Relentless Health Value

In Episode 338, Stacey Richter talks with Nikki King, DHA, about ideas to meet rural healthcare's toughest challenges. Nikki offers three community-centric ideas: freestanding ERs with the financial discipline not to take advantage of the communities they serve, telehealth that actually accounts for broadband access, and expanding nurse practitioner rights and PCP scope so more people in access deserts can get care — including low-risk maternity care.

WHAT YOU'LL LEARN

✅ Why rural hospital closures set off a downward spiral that's hard for a community to escape

✅ Three community-centric ideas to meet rural healthcare access challenges: freestanding ERs, broadband-aware telehealth, and expanded NP/PCP scope

✅ Why broadband access is a real roadblock to telehealth as a rural health solution

✅ Why maternity care access is a particular crisis in rural America, and what other countries do differently

✅ Why perfect can't be the enemy of the good when a community has no healthcare options at all

WHY THIS MATTERS

When a rural hospital closes, it's often a bellwether for a community caught in a downward spiral: providers leave, jobs disappear, families relocate, and eventually there isn't even a population base big enough to support a hospital if one wanted to open. Rural communities are trying very hard to hang on to what they have — and creative, community-centric solutions like freestanding ERs and expanded NP scope may be the difference between some access and none at all.

MENTIONED IN THIS EPISODE

EP312 with Douglas Eby, MD, MPH, CPE: Apple Podcasts | Spotify | Other Apps

=== LINKS ===

🔗 Show Notes with all mentioned links: Episode Page

🔗 Healthcare Industry Acronyms and Terms

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00:00 Introduction.

05:57 How dire is the rural hospital situation right now?

06:18 How could freestanding ERs be a potential solution for rural hospitals?

08:21 What are other potential rural health access solutions?

09:25 Why is broadband a roadblock to telehealth as a solution for rural health access?

14:06 The "hot potato" of nurse practitioners in the healthcare world.

15:05 "The number of residencies for physicians each year is not increasing, but the population … is increasing."

19:06 EP312 with Douglas Eby, MD, MPH, CPE, of the Nuka System of Care.

20:41 What's the issue with maternity care in rural America?

22:53 "As healthcare becomes more and more specialized, [the] ability to treat high-risk cases is better, but access gets worse."

26:50 How is mental health care affected in rural communities?

27:23 "Rural communities are trying very hard to hang on to what they have."

28:49 "When you look at the one market plan that's available in a rural community, you probably can't afford it."

30:39 What's the single biggest challenge to moving to a model that incentivizes keeping people healthy?

31:33 "The easiest low-hanging fruit … is having national Medicaid and have that put under the same hood as Medicare."

In Episode 337, Stacey Richter talks with Olivia Webb, PharmD, author of the Acute Condition newsletter, about what it would take to build a "patient-first specialty pharmacy" — one dedicated not just to giving patients a decent experience but to actually improving outcomes, in a system where the patient is too often the product, not the customer.

WHAT YOU'LL LEARN

✅ Why the specialty pharmacy operational model isn't built to serve patients, but to fight over revenue and captive patient populations

✅ What makes a drug qualify as a "specialty" drug — and why there's no single definition

✅ What a patient-centric specialty pharmacy would actually look like

✅ Why infusion centers can become high-drama places, and who has a vested interest in patients taking specialty medications correctly

✅ Why the time may be ripe for disruption in specialty pharmacy, and what barriers stand in the way

WHY THIS MATTERS

The whole PBM/insurer/specialty pharmacy vertical stack rarely deals with patients directly — and when a patient asks a simple question about a six-figure therapy being injected into their arm, it's too often the case that no one has a good answer. There's a strong financial and clinical case for building specialty pharmacy around the patient instead of around the fight for revenue, but that would mean confronting the root cause of why it isn't built that way already.

MENTIONED IN THIS EPISODE

AEE15 with David Carmouche, MD, of Ochsner: Apple Podcasts | Spotify

=== LINKS ===

🔗 Show Notes with all mentioned links: Episode Page

🔗 Healthcare Industry Acronyms and Terms

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00:00 Introduction.

04:11 Why did Olivia start thinking about a patient-centric specialty pharmacy?

05:33 "There's really no layer on top of it to make it look nice."

06:23 "You're kind of dealing with this vertical stack that doesn't really deal with patients frequently."

06:35 Is the specialty model more patient friendly or less?

07:08 What would a patient-centric specialty pharmacy look like?

07:58 "There's a lot of fragmentation; there's a lot of friction."

08:11 What's unique to specialty pharmacy prescriptions?

10:38 Why can infusion centers be a high-drama place?

12:15 What's "the question" around specialty pharmacy?

12:42 Who has the vested interest in ensuring patients take their medications correctly in specialty pharmacy?

14:39 "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."

16:05 Why might the time be ripe for disruption in the specialty pharmacy area?

19:56 "There's no one with a clear incentive to cap the prices."

20:09 What are the barriers in specialty pharmacy?

20:31 "The patient just isn't at the center, the financial incentive, in any direction."

29:22 "I think people who are designing these things need to see how patients are actually doing it."

29:50 "I think there's a lot of money here; I think this market is going to only increase in size."

30:10 "I think you need scale."

30:20 AEE15 with David Carmouche, MD, of Ochsner.

In Episode 336, Stacey Richter talks with Brandon Weber, cofounder and CEO of Nava, about the "barbarians at the gate" of the healthcare industry — the scale of capital and human capital now flowing into disruption, and why the platform companies and collaborative ecosystems quietly building underneath point solutions may be the real threat to incumbents.

WHAT YOU'LL LEARN

✅ What it means to have "barbarians at the gate" of healthcare, and why this wave is different from disruption attempts of the past

✅ Why innovation typically doesn't come from incumbents

✅ Why there's a growing need for a distribution layer in healthcare — the "pipes" that connect patients to solutions

✅ Why "if you build it, they will come" is absolutely not true in healthcare

✅ Why the benefits broker may be the most underappreciated stakeholder in the healthcare industry

WHY THIS MATTERS

Much of the attention around healthcare disruption goes to point solutions, but the less visible platform companies — the ones building the pipes and economies of scale underneath — combined with an unusual level of willingness to collaborate, may be what actually builds a flourishing alternative ecosystem in an industry designed for the big to keep getting bigger.

=== 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.

04:13 What does it mean to have "barbarians at the gate" of healthcare?

05:32 What is the overly complex gate to healthcare?

07:28 "No one can make the argument that we've seen this before."

08:37 Are the "barbarians" in healthcare going to expand the system that already exists?

09:25 What is the number one pain point in healthcare?

13:25 "Typically, the innovation doesn't come from the incumbents."

17:16 "We were actually just blown away by the amount of innovation that is already happening … [in] care delivery."

17:58 "The future is actually here; it's just not evenly distributed."

18:08 Why is there a need for a distribution layer in healthcare?

20:57 "Everyone is vying to be that one app in the pocket that acts as the aggregator, the hub, the steering point."

26:32 "If you build it, they will come … that is absolutely not true in [healthcare]."

29:46 "The benefits broker is likely the most underappreciated stakeholder in the healthcare industry."

In this In Between episode, Stacey Richter shares a hot take on why healthcare stakeholders need to collaborate with organizations across the care continuum — even the ones they have a problem with — and how fragmentation of care is directly tied to higher costs and lower quality.

WHAT YOU'LL LEARN

✅ Why the US ranks last among peer countries on healthcare fragmentation, according to a Commonwealth Fund study

✅ How fragmented care is linked to higher costs, more departures from clinical best practice, and higher rates of preventable hospitalizations

✅ Why fixing fragmentation requires stakeholders across the care continuum to collaborate, even with organizations they have a problem with

✅ What the difference is between collaboration and collusion

WHY THIS MATTERS

Fragmentation isn't an abstract inefficiency — it's measurably associated with worse outcomes and higher costs, even for patients with the same chronic condition. If the goal is to fix American healthcare, that means fixing fragmentation, and fixing fragmentation means stakeholders who may not love each other still have to find a way to work together.

=== 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

00:12 What's Stacey's hot take on collaboration in healthcare?

00:43 Why is collaboration so vital, and how does fragmentation play into that?

01:38 "To fix American healthcare, we need to fix fragmentation."

03:23 "Nobody gets to be holier than thou."

04:38 What is the bottom line on collaboration in healthcare?

05:20 What's the difference between collaboration and collusion?

05:35 "More is not usually better."

In this An Expert Explains episode, Stacey Richter talks with Brian Klepper, PhD, longtime healthcare analyst and former CEO of the National Business Coalition on Health, about the RUC — the AMA-run committee with a sole-source CMS contract to decide how many RVUs any given procedure is worth — and how its specialist-heavy makeup helped trample primary care.

WHAT YOU'LL LEARN

✅ What the RUC is, and why it has roughly four times as many specialists as PCPs

✅ What the specialists on the RUC are ultimately trying to achieve

✅ Why health plans, not just health systems, played a role in this dynamic

✅ How the historical war between the hospital community and the HMO community shaped today's incentives

✅ Why primary care has an undeserved reputation for being the "easy" specialty

WHY THIS MATTERS

The RUC's specialist-heavy composition isn't a technicality — it directly shapes how much any given procedure or service is worth, and over time those incentives have been formidable enough to trample primary care while it earned an unfair reputation for being the easy specialty.

=== 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

01:00 What is the RUC?

03:18 What is the goal of the specialists in the RUC?

04:32 Why health plans and not health systems?

06:55 "All this time, the hospital community was waging war against the HMO community."

07:59 "The incentives that have been at play have been very formidable."

08:23 "Primary care has developed a reputation for being the easy specialty … and it's just not so."

In Episode 335, Stacey Richter talks with Brian Klepper, PhD, longtime healthcare analyst and former CEO of the National Business Coalition on Health, about why private equity is willing to pay as much as $55,000 per patient to primary care start-ups — and the three distinct flavors of primary care operating today, from fee-for-service to direct primary care to what Brian calls industrialized (or advanced) primary care.

WHAT YOU'LL LEARN

✅ Why the 1990s HMO version of primary care was really a glorified, restrictive gatekeeper model

✅ The three kinds of PCPs operating today, and how they differ in the risk they take on

✅ What "industrialized" or advanced primary care (APC) requires to succeed — relationship, data, and digital capability

✅ Why a huge flurry of private equity investment into primary care can actually be a problem

✅ Why better patient-PCP relationships quantifiably translate to better care

WHY THIS MATTERS

Advanced primary care is, in Brian's view, one leg of a three-legged stool needed to transform healthcare — alongside high-performing specialty care and value-based reimbursement. But almost nobody in healthcare actually wants this transformation to happen, even though the math suggests we could get wildly better outcomes for 40% to 45% less than what's currently being spent.

MENTIONED IN THIS EPISODE

AEE5 with Alex Jung, Partner and Managing Director in Parthenon-EY, on why the HMOs crashed and burned

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

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🎤 Listen on Apple Podcasts

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=== CONNECT WITH THE RHV TEAM ===

✭ LinkedIn ✭ Threads ✭ Bluesky ✭ X

00:00 Introduction.

05:10 Is the HMO model of primary care a good model?

07:48 "Industrialized medicine is exciting."

08:59 What does primary care have the opportunity to do?

09:21 "The problem that goes along with that is that now immense amounts of money are being infused into primary care organizations."

10:15 Where does direct primary care and advanced primary care fit into this model?

13:35 "At the end of the day, what primary care really needs to be about is … the management of life issues as well."

14:05 EP295 with Rebecca Etz, PhD.

14:19 "Better relationships quantifiably translate to better care."

21:48 "Almost nobody in healthcare wants any of this to happen."

23:58 Why the huge amounts of money being invested into primary care is actually a big problem.

28:11 "We should be able to get wildly better health outcomes for about 40% to 45% of the money that we're currently spending."

In Episode 334, Stacey Richter talks with Sunita Desai, PhD, health economist at NYU Grossman School of Medicine, about whether price transparency tools actually drive consumers to lower-cost providers — and the barriers standing between price transparency and the consumerism it's supposed to enable.

WHAT YOU'LL LEARN

✅ The seven-step chain that has to hold for price transparency to actually improve quality and lower costs

✅ Why most people don't use shopping tools even when they're available — and what changes that

✅ Why people who do use price information often still don't switch to lower-cost providers

✅ Why bypassing the physician at the point of care limits the use of price transparency tools

✅ Why there isn't a strong correlation between provider prices and quality

WHY THIS MATTERS

Price transparency isn't an end in itself — it's supposed to enable shopping, which is supposed to reward higher-quality, lower-priced providers and punish the rest. But the research shows most people don't use shopping tools, and even those who do often don't act on the information. Understanding those barriers, rather than getting defensive about them, is the only way to actually make consumerism work in healthcare.

MENTIONED IN THIS EPISODE

EP284 with Carm Huntress: Apple Podcasts | Spotify

EP308 with Mark Fendrick, MD: 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 ===

✭ LinkedIn ✭ Threads ✭ Bluesky ✭ X

00:00 Introduction.

06:23 Why is everyone so interested in price transparency right now?

07:30 How does price transparency enable consumerism?

08:05 What are the two aspects to consumerism in order to enable it in health care?

11:01 Does access to price transparency tools lower costs and spending?

15:19 Why is there such low utilization of price transparency tools?

16:13 What's the first barrier to using price transparency tools?

17:10 Why bypassing the physician at the point of care limits the use of price transparency tools.

17:53 EP284 with Carm Huntress.

23:20 EP308 with Mark Fendrick, MD.

23:31 How does reducing spending with high-deductible health plans negatively affect high-value health care?

25:23 "There is not a strong correlation between prices of providers and quality."

28:48 How does a reduction in physician choices undermine price transparency?

29:30 "We owe that information to patients … it's useful for patients to know what out-of-pocket costs they should expect."

In Episode 333, Stacey Richter revisits the topic of actually using care plans in the real world, drawing on clips from past guests — Jeff Hogan, Darrell Moon, Grace Terrell, MD, Rich Klasco, MD, Nicole Bradberry, and Kelly Conroy — to explore why patients with the exact same clinical needs often walk away with very different care plans, even when the evidence should point to one.

WHAT YOU'LL LEARN

✅ Why patients with identical clinical profiles often receive different care plans depending on which clinician they see

✅ Why Darrell Moon walked away from being a hospital administrator over how care plans were actually happening

✅ Why population medicine and precision medicine aren't actually incompatible or opposites

✅ What "noncognitive" medicine is, and why it bogs physicians down

✅ How bringing data directly to physicians can change the way they practice

WHY THIS MATTERS

Most patients assume medicine is more science than it actually is when it comes to care planning — the same clinical profile, in the same practice, can generate very different care plans depending on which clinician a patient happens to see. Understanding what's at the core of appropriateness in care, and how data can open physicians' eyes to their own patterns, is a necessary step toward closing that gap.

MENTIONED IN THIS EPISODE

Episode 176 with Alex Akers of Health Catalyst: Apple Podcasts | Spotify

Episode 201 with Clint Phillips of Medici

EP309 with Jeff Hogan: Apple Podcasts | Spotify

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

EP305 with Darrell Moon: Apple Podcasts | Spotify

EP319 with Grace Terrell, MD: Apple Podcasts | Spotify | Other Apps

EP321 with Rich Klasco, MD: Apple Podcasts | Spotify

EP324 with Nicole Bradberry and Kelly Conroy: Apple Podcasts | Spotify

=== 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 ===

✭ LinkedIn ✭ Threads ✭ Bluesky ✭ X

00:00 Introduction.

02:10 Jeff Hogan (EP309) talks about the consequences of when there's a disconnect between what the patient thinks is happening and what is actually happening in a care plan.

03:48 EP315 with Bob Matthews.

03:58 Merrill Goozner's perspective on successful population health.

04:55 Why did Darrell Moon (EP305) give up being a hospital administrator because of care plans?

08:02 "It's a myth that population medicine … and precision medicine are incompatible or opposites."—Dr. Grace Terrell (EP319)

11:28 Dr. Rich Klasco (EP321) explains "noncognitive" medicine and why it bogs physicians down.

14:45 What is at the core of appropriateness for care?

16:33 "You start to bring that data to the physician, and it really does open their eyes."—Nicole Bradberry (EP324)

16:51 Nicole Bradberry and Kelly Conroy (EP324) discuss how to really change the way physicians work.

In Episode 332, Stacey Richter talks with Tony DiGioia, MD, orthopedic surgeon at UPMC and developer of the Patient Centered Value System (PCVS), about building a new operating system for provider organizations — one that traces the entire patient journey from the very first interaction to the very last and designs care delivery around what actually matters to patients.

WHAT YOU'LL LEARN

✅ What the Patient Centered Value System (PCVS) is, and why it could be the operating system health care needs

✅ The three steps to building a PCVS: trace the current patient journey, compare it to the ideal, then implement

✅ Why the patient is the one true common denominator across every fragmented setting and technology in health care

✅ The difference between asking patients "What is the matter with you?" and "What matters to you?"

✅ Why a PCVS process matters for bundle success, risk-based contracts, and competing with virtual-first care

WHY THIS MATTERS

Legacy health care has evolved to treat the insurance carrier or the revenue-driving specialist as the customer, not the patient. A patient-centered value system flips that: it rationalizes the patient journey end to end so that technology, staff, and processes are built around what patients actually need at each step — which increasingly determines whether bundles, risk arrangements, and patient satisfaction scores succeed or fail.

MENTIONED IN THIS EPISODE

EP328 with Marshall Allen: Apple Podcasts | Spotify | Other Apps

Encore! EP225 with Joe Selby, MD, MPH, of PCORI: Apple Podcasts | Spotify

=== 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.

06:19 What is the Patient-Centered Value System, and why should it be the operating system for all health systems moving forward?

07:47 "It's the infrastructure to allow us to redesign care delivery."

09:00 "These artificial silos that we have in health care have to be crossed and broken down."

10:03 "The patient is the common denominator. We have to follow the patient."

10:33 Why does the disjointed patient experience affect a patient's trust in their care delivery?

12:00 What are the steps to creating a patient-centric system?

12:30 "The challenge is to view all care through the eyes of patients and families."

13:19 "Our end users are patients and families. Period."

16:36 What's the difference between asking patients, "What is the matter with you?" and "What matters to you?"

19:56 How are nonclinician staff included in a patient-centric value system?

25:40 "We can give them the tools, wherever they're coming from."

29:33 "The bottom line is, these are engagement tools and technologies that we do need to start looking at to help redesign care delivery."

In Episode 331, Stacey Richter talks with Al Lewis, cofounder and CEO of Quizzify and founder of the Validation Institute, about six logical fallacies and computational tricks that wellness and point-solution vendors use to overstate their results — and why employers are worse than ever at evaluating these vendors.

WHAT YOU'LL LEARN

✅ Why employers are increasingly reliant on brokers and EBCs who may be taking money from the very vendors they recommend

✅ The six tricks vendors use to overstate cost savings: regression to the mean, participant vs. nonparticipant comparisons, trend inflation, plausibility testing, actuarial validation, and overstated engagement

✅ Why wellness done "for" employees works better than wellness done "to" employees

✅ Why actuaries can be easily corrupted, and what the Validation Institute does about it

✅ What questions employers should be asking their vendors and their brokers

WHY THIS MATTERS

With a flood of private equity dollars pouring into point solutions, employer customers are worse than ever at evaluating wellness and point-solution vendors — partly because so many backroom broker deals happen without employers ever knowing there's a vig involved. Buyer beware, and get a broker who's committed in writing to not taking payola from the vendors they recommend.

=== 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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🎤 Listen on Apple Podcasts

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=== CONNECT WITH THE RHV TEAM ===

✭ LinkedIn ✭ Threads ✭ Bluesky ✭ X

00:00 Introduction.

04:49 Are brokers going to have to become more transparent about where their money is coming from?

07:33 Are carriers transparent?

08:09 What's the goal of the Validation Institute?

08:55 "You either get a true statement put up or learn what you have to do in order to get a true statement put up."

11:18 How is Regression to the Mean (RTM) used in a flawed way?

16:32 "If you do wellness for employees instead of to employees, the people who want the wellness will be able to access it."

21:13 What is plausibility testing?

23:17 What about actuaries and validation?

23:40 "That's one of the reasons the Validation Institute exists, is because actuaries are easily corrupted."

25:18 What is a prime example of population health economics?

26:20 What does it mean to overstate engagement?

27:15 "How often did you use this and was it useful?"

28:55 "Are you validated by the Validation Institute, and if not, why not?"