Relentless Health Value

Why do so many digital health entrepreneurs set their sights on selling to employers? Per Barbara Wachsman, former director of strategy and engagement for enterprise benefits at Disney and now senior advisor at Frazier Healthcare Partners, the answer is the same one Willie Sutton gave when asked why he robbed banks: because that's where the money is. Stacey Richter and Barbara dig into what it actually takes for a digital health vendor or point solution to successfully sell to employers — and, in the process, give employers themselves a rare look at what's happening on the other side of the sales table.

WHAT YOU'LL LEARN

✅ Why the market for a digital health solution only exists if the problem it solves is big enough that employers feel the fallout — and why plenty of smart entrepreneurs build something valuable for patients or clinicians that nobody will actually pay for

✅ Why Barbara Wachsman says HR purchasing decisions shouldn't really be driven by improving health and well-being for its own sake — the real driver is optimizing human capital to produce a productive employee and better business outcomes

✅ Why true differentiation matters as much as market need, and what Barbara considers the compelling "secret sauces" among today's standout digital health companies

✅ Why navigating an employer's internal politics and finding a genuine internal champion is essential Selling 101 — and why the sales cycle at jumbo employers can take far longer than most entrepreneurs expect

✅ Why vendors need to manage their investors' expectations on sale timelines just as carefully as they manage prospective clients, and what the Livongo story teaches about that balance

WHY THIS MATTERS

Selling to employers isn't just a go-to-market strategy; it's a bet that a vendor has correctly identified a problem employers feel acutely enough to pay to solve, packaged into something genuinely differentiated, sold through a real internal champion, on a timeline investors will tolerate. Get any one of those wrong, and the vendor joins the long list of entrepreneurs who built something valuable that nobody would fund. For employers, understanding this dynamic offers a useful gut check: a vendor's pitch reveals as much about what they think employers actually care about as it does about the product itself.

MENTIONED IN THIS EPISODE

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

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

Encore! EP372 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.

06:55 Why have people cottoned on to selling to employers, and is it a good direction to focus?

07:28 What are the three ways healthcare gets paid for in America?

07:46 Where is the profit in the healthcare system?

08:32 What does an entrepreneur really need to understand in order to sell to employers?

13:05 "It really is about producing a productive employee."

17:49 Why it's not enough to understand the market but you must also differentiate.

21:01 What's the biggest misunderstanding entrepreneurs have about per member per month?

24:10 What companies are standing out right now as differentiators?

28:02 Why is it important to also show that you are improving quality?

28:51 EP331 with Al Lewis.

28:55 EP427 with Rik Renard.

29:33 EP372 with Cora Opsahl.

30:07 Why is it important to find a strong champion who will advocate for you as a partner?

35:05 Why is it important to manage your investors and set appropriate expectations around the timeline of a sale?

36:21 What's the lesson to be learned behind Livongo?

Most pharmacy pricing acronyms — AWP, WAC, and the rest — refer to a number with a dollar sign in front of it, and it's nearly impossible for a patient or plan sponsor to know how much that number actually reflects reality. Luke Slindee, PharmD, senior pharmacy consultant at Myers and Stauffer (the accounting firm that calculates the NADAC benchmark on behalf of CMS), joins Stacey Richter to follow a drug's dollar from the manufacturer's list price all the way through wholesalers, pharmacies, and PBMs to what a patient or plan sponsor actually pays — and to explain why the one benchmark in this whole chain that isn't a black box is the one CMS itself administers.

WHAT YOU'LL LEARN

✅ What AWP (Average Wholesale Price) and WAC (Wholesale Acquisition Cost) actually mean, how manufacturers arrive at these list prices, and why the difference between them matters

✅ How the drug dollar moves from manufacturer to wholesaler to pharmacy, and why pharmacies so often end up buying a drug at one price from the wholesaler while getting reimbursed an entirely different price to dispense it

✅ How PBMs ended up doing three jobs at once — adjudicating patient claims, negotiating manufacturer rebates, and setting pharmacy reimbursement — and why that concentration of roles is what makes spread pricing possible

✅ Why spread pricing (charging the plan sponsor more than the PBM pays the pharmacy, then calling the difference a trade secret) can exist and persist when so much of the transaction happens under cover of darkness

✅ What NADAC (National Average Drug Acquisition Cost) is, how it's calculated from a retail price survey, and why it's one of the only benchmarks in the entire pharmacy pricing stack that reflects an actual, transparent average of what pharmacies pay

WHY THIS MATTERS

The opacity baked into pharmacy pricing isn't incidental — it's the mechanism that makes spread pricing and inflated PBM margins possible in the first place. When plan sponsors can't see what a PBM actually paid a pharmacy for a given drug, they have no way to know whether they're being charged a fair and reasonable price or quietly funding someone else's markup. Understanding acronyms like AWP, WAC, and NADAC isn't academic trivia; it's the literacy plan sponsors need to ask the right questions of their PBMs before they end up in a lawsuit like the ones discussed on this show recently.

MENTIONED IN THIS EPISODE

EP423 with Joey Dizenhouse: Apple Podcasts | Spotify | Other Apps

EP344 with Steven Quimby, 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.

09:52 Why is it important for plan sponsors to understand the going rate for every point in the supply chain?

10:21 How do manufacturers come up with a list price?

10:40 What does AWP stand for?

10:59 What does WAC stand for?

11:06 How are AWP and WAC numbers chosen by the manufacturer?

13:22 What is the difference between AWP and WAC?

14:54 How much are wholesalers paying to manufacturers?

16:43 How much is the pharmacy paying for branded drugs from a wholesaler?

17:34 Why might pharmacies be buying drugs for less than what wholesalers are paying?

19:22 EP423 with Joey Dizenhouse.

20:33 Why do things get weird when a PBM gets involved?

21:58 How does all of this work for generic manufacturers?

25:20 EP344 with Steven Quimby, MD.

26:15 How did Civica Rx come about?

32:21 What's the difference between the NADAC and the AWP value?

36:04 Luke discusses the downstream effects to pharmacies.

No prudent fiduciary would knowingly agree to pay 250 times more than the price available to anyone off the street — yet that's the core allegation in the J&J lawsuit, where the company is accused of paying upwards of $10,000 for a drug available for cash for about $50. Rather than rehash the gory details of the J&J and DOL v. BCBS lawsuits, Julie Selesnick, senior counsel at Berger Montague's Employee Benefits and ERISA group, joins Stacey Richter to answer the more urgent question: if you're a plan sponsor, broker, or employee benefit consultant, what should you actually be doing right now?

WHAT YOU'LL LEARN

✅ Why getting your claims data is step one for every plan sponsor — and why that may require renegotiating administrative services agreements and scrutinizing CAA-mandated compensation disclosures from every covered service provider paid more than $1,000, not just brokers

✅ Why plan sponsors now need to verify not just that claims were paid correctly, but that the prices themselves — especially for generic specialty drugs — are fair and reasonable

✅ Why a payment integrity vendor should never be the same vendor (or share a parent company with the vendor) processing your claims — and why that setup is an obvious conflict of interest

✅ What cross-plan offsetting is, why the Department of Labor and multiple courts have found it violates ERISA, and why it's still happening at the majority of health plans anyway

✅ Julie Selesnick's practical advice for administering a plan well: form a health and welfare committee with an independent fiduciary expert, and make sure every committee member gets real fiduciary training on prudence, loyalty, self-dealing, and prohibited transactions

WHY THIS MATTERS

The J&J and DOL v. BCBS lawsuits aren't really about two isolated bad actors; they're a preview of what happens when plan sponsors have the data to spot a problem, don't act on it, and get named in a complaint alongside their brokers and consultants. Julie Selesnick's advice isn't about panicking over an impending wave of litigation — it's about closing the gap between what plan sponsors are now capable of knowing and what they're actually doing with that knowledge, before a lawsuit forces the issue.

MENTIONED IN THIS EPISODE

EP408 with Chris Deacon: Apple Podcasts | Spotify | Other Apps

Encore! EP379 with AJ Loiacono: Apple Podcasts | Spotify | Other Apps

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

EP285 with Dawn Cornelis: 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.

05:48 What's happening with the J&J lawsuit?

07:38 What's going on with the DOL v BCBS case?

08:49 What do these cases mean for plan sponsors?

09:21 Why is engaging with claims data critical?

12:30 EP408 with Chris Deacon.

14:20 EP379 with AJ Loiacono.

16:58 What's one solution to avoiding a conflict of interest?

18:02 Why there's still not a total understanding about what to do with claims data once acquired.

20:58 NADAC (National Average Drug Acquisition Cost) to check pharmacy prices.

21:31 What advice do plan sponsors need to know that never gets recommended to them when dealing with conflicting interests?

27:02 EP337 with Olivia Webb.

28:41 EP285 with Dawn Cornelis.

30:24 "As a fiduciary, your money should only go to pay your plan's benefits, not to other plan benefits."

30:59 What's Julie's advice to advisors?

33:17 "Giving nonconflicted advice … is something you really can only do if you have no conflicts."

35:57 What's Julie's advice for administering whole plans?

Digital health vendors and virtual care point solutions only have a reason to exist if they perform better than traditional community providers — better outcomes, better affordability, better engagement. So how are they actually doing? Rik Renard from Awell, coauthor of a survey of 235 digital health professionals conducted with Health Tech Nerds, joins Stacey Richter with an answer that's more sobering than reassuring: 84% of digital health vendors say they use standardized care flows, but only 16% base those flows on scientific evidence, and a mere 7% actually measure whether their care flows are working across the metrics that matter.

WHAT YOU'LL LEARN

✅ Why 84% of digital health vendors report using care flows, but only 16% of those flows are actually grounded in scientific evidence

✅ Why just 7% of digital health vendors measure all four things needed for a real picture of performance: engagement and compliance metrics, financial metrics like revenue per patient, clinician-reported outcomes, and patient-reported outcomes (PROMs)

✅ What Rik Renard calls "black box care" — the inevitable result when a vendor can't measure what its care flows are actually doing, meaning it can't manage or improve them either

✅ Why a digital health vendor's different payer and purchaser customers can demand conflicting care flows that ladder up to entirely different goals, complicating any single standard of care

✅ Why employers who lack the clinical expertise to evaluate quality tend to default to evaluating vendors on cost and service alone — creating a race to the bottom where being cheap and pleasant beats being effective

WHY THIS MATTERS

Standardized, evidence-based care flows are what let a digital health vendor deliver consistent, measurable outcomes at scale instead of results that depend entirely on which clinician a patient happens to get. Right now, the vast majority of vendors either aren't building on evidence or aren't measuring the results closely enough to know if their approach is actually working — which means most employers and purchasers evaluating these vendors have no reliable way to tell genuine performance from a well-produced pitch deck. Rik Renard's advice for any employer vetting a vendor is straightforward: ask to see the actual care flows, ask if they're evidence-based, and ask exactly what gets measured.

MENTIONED IN THIS EPISODE

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

Encore! EP392 with Emily Kagan Trenchard: Apple Podcasts | Spotify | Other Apps

EP412 with Robert Pearl, 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.

09:26 Why should clinicians care about care processes and care flows?

12:05 Why do care flows and care processes have a bad reputation?

12:31 What components does a good pathway include?

14:51 Why pathways need to be looked at as a process of continuous reconfiguration.

17:15 Who did Awell survey about care processes and flows?

18:42 How many clinicians were using care flows, and what did those care flows look like?

25:45 EP315 with Bob Matthews.

26:44 EP392 with Emily Kagan Trenchard.

28:21 EP412 with Robert Pearl, MD.

30:01 "Just document something."

30:14 What was a shocking find from this care process survey?

31:06 Is AI the answer?

34:13 Why is it important to get the foundation of data correct before introducing AI?

34:51 How should employers use this information to vet vendors?

How Much EBCs and Brokers Really Make Off Plan Sponsors, With AJ Loiacono (Encore EP379)

Why the CAA Makes This a "Magical Moment" to Demand Broker Fee Disclosure. Encore Episode 379.

What if your broker or employee benefit consultant is collecting $40 per prescription in hidden compensation from your PBM — and you have no idea? In this encore episode, Stacey Richter revisits her conversation with AJ Loiacono, CEO of Capital Rx, about the often-hidden ways EBCs, brokers, and even TPAs get paid, and why the Consolidated Appropriations Act (CAA) — in force since December 2021 — makes this a "magical moment" for plan sponsors to demand full compensation disclosure.

WHAT YOU'LL LEARN

✅ Real examples of the money at stake: a rumored $40-per-prescription commission and a $6-per-script kickback mailed quarterly to a PO box, both tied to which PBM won an RFP the EBC itself wrote and judged

✅ Why the CAA makes disclosure a fiduciary requirement under ERISA — plan sponsors must ensure every direct and indirect compensation paid on a plan's behalf is reasonable and free of conflict, not just what they're billed directly

✅ The exact process for requesting disclosure: ask for actual dollar amounts, not percentages, give the EBC or broker 30 to 90 days to respond, and report non-response to the Department of Labor

✅ Why non-compliance risk compounds over time — once one employer reports a broker for non-disclosure, that becomes public, exposing every other self-insured employer who used the same broker to class action risk

✅ Why AJ Loiacono calls this a "magical moment" for plan sponsors and for the honest brokers, EBCs, and PBMs already operating transparently

WHY THIS MATTERS

The Department of Labor is now putting the same enforcement emphasis on healthcare benefits that it put on 401(k) plans in the early 2000s, and the CAA gives plan sponsors the legal standing to act on it. Ignorance isn't a defense: if a plan sponsor doesn't know how much their EBC or broker is actually making off the plan, they can't evaluate whether that compensation is reasonable — and as fiduciary, it's the plan sponsor who bears the risk of getting that wrong.

=== 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

07:09 Who can get in trouble for mismanaging employee funds?

07:48 "When you talk about conflicts of interest, they're everywhere."

13:13 "You're paying for access."

13:34 Why is it important to request that they disclose direct and indirect compensation?

14:04 What are the layers to these hidden fees and compensations?

18:13 What is a reasonable fee for a good plan admin?

19:27 "I think people need to take a step back and say, 'How many different ways are they getting compensated?'"

24:50 "The compensation is not just unreasonable, but if they were to move it, they would lose access to an entire column of revenue."

25:06 "For every good broker consultant, there's a horrible individual lurking out there and it's easy to figure out: Ask for them to disclose their fees."

28:08 "You can't win if you can't even pay the house fee to come in."

31:35 Why do you need to ask for disclosure, and what do you need to ask specifically?

32:21 What are some of the characteristics of a good plan consultant?

Poor pharmacy benefit strategy has documented, unintended consequences: rising costs of care, bankruptcies, and declining member satisfaction — and that's before considering the human cost when a plan denies access to a drug a patient genuinely needs. Nina Lathia, RPh, MSc, PhD, CEO of Healthcare Decision Making and a former senior technical advisor at the UK's National Institute for Health and Care Excellence (NICE), joins Stacey Richter to unpack why so many employers struggle to buy pharmaceuticals in a genuinely value-based way, and what a practical path toward one actually looks like.

WHAT YOU'LL LEARN

✅ The four structural reasons value-based drug purchasing is hard for employers: no real pricing leverage with Pharma, pharmacy spend siloed away from medical spend, mismatched time horizons between plans and actual employee tenure, and FDA approvals based on thin evidence for expensive new drugs

✅ Why a PBM optimizing purely for pharmacy-spend reduction has no incentive to consider the ER visits or disease exacerbations that denying a drug might cause down the line

✅ Nina Lathia's five-step framework for a value-based formulary: set a stated goal, think holistically about total health spend, know the calculated value-based price of a drug, explore risk-based or installment payment deals with manufacturers, and build in shared decision-making with plan members

✅ How genetic testing can help determine whether an expensive drug will actually work for a specific patient before they take on its cost and side effects — turning a purely financial gatekeeping decision into a genuine clinical and patient benefit

✅ Why employers need to get more comfortable saying "no" to certain drugs, and what separates that kind of principled no from an opaque, value-blind prior authorization denial

WHY THIS MATTERS

Cost containment and value-based purchasing sound similar but aren't the same thing, and confusing them produces exactly the failure modes Nina Lathia describes: plans that either deny needed drugs to save money in a silo, or approve everything and drive premiums beyond what anyone can afford. Genuine value-based purchasing requires employers to look past pharmacy-only cost metrics, engage with the actual clinical evidence, and build real decision-making processes with the people who will be affected. None of this is easy, but the alternative — letting cost containment substitute for value — guarantees somebody loses, whether that's the plan's finances or a patient's access to care.

MENTIONED IN THIS EPISODE

EP352 with Pramod John, PhD: Apple Podcasts | Spotify | Other Apps

EP353 with Pramod John, PhD: Apple Podcasts | Spotify | Other Apps

Encore! EP337 with Olivia Webb: 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.

06:34 What does cost containment mean?

07:43 Why is it important to consider health outcomes?

10:00 What does value-based purchasing mean in Pharma?

11:09 What are the principles of cost-effectiveness analysis?

12:50 Pharmacy plan time horizons versus employer time horizons.

14:42 Why is it increasingly important for payers to take a more global look at health and cost outcomes?

16:14 Why is the first step establishing a value-based price for drugs?

16:43 Why is the second step thinking about risk-sharing agreements with manufacturers?

19:20 What should an employer do if there's only one drug option and the price is too high?

21:20 What's a specialty carve-out solution?

21:26 EP352 and EP353 with Pramod John, PhD, of VIVIO.

22:10 Why should employers get more comfortable with saying "no" to certain drugs?

25:36 Why is patient engagement key?

28:23 What does "good" look like for employers implementing drug-spend changes?

29:51 EP337 with Olivia Webb.

About half the time, the cash price for a medical service is actually cheaper than the "negotiated" insurance rate — a fact that matters enormously given that roughly 90% of patients never meet their deductible in any given plan year. Marshall Allen, investigative journalist and founder of Allen Health Academy, joins Stacey Richter to explain, in concrete operational terms, how a "regular" clinical practice that still takes insurance can also accept cash from insured patients when it's the better deal — without abandoning insurance altogether, and without running afoul of contracts that sound like they forbid it.

WHAT YOU'LL LEARN

✅ Why nearly half of insured commercial patients say they're delaying or forgoing care due to cost — and why those patients are invisible to clinicians who only see the people who show up

✅ How offering a clear, fixed cash price can reduce costly no-shows, which run practices as much as $7,500 a month, by giving patients pricing certainty for a next-day appointment instead of a six-months-out unknown

✅ The practical building blocks a practice needs to start taking cash from insured patients: a proper form, an actual set cash price, and a plan for how to market that option

✅ How Marshall Allen addresses the biggest objection practices raise — the belief that health plan contracts legally forbid accepting cash from an insured patient — including how HIPAA gives patients the right to request this

✅ Where to find fair-pricing benchmarks for setting a cash price, including tools like FAIR Health Consumer, BILLY, ColonoscopyAssist, Jason Health, and Green Imaging

WHY THIS MATTERS

This isn't a pitch for cash-only concierge medicine; it's about giving ordinary insurance-taking practices a legitimate, patient-friendly option for the very common situation where insurance makes care more expensive, not less. Practices that ignore this reality lose patients to care abandonment and revenue to no-shows, while patients who could have simply paid cash instead absorb costs they can't actually afford. Marshall Allen's framework turns a widely misunderstood pricing quirk into an accessible fix that benefits both sides of the exam table.

MENTIONED IN THIS EPISODE

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

EP413 with Will Shrank, MD: Apple Podcasts | Spotify | Other Apps

EP297 with Jerry Durham: 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.

07:04 What Allen Health Academy is doing.

11:01 What's the problem with the system now?

14:19 EP363 with David Scheinker, PhD.

14:27 EP413 with Will Shrank, MD.

14:34 What's the hack Marshall Allen shares for insured patients paying cash?

15:06 How can patients cite HIPAA to pay cash instead of using their insurance?

19:00 What's the first recommendation Marshall Allen has when dealing with healthcare billing?

21:26 EP297 with Jerry Durham.

21:48 What are the other benefits of a clinic accepting cash payments?

25:36 Why do we need to have more direct pay happening?

26:36 How should a medical provider set a cash price?

27:12 Research tools for fair pricing: fairhealthconsumer.org, BILLY, colonoscopyassist.com, Jason Health, Green Imaging.

32:36 How do you find the win-win between a patient and a doctor?

32:51 What's the final tier of partners in creating more direct-pay opportunities?

34:30 What's Marshall Allen's opinion on having to pay credit card fees?

Vegans and vegetarians who can't stand each other. Fantasy football leagues with bitter internal schisms. Branches of the same religion at war with one another. Stacey Richter uses these examples to introduce "the narcissism of small differences" — the psychological tendency for people who are mostly aligned to fixate on their remaining disagreements rather than uniting around what they share. In this solo inbetweenisode, she applies the concept directly to healthcare reform: while massive, well-funded, well-organized profit-extracting entities consolidate market power unchecked, the people trying to fix the system for patients keep splintering into micro-camps and sniping at each other over whose cause matters most.

WHAT YOU'LL LEARN

✅ What "the narcissism of small differences" means, and why it explains so much needless infighting among people who are actually 95% aligned on healthcare reform

✅ Why Jeff Hogan's framework for vetting conferences — is this a genuine platform for change, or an echo chamber for the same legacy incumbents who created the problem — is a useful gut check for evaluating any organization or event claiming to champion patients

✅ Why a corporate "transparency" talking point, repeated six times in five minutes by a PBM CEO, deserves scrutiny against what that entity's business model actually does

✅ Why working inside a profit-driven company doesn't automatically disqualify someone from being a genuine ally for patients — and why the people with the power to move the needle incrementally, at scale, are often still employed by the organizations we're skeptical of

✅ Why almost everything in healthcare sits on a matter of degrees — tip too far one way and costs exceed value delivered, tip too far the other way and the organization doing genuine good goes out of business

WHY THIS MATTERS

Achieving a real tipping point against consolidated, well-funded profit machines in healthcare requires mass — a village, not a handful of purists agreeing on every detail. When people who are mostly aligned spend their energy relitigating the 5% they disagree on instead of building on the 95% they share, the only winners are the entities with zero interest in patient outcomes at all. Stacey's point isn't that everyone working inside imperfect systems is beyond reproach — it's that reflexively excommunicating allies over minor differences, instead of judging people by whether their work actually moves outcomes for patients, guarantees the village stays too small to win.

=== 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

00:42 What "the narcissism of small differences" means.

02:18 How does this narcissism of small differences show up in the effort to fix the healthcare industry?

05:26 Quote from Jeff Hogan.

10:12 "What did the work we do add up to?"

16:31 Why we shouldn't judge someone for working within the "belly of the beast."

Not all hospital chains are the same, but today's conversation is about the big, rich, consolidated ones with the market and political power to shape entire regional economies. Peter Hayes, the recently retired president and CEO of the Healthcare Purchaser Alliance of Maine, joins Stacey Richter to lay out five things these behemoth health systems need to get real about in 2024 — even while they hold nearly unchecked leverage over the self-insured employers and communities that fund them.

WHAT YOU'LL LEARN

✅ Why the Consolidated Appropriations Act obligates plan sponsors to pay only "fair and reasonable" prices for medical care — and why that legal obligation is becoming one of the real levers moving hospital pricing behavior

✅ Why health systems need to get ruthlessly aggressive about administrative and technology efficiency just to survive shrinking commercial reimbursement, especially as administrative costs have dwarfed growth in what hospitals pay their actual clinical staff

✅ Why the shift from fee-for-service to real downside-risk, outcomes-based reimbursement means moving from maximizing patient revenue to maximizing patient health

✅ Why hospitals need to be transparent and accountable about how they use their tax-exempt status and the estimated $55 billion in net margin they realize from the 340B drug program

✅ Why patient safety can't stay an afterthought: about 46% of US hospitals carry a Leapfrog grade of C or lower, and the chance of a fatal avoidable error is 90% higher at those hospitals than at an A- or B-rated one

WHY THIS MATTERS

None of Peter Hayes's five things individually will topple consolidated hospital systems' market power on its own — but per Peter, tipping points rarely come from one single force. They come from a confluence: new legal obligations under the CAA, employers running out of room to absorb rising costs, transparency tools exposing price variation, and states starting to demand accountability for tax-exempt and 340B dollars. Nearly half of Americans have already delayed or forgone care due to cost, and record insurer and hospital-executive profits sit uneasily next to nurses and hospital staff who themselves rank among the groups most burdened by medical debt. The pressure is mounting from multiple directions at once, which is usually how real change actually arrives.

MENTIONED IN THIS EPISODE

EP390 with Gloria Sachdev, PharmD, and Chris Skisak, PhD: Apple Podcasts | Spotify | Other Apps

EP373 with Cora Opsahl: Apple Podcasts | Spotify | Other Apps

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

EP394 with Vikas Saini, MD, and Judith Garber, MPP: 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.

08:04 Why do hospitals need to get real about the implications of the Consolidated Appropriations Act?

10:09 What is considered fair pricing for hospitals?

13:00 EP390 with Gloria Sachdev, PharmD, and Chris Skisak, PhD.

15:59 The medical transparency tool, Billy.

16:34 How does lowering prices become more challenging with consolidated hospital systems?

18:07 What is one of the solutions available to combatting this now?

19:31 Why do hospital systems need to get real about administrative and technology efficiencies?

22:27 EP373 with Cora Opsahl.

26:51 Why do hospitals need to get real about pivoting from fee-for-service reimbursement to episode-based care?

30:16 EP415 with Rob Andrews.

30:53 Why do hospitals need to get real about the 340B program and their tax-exempt status?

35:38 EP394 with Vikas Saini, MD, and Judith Garber, MPP.

38:19 What are the ethical and moral issues that are coming to a head with healthcare costs?

39:03 Why do hospitals need to reexamine their care quality and patient safety?

40:05 "We just need to make sure that the health industry is as accountable as some of our other industries."

42:53 Why does Peter think it's going to take regulation to move the dial?

Copay maximizer programs started as pharma's workaround to PBM formulary leverage — cover the patient's out-of-pocket cost so a drug stays viable even when the PBM won't put it on formulary. But per Joey Dizenhouse, FSA, MAAA, CEO of SlateRx, that original chess move has since spawned an entire industry of maximizer and "the drug's not covered" schemes that plan sponsors are told will save money, and sometimes do the opposite. Stacey Richter walks through exactly how these programs work, who profits, and what a self-insured employer should actually be asking before signing on.

WHAT YOU'LL LEARN

✅ Why copay maximizer and copay accumulator programs exist in the first place — as pharma's response to PBM formulary leverage over patient out-of-pocket costs

✅ The two scenarios that determine whether a maximizer program actually helps a plan: one where a drug has no cheaper alternative and patients are simply protected from a huge annual out-of-pocket cost, and one where a cheap, equally effective alternative exists but patients are steered toward the expensive option because their out-of-pocket cost is zeroed out

✅ The difference between the "spread model" and the "transparent model" of maximizer programs, and why Joey Dizenhouse says the question to ask any vendor is simply, "How do you make money? Prove it"

✅ How the "the drug's not covered" approach works, and why it's often pitched to plan sponsors as savings without disclosing the misaligned incentives underneath

✅ Joey's three pieces of advice for any self-insured employer evaluating these programs: do real purchasing due diligence, don't assume your PBM contract is above average just because everyone assumes theirs is, and actually talk to plan members using these drugs instead of trusting the vendor's own satisfaction claims

WHY THIS MATTERS

Maximizer programs aren't inherently good or bad — the same mechanism that protects a patient from an unavoidable $8,000 annual out-of-pocket cost can just as easily steer another patient toward an $8,000 drug when a $70 alternative would have worked just as well. The deciding factor isn't the program's marketing; it's whether the vendor running it makes more money when drug costs go up. Any self-insured employer that doesn't ask, and verify, how its maximizer vendor actually gets paid is trusting an entity with directly misaligned incentives to police its own pharmacy spend.

MENTIONED IN THIS EPISODE

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

=== LINKS ===

🔗 Show Notes with all mentioned links: Episode Page

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00:00 Introduction.

06:21 How was the first iteration of maximizers conceived?

10:59 "I'd always encourage you to come back to the underlying incentives."

11:18 What does maximizer acceleration look like?

12:24 What are the two kinds of maximizers?

12:43 What is the spread model for a maximizer?

13:02 What is the transparent model for a maximizer?

15:26 "Ask the questions: How do you make money? Prove it!"

15:56 EP419 with Andreas Mang.

16:25 How might Pharma be making more money with maximizers?

26:14 What is the "it's not covered" approach?

32:29 "The right kind of program has been properly narrowed."

33:51 Is there a purpose that some of these programs can serve, issues aside?

35:57 How does a free drug program actually cost money?