Where Telehealth Reimbursement Policy Stands Right Now, With Josh LaRosa, MPP. Payment Parity, State Licensure, and the FFS Debate Hiding Inside Telehealth Policy. Episode 378. Stacey Richter talks with Josh LaRosa, MPP, vice president at Wynne Health Group, about the near-term future of CMS telehealth reimbursement and licensure flexibilities—and why the telehealth coverage debate is really a proxy for the larger fee-for-service versus value-based payment argument. WHAT YOU'LL LEARN ✅ Why Medicare currently has payment parity between in-office and telehealth visits, and what determines how much longer that lasts ✅ What pandemic-era telehealth "flexibilities"—including across-state-line licensure—are still in effect and which are at risk of expiring ✅ Why telehealth utilization concerns in a fee-for-service model don't apply the same way inside capitated or risk-based arrangements ✅ How the telehealth reimbursement debate is really a subset of the bigger FFS-versus-value-based-payment debate, not a standalone policy question ✅ Why patient safety concerns around telehealth fraud change shape once a practice isn't automatically paid more for doing more visits ✅ How individual states are shaping their own telehealth policy, using Arizona as a specific example WHY THIS MATTERS Telehealth coverage decisions often get discussed as if they're self-contained, but LaRosa's framing shows they're inseparable from the broader question of whether the underlying payment model is fee-for-service or value-based—and that context changes what "overuse" or "fraud" risk even means. Understanding where CMS reimbursement policy stands right now helps provider organizations and plan sponsors plan around genuine near-term uncertainty instead of outdated pandemic-era assumptions. === 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 📺 Subscribe to our YouTube channel 🎤 Listen on Apple Podcasts 🎤 Listen on Spotify === CONNECT WITH THE RHV TEAM === ✭ LinkedIn ✭ Threads ✭ Bluesky ✭ X 04:09 What is the story with telehealth policy right now? 06:08 What kind of flexibilities did HHS allow with telehealth after the pandemic? 09:46 Are we still under these pandemic flexibilities for telehealth? 12:15 Why isn't the government just making greater access to telehealth permanent? 18:24 How does telehealth lend itself to the risk of overspending when dealing with an FFS model? 21:13 Does telehealth fit into the new CMS fee schedule? 22:55 How do states factor into the future of telehealth? 24:40 What is Arizona doing specifically to improve and ensure the future of telehealth? 30:56 What's next in store for telehealth at the congressional level?

Collaboration Between Healthcare Providers, Payers, and Others Is Required to Improve Chronic Care Patient Outcomes (INBW35) Building on an earlier inbetweenisode, Stacey Richter distills a talk she gave at the Moving to Value Alliance symposium into the two major patient problems — care gaps and unaffordability — that can only be solved through healthcare stakeholder collaboration. WHAT YOU'LL LEARN ✅ Why "care gap" measurement often misses far more gaps than it catches ✅ How chronic care management by care gap is "like cooking with a fire extinguisher" ✅ Why financial toxicity is clinical toxicity, and why even insured patients still can't afford their care ✅ How to make healthcare more affordable by navigating patients to high-quality, fairly priced providers ✅ Why the business model of revenue maximization is the real root cause behind the lack of collaboration WHY THIS MATTERS Chronic care patients face two solvable problems — fragmented, gap-ridden journeys and unaffordable care — and both require genuine collaboration among stakeholders who don't always have aligned incentives. Success stories already exist at the local-market level; the work now is building the roadmap and the collaborations to scale them. === 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 📺 Subscribe to our YouTube channel 🎤 Listen on Apple Podcasts 🎤 Listen on Spotify === CONNECT WITH THE RHV TEAM === ✭ LinkedIn ✭ Threads ✭ Bluesky ✭ X 00:00 Introduction 01:41 What are the two major patient challenges in chronic patient care that can only be solved by collaboration? 01:56 What is the "care gap" problem? 03:19 EP361 with Carly Eckert, MD. 03:25 "Crappy prior auth processes create care gaps." 04:00 How do you eliminate care gaps proactively? 06:46 EP358 with Wayne Jenkins. 08:21 What is one way to make healthcare more affordable? 09:49 Why aren't more healthcare entities collaborating? 10:04 EP366 with Kevin Schulman, MD. 11:13 EP374 with Dave Chase. 11:18 EP372 with Cora Opsahl. 11:22 EP367 with Doug Hetherington. 11:25 Upcoming episode with Nick Stefanizzi. 12:00 EP364 with David Muhlestein, PhD, JD.

The Not Entirely New but Definitely Improved Way to Measure Primary Care, With Rebecca Etz, PhD (Encore! EP295) In this Encore, Stacey Richter revisits her conversation with Rebecca Etz, PhD, codirector of The Larry A. Green Center, about an 11-measure instrument built to fairly assess primary care performance — accounting for diverse patient populations without turning measurement into a procedural nightmare. WHAT YOU'LL LEARN ✅ Why measures are a form of communication, and why mismatched measures demoralize PCPs ✅ How financial incentives tied to hitting a target can distort what an EMR actually documents about patient health ✅ Why primary care is fundamentally a relational field, and why that matters for measuring quality ✅ How PCP practices can spend upward of $40,000 a year of uncompensated time reconciling mismatched measurement standards ✅ How the 11 measures performed differently during COVID, and what that revealed WHY THIS MATTERS Fair, well-validated primary care measures aren't a nice-to-have — they determine whether incentive programs reward the work PCPs actually do or push them toward gaming a target instead. Dr. Etz's 11-measure instrument, aligned across patients, clinicians, and payers, is a rare example of a measurement tool built from what primary care actually values rather than what's easiest to count. MENTIONED IN THIS EPISODE EP270 with Dave Chase: Apple Podcasts | Spotify (pod.link, unconfirmed — Spotify outage) | Other Apps EP272 with Guy Culpepper, MD: Apple Podcasts | Spotify (pod.link, unconfirmed — Spotify outage) | 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 📺 Subscribe to our YouTube channel 🎤 Listen on Apple Podcasts 🎤 Listen on Spotify === CONNECT WITH THE RHV TEAM === ✭ LinkedIn ✭ Threads ✭ Bluesky ✭ X 00:00 Introduction 04:58 Why is primary care one of the "best-kept secrets" of better health outcomes? 09:45 "Measures are a form of communication." 09:58 "If the way that you are assessed does not actually match up with the work you do…it's pretty demoralizing." 12:48 "It is the outcome of healthcare, but it is not the same thing as quality." 17:18 "It creates a financial incentive to hit a target by any means necessary." 18:53 "We incentivize people to have good outcomes…electronic medical records are no longer simply databases that tell us what the health of the population is." 21:54 "Primary care is a relational field." 23:02 "How does this relate to cost and utilization?" 27:45 How has the measure of PCPs in the time of COVID held up? 28:03 What measure performs worse in the time of COVID? 29:59 EP270 with Dave Chase and EP272 with Guy Culpepper, MD.

A Patient-First Specialty Pharmacy, Not a Money-First Specialty Pharmacy, With Olivia Webb (Encore! EP337) In this Encore, Stacey Richter revisits her conversation with Olivia Webb, healthcare strategist and author of the Acute Condition newsletter, about why the specialty pharmacy model is built around the power struggle for revenue between providers, PBMs, insurers, and Pharma — with patients too often an afterthought. WHAT YOU'LL LEARN ✅ Why specialty drugs — often biologics, infusions, or cancer therapies — get routed outside traditional retail pharmacy ✅ Why patients frequently can't get a straight answer about the six-figure therapy they're about to receive ✅ What a "patient-first specialty pharmacy" would actually look like, and why the incentives currently work against it ✅ Why the time may be ripe for disruption as lawsuits target PBM/insurer/specialty pharmacy vertical integration ✅ Why scale is required for any new entrant trying to build a better specialty pharmacy model WHY THIS MATTERS Specialty pharmacy is a battlefield between providers, PBMs, insurers, and Pharma over revenue and captive patient populations — and the patient, despite carrying the financial and clinical stakes, is rarely centered in that fight. Building a genuinely patient-first specialty pharmacy means confronting a system with no clear incentive to cap prices or prioritize the person actually receiving the drug. MENTIONED IN THIS EPISODE AEE15 with David Carmouche, MD: Apple Podcasts | Spotify | Other Apps (link unavailable) === 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 📺 Subscribe to our YouTube channel 🎤 Listen on Apple Podcasts 🎤 Listen on Spotify === CONNECT WITH THE RHV TEAM === ✭ LinkedIn ✭ Threads ✭ Bluesky ✭ X 00:00 Introduction 04:43 Why did Olivia start thinking about a patient-centric specialty pharmacy? 06:05 "There's really no layer on top of it to make it look nice." 06:55 "You're kind of dealing with this vertical stack that doesn't really deal with patients frequently." 07:07 Is the specialty model more patient friendly or less? 07:39 What would a patient-centric specialty pharmacy look like? 08:29 "There's a lot of fragmentation; there's a lot of friction." 08:42 What's unique to specialty pharmacy prescriptions? 11:09 Why can infusion centers be a high-drama place? 12:44 What's "the question" around specialty pharmacy? 13:11 Who has the vested interest in ensuring patients take their medications correctly in specialty pharmacy? 15:08 "It's really just a unique area of healthcare where the people that I think of as the good guys and the bad guys completely flips." 16:34 Why might the time be ripe for disruption in the specialty pharmacy area? 20:26 "There's no one with a clear incentive to cap the prices." 20:39 What are the barriers in specialty pharmacy? 21:01 "The patient just isn't at the center, the financial incentive, in any direction." 29:44 "I think people who are designing these things need to see how patients are actually doing it." 30:13 "I think there's a lot of money here; I think this market is going to only increase in size." 30:32 "I think you need scale." 30:42 AEE15 with David Carmouche, MD, of Ochsner.

The Strategic Chess Match Over Who Profits From Specialty Pharmacy, With Mike Baldzicki. Specialty Drugs Are 2% of Members but 30% of Costs—Here's Who's Fighting Over That Money. Episode 377. Stacey Richter talks with Mike Baldzicki, chief brand officer at AscellaHealth, about how self-funded employers, hospitals, PBMs, and pharma are all maneuvering to capture (or avoid overpaying for) specialty pharmacy dollars—and why outcomes-based contracts remain more talk than practice. WHAT YOU'LL LEARN ✅ Why specialty drugs represent about 2% of a typical employer's population but can consume up to 30% of total cost of care ✅ Why no employer or plan should pay more than acquisition price plus a reasonable professional fee, even though many do ✅ How employers who move specialty pharmacy business away from the "Big Three" or "Big Five" PBMs are actively steering members and managing benefits differently ✅ Why hospitals that lose buy-and-bill revenue often respond strategically by standing up their own specialty pharmacy or infusion center network ✅ How data insight—or the lack of it—determines whether an employer can actually negotiate plan language and coverage requirements effectively ✅ Why so few pharma outcomes-based contracts exist in practice, despite the "pay for value, not volume" logic applying just as well to drugs WHY THIS MATTERS Every stakeholder in the specialty pharmacy chain—hospitals, PBMs, pharma, employers—is maneuvering to either capture the outsized margin on these drugs or avoid getting stuck paying for someone else's markup, and most employers don't have the data insight to know which side of that fight they're actually on. Baldzicki's view from inside a specialty pharmacy company gives plan sponsors a map of the maneuvering so they can make deliberate choices instead of accepting default PBM arrangements. MENTIONED IN THIS EPISODE EP365 with Scott Haas: Apple Podcasts | Spotify | Other Apps EP337 with Olivia Webb: Apple Podcasts | Spotify | Other Apps EP370 with Erik Davis and Autumn Yongchu: Apple Podcasts | Spotify | Other Apps EP369 with Keith Hartman, RPh: 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 📺 Subscribe to our YouTube channel 🎤 Listen on Apple Podcasts 🎤 Listen on Spotify === CONNECT WITH THE RHV TEAM === ✭ LinkedIn ✭ Threads ✭ Bluesky ✭ X 04:27 Is it a conflict of incentives to worry about the cost of million-dollar pharmaceuticals? 06:24 "Really, does it make sense to carve up my specialty pharmacy benefit … away from my typical PBM model?" 06:48 What's the trend line with moving away from the big PBMs? 07:53 How does a small PBM contract with Pharma? 11:32 "We're still lacking the overall insight to data." 12:15 "When you have insight and good data, then you can start really driving the plan language and cover requirements." 13:07 "It is a frustrating game because … the large PBMs that have traditionally managed an employer's spend … doesn't give them the data that's needed." 13:48 What's going on with outcomes-based contracts? 14:16 What's the importance of aligning reimbursement around value instead of volume? 14:57 "The issue is, how real is the data?" 20:36 Are hospital-based specialty pharmacies teaming up with big PBMs? 22:01 "It's market ownership." 30:43 "These are real scenarios that are happening in the self-insured planned sponsor market." 30:59 "Employers really should start recognizing organizations that take more of an integrated and thoughtful approach."

A Field Guide to Who's Who in Healthcare Interoperability, With Lisa Bari, MBA, MPH. Interoperability Isn't a Technology Problem—It's an Organizational and Governance One. Episode 376. Stacey Richter talks with Lisa Bari, MBA, MPH, CEO of Civitas Networks for Health, about who the actual players are in healthcare interoperability—EHR systems, APIs, HIEs, and clearinghouses—and why more data-sharing infrastructure alone won't solve "the last mile" of getting the right information to the right clinician at the right time. WHAT YOU'LL LEARN ✅ Why interoperability matters most as a means to treating the whole patient, not as an end in itself ✅ How fee-for-service incentives actively favor siloed data, since eliminating duplicative services also eliminates the revenue those services generate ✅ The four main groups of players in the interoperability space: EHR systems, APIs, health information exchanges (both nonprofit and for-profit), and clearinghouses ✅ Why Larry Ellison's proposal for one national medical records database misreads interoperability as a technology problem rather than a business-case, workflow, and governance problem ✅ What TEFCA (Trusted Exchange Framework and Common Agreement) does and doesn't solve—it governs data exchange between organizations but not the clinical workflow itself ✅ Why succeeding in any value-based or risk-based arrangement depends on having complete, well-organized patient data at the point of care WHY THIS MATTERS Interoperability gets treated as a purely technical challenge, but Bari's field guide makes clear it's fundamentally an organizational and incentive problem—FFS rewards data hoarding, and no single database or framework can force clinical workflows to actually use the data that does get shared. Understanding who the real players are, and what TEFCA does and doesn't cover, helps health systems and ACOs invest in the right interoperability fixes instead of chasing a technology silver bullet. MENTIONED IN THIS EPISODE EP108 with Chris Klomp: links unavailable (2019 episode not indexed on Apple, Spotify, or pod.link) === 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 📺 Subscribe to our YouTube channel 🎤 Listen on Apple Podcasts 🎤 Listen on Spotify === CONNECT WITH THE RHV TEAM === ✭ LinkedIn ✭ Threads ✭ Bluesky ✭ X 06:30 How does value-based care depend on interoperability? 07:38 Why is it really important to exchange information at the right time with the right purpose? 08:00 What is one of the easiest low-hanging fruit to achieve in value-based care? 09:42 What are the four kinds of companies getting into the interoperability space? 11:51 "As we know, there's sort of technical interoperability … and then there's semantic interoperability." 12:59 Where are we right now with EHR basic interoperability? 15:33 Who should ACOs hire to get the right data at the right time? 17:00 Why is it important to delineate the different types of HIE? 22:09 What can ACOs assure with interoperability? 22:59 Is the demand among ACOs for interoperability there? 24:04 "If you're in value-based care, you better care about what's happening outside of the healthcare setting." 26:25 "Every couple of years, someone talks about creating the ultimate database to rule them all. … It hasn't happened yet, and I don't think it's going to happen." 26:56 "The difficult thing about healthcare data … interoperability … is an organizational and a governance problem." 28:49 "You've gotta start with the incentives … and then you do have to say … 'We are not gonna hoard any more data.'" 29:10 What is TEFCA, and how does it fit into this interoperability conversation? 32:17 "I think partners are trying to solve for value and outcomes."

Why Medicare Advantage Plans Are Facing Heightened Federal Scrutiny, With Betsy Seals. Sales Pitches, Improper Payments, and Upcoding: Inside the Federal Crackdown on Medicare Advantage. Episode 375. Stacey Richter talks with Betsy Seals, CEO and cofounder of Rebellis Group, about the three areas of Medicare Advantage that federal regulators are scrutinizing most closely right now: deceptive sales and marketing, improper payments, and general compliance oversight. WHAT YOU'LL LEARN ✅ Why third-party field marketing organizations selling Medicare Advantage plans have drawn CMS scrutiny for misleading sales pitches ✅ How CMS may actually be ahead of some Medicare Advantage plans on fraud detection and improper-payment analytics ✅ How upcoding through chart reviews and health risk assessments let some MA companies drive a disproportionate share of $9.2 billion in questionable risk-adjustment payments, per an OIG report ✅ Why getting members in for annual screenings matters to MA plans for diagnosis documentation, star ratings, and closing care gaps all at once ✅ What general compliance areas—grievances, appeals, formulary administration, models of care for special needs plans—CMS continues to monitor ✅ Why the CMS analytics advantage doesn't mean plans are off the hook: outlier codes and improper payments are getting recouped either way WHY THIS MATTERS Medicare Advantage has become one of the most profitable lines of business for many payers, and the current wave of federal oversight—sales practices, upcoding, and routine compliance—signals that regulators are trying to close the gap between MA's profitability and its accountability to the taxpayers funding it. Seals's insider view gives plan sponsors and MA-adjacent stakeholders a clear map of where scrutiny is concentrated right now. === 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 📺 Subscribe to our YouTube channel 🎤 Listen on Apple Podcasts 🎤 Listen on Spotify === CONNECT WITH THE RHV TEAM === ✭ LinkedIn ✭ Threads ✭ Bluesky ✭ X 08:15 What's happening with sales and marketing in the healthcare industry? 11:04 What's happening with the focus on recouping improper payments? 13:32 "When you look at the fundamentals of it, these are federal dollars. And what we're talking about is federal dollars that were paid when they should not have been paid." 15:39 Are improper claim payments an administrative problem, or something more intentional? 16:20 "The health plan has a responsibility to catch those issues." 20:10 What are specialty pharmacy prescriptions being scrutinized for? 22:12 "If this is where CMS is headed … the health plan should've already been doing this." 23:58 Why do you see a bigger focus on social determinants of health? 25:54 Do these health plan audits actually have any teeth? 27:01 What is the biggest penalty a health plan can face from an audit? 29:57 "Navigating the Medicare program … was near to impossible. I know the program, and even for me, it was hours and hours and hours and hours on the phone."

How to Grade a Health Plan, With Validated Employer Success Stories, With Dave Chase. Rosen Hotels Saved $450 Million on Healthcare. Here's the Playbook Behind It. Episode 374. Stacey Richter talks with Dave Chase, cofounder of Health Rosetta, about validated employer success stories like Rosen Hotels and Pacific Steel—and the Plan Grader tool Health Rosetta built to give employers an objective way to assess whether their health plan is actually working. WHAT YOU'LL LEARN ✅ How Rosen Hotels saved over $450 million in healthcare costs while spending 55% less per capita despite a challenging employee health population ✅ Why Pacific Steel's CFO said cutting healthcare spend in half had the same net income impact as growing top-line sales revenue by 25% to 30% ✅ How the Nuka System in Alaska delivers award-winning outcomes for a challenging patient population at lower cost than most Medicaid plans ✅ Why regional change tends to follow a "rule of three": once three employers in a market fix their health benefits, a cascade tends to follow ✅ Why Health Rosetta built a Plan Grader, assessing 40 attributes of a health plan, given the near-total absence of objective health plan quality benchmarks ✅ Why Chase argues that clinicians receive only $0.27 of every $1 spent on healthcare, with the rest going to price gouging, administrative bloat, fraud, and inappropriate treatment WHY THIS MATTERS With $1.5 trillion wasted annually in US healthcare—what Chase calls "Healthcare-istan"—and virtually no objective way to grade whether a given health plan is delivering value, employers have had few tools to separate real reform from vendor marketing. Chase's validated case studies and the Plan Grader give employers concrete proof points and a framework for holding their own health plan to the same standard. MENTIONED IN THIS EPISODE EP312 with Douglas Eby, MD, MPH, CPE: Apple Podcasts | Spotify | Other Apps EP365 with Scott Haas: Apple Podcasts | Spotify | Other Apps EP367 with Doug Hetherington: Apple Podcasts | Spotify | Other Apps EP350 with Katy Talento: 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 📺 Subscribe to our YouTube channel 🎤 Listen on Apple Podcasts 🎤 Listen on Spotify === CONNECT WITH THE RHV TEAM === ✭ LinkedIn ✭ Threads ✭ Bluesky ✭ X 06:57 Why did Dave Chase start Health Rosetta? 07:51 How does Health Rosetta deem which health plans are succeeding? 11:07 What are the most important areas and factors for grading health plans? 11:38 "That $1.5 trillion of waste, how is that possible? Well, it's all codified in the contracts." 12:18 "You can't manage what you can't measure." 16:59 "What could be more disruptive than 30 years of wage gains stolen by the status quo health plans?" 17:39 "This is the last major area to modernize inside of corporate America." 18:15 "This is not small dollars; there's a tremendous opportunity." 19:04 "Go back to PBM. That's the first thing that starts to get at the care delivery side." 21:52 "Can we even call it primary care if you can't get in to that doc for weeks?" 25:03 Where does Health Rosetta get their data to assess health plans? 27:00 Who are these self-insured employers, typically? 29:48 "3.5% [is] where the market flips." 33:13 "We like to fetishize big in this country."

How One Union Health Fund Cut a Major Hospital From Its Network, With Cora Opsahl. Why 32BJ Health Fund Decided a Major NYC Hospital System Wasn't Worth the Price. Episode 373. Stacey Richter continues her conversation with Cora Opsahl, director of the 32BJ Health Fund, about the data-driven decision to remove NewYork-Presbyterian from the fund's network—and what it took operationally to actually pull it off. WHAT YOU'LL LEARN ✅ Why 56% of 32BJ Health Fund's total spend goes to hospitals, making hospital pricing the highest-impact place to focus ✅ How the same procedure, like a CABG, can cost 10x more at one hospital than another in the same market with no quality difference ✅ Why 32BJ concluded it could not be sustainable without directly tackling hospital prices, since "you can't reduce spend by benefit design alone" ✅ Why claims of "razor-thin operating margins" don't hold up for large, consolidated health systems that received billions in COVID relief and posted record profit growth ✅ Why 32BJ repriced its claims using Medicare rates to reveal how far commercial prices had diverged ✅ What the HEAL Act is, and why 32BJ Health Fund supported it as part of asserting more control over its own benefit design WHY THIS MATTERS Removing a major hospital system from a network is disruptive and politically fraught, but Opsahl's account shows what it looks like when a fiduciary actually acts on what its own data reveals about price versus quality. For other employers and unions weighing whether a similar move is possible, 32BJ's experience is a rare real-world case study rather than a theoretical argument. MENTIONED IN THIS EPISODE EP368 with Ashleigh Gunter: Apple Podcasts | Spotify | Other Apps EP366 with Kevin Schulman, 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 📺 Subscribe to our YouTube channel 🎤 Listen on Apple Podcasts 🎤 Listen on Spotify === CONNECT WITH THE RHV TEAM === ✭ LinkedIn ✭ Threads ✭ Bluesky ✭ X 07:02 What motivated the decision for 32BJ to cut NewYork-Presbyterian out of their network? 09:14 How did 32BJ compare their spending at each hospital in their network? 13:01 "We cannot be sustainable as a health fund … without really tackling the challenge of hospital prices." 13:38 "It is one of the challenges as a self-funded plan that, even having this data, there's not a lot we can do with it." 16:10 What is 32BJ Health Fund's maternity program? 19:34 What is the HEAL Act, and why did 32BJ Health Fund support it? 21:39 "For us, we just don't feel it's right that anyone gets to dictate our benefit." 23:34 Why did 32BJ Health Fund reprice their claims using Medicare rates? 24:58 "It really goes to show you how high the commercial prices are in comparison to Medicare."

Why Getting Your Own Claims Data Is Step One for Employers and Unions, With Cora Opsahl. Step One for Any Self-Insured Employer or Union: Demand Your Own Data. Episode 372. Stacey Richter talks with Cora Opsahl, director of the 32BJ Health Fund, about why demanding full claims data from every vendor was the foundational move that let a 200,000-member union health fund make validated benefit decisions instead of guesses. WHAT YOU'LL LEARN ✅ Why 32BJ Health Fund successfully demanded its own data from 100% of its vendors, and why a vendor's reluctance to share data is itself a red flag ✅ How having your own data lets a plan sponsor accurately model the cost of a new program instead of relying on a vendor's estimate ✅ Why communicating with the right members, using data, is essential to making a new benefit design actually succeed ✅ How siloed pharmacy and medical data can hide cost-shifting—for example, a PBM claiming savings while pushing costs onto the medical side ✅ Why ensuring you're not overpaying a bill (writing a check for more than was actually billed) is a surprisingly common, fixable problem with the right data ✅ How 32BJ's data use breaks into three categories: cutting wasteful spending and fraud, making smart benefit decisions, and forecasting trends for financial solvency WHY THIS MATTERS A self-funded plan cannot be a responsible fiduciary without its own data—guesses about cost, trend, and vendor performance routinely turn out wrong once a fund actually looks at the numbers. Opsahl's account of how 32BJ built this capability gives other employers and unions a concrete starting point: demand the data first, then build the analytics and decisions on top of it. 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 ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter 🫙 Support the podcast with a small donation to the Tip Jar 📺 Subscribe to our YouTube channel 🎤 Listen on Apple Podcasts 🎤 Listen on Spotify === CONNECT WITH THE RHV TEAM === ✭ LinkedIn ✭ Threads ✭ Bluesky ✭ X 08:55 How much data does 32BJ Health Fund have, where do they get it, and how do they use it? 10:56 How did 32BJ Health Fund successfully demand their data from 100% of their vendors? 11:45 "We feel it's really important that we own this information ourselves." 12:08 "It always concerns me—if a vendor doesn't want to give you the information, what are they hiding?" 12:34 "It's not just getting the data; it's then using the data." 15:44 "Without data, you're really just taking a guess; and guesses are never gonna get you where you need to go." 21:07 "The use of data has really built our knowledge." 22:55 "It's really important to us that as we make benefit decisions, we're doing it smartly." 27:42 How is 32BJ Health Fund making their data knowledge actionable? 30:14 "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." 32:25 "It's really easy to think that we can solve this problem through benefit design … but in the end … it's the price."