Relentless Health Value

There's a 31-member AMA committee that, under a sole-source contract with CMS dating back to the late '80s, decides the relative value of every medical procedure — and 22 to 25 of those 31 seats go to specialists, leaving primary care with just five or six. Brian Klepper, PhD, a longtime healthcare analyst and former CEO of the National Business Coalition on Health, joins Stacey Richter to explain how the RUC (RVU Update Committee) works, why its math has almost nothing to do with patient or clinical value, and why it's a root cause of primary care's broken business model.

WHAT YOU'LL LEARN

✅ What the RUC is, who sits on it, and why a committee dominated by specialists ends up horse-trading over whose procedures get the highest relative value

✅ Why primary care has developed an unearned reputation as the "easy" specialty, when in reality it requires enormous diagnostic complexity in a 10- to 15-minute visit

✅ Why the RUC's RVU allocations are based only on physician work, practice expense, and professional liability — with zero weight given to value delivered to the patient

✅ Why CMS accepting roughly 90% of the RUC's recommendations effectively hands pricing power for the entire physician fee schedule to a specialist-dominated committee

✅ Why chronic disease prevention, behavioral health integration, and care coordination all register as low relative value under the current system — even though they're exactly the services value-based care is supposed to reward

WHY THIS MATTERS

Almost every conversation about fixing primary care and mental health care in America skips over the RUC entirely, even though it's the mechanism quietly setting the prices that make primary care financially unsustainable in the first place. Health plans that pay fee-for-service rates are often just passing through Medicare rates, which are themselves built on RUC-determined RVUs — meaning the undervaluation of primary care and behavioral health isn't an accident of the market, it's baked into the pricing infrastructure underneath it. Understanding the RUC is a prerequisite for anyone who wants to actually fix primary care's business model rather than just talk about value-based care in the abstract.

MENTIONED IN THIS EPISODE

EP436 with Elizabeth Mitchell: 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

🎤 Listen on Apple Podcasts

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=== CONNECT WITH THE RHV TEAM ===

✭ LinkedIn ✭ Threads ✭ Bluesky ✭ X

00:00 Introduction.

02:29 What is the RUC?

06:26 Why is primary care not the "easy" specialty?

09:42 What are three low-value things per RUC?

10:33 EP436 with Elizabeth Mitchell.

10:38 What is a root cause of why primary care doesn't get paid more?

12:50 Why doesn't value equal money?

When a TPA gets acquired by a health plan, history suggests it stops being a TPA and starts acting like a full health plan — ancillary fees, opt-out-proof bells and whistles, and all, whether or not that's what the self-insured employer actually wants. Elizabeth Mitchell, president and CEO of the Purchaser Business Group on Health, joins Stacey Richter to widen the inertia conversation beyond employers and look at the TPAs, ASOs, and health plans that are supposed to be helping jumbo employers deploy their benefits — and often aren't.

WHAT YOU'LL LEARN

✅ What a jumbo employer actually needs from a TPA or ASO, versus what many are getting instead: a de facto health plan charging health-plan-level fees

✅ Why the market genuinely lacks effective, independent TPAs that aren't owned by a health plan — and why that ownership structure tends to choke off both cost and quality data sharing

✅ What recent lawsuits against major carriers reveal about the scale of undisclosed fees flowing through TPA and ASO arrangements

✅ Why direct contracting between employers and providers is gaining traction as a way around TPA and health plan inertia

✅ Why some regional health plans are quietly doing this differently, and what that suggests is actually possible at scale

WHY THIS MATTERS

Employer inertia gets a lot of attention, but it's only part of the story: TPAs, ASOs, and health plans have their own structural reasons for maintaining the status quo, and those incentives don't always point toward serving the self-insured employers paying the bills. Lawsuits alleging hundreds of millions in undisclosed fees aren't outliers; they're a signal of just how much money is at stake when these entities operate with limited transparency and limited accountability. For jumbo employers trying to actually deploy their health benefits well, understanding where TPA and health plan incentives diverge from their own is a prerequisite to fixing it — whether that means direct contracting or simply demanding better data.

MENTIONED IN THIS EPISODE

Encore! EP337 with Olivia Webb: Apple Podcasts | Spotify | Other Apps

EP427 with Rik Renard: 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

🎤 Listen on Apple Podcasts

🎤 Listen on Spotify

📺 Subscribe to our YouTube channel

=== CONNECT WITH THE RHV TEAM ===

✭ LinkedIn ✭ Threads ✭ Bluesky ✭ X

00:00 Introduction.

06:48 What is the overarching context for health plans in healthcare purchasing?

09:00 Encore! EP337 with Olivia Webb.

11:44 Why is it important to reestablish a connection between the people paying for care and people providing care?

14:07 What are the needs of a self-insured employer when managing employee benefits?

19:41 Is it doable for employers to set their own contracts?

22:11 Is transparency presumed?

23:25 Will the new transparency upon us actually expose wasted expense?

27:45 "This is not about individual bad actors. … The systems … that is not aligned."

29:32 Are there providers who want to work directly with employers?

32:46 Why is it important that incentives need to be aligned?

34:25 Why is the quality of care even more important than transparency?

36:29 EP427 with Rik Renard.

38:08 What's missing from the conversation on changing health plans?

It costs providers roughly 14% of a transaction's value just to get paid for it, and payers tack on another 5% to 15% just to pay it — putting 20% to 30% of every healthcare transaction into pure administrative waste before anyone talks about redundant care or unnecessary procedures. David Scheinker, PhD, executive director of systems design and collaborative research at Stanford Children's Health, joins Stacey Richter in this encore episode to explain why that waste persists even though everyone agrees it's a problem — and to lay out a genuinely actionable fix: standardizing healthcare contracts the way industries like derivative trading and credit card processing already have.

WHAT YOU'LL LEARN

✅ How much administrative cost is actually baked into a typical healthcare transaction on both the provider side and the payer side, and how that adds up to 20% to 30% of total spend

✅ Why derivative traders cut their per-contract cost from $100,000 to $5,000 by standardizing how they transact — and why healthcare hasn't done the same, despite obvious parallels

✅ What it would mean to standardize healthcare contracts around shared "parameters" — similar to how Airbnb lets every listing negotiate price around a common set of defined variables like bedrooms and bathrooms

✅ Why some organizations actually profit from the current transactional waste, and why legacy technology, sunk costs, and CMS-driven regulatory complexity all work against collaboration

✅ Why Surescripts — created by a group of competing PBMs who needed a shared e-prescribing platform — is proof that healthcare competitors can and do collaborate around a genuinely common pain point

WHY THIS MATTERS

Administrative burden in healthcare isn't an unsolvable mystery; it's a coordination problem that other industries facing similar friction have already solved by standardizing how they transact. The obstacle isn't a lack of a workable solution — it's that some organizations profit from the current mess, legacy systems are expensive to unwind, and regulatory complexity makes collaboration harder than it needs to be. For anyone trying to reduce the real cost of getting paid and paying in healthcare, Dr. Scheinker's research points to a concrete, non-theoretical path forward: standardized contract parameters that leave plenty of room for competitive negotiation while making the underlying transactions dramatically cheaper to execute.

=== 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 ===

✭ LinkedIn ✭ Threads ✭ Bluesky ✭ X

00:00 Introduction

10:39 What's the quantitative administrative cost in an average transaction?

11:05 What's the quantitative administrative cost in a healthcare transaction?

11:58 What does the healthcare billing and administration cost add to the US's overall healthcare spend?

12:53 Is it possible to cut billing and administrative costs in healthcare?

14:17 "In some ways, the problem for healthcare should be simpler."

15:30 What does the complexity of the current system look like in a doctor's office?

18:42 How did David go about studying healthcare administrative costs?

21:34 "It doesn't have to be simple; it should be standardized."

24:50 What would be the pushback on standardizing contracts in healthcare?

25:43 Why is it possible to gain more value by losing customization in contracts?

27:20 "Never let a good crisis go to waste."

27:41 "It's much easier in healthcare to build something new than to change something that exists."

30:47 What benefits does telemedicine have to cutting administrative costs?

32:17 What is another significant benefit of using standardized contracts?

33:26 Why haven't standardized contracts become a common thing in the current healthcare system?

Practicing medicine without considering pharmacy is like getting to the 90-yard line, putting down the ball, and walking off the field — and yet almost no mainstream contract holds a PBM accountable for the downstream medical costs caused by suboptimal pharmacy benefit design. Dan Mendelson, CEO of Morgan Health at JPMorgan Chase, joins Stacey Richter to dig into five vital considerations for optimizing pharmacy benefits within value-based care, building on a LinkedIn post he wrote that kicked off this whole conversation.

WHAT YOU'LL LEARN

✅ Why pharmacy benefits have to be managed by a clinical team and integrated into the overall context of care — not purchased and siloed separately from medical benefits

✅ Why pharmaceutical companies need to be ready to contract on the basis of value, and what that actually requires from a manufacturer

✅ Why evidence requirements in pharmacy benefit design are good for everyone involved, including patients, plan sponsors, and manufacturers

✅ Why pooling risk matters for optimized pharmacy benefits, and how to do it without simply handing the problem to an insurance company

✅ Dan's specific advice for hospitals, primary care doctors, and entrepreneurs trying to operate in a value-based world where "buy and bill" no longer makes sense

WHY THIS MATTERS

Total cost of care, value-based medical care, and pharmacy benefits are not separate worlds, even though they're so often purchased and managed as if they were. A patient who gets an expensive organ transplant but can't afford the anti-rejection meds, or who's told to take insulin they can't afford, represents a system that optimized the medical side while leaving pharmacy as an afterthought — and the downstream costs of that gap land on patients, employers, and the system as a whole. Building pharmacy benefits with the same rigor, accountability, and clinical integration as medical benefits isn't optional if value-based care is the actual goal.

MENTIONED IN THIS EPISODE

Encore! EP206 with Ashok Subramanian: Apple Podcasts | Spotify | Other Apps

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

EP431 with Kenny Cole, MD: 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

🎤 Listen on Apple Podcasts

🎤 Listen on Spotify

📺 Subscribe to our YouTube channel

=== CONNECT WITH THE RHV TEAM ===

✭ LinkedIn ✭ Threads ✭ Bluesky ✭ X

00:00 Introduction.

04:50 How do we connect the dots between value-based care and pharmacy benefits?

07:43 Where do things need to go for employers in terms of drug spend integration?

08:42 How do we think about having a value-based component in the decision-making process?

09:44 How do we enable the necessary information to make proper decisions?

10:56 Encore! EP206 with Ashok Subramanian.

11:21 "Many payviders just haven't gotten to pharmacy yet; they need to."

14:14 Why do pharmaceutical companies need to be prepared to contract on the basis of value?

16:46 EP426 with Nina Lathia, RPh, MSc, PhD.

17:36 EP431 with Kenny Cole, MD.

18:07 Why is it important to "let the market work"?

21:04 Why do we have cost sharing, and when does it not make sense to have that as a co-pay?

23:59 Why are evidence requirements good for everyone?

28:45 Why is pooling of risk important?

29:49 How do you pool risk without going to an insurance company?

32:03 What is Dan's advice to hospitals?

33:30 "In a value-based world, buy and bill does not make sense."

33:36 What is Dan's advice to primary care doctors?

33:54 What is Dan's advice to entrepreneurs and innovators?

Most people who listen to this show know enough about bundled payments to be dangerous — which is exactly why Stacey Richter asked Ben Schwartz, MD, MBA, an orthopedic surgeon still in full-time clinical practice, what actually surprises people once they get past the basics. They walk through the four flavors of bundles currently in play — CMS bundles like BPCI and CJR, commercial carrier bundles, direct employer bundles, and condition- or diagnosis-specific bundles — and dig into why a program built to reward efficiency ends up penalizing the clinical teams who get too good at it.

WHAT YOU'LL LEARN

✅ What distinguishes the four types of bundled payments — CMS bundles (BPCI, CJR), commercial carrier bundles, direct employer bundles, and condition- or diagnosis-specific bundles — and why most current bundles are built around a surgical intervention

✅ Why CMS's BPCI bundles are being sunsetted, and how a program designed to reward efficient clinical teams ends up penalizing them once the goalposts keep shifting

✅ What surprises even people who already know the bundled payments landscape reasonably well

✅ Why direct employer bundles for musculoskeletal care are drawing entrepreneurial orthopedic surgeons who want to contract straight with employers and cut out the middleman

✅ How bundled payments connect to Centers of Excellence strategy, and where the model is likely headed next

WHY THIS MATTERS

Bundled payments are one of the clearer on-ramps to value-based care, but the mechanics matter enormously: a CMS program that rewards efficiency in year one and penalizes that same efficiency in year three teaches clinical teams the wrong lesson, and a bundle built around a surgical intervention doesn't translate cleanly to condition-specific care. For plan sponsors, health systems, and clinicians alike, understanding which type of bundle is in play, who's setting the rules, and how those rules shift over time is the difference between a bundle that drives real value and one that just shuffles risk around.

MENTIONED IN THIS EPISODE

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

EP346 with Peter Hayes: Apple Podcasts | Spotify | Other Apps

Encore! EP294 with Steve Schutzer, MD: Apple Podcasts | Spotify | Other Apps

EP331 with Al Lewis: Apple Podcasts | Spotify | Other Apps

Encore! EP372 with Cora Opsahl: Apple Podcasts | Spotify | Other Apps

EP373 with Cora Opsahl: 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

🎤 Listen on Apple Podcasts

🎤 Listen on Spotify

📺 Subscribe to our YouTube channel

=== CONNECT WITH THE RHV TEAM ===

✭ LinkedIn ✭ Threads ✭ Bluesky ✭ X

00:00 Introduction.

06:07 Where are we in the development of the bundled payments space?

08:09 What are the four types of bundled payments?

09:52 How can bundled payments create perverse incentives?

11:04 What are the positives in bundled payments, and how can they help push us toward value-based care?

13:02 What is surprising about bundled payments?

18:50 EP415 with Rob Andrews.

27:03 How do Centers of Excellence connect back to bundled payments?

29:00 EP346 with Peter Hayes.

30:29 Encore! EP294 with Steve Schutzer, MD.

33:38 EP331 with Al Lewis.

33:43 Encore! EP372 and EP373 with Cora Opsahl.

37:13 What does Dr. Schwartz think the future is for bundled payments?

Every week, self-funded employers get hit with a claims wire — a charge from their TPA or ASO vendor to cover plan expenses in weekly increments — and depending on how sophisticated the plan or its advisor is, that invoice might be a single lump total or a detailed breakdown. Justin Leader, president and CEO of BenefitsDNA, joins Stacey Richter to walk through five fees that frequently get buried inside that claims wire without ever showing up on an administrative invoice or in the ASO finance exhibit — plus a bonus mechanism, medical claims spread pricing, that moves money to vendors in ways plan sponsors often don't realize.

WHAT YOU'LL LEARN

✅ What a shared savings fee is — including how it can quietly extend to overpayment recoupment fees, where a TPA charges the plan sponsor a percentage of money recovered after correcting its own mistake

✅ How prior auth fees, prepayment integrity fees, pay and chase fees, and TPA claims review fees each work, and why several of them charge extra for functions a TPA is arguably already being paid to perform

✅ Why so many of these fees are structured as a percentage of vendor-reported (and largely unvalidated) savings — and why that means the fees quietly grow every year right alongside medical trend

✅ What medical claims spread pricing is, and how a plan sponsor can end up paying a provider more than the actual check written for the service rendered

✅ Why identifying, reviewing, and documenting every fee in a vendor contract needs to become standard practice ahead of every renewal or RFP negotiation

WHY THIS MATTERS

If a fee has to be hidden to get paid, that alone is a signal worth taking seriously — even when the underlying service is legitimate. The core problem isn't that TPAs and ASO vendors charge for extra work; it's that plan sponsors are frequently paying for that work without ever agreeing to a known rate, without visibility into what's being charged, and without any way to validate the savings those fees are calculated against. For any employer or plan sponsor trying to control healthcare costs, understanding exactly what's buried in the weekly claims wire isn't a nice-to-have audit exercise — it's the baseline information needed to negotiate from a position of actual knowledge rather than trust.

=== 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

🎤 Listen on Spotify

📺 Subscribe to our YouTube channel

=== CONNECT WITH THE RHV TEAM ===

✭ LinkedIn ✭ Threads ✭ Bluesky ✭ X

00:00 Introduction.

07:55 How is the claims wire typically explained to a plan sponsor?

11:18 What is the whole point of self-funding?

11:27 Why is it so vital to understand what you're paying for?

12:38 What are the five "buried" items that wind up in these claims wires?

13:03 What is a shared savings fee?

17:10 "Rates are important, but so are your rights."

21:01 What's going on with prior auth fees?

23:35 What is prepayment integrity?

28:16 What is pay and chase?

31:54 What is a TPA claim review?

35:47 Is there medical claim spread pricing?

Scott Conard, MD, grew a solo practice into a 510-clinician, value-based integrated delivery network that reduced the cost of care through prevention and proactive engagement — and then watched it get acquired by a hospital system whose incentives ran the opposite direction. In this encore episode, he tells Stacey Richter the story in detail, including how one North Texas health system managed to raise local healthcare spend by $100 million in a single year, partly by pulling back the population-health infrastructure that had been keeping patients out of hospital beds. It's a case study in what happens when margin quietly shoves mission off the bus — and Dr. Conard is careful to note that the people making these calls upstairs are rarely the doctors themselves.

WHAT YOU'LL LEARN

✅ Why a PCP can produce genuinely high-value care inside a fee-for-service model — if they're willing to change practice patterns and think of themselves as a risk-management expert, not just someone who treats symptoms

✅ What a "Whole-Person Risk Score" is, and how it helped move Dr. Conard's practice from a transactional model to a relationship model

✅ Why total cost of care — not just primary care cost — is the number that actually matters when evaluating a risk-based contract

✅ How a local health system raised North Texas healthcare spend by $100 million year over year, partly by scaling back the very population-health efforts that kept patients out of hospital beds

✅ Why "fiduciary responsibility" so often functions as a euphemism for decisions with questionable community benefit — and why that's a systemic incentive problem, not evidence of bad people

WHY THIS MATTERS

Dr. Conard's story is a case study anyone trying to level up primary care should sit with: doing the right thing clinically doesn't protect a practice from getting acquired, financialized, and repurposed toward incentives that undo the very outcomes it was built to produce. As he puts it, this isn't about villainizing the people inside not-for-profit hospital systems — it's about recognizing that even well-intentioned organizations operate under incentives that can quietly increase spend, reduce prevention, and produce moral injury in the clinicians caught in the middle. Fixing that requires looking at the system's incentive structure, not just the intentions of the people working inside it.

MENTIONED IN THIS EPISODE

Encore! EP335 with Brian Klepper, PhD: Apple Podcasts | Spotify | Other Apps

Encore! EP381 with Karen Root: Apple Podcasts | Spotify | Other Apps

EP364 with David Muhlestein, PhD, JD: Apple Podcasts | Spotify | Other Apps

EP384 with Wendell Potter: 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

🎤 Listen on Apple Podcasts

🎤 Listen on Spotify

📺 Subscribe to our YouTube channel

=== CONNECT WITH THE RHV TEAM ===

✭ LinkedIn ✭ Threads ✭ Bluesky ✭ X

00:00 Introduction

06:54 What triggered Scott's career journey?

07:31 What caused Scott to rethink what is good primary care?

08:11 Why did Scott realize that he is actually a risk-management expert as a primary care doctor rather than someone who treats symptoms?

09:25 Encore! EP335 with Brian Klepper, PhD.

09:53 How did Scott's practice change after this realization?

10:04 What is a "Whole-Person Risk Score"?

13:05 "You start to move from a transactional model to a relationship model."

15:31 Did Scott have any risk-based contracts?

16:08 Why is it so important to look at total cost of care and not just primary care cost?

22:13 Encore! EP381 with Karen Root.

30:43 Why did Scott move over to help corporations?

33:10 EP364 with David Muhlestein, PhD, JD.

33:51 "Everybody thought they were honoring their fiduciary responsibility, and the incentives are completely misaligned."

34:31 EP384 with Wendell Potter.

34:43 "It's the system that's broken; it's not bad people."

The front desk is usually the most physically walled-off part of any healthcare practice — a half-wall at minimum, sometimes a full glass barrier — and that architecture sends a message: this team has nothing to do with the mission of anyone else in the building. Jerry Durham, a physical therapist turned practice consultant and founder of The Client Experience Company, joins Stacey Richter in this encore episode to make the case that the front desk is actually the most overlooked lever for patient outcomes, clinician burnout, and practice success — and that treating it as a separate fiefdom is costing practices on all three fronts.

WHAT YOU'LL LEARN

✅ Why the front desk isn't just an administrative function but "phase two" of the patient life cycle — the moment a person first engages with a practice, with its own objectives and its own owner

✅ Why the front desk's three real objectives — building a relationship, being a problem solver, and setting the provider up for success — get replaced in most practices with a single, counterproductive goal: get everybody scheduled

✅ Why trust and expectations built before a patient ever reaches the exam room are what the research shows actually correlate with better outcomes

✅ Why an unoptimized front desk doesn't just hurt patient experience — it quietly drives clinician burnout by loading providers with the entire burden of patient success or failure

✅ Why culture change here can't happen from the middle of the org chart — it has to be driven by someone senior enough to sit where the front desk and clinical reporting lines actually meet

WHY THIS MATTERS

Provider organizations spend enormous energy on clinical protocols and data tools while treating the front desk as a separate, lower-stakes operation — even though it's the team setting expectations, building trust, and effectively pre-loading the outcome of every visit before the provider ever walks in the room. For any practice trying to succeed in value-based care, get into narrow or Centers of Excellence networks, or simply reduce clinician burnout, the front desk isn't a support function to optimize last; it's frequently the first and most consequential touchpoint a patient has with the entire system.

MENTIONED IN THIS EPISODE

EP236 with Liliana Petrova: Apple Podcasts | Spotify | Other Apps

EP228 with Julie Rish, PhD: 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

🎤 Listen on Apple Podcasts

🎤 Listen on Spotify

📺 Subscribe to our YouTube channel

=== CONNECT WITH THE RHV TEAM ===

✭ LinkedIn ✭ Threads ✭ Bluesky ✭ X

00:00 Introduction

05:49 What is the patient life cycle?

06:48 What are the milestones of the patient life cycle? When does it start?

10:05 "This isn't a business solution; this is a patient-driven solution."

10:21 "What is best for the patient is best for business."

13:25 "The takeaway there is that your team members are all driving toward the same goal."

14:34 How does the front desk impact health outcomes?

16:41 What is the objective of a front desk to reduce provider burden?

20:03 EP236 with Liliana Petrova.

21:18 "There's actually three roles at the front desk."

30:37 EP228 with Julie Rish, PhD.

Almost no digital health delivery solution providers measure outcomes of any kind — which raises an uncomfortable question: how do you know if the "waste" you're cutting to hit margin targets is actually waste at all? Kate Wolin, ScD, a behavioral epidemiologist who bootstrapped a digital health start-up to profitability before selling it to Anthem, joins Stacey Richter to talk about the knifepoint where margin and mission meet — and why the things that look most cuttable in the name of efficiency (slow conversations, relationship-building, trust) are often exactly what makes a clinical model work in the first place.

WHAT YOU'LL LEARN

✅ Why efficiency without a clear outcome in mind is efficient toward nothing — and why so few healthcare delivery solutions actually measure whether they're achieving anything

✅ Why the things that read as "waste" on a spreadsheet — time spent building trust, engaging patients, assessing risk — are often the load-bearing parts of a clinical model that works

✅ Why founders and investors being genuinely aligned on the pace of growth is essential, and what happens to clinical quality when they aren't

✅ Why clinical leadership and a team dynamic that allows for innovation — without sacrificing clinical soundness — has to be built in deliberately, not left to chance

✅ Why measuring what actually matters, and communicating it in a way that inspires a mission-driven culture, is what lets a team scale without losing what made it work

WHY THIS MATTERS

Every healthcare business eventually hits the same tension: the pressure to scale, cut costs, and satisfy investors runs headlong into the slow, relational, hard-to-measure work that actually produces good outcomes. Cutting the wrong things in the name of efficiency doesn't just risk patient outcomes; it risks the business model itself, since a solution that stops working stops being worth paying for. Dr. Wolin's advice — align founders and investors, protect clinical leadership's ability to innovate soundly, and measure what actually matters — is a practical checklist for anyone trying to keep margin and mission from cutting each other's throats.

MENTIONED IN THIS EPISODE

Encore! EP361 with Carly Eckert, MD, PhD(c), MPH: Apple Podcasts | Spotify | Other Apps

EP297 with Jerry Durham: Apple Podcasts | Spotify | Other Apps

EP427 with Rik Renard: Apple Podcasts | Spotify | Other Apps

EP421 with Jodilyn Owen: 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

🎤 Listen on Apple Podcasts

🎤 Listen on Spotify

📺 Subscribe to our YouTube channel

=== CONNECT WITH THE RHV TEAM ===

✭ LinkedIn ✭ Threads ✭ Bluesky ✭ X

00:00 Introduction.

06:24 Irrespective of money, what works in clinical care and population healthcare?

09:51 Encore! EP361 with Carly Eckert, MD, PhD(c), MPH.

10:26 Why is creating a gathering place and sense of community important in clinical care?

12:46 "Sometimes, we make this about the clinical provider. It always makes me think about the rest of the people in an ecosystem that create trust."

13:49 EP297 with Jerry Durham.

14:11 Where can things go wrong when we start to think about the margin in respect to the clinical care that works?

16:47 EP427 with Rik Renard.

19:35 "We're actually very unspecific in what we're trying to achieve a lot of times in these digital health programs."

24:00 "Are you aligned as a founder, as a business with your investors on the pace of growth and what is feasible … ?"

25:30 Why is Dr. Wolin optimistic about achieving growth and still providing value?

28:17 Why is it important to ask why something is being done?

30:39 EP421 with Jodilyn Owen.

34:35 How are people motivated, and how can you use that to reduce turnover?

35:21 Why measuring what matters and communicating that is important.

Dr. Kenny Cole splits his time between seeing patients one day a week as a primary care internist and serving as system vice president for Ochsner Health, where he designs and develops new care models. Stacey Richter talks with him about what it actually takes to make accountability for outcomes real in a clinical setting — measurable results, care flows that clinicians actually follow, and trust that patients can feel.

WHAT YOU'LL LEARN

✅ Why clinical teams have to be accountable for outcomes that are actually measurable — not just asked to "deliver good care" in the abstract

✅ Why clinical teams need to see with their own two eyes and believe that a clinical goal is achievable before they'll genuinely commit to it

✅ What a care flow is, and why getting everyone aligned on what best-practice care looks like — and operationalizing how to achieve it — matters as much as the goal itself

✅ Why building trust and connecting with patients isn't a soft nice-to-have, but something a standardized care flow has to be built to support

✅ Why aligning clinical pathways with financial viability is the real challenge for any practice or health system trying to pull away from the status quo

WHY THIS MATTERS

Accountability for outcomes sounds simple until someone tries to operationalize it inside a clinic. Dr. Cole's four points — measurable and accountable outcomes, clinical teams who believe a goal is achievable, care flows that operationalize best practice, and patient trust — aren't independent checkboxes; they're sequential dependencies. A clinical team won't commit to a goal it doesn't believe is possible, and a care flow patients don't trust won't produce the outcomes it was built to standardize. For anyone building, selling to, or working inside a health system trying to reinvent its business model, this is a working blueprint for how clinical excellence and financial viability actually get reconciled in practice — not on a strategy whiteboard.

MENTIONED IN THIS EPISODE

EP412 with Robert Pearl, MD: Apple Podcasts | Spotify | Other Apps

EP315 with Bob Matthews: Apple Podcasts | Spotify | Other Apps

EP242 with Marty Makary, MD: Apple Podcasts | Spotify | Other Apps

EP427 with Rik Renard: Apple Podcasts | Spotify | Other Apps

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

EP391 with Scott Conard, MD: Apple Podcasts | Spotify | Other Apps

=== LINKS ===

🔗 Show Notes with all mentioned links: Episode Page

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00:00 Introduction.

07:38 Is there an optimal care pathway where there might be a lot of treatment variability?

11:01 Why doesn't Dr. Cole like the terms "noncompliant" and "nonadherent"?

11:45 EP412 with Robert Pearl, MD.

13:50 Why is it important to start with the end in mind?

17:20 How do you scale clinical excellence?

20:21 EP315 with Bob Matthews.

21:15 EP242 with Marty Makary, MD.

23:49 Why is it important simply to demonstrate what's possible for better health outcomes?

24:58 EP427 with Rik Renard.

26:10 How do we reinvent the business model of healthcare?

27:50 EP415 with Rob Andrews.

30:06 EP391 with Scott Conard, MD.

38:37 Dr. Cole is published in various healthcare journals; check out his most recent article.