Relentless Health Value

What would you do if you owned an independent pharmacy and discovered that nearly all of your profit came from just 10% of the prescriptions you fill — and that you'd actually make more money by firing most of your staff and refusing to fill the other 90%? That's the math Benjamin Jolley, PharmD, a third-generation independent pharmacy operator and consultant, lays out for Stacey Richter in this episode, a natural companion to the recent conversations with Mark Cuban and Ferrin Williams (EP418) and Ge Bai (EP420). And here's the kicker: the 10% of drugs that actually make an indie pharmacy money are, unsurprisingly, the exact same drugs that PBM-owned mail-order pharmacies mandate get filled through them instead.

WHAT YOU'LL LEARN

✅ Why roughly 10% of prescriptions generate nearly all of an independent pharmacy's profit — and why that 10% happens to be the same drugs PBM-owned mail-order pharmacies steer away from independents

✅ The two ways an indie pharmacy actually loses money on a prescription: when the PBM-mandated reimbursement is less than the drug's acquisition cost, and when the dispensing overhead (like the pill bottle itself) exceeds the profit on an ultra-cheap generic, even at a 100% margin

✅ Why what a patient pays at the counter has no real relationship to what the pharmacy is actually paid or to what the employer plan spends — because the PBM sitting in the middle controls all three independently

✅ Why, per Ge Bai's research (EP420), $41 of every $100 spent on generic drugs goes to the PBM — and why patients paying cash out of pocket often come out ahead of patients using their own insurance

✅ What Benjamin Jolley thinks independent pharmacies and employers can actually do to make the PBM less relevant to a transaction it has no legitimate role in

WHY THIS MATTERS

The core absurdity here is structural: a third party that never touches the drug, the patient, or the pharmacy's costs still controls what everyone pays and gets paid — and does so in a way that specifically starves independent pharmacies of the 10% of prescriptions that keep them financially viable. Benjamin Jolley's math isn't a complaint about margins; it's a demonstration that the PBM's role in routine generic drug transactions has become disconnected from any value it actually adds. For employers and patients alike, that disconnect is exactly where the money is quietly disappearing.

MENTIONED IN THIS EPISODE

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

=== LINKS ===

🔗 Show Notes with all mentioned links: Episode Page

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00:00 Introduction.

04:47 Benjamin Jolley's recent revelation.

06:14 What are the 10% of drugs that provide all the profit for pharmacies?

09:21 What's happening with the other 90% of drugs that pharmacies are filling?

11:05 What is the breakdown of costs when fulfilling prescriptions and running a pharmacy?

18:50 EP379 with AJ Loiacono.

21:42 What is the "cost savings" within the "insane system" of PBMs not sharing profit with independent pharmacies?

23:00 What is one of the things that PBMs and pharmacies don't often talk about?

26:39 What can employers do so that patients aren't getting overcharged by PBMs?

27:51 "How do I make the PBMs irrelevant?"

33:30 What's the difference between an independent pharmacy delivery service and a service like Express Scripts?

34:36 What's the other potential solution in solving the problems independent pharmacies face, and why does Benjamin Jolley feel that it's not the best solution to pursue?

Electronic health records were purpose-built for billing — some have called them glorified cash registers — which means the vast majority of a person's health-relevant life never gets captured anywhere. Stacey Richter re-airs this conversation after attending both the NODE (Network of Digital Evidence) conference and an employer-focused summit with the Pittsburgh Business Group on Health, because what Emily Kagan Trenchard describes isn't a nice-to-have for digital health entrepreneurs; it's a must-have for the self-insured employers quietly paying for every fragmented, unsupported patient journey through escalating commercial rates. Emily is SVP and chief of consumer digital solutions at Northwell Health, New York State's largest health system (21 hospitals, 850 outpatient clinics, 300,000 patients a year), and a former spoken-word poet who now works to put the human back into healthcare's digital infrastructure.

WHAT YOU'LL LEARN

✅ Why EHRs, built around federal billing mandates, only capture the narrow slice of a person's life when they're actively a "patient" in a clinical encounter — and why everything that happens on someone's couch, with their COPD medication or their support network, falls outside that architecture entirely

✅ Emily Kagan Trenchard's four "tentpoles" health systems need to properly support patients and everyone around them: the EHR, a CRM (treated as a relationship-building philosophy, not just software), a cloud platform for data and analytics, and a data exchange

✅ The two facts driving Emily's thinking: providers and patients are increasingly intolerant of friction, and whatever is easiest is what people will actually do — the same logic Amazon and Google already build around

✅ Why treating population health seriously means understanding a patient's network of relationships — caregivers, family, community — not just the patient as an isolated data point, something EHRs are structurally unsuited to do

✅ Why non-purpose-built technology doesn't just frustrate patients; it drives clinician burnout and turnover, which is its own expensive, measurable cost to health systems

WHY THIS MATTERS

Every fragmented, friction-filled patient interaction that falls outside the EHR's billing-shaped architecture is a cost somebody eventually pays — usually the self-insured employer footing the bill through ever-escalating commercial rates. Emily Kagan Trenchard's framework reframes digital health investment not as a marketing or patient-experience nicety but as core infrastructure, on par with the clinical tech stack. Health systems that keep defaulting to the EHR as the center of the universe are optimizing for billing, not for the actual people — patients and everyone around them — the system is supposed to serve.

=== LINKS ===

🔗 Show Notes with all mentioned links: Episode Page

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00:00 Introduction

07:08 How does customer digital solutions fit into the larger technology infrastructure in healthcare?

09:07 "Where else do you have centers of gravity that you should respect in the architecture?"

09:25 "There is a constellation of need here."

11:05 "We interact with way more than just patients."

13:42 "We have to be able to understand the network of relationships in a population."

14:25 How do EHRs and CRMs interact as two tentpoles in healthcare?

16:45 "The question is, where does a human being work?"

19:07 How are patients staying on a nonfragmented care journey in a proactive way?

23:00 "Anybody who's a consumer of our digital offerings has a relationship with us."

28:46 "The medicine is being practiced not only on our physical bodies but on our digital bodies."

"You cannot make smart … decisions and be a fiduciary of a fund without having data," as Cora Opsahl, director of the 32BJ Health Fund, puts it. Stacey Richter is re-airing this conversation because it's the missing prerequisite behind nearly everything discussed on this show lately — the recent episodes with Andreas Mang (EP419), Dan Mendelson (Encore EP385), and Mark Cuban and Ferrin Williams (EP418) all assume an employer actually has the data to act on. 32BJ Health Fund, a self-funded plan covering 200,000 union members (doormen, maintenance workers, security, cleaners, and more across 11 states), demanded its data from every vendor and used it to remove an overpriced hospital system from its network — saving $35 million and funding the union's biggest wage increase in years.

WHAT YOU'LL LEARN

✅ How 32BJ Health Fund got 100% of its vendors to hand over data, and why Cora Opsahl treats a vendor's reluctance to share data as itself a red flag

✅ How 32BJ used its data to remove an overpriced hospital system from its network, saving $35 million — enough to fund the union's biggest wage increase in years plus a premium holiday for employers

✅ Why validating vendor cost estimates with your own data almost always tells a different story than what the vendor projected, and why that matters before adding any new benefit or program

✅ Why siloing pharmacy and medical data lets one side claim savings while quietly shifting costs to the other — the "squeezing the balloon" problem — and why only fund-level data can catch it

✅ The three things data ultimately buys a self-insured employer or union: cutting wasteful spending and catching fraud, making validated (not guessed-at) benefit decisions, and forecasting trends far enough ahead to protect financial solvency

WHY THIS MATTERS

Every strategy discussed on this show for improving employer and union health benefits — auditing vendors, redesigning benefits, holding hospitals accountable — depends on first having the data to know what's actually happening inside the plan. 32BJ's $35 million hospital-network decision wasn't a hunch; it was a direct result of demanding and using data most funds never bother to collect. Employers and unions that skip this step aren't just leaving savings on the table — per Cora Opsahl, they risk becoming imprudent fiduciaries, a fact class action attorneys are increasingly aware of.

MENTIONED IN THIS EPISODE

EP285 with Dawn Cornelis: Apple Podcasts | Spotify | Other Apps

EP358 with Wayne Jenkins, MD: Apple Podcasts | Spotify | Other Apps

=== LINKS ===

🔗 Show Notes with all mentioned links: Episode Page

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00:00 Introduction

06:53 How much data does 32BJ Health Fund have, where do they get it, and how do they use it?

08:52 How did 32BJ Health Fund successfully demand their data from 100% of their vendors?

09:42 "We feel it's really important that we own this information ourselves."

10:05 "It always concerns me—if a vendor doesn't want to give you the information, what are they hiding?"

10:32 "It's not just getting the data; it's then using the data."

13:41 "Without data, you're really just taking a guess; and guesses are never gonna get you where you need to go."

15:19 EP285 with Dawn Cornelis.

15:40 Is the cost of creating a data analytics team worth the cost savings of those data discoveries?

19:03 "The use of data has really built our knowledge."

20:52 "It's really important to us that as we make benefit decisions, we're doing it smartly."

25:27 EP358 with Wayne Jenkins, MD.

25:38 How is 32BJ Health Fund making their data knowledge actionable?

28:11 "If we can figure out how to make telehealth accessible … there may be an opportunity for telehealth … to upset some of these … monopoly systems or low-choice options."

30:22 "It's really easy to think that we can solve this problem through benefit design … but in the end … it's the price."

"It's not a big mystery in the US economy that people do what you pay them to do," as Rob Andrews put it on this show a few weeks back (EP415). Stacey Richter opens this episode with his framing of maternal health's broken incentives — where a hospital system profits from a full NICU and carriers make the same money whether a baby is born healthy or in crisis — before turning to a clinic that proves the opposite is possible. Jodilyn Owen, clinical director of the Rainier Valley Birth & Health Center in one of the most linguistically diverse and medically underserved zip codes in Seattle, has built outcomes that beat the wealthy neighborhood down the road, where residents live 17 years longer. This episode is about how, and about the very unglamorous economics of getting anyone to actually pay for it.

WHAT YOU'LL LEARN

✅ Why Rob Andrews' framing of misaligned incentives — where hospitals profit from a full NICU and carriers earn the same fee regardless of outcome — sets up exactly why a clinic like Jodilyn Owen's stays hard to fund

✅ How Rainier Valley Birth & Health Center, serving a zip code with 79 languages spoken and designated as a provider shortage area, achieves far lower cesarean rates, NICU admissions, and gestational diabetes rates than the wealthy hospital across town

✅ Why Jodilyn's birth bundle costs $5,000 to $7,000 total — a fraction of what a single NICU admission costs — and why most payers still won't contract with her clinic despite the math

✅ Why Jodilyn Owen says her clinic's real "secret sauce" is trust, relationships, listening to the patient, and being genuinely embedded in the local community — not a novel clinical protocol

✅ Why Dave Chase's line that "every big problem in healthcare has already been solved" applies directly here — the challenge isn't discovering what works, it's replicating it at scale

WHY THIS MATTERS

Maternal health is a case study, but the lesson generalizes to primary care, chronic disease management, and anywhere the person actually providing good care isn't the one who financially benefits from it. Jodilyn Owen's clinic didn't out-innovate the healthcare system with new technology; it out-performed a wealthier neighborhood by treating patients as whole people embedded in a community, and it's still fighting for the contracts that would let it exist sustainably. If the industry is serious about better outcomes, the obstacle isn't knowing what works — it's whether payers and self-insured employers are willing to pay for it.

MENTIONED IN THIS EPISODE

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

Summer Shorts 3 with Vivek Garg, MD, MBA: Apple Podcasts | Spotify | Other Apps

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

=== LINKS ===

🔗 Show Notes with all mentioned links: Episode Page

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🎤 Listen on Apple Podcasts

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=== CONNECT WITH THE RHV TEAM ===

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00:00 Introduction.

07:12 How much cost savings is there when you avoid a NICU admission?

09:43 How is "slow care" feasible among an ob-gyn shortage in many communities?

10:42 "Start people at the risk that they are appropriate for."

11:37 EP407 and Summer Shorts 3 with Vivek Garg, MD, MBA.

13:50 "To effect change, we have to unwind what has been wound so tightly and so carefully through medical … education."

14:13 "It's not a people problem; it's a system problem."

18:46 What does relationship-based care mean?

22:32 "Everything in pregnancy at least is a trend."

28:01 How does Jodilyn's practice work with payers?

31:08 EP409 with Larry Bauer, MSW, MEd.

32:24 Why is it important to address the root of this problem in the education space?

Cash-pay generic drugs sound like a fringe idea until you look at the numbers: for patients in their deductible phase, paying cash beats the price their PBM "negotiated" 79% of the time. Following on directly from last week's conversation about the financialization of health benefits (EP419), Stacey Richter talks with Ge Bai, PhD, CPA — a professor of accounting at Johns Hopkins Carey Business School who studies nothing but healthcare dollars — about two studies that reframe how cheap generic drugs actually get priced, and about who really profits when a patient runs a $3 prescription through insurance instead of just paying for it.

WHAT YOU'LL LEARN

✅ Why generic drugs are already cheap thanks to manufacturing competition — and why that undercuts the whole rationale for a PBM's market power to "negotiate" a better price

✅ The study showing that for patients in their deductible phase, paying cash for a generic beats the PBM-negotiated price 79% of the time

✅ Why PBMs, not manufacturers, pharmacies, or wholesalers, capture the largest margin in a typical generic drug transaction — by about 10 percentage points

✅ Why insurance and PBMs exist to pool risk, and why the administrative cost of spreading a $3 drug expense across an entire risk pool can end up costing more than the drug itself

✅ Why Ge Bai is skeptical that HSAs solve the affordability problem, given how much financial literacy they demand from patients who already can't reliably explain what a deductible is

WHY THIS MATTERS

Insurance and PBMs are built to pool risk for expensive, unpredictable events — not to add an administrative toll booth in front of a $3 prescription that's already competitively priced. When the intermediary designed to lower costs ends up capturing the largest margin in the transaction, the system isn't protecting patients from unaffordable care; it's manufacturing unaffordability out of something that was already cheap. Ge Bai's research suggests the bar for doing better by patients on generics is lower than most people assume — it just requires asking who actually benefits from routing a cheap drug through an expensive process.

MENTIONED IN THIS EPISODE

EP344 with Steven Quimby, MD: Apple Podcasts | Spotify | Other Apps

=== LINKS ===

🔗 Show Notes with all mentioned links: Episode Page

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00:00 Introduction.

06:13 What is the background on generic drugs that is need-to-know?

06:39 EP344 with Steven Quimby, MD.

07:04 Do we have affordability for generic drugs?

15:40 What's the policy failure around generic drugs?

18:34 Why is there a huge health equity issue?

20:13 How do PBMs have both a monopoly and a monopsony?

21:59 What should be the goal for cheap generics?

23:36 "Whenever we have no competition, we'll see high price."

26:00 What's the best approach to addressing operational challenges behind generic drug costs?

28:42 How do we solve generic drug costs on the back end?

31:15 "Healthcare insurance is not the same as health."

36:07 "It's time for us to reflect and think whether there is a better way to try."

Are you on the board of directors of a company? A shareholder of a publicly traded one? A CEO or CFO who reports to a board? This episode is for you. Following up on last week's conversation with Mark Cuban (EP418), Stacey Richter talks with Andreas Mang, senior managing director and CEO of Equity Healthcare at Blackstone, about how healthcare has become financialized at the exact moment health benefits became most companies' second-biggest line-item expense — and about the concrete, unglamorous purchasing discipline that can claw back 10% or more of that spend while improving employee health.

WHAT YOU'LL LEARN

✅ Why Andreas Mang says it's an "unnatural act" for a non-healthcare company to dig into its own health benefits — and why that reluctance is exactly what lets financial actors take a bigger slice of the pie

✅ Andreas's six-item checklist for cutting health benefit spend by 10% or more: year-round CFO engagement, self-insuring once you hit a certain size, choosing brokers/consultants against five hard criteria, RFP'ing carriers and TPAs every three years, running dependent eligibility audits, and cautiously leveraging pharmacy coalitions and stop-loss collectives

✅ The five things Andreas says need to be true of any broker or benefits consultant: real experience doing the job, a flat-fee compensation model, no product pushing, 30%-or-more of fees genuinely at risk, and simple termination provisions

✅ Why self-insuring can save 5% to 9% automatically once a company reaches the right size, and why that funding decision is "a CFO thing," not a healthcare thing

✅ Why "where there's mystery, there's margin" — and why the C-suite's discomfort with healthcare complexity is itself a business strategy for the vendors profiting from that confusion

WHY THIS MATTERS

This isn't a story about paying more or less for better or worse employee health — it's a story about what happens when nobody in the C-suite is minding the shop. When that happens, financial intermediaries simply take a larger share of a company's second-biggest expense line, and both the employer and its employees lose while nobody notices. Andreas Mang's list isn't theoretical: it's the same purchasing discipline companies already apply to every other major expense, just finally pointed at health benefits.

=== LINKS ===

🔗 Show Notes with all mentioned links: Episode Page

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🎤 Listen on Apple Podcasts

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=== CONNECT WITH THE RHV TEAM ===

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00:00 Introduction.

04:19 Why Andreas starts every conversation with the question, "How's your healthcare company?"

07:04 Why is it important, as a self-insured employer, to treat your business as a small healthcare company?

08:42 Why is it unnatural for companies to be providing health insurance?

10:13 What can be achieved when there is alignment between employers and insurers?

12:07 What things can a company do to reduce spend by 10%?

13:40 Why is it better to have CFO engagement in the benefits plan throughout the year?

15:51 Why does self-insurance save 5% to 9% for companies automatically?

17:41 "The funding isn't a healthcare thing; it's a CFO thing."

17:54 Why is it vital to have a reliable, trustworthy broker?

24:38 When is the last time your company has RFP'd their health plan?

27:06 Why does changing a health plan feel scary but is necessary?

27:58 What is an independent eligibility audit?

30:48 Why are employers better together?

34:02 How do employers truly get a flat-fee model with brokers?

"The Achilles' heel for most healthcare innovators is overlooking the role of change management," as a recent tweet from Rik Renard put it — the deal isn't sealed until the whole team is on board, and adoption never automatically follows a good idea. Stacey Richter is re-airing this conversation with Karen Root, director of experience strategy at Boehringer Ingelheim, because it fits squarely into an ongoing series for boards, CEOs, and CFOs of self-insured employers: last week's episode with Mark Cuban and Ferrin Williams (EP418) argued that dealing with healthcare's financialized layer requires customer centricity and change management at the employer level too. This conversation is about what it actually takes to drive transformation or innovation inside a very large organization, using pharma as the case study but applicable to just about any big, complicated institution.

WHAT YOU'LL LEARN

✅ Karen Root's six essentials for making organizational transformation actually stick: a compelling, realistic vision; systems thinking about who and what will be affected; identifying the right entry point (a quick win or emotionally resonant "moment that matters"); measuring both the quick win and the broader effort; a clear before-and-after story arc; and never forgetting you're dealing with human beings, not rational economic actors

✅ What the "J curve" is, and why every transformation effort hits a "trough of disillusionment" that can kill the whole initiative if leadership's vision or will isn't strong enough to push through it

✅ Why so many pharma companies say they're patient-centric while remaining fundamentally brand-centric — and why that gap shows up in the halls, not on the walls, in things like reps who get kicked out of hospital systems for adding little value

✅ Why starting with a small, well-chosen quick win (like fixing a common complaint pulled straight from call center logs) makes it much harder for skeptics to defend the status quo

✅ Why measuring transformation qualitatively as well as quantitatively matters, and why leadership needs an actual story to tell, not just a vision statement

WHY THIS MATTERS

Most large organizations don't fail at innovation because they lack good ideas — they fail because they underestimate the change management required to get an entire team, department, or company to actually adopt something new. Karen Root's framework treats the human, emotional, and narrative dimensions of transformation as just as essential as the strategy itself, which matters because the organizations that quit during the J curve's trough of disillusionment don't just lose that initiative — they poison the well for every future attempt at change.

=== LINKS ===

🔗 Show Notes with all mentioned links: Episode Page

✉️ Enjoy this podcast? Subscribe to the free weekly newsletter

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🎤 Listen on Apple Podcasts

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=== CONNECT WITH THE RHV TEAM ===

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00:00 Introduction

08:51 What skills does leading a large company in customer centricity require?

10:36 What needs to be included in a vision for customer-centric change?

11:01 "In transformation, we have to adjust the approach to that vision. We have to break it down into a couple of key steps."

11:39 What is the J curve?

12:26 "Disruption is going to happen; it's just how do we minimize its impact."

14:00 Why is hope so important for success in change?

17:22 "Leverage your people; understand where they are in the change curve."

26:24 "We can't manage what we don't measure."

26:33 "We have to not only measure in quantitative ways but qualitative."

27:35 What's the downside to not being able to innovate?

28:55 Why does leadership need to have a story to tell?

31:19 "We have to remember that these are human beings and to look for those tells."

Healthcare benefits are usually a company's second-biggest line-item expense after payroll, yet most CEOs and CFOs never actually dig into where that money goes. In this episode, Stacey Richter talks with Mark Cuban and Ferrin Williams, PharmD, MBA, chief pharmacy officer at Scripta, about what happened when Cuban actually looked into his own company's benefits program — and about the financialized layer of consultants, PBMs, and administrators sitting between employers and their employees' health that's quietly extracting hundreds of thousands to millions of dollars a year.

WHAT YOU'LL LEARN

✅ What Mark Cuban found when he actually dug into his own company's benefits program, and why it took him ten minutes to see the order of magnitude of what "trusted" consultants, PBMs, and ASOs were extracting from his business

✅ Why healthcare spend is disproportionately driven by a company's sickest employees — and why that means healthy employees' paychecks are effectively subsidizing a system CEOs and CFOs rarely examine

✅ Why rebates are going away without necessarily changing what PBMs actually earn, and what that reveals about how rebate-based pricing really worked

✅ How Mark Cuban Cost Plus Drug Company's direct-from-manufacturer, cost-plus-15%-plus-fees model routinely beats what plans pay their PBMs, and what Ferrin Williams and Scripta are building to help employees find the lowest-cost prescriptions

✅ Why CEOs and CFOs specifically hold the power to change healthcare economics for their companies — and why employers who skip that due diligence now risk ERISA-related legal exposure from their own employees

WHY THIS MATTERS

The healthcare benefits industry has been financialized to the point that opacity itself has become a business model, and per Mark Cuban, that opacity survives specifically because CEOs and CFOs treat healthcare benefits as someone else's problem. The fix isn't complicated in principle: roll up your sleeves, look at where the money actually goes, and push back the way Cuban did. But it does require the C-suite to treat health benefits with the same financial scrutiny they'd apply to any other multimillion-dollar line item — because right now, that scrutiny is exactly what's missing, and employees are the ones absorbing the cost of its absence.

=== 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

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=== CONNECT WITH THE RHV TEAM ===

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00:00 Introduction.

05:41 What was Mark Cuban's own journey as a self-insured employer with Cost Plus Drug Company?

06:56 What did Mark find when he decided to go through and look through his company's benefit program?

08:23 "When you think it through, you start to realize that money is being spent primarily by your sickest employees." —Mark

09:13 How do you get CEOs and CFOs of self-insured employers to realize that their sickest employees are the ones subsidizing their checks?

12:10 What is the role of insurance in healthcare?

13:42 "If you can't convince them, confuse them and hide it." —Mark

14:35 The reality behind getting a rebate check.

15:32 Why are rebates going away, and why isn't that changing PBM earnings?

18:17 How do you get CEOs and CFOs to dig into their benefits plan?

20:13 Does morally abhorrent move the needle?

20:47 "What we're trying to do is just simplify the [healthcare] industry." —Mark

23:33 What's been changing in consumer behavior?

24:18 "Transparency is a huge part of building that trust." —Ferrin

24:33 Why CEOs and CFOs really have the power to change healthcare.

31:42 What are Cost Plus Drugs' plans to expand?

38:36 Where is the future of the prescription drug market going?

41:25 What will happen to the prescription drug market in 10 to 20 years?

47:56 The wake-up call self-insured employers should be acknowledging now.

51:18 Where is the real change in the healthcare industry going to come from?

A physician practice can only truly transform from a fee-for-service volume machine into something built around health and value once it hits a tipping point: enough of its patients in value-based, risk-based arrangements to make accountability actually feasible. Self-insured employers, who cover roughly 150 million American lives, have an outsized opportunity to help local practices hit that tipping point — but most aren't offering any kind of accountable care arrangement at all. Stacey Richter is re-airing this conversation with Dan Mendelson, CEO of Morgan Health at JPMorgan Chase, as the first of an employer CEO/CFO trilogy on the podcast (Mark Cuban and Andreas Mang follow in the coming weeks), diving into the five concrete things Mendelson says self-insured employers should be doing right now to improve employee health.

WHAT YOU'LL LEARN

✅ Why physician practices need a critical mass of patients in value-based, risk-based arrangements before transformation away from fee-for-service becomes financially feasible — and why the whole community benefits once a local practice hits that tipping point

✅ Why self-insured employers, who collectively cover about 150 million American lives, are mostly not offering accountable care arrangements — leaving huge swaths of provider patient panels stuck in the FFS status quo

✅ Dan Mendelson's five things employers should do right now: expand access to accountable care models, invest in the data needed to assess health outcomes, align employee benefits with population health outcomes, prioritize care models that meet employees where they are, and make care navigation central to the benefits experience

✅ What Morgan Health is actually building to help self-insured employers execute on these five things, not just understand them in theory

✅ Why alignment has to include the 150 million Americans getting insurance through their employer, not just providers and payers, for value-based care to actually work at scale

WHY THIS MATTERS

Self-insured employers sit on enormous latent leverage: enough collective patient volume to tip local provider practices into genuine value-based transformation, with benefits that spill over to the entire community once that happens. But per Dan Mendelson, most employers are stuck doing this year what they did last year, which means their communities stay stuck too. Mendelson's five things aren't abstract advice — they're a starting checklist for any self-insured employer ready to use its purchasing power to actually move outcomes, not just costs.

MENTIONED IN THIS EPISODE

Article: Dan Mendelson's "5 Things CEOs Can Do Today to Improve Employee Health" (Forbes)

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

EP358 with Wayne Jenkins, MD: Apple Podcasts | Spotify | Other Apps

EP308 with Mark Fendrick, MD: Apple Podcasts | Spotify | Other Apps

EP334 with Sunita Desai, PhD: Apple Podcasts | Spotify | Other Apps

=== LINKS ===

🔗 Show Notes with all mentioned links: Episode Page

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00:00 Introduction

06:03 What does an accountable care model mean to a self-insured employer?

07:58 "This alignment of value will never work … if the 150 million Americans … getting their health insurance through their employer are not also aligned in the same way."

11:28 "We're offering them a higher level of service."

11:40 "Everything that we do is intended to be scalable and not just for us."

12:09 "We have an obligation to do better for our employees."

14:52 "Employers need to understand, the only way to get outstanding care is locally."

18:18 Why is getting quantitative metric data important?

20:58 "This is a much broader vision of accountable care than … primary care."

22:48 "Until everything is aligned, the employer is just not going to be providing an optimal product."

23:39 "There are substantial issues with … health equity, and employers are paying for the care of 150 million Americans in this country."

25:23 Is digital health access important for creating meaningful relationships between patients and providers?

29:50 What is the myth that employers need to tackle?

30:18 Why is care navigation important for employees?

Most payer-provider relationships aren't collaborative — they're fairly adversarial, especially from the standpoint of provider organizations trying to find a payment model that lets them actually do right by patients. In this episode, Stacey Richter talks with Josh Berlin, JD, CEO of Rule of Three, about the real why, what, and how of payer-provider collaboration: what actually motivates a payer to collaborate (since payers other than in their fully insured book are just intermediaries, not the ones bearing the risk), the five distinct kinds of collaboration that exist, and the five must-haves that determine whether any of them actually work.

WHAT YOU'LL LEARN

✅ Why "saving money" alone isn't actually a compelling reason for a payer to collaborate with providers — and what genuinely motivates payers instead: predictable spend, competitive differentiation, market resilience, margin, and Star Ratings/HEDIS-linked dollars

✅ The five kinds of payer-provider collaboration, ranked by depth of entanglement: sharing data, joint programmatic work like clinical pathways, joint ventures on narrow-network products, becoming capital partners, and full risk-bearing relationships where the provider gets a piece of the premium dollar

✅ The five must-haves Josh Berlin says any collaboration needs before it starts: complementary, scalable capabilities; shared goals and time horizon; flexibility on both sides; genuine skill at collaborating (not just stated intention); and compatible risk profiles

✅ Why "you have to be collaborative to collaborate" sounds obvious but is frequently an unexamined blind spot inside payer organizations — and what it actually looks like when a payer isn't

✅ Why Ochsner stands out as a real-world example of payer-provider collaboration working, and what a notable collaboration failure like Haven can teach about what goes wrong

WHY THIS MATTERS

Payer-provider relationships default to adversarial not because collaboration is impossible, but because most attempts skip the unglamorous prerequisites: shared goals, real flexibility, and the actual cultural capacity to collaborate rather than just the stated desire to. Josh Berlin's five-and-five framework gives both sides a concrete way to diagnose whether a proposed collaboration is set up to succeed before committing real time and capital to it — which matters, because plenty of providers and payers who've tried this confirm just how rare and hard-won a functioning collaboration actually is.

MENTIONED IN THIS EPISODE

EP359 with Dan O'Neill: 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.

06:06 Why should payers want to collaborate with providers?

09:46 "Collaboration … is bilateral. … Both sides, plan and provider, should be equally as interactive with the individual populations they work with."

12:37 What are the must-haves for collaboration between providers and payers?

13:10 What are the five different types of collaboration?

16:03 What are the five characteristics you want to be focused on in partnership?

22:16 In order to collaborate, do you have to be collaborative?

26:11 Ochsner as a great example of collaboration.

27:46 Episodes with David Carmouche, MD, and Eric Gallagher.

28:51 A collaboration failure in Haven.