Relentless Health Value

How Specialty Pharmacy Rebates and Formularies Really Work, With Pramod John, PhD. Inside the Rebate Math That Decides Which Specialty Drugs Make Your Formulary. Episode 353.

In part 2 of her conversation with Pramod John, PhD, founder and CEO of VIVIO Health, Stacey Richter breaks down the mechanics of pharmaceutical rebating—how PBMs use rebate walls and exclusive formulary deals to maximize their own revenue, often at the expense of patients and plan sponsors footing the bill.

WHAT YOU'LL LEARN

✅ How PBMs collect rebates from manufacturers in exchange for formulary placement or exclusivity—and why bigger rebates mean fewer competing drugs on formulary

✅ How "rebate walls" make it nearly impossible for cheaper new entrants to compete against an already-exclusive incumbent drug

✅ Why patients with coinsurance pay a percentage of the pre-rebate list price, not the discounted price the PBM actually negotiates

✅ How self-insured employers use rebate dollars to lower premiums, effectively having the sick subsidize the well

✅ Why some plans are saving 30% or more on drug spend by moving away from rebate-driven PBM models

✅ How psychology around drug risk shapes prescribing even when the underlying data is the same

WHY THIS MATTERS

The rebate system that determines which specialty drugs land on a formulary is optimized for PBM revenue, not patient outcomes or total cost of care—and plan sponsors who don't understand the mechanics end up subsidizing that system through their premiums. Moving toward pricing and formulary design based on what actually works for patients, rather than rebate size, is where John sees the real savings.

MENTIONED IN THIS EPISODE

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

EP289 with Bishal Gyawali, MD, PhD: Apple Podcasts | Spotify | Other Apps

EP345 with Paul Simms: Apple Podcasts | Spotify | Other Apps

=== LINKS ===

🔗 Show Notes with all mentioned links: Episode Page

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00:00 Introduction.

08:31 How does drug efficacy affect pharmacy rebates?

09:39 Do purchasers have the power to change the course of Pharma?

12:11 How do formularies affect the supply of effective drugs?

14:07 "This is about science, and it's about published data and facts."

15:39 How do you fix high drug costs and wasteful spending?

19:06 "Where's the money to be made or saved?"

19:28 Why do we pay for benefits?

23:04 "About 1.5% of the population spends over 60% of all dollars that are spent on drugs."

26:45 "Does anybody want to be a traffic cop in this [situation]?"

27:58 "We all make assumptions about how things work … and if there's one thing that we've learned from this COVID experience … is that we need to be able to separate the beliefs of experts from the facts."

29:47 "We can build a better system. And that's what we do every day."

Efficacy vs. Effectiveness in Specialty Pharmaceuticals, With Pramod John, PhD. Why Only 2% of Patients Get the Expected Benefit From Some Expensive Specialty Drugs. Episode 352.

Stacey Richter talks with Pramod John, PhD, founder and CEO of VIVIO Health, about the gap between a specialty drug's clinical trial efficacy and its real-world effectiveness—and why limiting a formulary to just one or two drugs per category can mean paying huge sums for treatments that don't work for most of the patients taking them.

WHAT YOU'LL LEARN

✅ Why specialty drugs are less than 2% of prescriptions but account for roughly half of the $500 billion the US spends annually on prescription drugs

✅ The difference between a drug's efficacy (how it performs in trials) and its effectiveness (how it performs in the real world)

✅ Why limiting formulary access to one or two drugs per therapeutic category reduces the odds that any given patient lands on the drug that actually works for them

✅ How the concepts of NNT (number needed to treat) and NNH (number needed to harm) should factor into patient decision-making

✅ Why expanding access to more drugs in a therapeutic category, rather than narrowing formularies, can improve outcomes and lower total cost

✅ How VIVIO's model has generated 35% to 40% savings on drug acquisition costs while improving outcomes

WHY THIS MATTERS

When formularies are built around rebate economics rather than which drug actually works for which patient, purchasers pay enormous sums for treatments that a majority of patients get no benefit from—and sometimes serious side effects instead. Understanding efficacy versus effectiveness, and NNT versus NNH, gives employers and plan sponsors the vocabulary to demand a formulary strategy built around what actually helps patients.

MENTIONED IN THIS EPISODE

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

EP303 with Anna Kaltenboeck: Apple Podcasts | Spotify | Other Apps

=== LINKS ===

🔗 Show Notes with all mentioned links: Episode Page

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00:00 Introduction.

05:34 What does a good response mean in pharmaceutical products?

06:06 "Different people get different utility out of something."

06:31 Why doesn't efficacy mean what you think it means in terms of pharmaceutical products?

08:40 What is the difference between efficacy and effectiveness in Pharma?

09:10 Why aren't drugs' major side effects factored into a drug's efficacy and effectiveness?

10:14 "What's the benefit of this versus what's the harm in this?"

13:35 "Clearly as consumers, we all feel that we're special. But what about physicians?"

14:14 "The benefit itself—what does it have to be?"

17:11 "We tend to think of things as a binary distribution—it works or it doesn't."

18:22 "The default choice that we start with is often the wrong one."

20:54 "It doesn't matter why if we can't fix the reason."

22:02 "At some point, the question becomes, 'Do we have any information?'"

22:36 Why do other developed countries pay less for their drugs?

24:21 How do we end up with crappy drugs on the market that don't really move the dial?

27:22 "We can build a better system. And that's what we do every day."

Healthcare Consolidation and Vertical Integration, With Eric Bricker, MD. Why Everyone in Healthcare Is Getting Up in Everyone Else's Business. Episode 351.

Stacey Richter talks with Eric Bricker, MD, founder of AHealthcareZ and former chief medical officer of Compass Professional Health Services, about the decades of horizontal and vertical consolidation reshaping payers, PBMs, and hospital systems—and why that consolidation, more than the ACA, is a real driver of runaway healthcare costs.

WHAT YOU'LL LEARN

✅ How horizontal consolidation among payers, PBMs, and hospital systems lets dominant players charge more without competing on patient experience

✅ Why commercial insurance costs have risen roughly 4x the rate of other benchmark goods and services, per research cited in the episode

✅ How vertical integration is reshaping which "swim lanes" digital health disruptors are diving into

✅ Why low interest rates, cheap debt, and a desire to eliminate competition are cited as bigger drivers of consolidation than the ACA

✅ Why hospitals remain the largest source of healthcare costs, and what that means for payment reform

✅ How financial incentives, not good intentions, ultimately determine whether new technology helps or hurts patient care

WHY THIS MATTERS

Extreme consolidation across payers, PBMs, and health systems doesn't just raise prices—it shows up in wage stagnation, patients hopping from the frying pan into the fire with nowhere better to go, and burned-out clinicians stuck in a monopoly customer-service quagmire. Bricker argues that until financial incentives are realigned, more technology and more consolidation will keep producing the same result: the money wins, patient care doesn't.

MENTIONED IN THIS EPISODE

EP330 with John Marchica: Apple Podcasts | Spotify | Other Apps

EP343 with David Carmouche, MD: Apple Podcasts | Spotify | Other Apps

=== LINKS ===

🔗 Show Notes with all mentioned links: Episode Page

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=== CONNECT WITH THE RHV TEAM ===

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00:00 Introduction.

06:30 What is this "megatrend" happening in healthcare right now?

07:52 How has consolidation changed the healthcare landscape?

10:22 What is vertical integration within healthcare?

11:48 Why doesn't inorganic growth benefit patients?

13:33 "What is best for the patient does not necessarily make the most money."

14:43 "It's not that it's above the law … it is just intentionally obscured."

18:58 "Healthcare is glacial. It is slow."

23:23 "The largest source of healthcare costs is hospitals."

29:17 "What have the historical priorities been of the administrators of those hospitals?"

29:32 "Every hospital CFO knows that they need sick people."

30:59 "The payment change has to come first."

32:17 "The money wins."

34:12 "You've got to put the financial incentives in place … to make people actually behave the way that they should."

Direct Contracting With Hospitals in Real Life, With Katy Talento. What Direct Contracting Between Employers and Hospitals Actually Looks Like in Practice. Episode 350.

In this episode, Stacey Richter talks with Katy Talento, CEO of AllBetter Health and former health policy lead in the White House, about what direct contracting between self-insured employers and hospitals looks like once you get past the theory. Talento walks through why cutting out the insurance middleman can be a win for employers, providers, and patients alike—and the practical steps and challenges of setting one up.

WHAT YOU'LL LEARN

✅ How direct contracting lets an employer pay a provider organization a set percentage over Medicare rates instead of going through a carrier

✅ Why direct contracting is a two-way negotiation, unlike reference-based pricing, where the payer largely sets the price unilaterally

✅ Why hospitals only get patient steering for the services they're willing to compete on price for, not for everything they offer

✅ Why a hospital should not be a freestanding profit center, per Talento

✅ What roles the TPA and the repricer play in making a direct contract work

✅ Why having a benefits advisor who knows how to execute all of this is what actually makes direct contracting work in practice

WHY THIS MATTERS

Direct contracting promises real savings for self-insured employers, but only when it's structured as a genuine negotiation between employer and provider rather than a unilateral price-setting exercise. Talento's experience in the field shows what separates a direct contract that actually reduces friction and cost for patients from one that just shifts the same broken incentives to a new set of players.

=== LINKS ===

🔗 Show Notes with all mentioned links: Episode Page

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=== CONNECT WITH THE RHV TEAM ===

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00:00 Introduction.

05:21 Why are employers direct contracting?

06:37 "When you directly contract … you don't have to chase patients."

07:43 Why the growing 501(r) movement is making direct contracting more enticing.

10:16 "They're going to be giving better rates, whether they want to or not."

11:46 "I think it's the future hospitals want, too."

12:58 What is the primary driver of increased healthcare costs?

14:56 "The fixed costs that the hospitals … have may not be so fixed."

15:08 "A hospital should not be a freestanding profit center. … The hospital is a failure of healthcare. It alone should not be profitable."

15:35 "We have the system we have, but why do we have to live with it? We don't have to."

17:15 What's step 1 of direct contracting?

24:12 What's the TPA's role in direct contracting?

25:21 What's the repricer's role in direct contracting?

33:28 "I think the thing that makes all this work is having a benefits advisor that knows how to do all this."

Thank You, and a Few Thoughts (INBW33)

In this short inbetweenisode, Stacey Richter takes a moment to thank the Relentless Tribe — listeners, guests, reviewers, and writers — for a year of support, reflecting on gratitude as a mental-health practice even amid ongoing pandemic-era healthcare strain.

WHAT YOU'LL LEARN

✅ Why celebrating bright spots matters for mental health, even when the timing feels off

✅ Key stats from the Doximity Physician Compensation Report on physician overwork and burnout

✅ Why recruiting fellow thinkers is how meaningful healthcare change actually scales

✅ A shoutout to the writers, podcasters, and LinkedIn voices shaping healthcare discourse worth following

WHY THIS MATTERS

Gratitude isn't just a nice sentiment — Stacey frames it as part of the work itself. The more people who consider themselves part of the push for healthcare change, the more effective that push becomes, and recognizing the community of listeners, guests, and voices doing that work is how the momentum keeps building.

=== LINKS ===

🔗 Show Notes with all mentioned links: Episode Page

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=== CONNECT WITH THE RHV TEAM ===

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The Ultimate Impact of Telehealth: A Thought Experiment (INBW32)

In this inbetweenisode, Stacey Richter runs a solo thought experiment: what's the ultimate impact of telehealth, viewed not as a passing trend but as a leading indicator for the rest of the care delivery business?

WHAT YOU'LL LEARN

✅ Why telehealth should be understood as a leading indicator rather than a temporary pandemic trend

✅ How virtual care functions as a "head in the bed at the hospital" demand destroyer for traditional systems

✅ Why patients don't necessarily believe in-person care is superior to virtual visits

✅ How virtual-first entities are steering patients toward clinically integrated networks

✅ Why care delivery organizations that ignore telehealth risk an existential business problem down the road

WHY THIS MATTERS

Telehealth isn't going away once pandemic-era urgency fades — it's a leading indicator of where care delivery is headed next. Organizations that treat it as a temporary accommodation rather than a permanent shift in how patients access care risk finding themselves in a "very problematic position" once tele-whatever becomes existential for laggards.

=== LINKS ===

🔗 Show Notes with all mentioned links: Episode Page

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=== CONNECT WITH THE RHV TEAM ===

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00:00 Introduction

02:30 Should provider organizations be getting rid of telehealth?

02:40 EP330 with John Marchica.

04:36 EP349 with Lisa Trumble.

05:07 Should telehealth be viewed as a threat?

05:40 "Virtual is a 'head in the bed at the hospital' demand destroyer."

06:45 "'Virtual' is the scapegoat."

07:42 Patients/Consumers: Is in person really better?

10:42 EP338 with Nikki King; EP347 with Ian Tong, MD; EP320 with Christian Milaster; and EP302 with Blake McKinney, MD.

11:06 How one VP of finance justifies a facility fee for a telehealth visit.

11:54 Do patients actually act like consumers in the digital age?

12:12 Why are virtual-first entities steering patients to clinically integrated networks?

13:08 How is telehealth changing healthcare costs?

14:21 "It adds up to telehealth being inexorable. It's a done deal. It's not a trend."

15:17 "If telehealth is a leading indicator, anybody in the care delivery business who isn't…trying to figure out how to make telehealth work in their core business is gonna find themselves…in a very problematic position."

16:50 "When will tele-whatever become an existential problem for laggard traditional provider organizations?"

For this Encore rebroadcast of EP294 (originally aired October 2020), the guest himself takes over hosting duties: Steve Schutzer, MD, an orthopedic surgeon and founding medical director of the Connecticut Joint Replacement Institute, records his own updated introduction reflecting on how quickly Centers of Excellence (COEs) have moved from theory to proven ROI in just the year since his original conversation with Stacey Richter. The interview itself digs into what it actually takes for physician entrepreneurs to build a COE: a playbook grounded in trust, actionable data, and end-to-end care redesign rather than just bundled pricing.

WHAT YOU'LL LEARN

✅ Why COEs are the common pathway self-funded employers, advanced primary care groups, and Medicare Advantage plans all use to steer patients toward high-quality specialists willing to take on total cost of care for a defined set of services

✅ The seven building blocks Dr. Schutzer identifies as necessary to build a functioning Center of Excellence — and why trust between physicians and hospital partners is the most fundamental of them

✅ Why "actionable" data matters more than data volume: physicians naturally distrust data, so a COE has to make the data usable, not just available

✅ Real-world ROI evidence updating the original 2020 conversation: a RAND Corporation study of over 2,300 joint, spine, and bariatric surgery patients found savings of over $16,000 per procedure and an 80% reduction in readmissions at Carrum Health COEs, plus a Healthcare Purchaser Alliance of Maine report of 58% ROI and nearly $1 million in plan savings

✅ Why building a COE requires an end-to-end care redesign process, not just negotiating a bundled payment rate — and why Dr. Schutzer argues the implementation process itself creates value even before a single bundle is signed

WHY THIS MATTERS

In the year between EP294's original airing and this Encore, Dr. Schutzer says the COE model moved from theoretical to proven, with real independent data now backing the ROI case that was mostly promise before. As fee-for-service's dominance keeps eroding, physician entrepreneurs willing to build the trust-based relationships and end-to-end care redesign a COE requires have a genuine opportunity — not to disrupt on a Tuesday, as Stacey has said, but to start building on Monday.

MENTIONED IN THIS EPISODE

Article: Slide deck on the definition of a COE and its seven building blocks

=== 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

04:52 Why would competitive physician groups gang together?

09:02 "Even if you never…bundle, going through the implementation process…will yield incredible unrecognized value."

10:19 "It demands an end-to-end care redesign process."

11:40 "The value of a COE is really unquestionable."

11:48 "For every dollar saved [in a COE], two-thirds was in the quality side, and one-third was in the price point."

15:06 "I'm talking about business relationships between the physicians…these are the most fundamental [relationships]."

16:24 "It is all about trust."

16:49 What is the most central issue as to why a COE does well or fails?

17:26 "It's not just data. It has to be actionable data because physicians naturally don't trust data."

22:55 "Employers are definitely taking note to patient-reported outcomes."

23:38 What is the seventh element that is necessary for a COE, and what is fundamental to that element?

24:28 Where will fee-for-service doctors be in 2 to 3 years?

25:46 "The only way that we can accrue the value that we deserve is through these types of relationships."

26:12 "The supreme motivator is opportunity."

28:03 How do physicians and providers begin a transformation of the marketplace they're in?

28:38 "What they need from us is product. They need products to disrupt the status quo."

31:27 "The problem is that there are vendors who are working at the margin."

In Episode 349, Stacey Richter talks with Lisa Trumble, president and CEO of SoNE HEALTH, a clinically integrated network (CIN) formed to integrate three ACOs across two states. The conversation covers what a CIN actually is, how it differs from — and overlaps with — an ACO, and why aggregation alone doesn't equal integration. Lisa and Stacey also discuss hybrid CIN models, the deep work required for data integration among member organizations, and the potential impact of direct contracting on the healthcare marketplace.

WHAT YOU'LL LEARN

✅ Why accountability and integration go hand in hand, and what breaks down in a fee-for-service world without them

✅ What a clinically integrated network (CIN) actually is, and how it's different from — and similar to — an ACO

✅ Why aggregation for its own sake doesn't necessarily produce better outcomes

✅ What a hybrid CIN model looks like, and how much work goes into data integration among member organizations

✅ How direct contracting could significantly change the healthcare marketplace

WHY THIS MATTERS

If anyone wants to get paid to create patient health, they have to be accountable for the outcomes created — upside and downside. Aggregation just for the point of aggregation doesn't necessarily produce better outcomes; real integration requires care coordination and data sharing across a whole constellation of providers, not just a shared name on the door.

MENTIONED IN THIS EPISODE

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

=== LINKS ===

🔗 Show Notes with all mentioned links: Episode Page

🔗 Healthcare Industry Acronyms and Terms

✉️ Enjoy this podcast? Subscribe to the free weekly newsletter

🫙 Support the podcast with a small donation to the Tip Jar

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=== CONNECT WITH THE RHV TEAM ===

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00:00 Introduction.

06:20 Why do accountability and integration go hand in hand?

08:56 "Aggregation just for the point of aggregation doesn't necessarily produce better outcomes."

09:18 What questions should we be asking when considering aggregation?

09:45 Does aggregation equal integration?

11:42 What exactly is a clinically integrated network?

12:26 What is the intention of a clinically integrated network?

13:22 Are all CINs ACOs? Are all ACOs CINs?

17:22 What entities make up a clinically integrated network?

19:26 "We want providers that are able to generate the outcomes that we're expecting."

20:44 "There is a lot of work that goes into data integration."

23:14 What is a hybrid CIN model?

25:22 Encore! EP206 with Ashok Subramanian.

26:53 "Everyone is sitting around the table proactively."—Stacey

29:37 What kind of structure could move the Medicare market quickly?

In Episode 348, Stacey Richter talks with Jeb Dunkelberger, CEO of Sutter Health | Aetna, about payviders — entities that both deliver care and write insurance products, taking on risk rather than just capitated payments or direct contracting. Jeb explains the concept of "demand destruction" and why taking on value-based risk is easier the smaller a percentage of total healthcare spend an organization represents. The conversation also digs into workforce repurposing and what actually happens to costs, jobs, and hospitals if the industry succeeds in taking money out of the system.

WHAT YOU'LL LEARN

✅ What a payvider actually is — an entity that delivers care and writes insurance products and takes risk for them

✅ The concept of "demand destruction," and why it's easier to take on value-based risk the smaller your share of total healthcare spend

✅ What incentivizes providers to partner with payers in a payvider model

✅ Why taking costs out of the healthcare system raises hard questions about hospital closures and job losses

✅ What it means to repurpose and upskill the healthcare workforce as value-based care changes what's needed

WHY THIS MATTERS

It's just math: the amount of lives times the amount of utilization multiplied by your unit costs. Value-based care is fundamentally about demand destruction — and if a health system is also the largest employer in town, unit cost concessions year over year raise a hard question about whether that system, and the jobs it supports, can actually survive the transition.

=== LINKS ===

🔗 Show Notes with all mentioned links: Episode Page

🔗 Healthcare Industry Acronyms and Terms

✉️ 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

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=== CONNECT WITH THE RHV TEAM ===

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00:00 Introduction.

03:58 What all does Sutter Health | Aetna entail?

04:31 What does it mean to be a "performance network"?

04:48 What does it mean to be a payvider?

06:35 How common are payviders?

07:31 "We are writing direct risk."

09:21 How does the fully insured product work?

12:30 "You want to hold their feet to the fire, from a value-based perspective."

12:42 What's the incentive for providers to partner with payers?

15:25 "It's just math. It's the amount of lives times the amount of utilization multiplied by your unit costs."

20:58 "You have to have a day of reckoning, and that only comes from financial incentives creating that gateway out."

24:55 How do we think about reform and taking money out of the healthcare system?

26:58 "We also have to talk about repurposing the workforce."

27:27 "We need to upskill our workforce."

30:14 "Can a health system survive as the largest employer, year over year, if they give unit cost concessions, year over year? … The answer is no."

In Episode 347, Stacey Richter talks with Ian Tong, MD, chief medical officer at Included Health, about the Black Community Innovation Coalition — a new virtual-care program formed by Walmart, six other employers, and Included Health, aimed at combating health disparities among African American workers. The conversation covers how the coalition leverages existing employee resource groups (ERGs) to build engagement directly into program design, rather than treating engagement as an afterthought or a separate "marketing" function bolted on after the fact.

WHAT YOU'LL LEARN

✅ What the Black Community Innovation Coalition is, and which partners are behind it

✅ Why a one-size-fits-all approach to employee health benefits isn't adequate or complete

✅ How the coalition uses existing ERGs (employee resource groups) as a channel to build trust and engagement

✅ Why the best practice is building the engagement mechanism into a program's design from the start, not treating it as an afterthought

✅ Why virtual primary care matters for self-insured employers, and why low-value encounters are something the system can't afford

WHY THIS MATTERS

If you take a one-size-fits-all approach to your employees, that is not going to be adequate or complete. So often engagement is treated as a separate, sequential "marketing" function bolted onto a program after it's already built. The Black Community Innovation Coalition's approach — building engagement into the design itself, using channels like ERGs that already carry trust — is worth considering for anyone trying to improve health equity and outcomes for populations the healthcare system doesn't serve well.

MENTIONED IN THIS EPISODE

EP338 with Nikki King, DHA: Apple Podcasts | Spotify | Other Apps

EP295 with Rebecca Etz, PhD: Apple Podcasts | Spotify | Other Apps

=== LINKS ===

🔗 Show Notes with all mentioned links: Episode Page

🔗 Healthcare Industry Acronyms and Terms

✉️ 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

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=== CONNECT WITH THE RHV TEAM ===

✭ LinkedIn ✭ Threads ✭ Bluesky ✭ X

00:00 Introduction.

04:33 What is the Black Community Innovation Coalition?

05:06 Who are the partners behind the Black Community Innovation Coalition?

06:23 How is the Black Community Innovation Coalition focusing on patients?

08:05 "If you take a one-size-fits-all approach to your employees, that is not going to be adequate or complete."

08:56 How the Black Community Innovation Coalition is incorporating engagement into its core foundation.

13:18 "There's a great deal of hesitancy around engaging care, and there's a high level of avoidance."

15:26 EP338 with Nikki King, DHA.

16:34 "The technology is not making that experience worse. It's a bad experience, and it's broken already."

23:27 "I feel very strongly that everyone should probably have a virtual primary care clinician."

27:20 EP295 with Rebecca Etz, PhD.

28:15 "We really want to pay attention to that encounter being the best encounter possible because that … might be the only chance you get to engage that patient."

29:00 Why is virtual care important for self-insured employers?

32:08 "We cannot afford to have low-value encounters."