A Framework for Transforming the Healthcare Industry, With David Muhlestein, PhD, JD. Repair, Remodel, or Rebuild: A Framework for Transforming Any Healthcare Organization. Episode 364. Stacey Richter talks with David Muhlestein, PhD, JD, chief research and innovation officer at Health Management Associates, about a holistic framework for how healthcare organizations—and the industry as a whole—can actually change, starting with getting brutally honest about who the real customer is. WHAT YOU'LL LEARN ✅ Why healthcare being nearly 20% of GDP and the largest employer in 47 states is treated as a problem, unlike other large economic sectors ✅ Why dollars spent on healthcare or insurance premiums carry no marginal utility for consumers, unlike most other spending ✅ Why changing payment incentives alone isn't enough unless organizations upstream and downstream share the same objective—otherwise it's "game on" for revenue-maximizing loopholes ✅ Why leadership teams need to honestly identify their actual paying customer, since 99% of the time it isn't the patient, regardless of what's printed on the front door ✅ Muhlestein's four-step framework for organizational change: understand your current state, consider your timeline to existential demise, decide what legacy you want to leave, and then repair, remodel, or rebuild ✅ Why cost-related nonadherence is projected to become a leading cause of death in the US by 2030, surpassing diabetes, influenza, pneumonia, and kidney disease WHY THIS MATTERS Real transformation in healthcare requires more than swapping in a new payment model—it requires organizations to honestly name who they actually serve today and confront how long they can survive without changing. Muhlestein's repair-remodel-rebuild framework gives health system and payer leadership a structured way to move past inertia instead of waiting until an existential threat forces the decision. === 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 07:38 Is it an issue for the healthcare industry that it is one of the largest employers in the country? 08:42 "I think that we need to figure out what is an appropriate amount to spend on healthcare and get to that level." 09:01 How do we not decrease the amount of healthcare we're receiving while paying less for that healthcare? 10:11 What are the two ways we can look at decreasing healthcare spend? 15:39 "I think that a regional approach may happen." 16:56 "When somebody takes less, others are going to follow them." 17:33 Who is really paying in our current healthcare system? 19:47 "Any sort of a model that you start with influences everything else that you do." 20:09 What's the common challenge David Muhlestein sees in value-based care systems? 23:21 "There are countless things that you can do to improve the current system today." 27:25 What are the three options for building up better healthcare? 28:19 David's advice for healthcare executives. 33:22 "To really lower the total cost of … healthcare, it's a 30-year process."

The Case for Standardizing Healthcare Contracts to Cut Admin Costs, With David Scheinker, PhD. One Standard Contract Template Could Cut Healthcare's Administrative Burden in Half. Episode 363. Stacey Richter talks with David Scheinker, PhD, of Stanford's Lucile Packard Children's Hospital and lead author of a paper on healthcare administrative costs, about why standardizing the parameters used in every payer-provider contract—not simplifying them—is the biggest lever for cutting billing and administrative waste. WHAT YOU'LL LEARN ✅ Why administrative costs should be quantified transaction by transaction: what it costs to send a bill, file an appeal, or process a denial ✅ Why the paper's headline recommendation is standardization, not simplification—every payer and provider using one contract template built from shared parameters ✅ How an Airbnb-style parameter model (number of bedrooms, bathrooms, amenities) could apply to healthcare contracts, letting negotiation happen on price per parameter instead of on the contract structure itself ✅ Why standardized parameters make it possible to build automation and analytics without writing algorithms full of exponential variables ✅ Why labor-cost pressure on health systems makes automating administrative functions more urgent than in the past, when staffing shortfalls were solved by throwing more people at the problem ✅ What pushback Scheinker expects to standardizing contracts, and why he argues the value gained outweighs the customization lost WHY THIS MATTERS Administrative costs in US healthcare are frequently blamed for driving up total spend, but Scheinker's research reframes the fix: it's not about doing away with complexity but about making it consistent, so technology can actually automate what today requires armies of billing staff and mailed paperwork. For plan sponsors and providers alike, standardized contract parameters are a concrete lever for reducing waste that doesn't require waiting on payment reform. === 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 07:23 What's the quantitative administrative cost in an average transaction? 07:49 What's the quantitative administrative cost in a healthcare transaction? 08:43 What does the healthcare billing and administration cost add to the US's overall healthcare spend? 09:38 Is it possible to cut billing and administrative costs in healthcare? 11:01 "In some ways, the problem for healthcare should be simpler." 12:14 What does the complexity of the current system look like in a doctor's office? 15:26 How did David go about studying healthcare administrative costs? 18:17 "It doesn't have to be simple; it should be standardized." 21:41 What would be the pushback on standardizing contracts in healthcare? 22:35 Why is it possible to gain more value by losing customization in contracts? 24:11 "Never let a good crisis go to waste." 24:33 "It's much easier in healthcare to build something new than to change something that exists." 27:39 What benefits does telemedicine have to cutting administrative costs? 29:09 What is another significant benefit of using standardized contracts? 30:17 Why haven't standardized contracts become a common thing in the current healthcare system?

A CFO's Playbook for a Sustainable Telehealth Business Model, With Ali Ucar. Why a Telehealth Program Needs a Business Model Before It Needs a Vendor. Episode 362. Stacey Richter talks with Ali Ucar, CFO of Care Solutions Group, which provides mobile physician services to seniors, about how a traditional in-person provider organization built two sustainable telehealth programs by starting with the business model instead of the technology. WHAT YOU'LL LEARN ✅ Why the anecdotal complaint that "patients and clinicians don't like telehealth" usually signals underinvestment, not real disinterest ✅ Ucar's stepwise approach: first define what you're trying to do for patients, then figure out how you'll get paid sustainably ✅ The two ways to get paid for telehealth: direct FFS billing, or identifying another stakeholder who benefits and billing them instead ✅ Why the operational side of the business model—workflows, roles, and responsibilities—gets treated as an afterthought even though it's just as important as the revenue model ✅ How Care Solutions' tele-urgent care and care-transitions programs both aim to keep discharged patients out of the ER and out of 30-day readmissions ✅ Why 82% of health systems now see telehealth companies as competitors, according to Chartis Group research cited in the episode WHY THIS MATTERS Provider organizations that bolt telehealth onto their existing workflow without rethinking the business model behind it tend to get the underwhelming results they predicted—while organizations that build the revenue and operational model deliberately, as Care Solutions did, find real financial and clinical upside. Ucar's CFO-level view gives provider finance leaders a concrete sequence to follow instead of treating telehealth as a bolt-on cost center. MENTIONED IN THIS EPISODE EP320 with Christian Milaster: Apple Podcasts | Spotify | Other Apps EP357 with Liliana Petrova: Apple Podcasts | Spotify | Other Apps EP354 with Shawn Rhodes: 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 07:45 How do Care Solutions' telehealth programs do payments? 09:33 "As you go deeper into it, you're coupling that telehealth with transitional care, chronic care; you can also address … health equity issues in … areas which may be difficult to reach." 10:02 As a CFO, how is Ali Ucar involved in the telehealth strategy development? 11:26 How have Care Solutions' telehealth programs become sustainable? 13:02 Why would it make financial sense for Care Solutions to continue their telehealth programs? 18:55 How does the work that Care Solutions' telehealth programs do benefit customers? 21:50 Does Care Solutions have a proactive strategy to building out their telehealth programs? 24:34 How do Care Solutions' telehealth programs add value to provider organizations? 26:33 "It's basically refining your practice. That's the way I look at it." 27:58 How does Ali Ucar, as a CFO, evaluate the success of his telehealth programs? 30:09 "I think the most frustrating thing from a patient standpoint may be if they don't have those needs addressed quickly."

Why Closing Care Gaps Isn't the Same as Fixing Population Health, With Carly Eckert, MD. Care Gap Whack-a-Mole: Why Retroactively Closing Gaps Isn't a Population Health Strategy. Episode 361. Stacey Richter talks with Carly Eckert, MD, MPH, a physician, epidemiologist, and product leader at Olive AI, about why treating "closing care gaps" as the whole of population health keeps healthcare stuck reacting to problems that a proactive, whole-person model could prevent in the first place. WHAT YOU'LL LEARN ✅ Why closing care gaps retroactively, one missed preventive opportunity at a time, is really a model of care gap "whack-a-mole" ✅ Why identifying and addressing care gaps is useful but insufficient on its own for real population health ✅ How a single dedicated nurse in an under-resourced community achieved outsized reductions in heart failure admissions through trusting, longitudinal relationships ✅ Why weak financial incentives leave most provider organizations minimally tweaking workflow instead of restructuring care delivery ✅ Why taking small, individualized steps with patients—rather than a one-size-fits-all approach—matters for closing gaps that stick ✅ Why diversity of the clinical workforce is a meaningful lever for closing care gaps and improving trust WHY THIS MATTERS When provider organizations are paid mostly fee-for-service with a thin layer of quality bonuses, the rational response is to squeeze care-gap closure into a 7- to 15-minute visit rather than build proactive, whole-person population health programs—and clinicians burn out trying to make up the difference. Eckert's reframing shows purchasers and provider organizations what it would actually take to move from reactive whack-a-mole to a nonfragmented system of care. MENTIONED IN THIS EPISODE EP322 with Monica Lypson, MD, MHPE: Apple Podcasts | Spotify | Other Apps EP347 with Ian Tong, 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 06:59 What is the true goal in making population health successful? 07:26 How does the clinical pathway need to manifest in population health? 08:00 How do we get a nonfragmented state of care? 08:25 What is the best model of care? 10:08 "Identifying and addressing care gaps is an important element of population health." 13:01 Closing care gaps vs creating a nonfragmented system of care. 17:11 "I think you have to take small steps with people." 18:18 "There's a lot of power in peer support." 18:52 Why should provider organizations connect with peer groups? 20:39 "The key is that it's not going to be the same for everybody." 24:43 Why is diversity of the workforce key to closing care gaps? 30:09 Where can providers improve transparency to help close care gaps?

The Operational Playbook for Value-Based Care, With Jeb Dunkelberger. Three Things Providers Must Fix to Actually Deliver on Value-Based Payment Contracts. Episode 360. Stacey Richter talks with Jeb Dunkelberger, CEO of Sutter Health | Aetna, a full-risk payvider, about what has to change operationally—not just contractually—for a provider organization to actually deliver value-based care once it signs a value-based payment contract. WHAT YOU'LL LEARN ✅ Why providers won't switch up their fee-for-service business model unless value-based payments actually reward the value they create ✅ The five clinical-workflow fixes Dunkelberger says are essential: right data at the point of care, generics-first pick lists, easy access to pended orders, empowered medical assistants, and built-in referral management ✅ Why care navigators matter even more when the EHR doesn't support referral navigation on its own ✅ Why aligning physician compensation to organizational goals is a required third leg of the stool, not an optional extra ✅ Why claims data from payers needs to actually reach clinicians at the point of care, not just live in a report ✅ Why changing provider behavior is "an absolute art and science" that technology alone can't solve WHY THIS MATTERS Signing a value-based contract doesn't automatically produce value-based care—providers have to rebuild the clinical workflow, add navigation, and realign physician pay, or the incentive changes just sit on paper. Dunkelberger's framework, from a CEO actually running a full-risk payvider, gives provider organizations a concrete operational checklist instead of a vague call to "do better." === 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 08:36 What must a provider organization consider operationally when incorporating value-based care and value-based payments? 09:44 How can you use perverse incentives to encourage people to do the right thing? 12:25 How should clinical workflows operate to incorporate value-based care? 14:10 "How do you align patients?" 15:52 How should the EHR operate to maximize value-based workflow? 16:52 Why is taking action on claims data and clinical data together important? 20:26 "Have they actually solved the last mile of integrations?" 21:15 "Changing the behavior of a provider is an absolute art and science." 22:57 "We have to do more." 27:09 "That administrative headache … doesn't just end with the insurer."

Why Value-Based Payments Don't Always Change Care Delivery, With Dan O'Neill. You Get What You Pay For: Why Most Value-Based Contracts Don't Change Physician Behavior. Episode 359. Stacey Richter talks with Dan O'Neill, chief commercial officer at Pine Park Health, about the gap between value-based payment models and the value-based care they're supposed to incentivize—and why so many contracts fail to change anything because the physicians actually making care decisions are still paid on FFS-style incentives underneath. WHAT YOU'LL LEARN ✅ Why a value-based payment model and value-based care are two distinct things—and why changing one without the other accomplishes nothing ✅ A litmus test for whether a value-based program is meaningfully changing care: check whether participating physicians are still paid via FFS incentives like RVUs ✅ The four gradations of value-based payment, from pure fee-for-service to full global risk ✅ Why insurers and IPAs need to clear a genuine path, not just a token option, for providers who want to move to value-based care ✅ How Goodhart's Law applies to value-based metrics: once a measure becomes a target, it stops being a good measure ✅ Why organizational change toward value-based care is exceedingly difficult even when the financial case is clear WHY THIS MATTERS Changing the payment model without changing physician-level incentives just adds administrative complexity without changing outcomes—value-based payments only work when the behavior change actually reaches the clinician making care decisions. O'Neill's framework gives employers and payers a concrete way to check whether their value-based contracts are real or just relabeled fee-for-service. MENTIONED IN THIS EPISODE EP351 with Eric Bricker, 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 05:06 What is the spectrum of value-based contracts? 07:24 Why don't value-based contracts at the organizational level always trickle down to the provider level? 11:25 What are the two things that need to happen to drive outcomes in value-based healthcare? 15:24 How do insurers play into improving value-based contracts? 19:46 "There's a strong case to actually clamp down on prices." 23:47 "Right now, we're still in a place where if you want to do something other than fee for service … you have to fight like hell." 24:03 What's the first step to making value-based contracts more accessible? 24:27 What's the second step to making value-based contracts accessible? 25:23 Why are the incentives to change American healthcare pretty weak? 27:10 "Organizational change is just exceedingly difficult." 28:45 What should you do if you want to start pushing organizations toward value-based contracts?

Standing Up Telehealth That Advances Your Core Business, With Liliana Petrova. Why Most Telehealth Programs Fail to Move Beyond a Single Visit. Episode 357. Stacey Richter talks with Liliana Petrova, CEO of The Petrova Experience and former director of customer experience at JetBlue, about why so many telehealth programs stall out as a disconnected "check the box" service—and what it actually takes to integrate telehealth into an organization's core clinical workflow and business strategy. WHAT YOU'LL LEARN ✅ Why telehealth programs treated as a one-time technology install, rather than a strategic imperative, rarely get real adoption from patients or clinicians ✅ Why cross-disciplinary "telehealth boards" with executive-level authority are essential to building a program that lasts ✅ How the role of IT needs to evolve from help-desk support to a core part of delivering technology-augmented care ✅ Why identifying a physician ambassador internally helps drive clinician adoption of telehealth ✅ Why systematically collecting patient feedback is a surprisingly rare practice, even at "patient-centric" health systems ✅ Why patient navigation may be the single most important lever for telehealth success WHY THIS MATTERS When organizations judge telehealth's value using unreliable anecdotal data—like low usage rates driven by a buried link and a clunky scheduling system—they wrongly conclude patients and clinicians don't want telehealth, and pull funding instead of fixing the experience. Petrova's framework shows what it takes to build a telehealth program that survives past the initial rollout and actually integrates into how care gets delivered. MENTIONED IN THIS EPISODE EP332 with Tony DiGioia, 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 06:59 Who should be on the telehealth board to incorporate telehealth successfully? 08:44 What is the population that you're serving, and how does telehealth serve that population? 09:45 "When they think of this as a project versus a program or a strategic imperative, then there is no business case." 11:49 "How do you integrate telehealth in your core business?" 12:32 What does a CIO need to do to be best equipped to serve their organization? 14:05 Why are CIOs and CFOs naturally in conflict these days? 15:30 Why is it important to have a physician be an ambassador for telehealth implementation? 17:05 Why is it important to utilize patient feedback properly? 18:37 Why must the patient own their own health? 20:29 "The key is, if you start at the strategic level with cross-functional leaders, then the working team will also be cross-functional." 21:49 "You won't have a successful telehealth experience if you don't think through the end-to-end experience." 23:40 Who is the digital navigator in implementing telehealth? 24:55 What is a digital navigator, and how does it show up in the telehealth journey? 30:55 Why is it important to have continuous growth in telehealth?

Standing Up Telehealth That Advances Your Core Business, With Liliana Petrova. Why Most Telehealth Programs Fail to Move Beyond a Single Visit. Episode 357. Stacey Richter talks with Liliana Petrova, CEO of The Petrova Experience and former director of customer experience at JetBlue, about why so many telehealth programs stall out as a disconnected "check the box" service—and what it actually takes to integrate telehealth into an organization's core clinical workflow and business strategy. WHAT YOU'LL LEARN ✅ Why telehealth programs treated as a one-time technology install, rather than a strategic imperative, rarely get real adoption from patients or clinicians ✅ Why cross-disciplinary "telehealth boards" with executive-level authority are essential to building a program that lasts ✅ How the role of IT needs to evolve from help-desk support to a core part of delivering technology-augmented care ✅ Why identifying a physician ambassador internally helps drive clinician adoption of telehealth ✅ Why systematically collecting patient feedback is a surprisingly rare practice, even at "patient-centric" health systems ✅ Why patient navigation may be the single most important lever for telehealth success WHY THIS MATTERS When organizations judge telehealth's value using unreliable anecdotal data—like low usage rates driven by a buried link and a clunky scheduling system—they wrongly conclude patients and clinicians don't want telehealth, and pull funding instead of fixing the experience. Petrova's framework shows what it takes to build a telehealth program that survives past the initial rollout and actually integrates into how care gets delivered. MENTIONED IN THIS EPISODE EP332 with Tony DiGioia, 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 06:59 Who should be on the telehealth board to incorporate telehealth successfully? 08:44 What is the population that you're serving, and how does telehealth serve that population? 09:45 "When they think of this as a project versus a program or a strategic imperative, then there is no business case." 11:49 "How do you integrate telehealth in your core business?" 12:32 What does a CIO need to do to be best equipped to serve their organization? 14:05 Why are CIOs and CFOs naturally in conflict these days? 15:30 Why is it important to have a physician be an ambassador for telehealth implementation? 17:05 Why is it important to utilize patient feedback properly? 18:37 Why must the patient own their own health? 20:29 "The key is, if you start at the strategic level with cross-functional leaders, then the working team will also be cross-functional." 21:49 "You won't have a successful telehealth experience if you don't think through the end-to-end experience." 23:40 Who is the digital navigator in implementing telehealth? 24:55 What is a digital navigator, and how does it show up in the telehealth journey? 30:55 Why is it important to have continuous growth in telehealth?

How PBMs Are Reacting to GoodRx, Cuban, and Amazon Pharmacy, With Ge Bai, PhD, CPA. Why the Big Three PBMs Are Suddenly Nervous About GoodRx and Mark Cuban. Episode 356. Stacey Richter talks with Ge Bai, PhD, CPA, professor at Johns Hopkins, about how the "Big Three" PBMs—Express Scripts, OptumRx, and CVS—are reacting now that GoodRx, Amazon Pharmacy, and Mark Cuban's cost-plus model are giving cash-pay patients a real alternative to the spread-pricing status quo. WHAT YOU'LL LEARN ✅ How PBM spread pricing works: patients and plans pay a marked-up price for generics while the PBM pockets the difference between that price and its own acquisition cost ✅ Why GoodRx's cash prices for generics are so often lower than what patients pay using their own insurance ✅ Why PBMs originally welcomed GoodRx as a way to reach uninsured patients, before it started pulling insured patients away from using their benefits ✅ Why 67% of patients are unaware they might get a better price by not using their insurance at all for generic drugs ✅ How Express Scripts' new automatic-discount benefit reads as a defensive response to GoodRx and Amazon ✅ How cost-plus pharmacy models are forcing a "potential sea change" in how PBMs have to compete on generic drug pricing WHY THIS MATTERS The PBM spread-pricing model depends on patients not shopping around—and now that GoodRx, Amazon, and cost-plus pharmacies are giving a growing share of consumers a reason to bypass their insurance for generics, PBMs are being forced to give some of that margin back. Bai's analysis suggests plan sponsors who understand this dynamic have real leverage to negotiate better generic drug pricing rather than accepting PBM spread as a cost of doing business. MENTIONED IN THIS EPISODE EP344 with Steven Quimby, 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 ✉️ 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 08:45 What is ESI doing by automatically applying discounts to generic drugs? 10:00 Why are PBMs losing money when consumers don't use their benefit? 10:46 "GoodRx disrupted the ongoing game." 11:04 How are PBMs using the Amazon discount card to discourage their patients from moving away from using their benefits? 12:13 Amazon pricing versus GoodRx pricing. 12:50 How much money is a PBM really making? 14:43 How is future fear playing into the PBM business model? 16:55 Is there a negative consequence to subtracting from the bottom line in a PBM model? 17:50 "I think to have strong PBMs does not mean necessarily bad things for patients." 19:39 What happens if everyone uses Amazon for drugs? 22:40 If every PBM gets their own discount cards, what will happen? 25:38 "We are actually witnessing a potential sea change." 26:25 How do cost-plus pharmacies factor into the current market? 29:16 Is a profit shortfall inevitable? 29:35 "PBMs have to give a slice of their profit back to consumers. That's just reality." 30:11 Can anything be done on the PBM side to generate a higher margin in the generic space? 31:41 "Naive plan sponsors are a big problem."

The 5 Business Models of Digital Health, With Nikhil Krishnan. Why Digital Health Companies All Eventually Land on One of Five Business Models. Episode 355. Stacey Richter talks with Nikhil Krishnan, founder of the Out-Of-Pocket newsletter, about the five business models digital health companies eventually settle into—and why knowing who's actually paying the bill matters more to a startup's success than any promise about improving patient outcomes. WHAT YOU'LL LEARN ✅ The five business models digital health companies eventually fall into: cash-pay disruption, middleware, incumbent-serving front doors, joint ventures, and legacy incumbents ✅ Why "who is paying" drives a digital health business's viability far more than patient outcomes do ✅ Why pitching lower total cost of care doesn't work with payers or provider organizations that don't bear that risk ✅ Why so many digital health founders struggle to identify their actual customer before building their product ✅ How joint-venture digital health models emerged and where they tend to show up on the payer/provider side ✅ Why mission-driven healthcare companies still need a sustainable business model to keep serving patients well WHY THIS MATTERS Founders who build for "lower costs and better outcomes" as an abstract mission, without identifying who actually pays and what that payer's incentives are, routinely get cast out of the rooms where healthcare buying decisions get made. Understanding these five business models gives investors, operators, and health system buyers a shared vocabulary for evaluating whether a digital health company's model can actually survive contact with how healthcare money really moves. === 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 05:31 What are the different models of digital health? 07:17 What are the different motives for cash-pay digital health models? 13:08 "One of healthcare's original sins is that every solution deployed has been a custom solution for the end user." 13:31 How willing will these companies be to share their data with third parties? 17:20 "I don't think selling tech to large incumbents is going to move the needle." 20:27 "These companies, most of them are actually getting extra money for the more expensive stuff." 22:11 How did joint-venture digital health business models come about? 25:50 Why do you see partnerships more on the payer/provider side? 26:41 Who are the old-school digital health companies that could be considered incumbents? 28:48 Why do so many digital health start-ups have a hard time pinpointing who will pay for their services? 31:22 "The ability to go through the idea maze is way faster now." 34:08 "The field is wide open to help teach people how healthcare works."