Relentless Health Value

In Episode 451 of Relentless Health Value, host Stacey Richter converses with Dr. Spencer Dorn about the implications of AI in healthcare, referencing lessons learned from EHR implementations. They discuss Kranzberg's first law of technology, which advises against labeling a technology as inherently good, bad, or neutral, emphasizing instead the importance of its application, configuration, and the human decisions surrounding its use. Dorn and Richter explore both the potential benefits and drawbacks of AI, drawing parallels with past experiences in healthcare digitization — including lessons from the earlier show about EHRs (episode 446).

WHAT YOU'LL LEARN

✅ Kranzberg's First Law of Technology, and why it's the wrong move to label any technology — including AI — as inherently good, bad, or neutral

✅ What lessons from digitizing healthcare (EHR implementation) actually transfer to how we should think about deploying AI

✅ Why the ultimate impact of a technology depends on the people, processes, and configuration around it, not the technology itself

✅ How AI could make things better and worse simultaneously, and why that duality isn't a contradiction

✅ Why it's important to look past both the hype and the pessimism to make a clear-eyed assessment of AI in healthcare

WHY THIS MATTERS

The first takeaway is the same as it was for EHRs: don't ascribe any given technology a label of good, bad, or even neutral. That's Kranzberg's First Law of Technology, and it applies just as much to AI. The second: the ultimate impact will never be a black-and-white binary — it depends entirely on the people and processes surrounding the technology, not the technology itself.

=== LINKS ===

🔗 Show Notes with all mentioned links: Episode Page

🔗 Healthcare Industry Acronyms and Terms

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00:00 Introduction.

05:23 What could happen with AI in healthcare if we aren't thinking about how we're deploying it?

05:58 How could the lessons from digitizing healthcare help us with employing AI?

08:25 How could artificial intelligence make things better and simultaneously worse?

10:55 Why is it important to look beyond the hype and pessimism and make a clear-eyed assessment?

In Episode 450, Stacey Richter speaks with Marilyn Bartlett, a renowned CPA in the healthcare field, about her remarkable achievement of transforming the state of Montana's employee health plan from $9 million in debt to a surplus of $112 million within three years. Marilyn discusses the steps she took, including identifying financial inefficiencies, targeting high-cost areas, and implementing data-driven strategies to produce quick wins and sustainable results. The conversation delves into the importance of having the right team, communicating effectively with stakeholders, and staying focused amidst challenges. Listeners will gain valuable insights into strategic change management and actionable advice for improving healthcare plans.

WHAT YOU'LL LEARN

✅ How Marilyn Bartlett transformed Montana's state employee health plan from $9 million in debt to a $112 million surplus in three years

✅ What gave Marilyn the confidence — and the mandate — to make sweeping changes to a state health plan

✅ What "quick wins" looked like early in her tenure, and why they mattered for building momentum

✅ How Marilyn structured her plan and built the right team to execute it

✅ What happened to plan costs after Marilyn moved on, and what that says about the durability of the changes she made

WHY THIS MATTERS

It's amazing what a dedicated CPA with a spreadsheet and their eye on the target can accomplish in the real world when they just follow the dollar. Marilyn Bartlett isn't called the "Queen of Healthcare" for nothing — she was among the first to systematically identify how much money was getting pulled out of the pockets of taxpayers, employers, and plan members and into the healthcare, insurance, and consulting industries, and then actually do something about it.

=== LINKS ===

🔗 Show Notes with all mentioned links: Episode Page

🔗 Healthcare Industry Acronyms and Terms

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=== CONNECT WITH THE RHV TEAM ===

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00:00 Introduction.

06:45 What gave Marilyn the confidence to fix Montana's state health plan?

08:11 Why Marilyn knew she would have enough power to make the changes needed in Montana's state health plan.

09:11 What Marilyn achieved in her time as the administrator of the Montana State Employee Health Plan.

10:38 What were the "quick wins" Marilyn was able to achieve when she first took over as administrator?

17:33 Stay tuned for an upcoming episode that covers RFP in detail.

17:50 How Marilyn structured her plan for the Montana State Employee Health Plan.

21:21 What's the key to setting yourself up for success when doing what Marilyn was able to achieve?

25:02 Why putting together your own team is so important.

29:07 What happened when Marilyn left the Montana State Employee Health Plan?

31:08 Have the costs of the plan gone up since Marilyn's time working on it?

Stacey Richter had a chance to read Dr. Marty Makary's new book, Blind Spots, and invited him back on Relentless Health Value to talk about something he said on page 127: the idea of what is appropriate care and how good the industry actually is at ensuring patients and members get it. Appropriate care has come up repeatedly on the show — with Ben Schwartz, MD, MBA (EP434); John Lee, MD (EP438); Spencer Dorn, MD, MPH, MHA (EP446); and Tom Lee, MD (EP445). An estimated 21% of all medical care is potentially unnecessary, per a national survey of physicians: 25% of diagnostic tests, 22% of all medications, and 11% of all procedures are unnecessary or inappropriate — billions of wasted dollars doing stuff that shouldn't be done. Dr. Makary and Stacey delve into the challenges of ensuring patients receive appropriate care, touching on medical dogma, financial, business, and legal incentives, and the importance of measuring practice patterns. Dr. Makary provides practical advice for clinical leaders, payers, and plan sponsors on promoting transparency, improving health literacy, and steering members toward higher-performing providers.

WHAT YOU'LL LEARN

✅ What "appropriate care" actually means, and why an estimated 21% of all medical care may be unnecessary

✅ Why medical dogma and absolutism get in the way of patients receiving appropriate care

✅ How groupthink shows up in medicine, and why providers resist new ideas even in the face of good evidence

✅ Why "if you leave it to the medical profession to fix itself … so far, it's not going well" — and what has to change instead

✅ Practical advice for clinical leaders, payers, and plan sponsors on promoting transparency, health literacy, and steering members toward higher-performing providers

WHY THIS MATTERS

"People need to find their care based on quality and price." Dr. Makary's argument isn't that providers are acting in bad faith — it's that medical dogma, financial incentives, and legal exposure combine to make appropriate care surprisingly hard to define and even harder to deliver consistently. Fixing that requires transparency and measurement, not just good intentions.

=== LINKS ===

🔗 Show Notes with all mentioned links: Episode Page

🔗 Healthcare Industry Acronyms and Terms

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00:00 Introduction.

07:32 What is appropriate care?

10:19 Why what we think might be appropriate care might not be appropriate care.

10:34 Why is medical dogma damaging to appropriate care?

12:45 Why we need less absolutism in medical practice.

13:37 How is groupthink prevalent in medicine?

14:02 Why do we resist new ideas?

17:43 How do providers figure out what to believe and what not to believe?

20:59 "If you leave it to the medical profession to fix itself … so far, it's not going well."

22:33 How does supporting health literacy affect appropriate care?

30:23 "People need to find their care based on quality and price."

34:28 What proportion of medical care is deemed unnecessary right now?

This is Part 2 of Stacey Richter's deep dive into the 340B program with Shawn Gremminger — these episodes don't have to be listened to in order, so it's fine to start here. This part focuses on how 340B impacts employers, commercial plans, and other plan sponsors. As just one example of why employers should care: if an employee or member of a commercial plan gets a drug at a contract pharmacy participating in 340B, the employer does not get the rebate — the employer pays list price for that med. 340B is currently so gargantuan that it creates market distortions that bleed into the prices, and possibly the quality, of healthcare for everybody, all Americans. For more on the history and origins of the program, see Part 1 of this episode.

WHAT YOU'LL LEARN

✅ Why employers, Taft-Hartley plans, and other commercial payers should care about 340B — a program originally designed for Medicaid and safety-net providers

✅ Why an employer doesn't get the rebate when an employee fills a drug at a 340B contract pharmacy — and ends up paying list price instead

✅ How 340B's scale, a $53 billion program, creates market distortions that bleed into prices and possibly quality for everybody, not just Medicaid patients

✅ Findings from Zack Cooper, PhD's research on distorted pricing models at 340B hospitals

✅ Why employers need to stop playing the blame game and start engaging directly with how 340B affects their own plan spend

WHY THIS MATTERS

340B is currently so gargantuan that it creates market distortions that bleed into the prices — and possibly the quality — of healthcare for everybody, not just the low-income patients it was designed to help. That's Part 2's core argument: this isn't a niche Medicaid issue, it's a commercial-market cost driver hiding in plain sight.

=== LINKS ===

🔗 Show Notes with all mentioned links: Episode Page

🔗 Healthcare Industry Acronyms and Terms

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00:00 Introduction.

09:11 Why do employers care about 340B, which is a Medicaid program?

11:30 Why do I care as an employer, even if I'm not Pharma?

12:44 Why is 340B causing employers to pay significantly more for healthcare?

14:36 Study by Zack Cooper, PhD.

15:06 Why are there distorted pricing models at 340B hospitals?

21:22 Why do employers need to stop playing the blame game?

Stacey Richter decided to release this conversation with Shawn Gremminger about 340B in two parts — listen to one, listen to both. Shawn came up with three really important takeaways relative to 340B, a feat unto itself considering how sprawling this conversation can be. This first part zeros in on Shawn's first takeaway: whether or not the original intent, or the presumed original intent, of the 340B program has actually been met. 340B began life as a lowly bureaucratic fix, but over the past 15 years it has grown into a 500-pound gorilla that sits in the corner of a lot of rooms, probably more than many people realize. By the end of this first part, listeners should be able to competently assess whether 340B, in fact, adequately helps underserved communities get better healthcare. Part 2 of the show, a separate episode, covers how all of this impacts employers and commercial plans.

WHAT YOU'LL LEARN

✅ Shawn Gremminger's three key takeaways about the 340B program, starting with whether the program has actually met its original intent

✅ How 340B went from "a lowly bureaucratic fix" to a $53 billion, 500-pound gorilla that most people don't realize sits in the room

✅ Why Medicaid has to get the best price, and how that requirement shaped 340B's design

✅ How more than half of acute care hospitals now qualify for 340B, and how hospital consolidation has accelerated that shift

✅ Why there isn't a real patient definition in 340B, and what that ambiguity allows to happen

WHY THIS MATTERS

340B began life as a lowly bureaucratic fix — a way to help safety-net providers stretch scarce resources. Fifteen years later, per Shawn Gremminger, it's become a 500-pound gorilla that sits in the corner of a lot of rooms, more than many people realize. Part 1 asks the foundational question: does 340B actually still help the underserved communities it was designed for?

MENTIONED IN THIS EPISODE

EP394 with Vikas Saini, MD, and Judith Garber, MPP: Apple Podcasts | Spotify | Other Apps

=== LINKS ===

🔗 Show Notes with all mentioned links: Episode Page

🔗 Healthcare Industry Acronyms and Terms

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=== CONNECT WITH THE RHV TEAM ===

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00:00 Introduction.

05:25 Shawn's three takeaways from the 340B program.

06:04 What is the intent of the 340B program?

08:22 Read the full 32-page report of the Energy and Commerce Committee.

09:17 Why does Medicaid have to get the best price?

13:26 Why was there a shift in how the 340B program looked starting in the mid-2000s?

15:11 Why do more than half of acute care hospitals now qualify for 340B?

18:18 How has hospital consolidation affected 340B?

20:37 What is the misalignment between how a hospital qualifies for 340B and how it benefits said hospitals?

24:11 How is a 340B designed for hospitals to make a profit?

28:45 Why isn't there a real patient definition in 340B?

31:46 Why is 340B still popular among policymakers?

33:05 Are 340B dollars being used in underserved communities?

In this Summer Short Episode, host Stacey Richter discusses the hidden costs and inefficiencies of value-based care with Elizabeth Mitchell, President and CEO of the Purchaser Business Group on Health (PBGH). They uncover how value-based care, often touted as the ideal system, can be manipulated by middlemen to extract more money from plan sponsors without delivering real value to patients. Elizabeth argues for for-real alternative payment models that are transparent to employer plan sponsors: prospective or bundled payments, with warranties that are measurable, delivering integrated whole-person care in a way most health plans (i.e., middlemen) either cannot or will not administer. She says cooperation between employers, employees, and primary care providers is crucial — direct contracts — and that this effort is urgently needed given the affordability crisis affecting many Americans, with 48% of Americans with commercial insurance delaying or forgoing care due to cost.

WHAT YOU'LL LEARN

✅ How value-based care, often touted as the ideal system, can be manipulated by middlemen to extract more money from plan sponsors without delivering real value to patients

✅ Why most health plans can't or won't administer real alternative payment models like prospective or bundled payments with measurable warranties

✅ Why direct cooperation between employers, employees, and primary care providers is crucial to achieving actual care that delivers value

✅ Why fee-for-service structurally can't support effective primary care, and why "no one makes money in a fee-for-service system if people are healthy"

✅ Why 48% of Americans with commercial insurance are delaying or forgoing care due to cost — and why that matters even for self-insured employers with highly compensated employees

WHY THIS MATTERS

"We do not have value in the US healthcare system." Elizabeth Mitchell's case is urgent: billions of dollars are being siphoned off the top by middlemen and their shareholders — dollars partially paid for by employees and plan members. Real alternative payment models, not more incremental value-based care rhetoric, are what she says is actually needed.

=== LINKS ===

🔗 Show Notes with all mentioned links: Episode Page

🔗 Healthcare Industry Acronyms and Terms

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=== CONNECT WITH THE RHV TEAM ===

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00:00 Introduction

10:36 What are members and providers actually asking for in terms of value-based care?

10:56 Why won't most health plans administer alternative payment models?

12:17 "We do not have value in the US healthcare system."

12:57 Why you can't do effective primary care on a fee-for-service model.

13:30 Why have we fragmented care out?

14:39 "No one makes money in a fee-for-service system if people are healthy."

17:27 "If we think it is not at a crisis point, we are kidding ourselves."

In this encore episode, Stacey Richter's conversation is with Will Shrank, MD. Dr. Shrank led the evaluation group at CMMI (Center for Medicare and Medicaid Innovation), spent time in the private sector at CVS Health and UPMC as chief medical officer of the health plan in Pittsburgh, and then as chief medical officer for Humana. Now he is a venture partner at Andreessen Horowitz and does some consulting for CMMI. The conversation starts with waste in healthcare — Dr. Shrank was on a team who did a study about waste in the US healthcare system, estimating upwards of a trillion dollars of waste a year, categorized into administrative and clinical failures. Dr. Shrank emphasizes the need for aligning incentives with higher quality care, paying for patient outcomes, and highlights the potential rising power of PCPs.

WHAT YOU'LL LEARN

✅ The six categories of "healthcare waste" Dr. Shrank's study identified, and how much money — upwards of a trillion dollars a year — that waste actually represents

✅ Why we've "built a backbone of extraordinary waste on a fee-for-service chassis," and how that waste splits between administrative and clinical failures

✅ Why aligning incentives with higher quality care and paying for patient outcomes matters more than simply tightening administrative processes

✅ Dr. Shrank's warning to providers, and why there might be a generational shift among younger providers looking to work with different care models

✅ How Dr. Shrank's background — CMMI, CVS Health, UPMC, Humana, and now Andreessen Horowitz — shapes how he thinks about fixing healthcare waste

WHY THIS MATTERS

"We've built a backbone of extraordinary waste on a fee-for-service chassis." Dr. Shrank's study puts a number on what many in healthcare already sense: upwards of a trillion dollars a year in waste, split between administrative and clinical failures. His prescription is aligning incentives with quality and outcomes — not just trimming around the edges of a fee-for-service system built to reward volume.

MENTIONED IN THIS EPISODE

EP363 with David Scheinker, PhD: Apple Podcasts | Spotify | Other Apps

EP409 with Larry Bauer, MSW, MEd: Apple Podcasts | Spotify | Other Apps

EP359 with Dan O'Neill: Apple Podcasts | Spotify | Other Apps

Summer Shorts 2 with Scott Conard, MD: Apple Podcasts | Spotify | Other Apps

=== LINKS ===

🔗 Show Notes with all mentioned links: Episode Page

🔗 Healthcare Industry Acronyms and Terms

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=== CONNECT WITH THE RHV TEAM ===

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00:00 Introduction

06:54 Can we cut healthcare waste while improving patient care?

07:33 What does "healthcare waste" consist of?

07:46 What are the six categories of "healthcare waste"?

10:37 How much money does Dr. Shrank estimate is wasted each year in healthcare?

13:09 Where is that healthcare waste going, and why does it happen?

20:07 Uncaring by Robert Pearl, MD.

21:18 "We've built a backbone of extraordinary waste on a fee-for-service chassis."

26:02 Dr. Shrank's warning to providers out there.

31:41 Why there might be a generational shift among younger providers looking to work with different models.

In this encore episode, host Stacey Richter speaks with Dr. Amy Scanlan, Chief Medical Officer of the Clinically Integrated Network, a joint venture between Intermountain Health and UC Health in Colorado. They discuss the complexities of transitioning to value-based care, including the need for infrastructure, data, technology, and team collaboration. Dr. Scanlan emphasizes the importance of listening to practices, fostering medical culture change, and addressing the powerful influence of fee-for-service incentives. They also explore the necessity of strong interpersonal relationships and the critical role of leaders in facilitating effective care integration. Despite the challenges, Dr. Scanlan offers valuable advice for those embarking on the journey toward clinically integrated networks.

WHAT YOU'LL LEARN

✅ What it takes to transition to value-based care: infrastructure, data, technology, and team collaboration all have to move together

✅ Why "the hard part is the in-between spaces," and how Dr. Scanlan thinks about helping practices get from fee-for-service to integrated care

✅ Why team-based care done badly is "really just a series of handoffs" instead of true collaboration

✅ Why physicians need to be accountable for cost of care as well as outcomes, and how physician burnout paradoxically gives Dr. Scanlan hope

✅ Dr. Scanlan's practical advice for anyone trying to stand up a Clinically Integrated Network (CIN)

WHY THIS MATTERS

"Team-based care done badly is really just a series of handoffs." Dr. Scanlan's core argument is that clinical integration isn't primarily a technology problem — it's a culture and relationship problem. Infrastructure and data matter, but without genuine collaboration and shared accountability for cost and outcomes, integration stalls in what she calls "the in-between spaces."

MENTIONED IN THIS EPISODE

EP407 with Vivek Garg, MD, MBA: Apple Podcasts | Spotify | Other Apps

EP393 with David Muhlestein, PhD, JD: Apple Podcasts | Spotify | Other Apps

=== LINKS ===

🔗 Show Notes with all mentioned links: Episode Page

🔗 Healthcare Industry Acronyms and Terms

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=== CONNECT WITH THE RHV TEAM ===

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00:00 Introduction

06:35 How is Dr. Scanlan thinking about the transformation process and the shift to value?

09:16 "It is really trying to think about, how do we help practices get there?"

11:48 "The hard part is the in-between spaces."

14:12 "Team-based care done badly is really just a series of handoffs."

15:52 "We have to get to that point where the culture of collaboration is more pervasive."

19:58 "How do we as healthcare providers step in and solve this problem?"

20:06 Why do providers have a responsibility to step in and try to fix the healthcare system?

20:22 Article (unpaywalled) by Eric Reinhart, MD, PhD.

21:51 Why do physicians need to be accountable for the cost of care as well as outcomes?

23:38 Why does physician burnout give Dr. Scanlan hope?

24:26 What is the solution to changing fee-for-service incentives?

25:43 What are some of the challenges facing changing incentives?

27:16 Why is data so important?

30:13 "It's important to understand that we are in the middle of this change."

31:18 Dr. Scanlan's advice for those trying to stand up a CIN.

When a company wants to change clinician behavior or close a care gap and comes in asking for an "EHR strategy" — or, more often, an "Epic strategy" — as step one, that's a red flag. In this healthcare podcast, Ashleigh Gunter, president of Translucent Healthcare Consulting and a 30-year veteran of management consulting, joins Stacey Richter to explain why an Epic strategy is necessary but nowhere near sufficient for actually changing behavior inside a hospital or physician organization — and what real change management requires instead.

WHAT YOU'LL LEARN

✅ Why an "EHR strategy" (or "Epic strategy") is not the same as a change management strategy — it's necessary but not sufficient to actually change clinician behavior

✅ Ashleigh Gunter's five steps to effective change management: great leadership, creating a case for change, finding champions, overcommunicating, and measuring and celebrating progress

✅ Why "communication of change, in and of itself, isn't change management" — and what has to happen before communication can actually work

✅ Why frontline care delivery experience is too often left out of change management efforts, and what that costs an initiative

✅ How identifying and mobilizing "change champions" — people who have to change and can help others do the same — makes or breaks adoption inside a health system or health plan

WHY THIS MATTERS

The best tech tools, care models, and forward-thinking concepts don't matter if no one can be convinced to adopt them — and in a complicated, multilayered system like healthcare, it only takes one ounce of resistance to sabotage an entire effort. An EHR or Epic strategy can make the mechanics of change easier once people are already bought in, but it supplies no "why," and no case for change slithers spontaneously out of anyone's API. Real change management starts with leadership and a case for change grounded in what the people being asked to change actually care about — not with the software they'll eventually use.

=== 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

🎤 Listen on Apple Podcasts

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=== CONNECT WITH THE RHV TEAM ===

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00:00 Introduction.

09:22 How does change management go wrong in healthcare?

09:56 "Communication [of change] in and of itself isn't change management."

10:53 How does change management work on the provider organization side?

15:33 "You want to ensure you are educating the operational folks."

16:35 What is change management?

17:36 What does great leadership look like in change management?

18:55 "Leadership sets the tone."

19:04 What makes change management so hard?

19:31 "What's the company reason to make this change happen?"

20:51 What are change champions, and why do you need to create them when changing your benefit plan?

21:57 Crossing the Chasm by Geoffrey A. Moore.

23:21 Why is it important to overcommunicate change?

26:47 Why is it important to measure your successes and communicate those after a change?

Spencer Dorn, MD, MPH, MHA — a gastroenterologist, academic practice leader, and clinical informaticist at UNC — joins Stacey Richter to talk about EHRs (electronic health records) without really talking about EHRs. The real subject is Kranzberg's First Law of Technology: technology is never good, bad, or neutral on its own. Whether an EHR ends up empowering clinicians or burying them in information, extending human connection or eroding it, depends almost entirely on how it's implemented — the workflows, training, staffing, and people around it — not on the software itself.

WHAT YOU'LL LEARN

✅ Why Dr. Dorn insists there's no intrinsic property of technology, including EHRs, that determines whether it helps or hurts — outcomes depend entirely on implementation, per Kranzberg's First Law of Technology

✅ Why the same EHR system deployed in two different places can produce wildly different results depending on workflow, training, staffing, and change management, not the software itself

✅ How EHR-embedded information can just as easily empower clinicians as overwhelm them, and why that outcome sits on a continuum rather than being a binary

✅ Why "optimizing the EHR" is often the wrong framing, and why reframing conversations around optimizing the patient-doctor encounter or clinician teamwork gets closer to the real goal

✅ How EHR deployments can either extend or diminish human connection between doctors and patients, and between clinicians working together

WHY THIS MATTERS

It's tempting to praise or blame a piece of healthcare technology as if the software itself carries some inherent verdict — good, bad, or neutral. Kranzberg's First Law of Technology says otherwise: technology is never neutral, but it's also never predetermined. The same EHR system can empower one care team and overwhelm another, and the difference almost always comes down to workflow design, training, staffing, and the people implementing it, not the code. For anyone evaluating or purchasing healthcare technology, the real question isn't whether the tool is good — it's whether the surrounding people and processes are set up to make it good.

=== 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

🎤 Listen on Apple Podcasts

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=== CONNECT WITH THE RHV TEAM ===

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00:00 Introduction.

06:15 Breaking down Kranzberg's Laws of Technology.

08:16 How do EHRs go right?

12:49 "EHRs empower us with information, yet they also overwhelm us with information."

16:00 How do EHRs bring healthcare workers closer together?

19:35 The Digital Doctor by Robert Wachter.

21:33 "The whole point of healthcare is to help people live healthier, happier lives."

22:41 How the same EHR deployed in different places can be more or less efficient.

25:51 Why the problem is not necessarily the EHR but actually operational.

28:51 How technology has also changed our expectations on timing and value.