industry Acronyms and Terms

✉️ Enjoy this podcast? Subscribe to the free weekly newsletter

🫙 Support the podcast with a small donation to the Tip Jar

📺 Subscribe to our YouTube channel

🎤 Listen on Apple Podcasts

🎤 Listen on Spotify

=== CONNECT WITH THE RHV TEAM ===

✭ LinkedIn ✭ Threads ✭ Bluesky ✭ X

00:00 Introduction.

08:29 Why is it important to understand the term "value" in respect to medicine?

10:07 Why is it important to consider all the players affected by the idea of this "value"?

11:06 Who are the ultimate purchasers in Pharma?

12:23 Findings of the Kaiser Employer Health Benefits Survey.

14:52 Why does it matter that we consider what value looks like to all players affected by Pharma?

20:04 What does Pharma need to do to showcase their value when PBMs are often "locked in" at the moment?

23:11 Why Brian is celebrating companies that put their prices in their press releases.

32:31 Why does Pharma have an obligation to explain their value?

33:39 Why is it important for Pharma to keep an eye on hospital monopoly behavior?

37:44 Why Pharma needs to capitalize on alignment.

In this conversation, Stacey Richter engages with healthcare leader Dr. Beau Raymond from Ochsner Health Network to explore the blueprint for better patient care through enlightened leadership, data-driven strategies, and localized health initiatives. The discussion covers shifting from 'sick care' to preventative healthcare, integrating technology and data tools like glucometers for health coaching, and addressing health equity through accurate data and regional strategies. The conversation explains the importance of stakeholder engagement, setting clear goals, financial incentives aligned with patient care, and continuous improvement through feedback loops. Practical steps such as weekly huddles for primary care teams and the role of digital health in managing chronic conditions like diabetes and hypertension are also highlighted to improve healthcare outcomes and operational excellence.

WHAT YOU'LL LEARN

✅ Why enlightened leadership is described as critical to achieving measurably better patient care, and what that looks like day to day

✅ How data-driven strategies and localized health initiatives combine to shift care from "sick care" toward preventative healthcare

✅ How integrating technology and data tools like glucometers supports health coaching for chronic conditions like diabetes and hypertension

✅ Why accurate data and regional strategies are essential to addressing health equity, and how Ochsner approached this without singling out individual physicians

✅ Why weekly huddles for primary care teams and continuous feedback loops matter more than one-time initiatives for sustaining improvement

WHY THIS MATTERS

"It's really about engaging with the patient." Dr. Raymond's blueprint ties enlightened leadership, data, and local execution together: goals have to be clear, financial incentives have to align with patient care, and feedback loops have to be continuous — otherwise data-driven strategy stays theoretical instead of showing up in weekly huddles and patient outcomes.

=== LINKS ===

🔗 Show Notes with all mentioned links: Episode Page

🔗 Healthcare Industry Acronyms and Terms

✉️ Enjoy this podcast? Subscribe to the free weekly newsletter

🫙 Support the podcast with a small donation to the Tip Jar

📺 Subscribe to our YouTube channel

🎤 Listen on Apple Podcasts

🎤 Listen on Spotify

=== CONNECT WITH THE RHV TEAM ===

✭ LinkedIn ✭ Threads ✭ Bluesky ✭ X

00:00 Introduction.

10:44 Why is it important to be flexible while keeping your goals in sight?

11:48 Dr. Eboni Price-Haywood's article on disparities in COVID.

12:29 How is equity a data point to achieving overall care improvement?

15:01 "If you can't measure it … accurately, you're not going to be able to do anything differently."

20:52 What strategies have been successful in using data to improve healthcare outcomes?

23:17 Why did Ochsner Health avoid looking at the individual physician standpoint in regard to an equity standpoint?

30:40 Why engaging patients in their healthcare actually improved patient visits and did not necessarily reduce patient visits.

34:49 "It's really about engaging with the patient."

In this episode, host Stacey Richter and guest Brendan Keeler dive deep into the significant legal clash between Epic and Particle over electronic health record (EHR) data access and market competition. This episode examines the broader repercussions on healthcare data exchange, including antitrust concerns, data liquidity, and the ethical considerations around secondary use of treatment data. The discussion brings to light how the outcome of such lawsuits could influence data transparency, interoperability, and the rules governing data sharing among plan sponsors, employers, and healthcare providers. Notable points include the shift to a judicial era impacting health tech companies and the potential for regulatory and judicial actions to improve data access and efficiency within healthcare networks. The episode emphasizes the critical need for clear pathways, accountability, and structured regulations to enhance patient care and reduce fraud in the healthcare data ecosystem.

WHAT YOU'LL LEARN

✅ What the Epic v Particle lawsuit is actually about, and why it matters for plan sponsors and public health efforts trying to access data

✅ Who can gain access to EHR data, and what limits (if any) exist on how that data can be used secondarily

✅ Why this moment represents a shift to what Brendan calls a "judicial era" for health tech companies

✅ What progress has been made since the lawsuit began, and who else stands to be affected by the rule this case is likely to set

✅ Why clear pathways, accountability, and structured regulations are needed to improve data access while also reducing fraud in the healthcare data ecosystem

WHY THIS MATTERS

The Epic v Particle dispute is a proxy fight over who controls health data liquidity — and its outcome will shape interoperability rules well beyond the two companies involved. Brendan Keeler's read: regulatory and judicial action, not voluntary industry cooperation, is what's actually going to move data access and efficiency forward from here.

=== LINKS ===

🔗 Show Notes with all mentioned links: Episode Page

🔗 Healthcare Industry Acronyms and Terms

✉️ Enjoy this podcast? Subscribe to the free weekly newsletter

🫙 Support the podcast with a small donation to the Tip Jar

📺 Subscribe to our YouTube channel

🎤 Listen on Apple Podcasts

🎤 Listen on Spotify

=== CONNECT WITH THE RHV TEAM ===

✭ LinkedIn ✭ Threads ✭ Bluesky ✭ X

00:00 Introduction.

07:21 Who can gain access to EHR data?

10:31 Are there limits to how EHR data can be used secondarily?

11:36 Can EHR data be shared secondarily?

15:47 Part one and part two of Brendan's comprehensive account of the Epic/Particle dustup.

15:57 What was the dispute that started Epic v Particle?

18:21 What are the two viewpoints in this dispute with Epic's actions?

26:16 What progress has been seen since this lawsuit began?

28:00 Who else will be impacted by the likely rule cementing from this lawsuit?

In this episode, host Stacey Richter delves into the complexities of the Third Party Administrator (TPA) Request for Proposal (RFP) process with guest Claire Brockbank from 32BJ Union. The discussion highlights the critical role of contracts in managing health plans effectively and the potential pitfalls of accepting contracts crafted by TPAs without thorough review. Drawing from Claire's experience, they explore tactics like starting with your own contract paper in RFP processes to gain negotiation leverage, and the benefits of employer coalitions in navigating healthcare complexities. As one example — and Cora Opsahl spoke about this in the prior episode, and Claire talks about it here too — allowing upside-down payments, common in a lot of ASO contracts, meant that 32BJ spent around $10 million paying more than the bill was for in one year. If a plan signs the contract as handed to them by the carrier, the plan is contractually obligating itself to pay more than the price the clinical practice actually charged: a doctor sends a bill for $100, and the carrier pays that practice $200 on the plan sponsor's behalf, leaving the plan sponsor paying $200 for a $100 bill. Real-world examples underscore the financial impact of poorly negotiated contracts and highlight successful strategies for health plan sponsors to optimize costs and services.

WHAT YOU'LL LEARN

✅ Why accepting a TPA's own contract paper without review can quietly cost a plan sponsor millions — illustrated by 32BJ's real $10 million upside-down-payment example

✅ How starting an RFP process with your own contract paper, instead of the carrier's, gives plan sponsors real negotiation leverage

✅ What "upside-down payments" are, and why they can turn a $100 bill into a $200 charge to the plan sponsor

✅ Why employer coalitions and open-source contracts, like the one 32BJ makes available, help level the playing field against carriers and TPAs

✅ Why it's important to keep probing brokers and consultants, even loyal ones, throughout the RFP and contracting process

WHY THIS MATTERS

Is paying $200 for a $100 bill a conflict of interest? Imprudent? A fiduciary breach? Claire Brockbank's answer, backed by 32BJ's own numbers, is that plan sponsors who sign TPA-drafted contracts without review are often unknowingly agreeing to exactly this kind of upside-down payment structure — and the fix starts with writing the contract yourself.

MENTIONED IN THIS EPISODE

EP433 with Justin Leader: Apple Podcasts | Spotify | Other Apps

EP428 with Julie Selesnick: Apple Podcasts | Spotify | Other Apps

=== LINKS ===

🔗 Show Notes with all mentioned links: Episode Page

🔗 Healthcare Industry Acronyms and Terms

✉️ Enjoy this podcast? Subscribe to the free weekly newsletter

🫙 Support the podcast with a small donation to the Tip Jar

📺 Subscribe to our YouTube channel

🎤 Listen on Apple Podcasts

🎤 Listen on Spotify

=== CONNECT WITH THE RHV TEAM ===

✭ LinkedIn ✭ Threads ✭ Bluesky ✭ X

00:00 Introduction.

05:36 How does the initial contract writing affect how events in your healthcare plan will go?

06:56 What happens if a plan sponsor or employer doesn't do the contracting right?

10:42 How much could be saved by doing contracting right?

12:22 How do you start an RFP process with your own contract?

14:06 What Claire Brockbank recommends doing to do a TPA RFP process in a way that's best for you.

19:46 What factors do carriers need to get an ASO or TPA to respond to using your contract?

21:11 Open-source contract available from 32BJ.

21:57 Why it's important to really probe brokers, despite loyalty to your broker/consultant.

24:30 Who are the reliable agents and experts when carriers are looking to start this process?

27:56 What's the silver lining to this effort?

29:17 Why is it important to make it clear why you're doing what you're doing for your lawyers and any other support team you need?

31:39 What does "good" look like in this process?

34:15 Why is it important to continue to hold your ASO accountable?

In this episode Stacey Richter interviews Cora Opsahl from the 32BJ Health Fund to examine the intricate dynamics between fiduciary duties and the entrenched status quo in healthcare. The discussion focuses on the challenges employers face when dealing with anti-competitive contracts and their responsibility to ensure plan expenses are reasonable. Cora Opsahl is the director of the 32BJ Health Fund, serving over 200,000 folks. Their ability to remove NewYork-Presbyterian — a big, consolidated, expensive hospital — from their network in 2018 enabled them to offer maternity benefits for $40 in total out-of-pocket for members. Employees also got their biggest raise ever; employers got a premium holiday and a 3% rate increase cap for a number of years after that. The episode's show notes include a template health savings calculator for plan sponsors and a template contract, both made available by 32BJ.

WHAT YOU'LL LEARN

✅ Why 32BJ Health Fund's decision to remove NewYork-Presbyterian from their network in 2018 became a case study in what fiduciary duty can actually accomplish

✅ How analyzing claims data allowed 32BJ Health Fund to completely reshape its benefit design

✅ What anticompetitive contract rights limited 32BJ's ability to manage its own benefit design, and how those rights carry both cost and quality implications

✅ Why 32BJ Health Fund has moved beyond benefit design alone to actively manage and control the contracting process itself

✅ Cora Opsahl's four non-negotiables, and her advice for getting high-quality healthcare at an affordable price

WHY THIS MATTERS

Kicking a big, consolidated, expensive hospital system out of network sounds risky. For 32BJ Health Fund, it enabled $40 total out-of-pocket maternity benefits, employees' biggest raise ever, a premium holiday for employers, and years of a 3% rate increase cap. Cora Opsahl's case for fiduciary duty isn't theoretical — it's backed by what happened when 32BJ actually exercised it.

MENTIONED IN THIS EPISODE

EP419 with Andreas Mang: Apple Podcasts | Spotify | Other Apps

=== LINKS ===

🔗 Show Notes with all mentioned links: Episode Page

🔗 Healthcare Industry Acronyms and Terms

✉️ Enjoy this podcast? Subscribe to the free weekly newsletter

🫙 Support the podcast with a small donation to the Tip Jar

📺 Subscribe to our YouTube channel

🎤 Listen on Apple Podcasts

🎤 Listen on Spotify

=== CONNECT WITH THE RHV TEAM ===

✭ LinkedIn ✭ Threads ✭ Bluesky ✭ X

00:00 Introduction.

06:16 Why is it imperative for employers to do something differently when it comes to being plan sponsors?

09:22 How analyzing claims data allowed 32BJ Health Fund to reshape their benefit design.

12:09 What anticompetitive rights did 32BJ run into that limited 32BJ Health Fund from managing their benefit design?

14:12 How do these anticompetitive rights have quality implications as well as cost implications?

18:43 How did 32BJ Health Fund remove NewYork-Presbyterian from their network, and how much did it save 32BJ Health Fund per year?

19:46 What did the healthcare savings allow the unions and employers to do?

20:46 Study by Zack Cooper, PhD.

21:26 Why rising healthcare costs has pushed 32BJ Health Fund to move beyond benefit design to manage healthcare spend.

24:15 Why 32BJ Health Fund wants to control the contracting process.

27:18 What are 32BJ Health Fund's four non-negotiables?

33:17 Wall Street Journal article on health insurance contract.

35:30 Upcoming episode with Claire Brockbank.

36:14 What is the challenge that exists in our current healthcare environment?

37:43 Cora's advice on how to get high-quality healthcare at an affordable price.

In this Spotlight Episode, host Stacey Richter discusses the management of oncology side effects with Dan Nardi, CEO of Reimagine Care. Highlighting the challenges cancer patients face, especially following chemotherapy which often leads to nausea and readmissions, the conversation delves into how Reimagine Care facilitates at-home integrative cancer care. Their services focus on proactive and reactive support via AI-driven tools like 'Remy' to assist patients outside of clinical environments. This approach aims to reduce emergency visits and improve patient outcomes while easing the workload on healthcare providers. The discussion underscores the role of patient-reported outcomes and the integration of technology with human care to improve the quality of oncology treatment pathways.

WHAT YOU'LL LEARN

✅ Why chemotherapy-related side effects like nausea so often lead to costly hospital readmissions, and what's difficult about navigating cancer care pathways in the first place

✅ How Reimagine Care delivers at-home integrative cancer care through both proactive and reactive support

✅ How Reimagine Care's AI-driven tool "Remy" assists patients outside of clinical environments to help reduce emergency visits

✅ How Reimagine Care measures its own performance, and how that work has actually affected patient outcomes

✅ Where technology can make the biggest real difference in cancer care, and how providers feel about the services Reimagine Care offers

WHY THIS MATTERS

Cancer patients navigating treatment side effects largely on their own is both a quality problem and a financial one — the outcome and cost issues compound when there's no proactive support in place. Dan Nardi's case for at-home, tech-enabled oncology support, blended with human care, is that catching side effects early, before they become ER visits, is better for patients and providers alike.

MENTIONED IN THIS EPISODE

EP157 with Ethan Basch, MD: Apple Podcasts | Spotify | Other Apps

=== LINKS ===

🔗 Show Notes with all mentioned links: Episode Page

🔗 Healthcare Industry Acronyms and Terms

✉️ Enjoy this podcast? Subscribe to the free weekly newsletter

🫙 Support the podcast with a small donation to the Tip Jar

📺 Subscribe to our YouTube channel

🎤 Listen on Apple Podcasts

🎤 Listen on Spotify

=== CONNECT WITH THE RHV TEAM ===

✭ LinkedIn ✭ Threads ✭ Bluesky ✭ X

00:00 Introduction.

03:38 Why is it really important to keep track of oncology patients and their side effects?

04:27 Why is cancer treatment such a complex care journey?

05:57 Are there outcome and financial issues that compound when an oncology patient is left to navigate their care journey on their own?

08:53 What is difficult in navigating cancer treatment care pathways, and what does Reimagine Care tackle within that?

10:17 How does Reimagine Care proactively check in with oncology patients to help them navigate their care pathways?

12:41 How does Reimagine Care measure their performance, and how did their work affect patient outcomes?

13:28 The Reimagine Care white paper.

14:57 How do providers feel about Reimagine Care services?

17:37 Where can technology really make a difference in cancer care?