Relentless Health Value

When Risk-Based Payment Becomes Its Own Upcoding Arms Race

Medicare Advantage plans get paid more for sicker patients, which is why upcoding became a problem — and now health systems are upcoding visit complexity right back, with MA plans automatically downcoding in response. In this episode, Stacey Richter plays an unpublished clip from her conversation with Ahilan Sivaganesan, MD (Dr. Siva), a neurosurgeon and head of quality and value at Mishe Health, on why physicians must understand their own costs before taking on financial risk, then revisits an earlier conversation with Monica Lypson, MD, MHPE, vice dean for medical education at Columbia University Irving Medical Center, on whether handing health systems that same risk-based incentive could end up worsening the very disparities value-based care is meant to fix.

WHAT YOU'LL LEARN

✅ Why Medicare Advantage plans' incentive to upcode patient complexity is now mirrored by health systems upcoding visit complexity — triggering automatic downcoding wars between MA plans and providers

✅ Why physicians can't responsibly go at risk for outcomes and costs without first understanding their own costs through time-driven activity-based costing — without it, Dr. Siva says, you're "jumping blind into an abyss," straight toward cherry-picking and lemon-dropping patients

✅ How sliding-scale bundled payments, calibrated to patient and procedure complexity rather than a flat lump sum, could let practices take on bundled risk without being punished for treating sicker patients

✅ Why handing health systems a sliding-scale risk adjustment framework risks recreating the same upcoding incentives that plagued Medicare Advantage, just one level up the chain

✅ How perverse incentives baked into value-based and risk-based contracting can worsen existing healthcare disparities when systems are structurally rewarded for avoiding complex or costly patients

WHY THIS MATTERS

Risk-based and value-based payment models are often framed as the fix for fee-for-service's worst incentives. But if the underlying cost data and risk-adjustment frameworks aren't built carefully, the same gaming that plagued Medicare Advantage — and fee-for-service before it — can simply move up the chain to health systems and physician practices, with disparities in care quietly bearing the cost.

MENTIONED IN THIS EPISODE

EP505 with Ahilan Sivaganesan, MD: Apple Podcasts | Spotify | Other Apps

EP485 with Cristin Dickerson, MD: Apple Podcasts | Spotify | Other Apps

EP436 with Elizabeth Mitchell: Apple Podcasts | Spotify | Other Apps

EP491 with Elizabeth Mitchell: Apple Podcasts | Spotify | Other Apps

SUMS9 with Elizabeth Mitchell: Apple Podcasts | Spotify | Other Apps

EP462 with Scott Conard, MD: Apple Podcasts | Spotify | Other Apps

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

EP431 with Kenny Cole, MD: Apple Podcasts | Spotify | Other Apps

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

EP495 with Mick Connors, MD: Apple Podcasts | Spotify | Other Apps

Post by Mark Weber

EP484 with Dave Chase: Apple Podcasts | Spotify | Other Apps

=== LINKS ===

🔗 Show Notes with all mentioned links: Show Notes

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

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=== CONNECT WITH THE RHV TEAM ===

✭ LinkedIn ✭ Threads ✭ Bluesky ✭ X

TIMESTAMPS

00:00 Introduction to this episode.

05:22 What is the minimum requirement for physicians to go at risk?

07:22 How sliding scale bundle payments can reduce risk for physicians.

10:43 The question covered in the upcoming episode.

13:19 Is value-based care good for underserved communities?

15:01 "If you create perverse incentives, you actually might make known healthcare disparities worse … to meet the demand's value." —Dr. Lypson

16:18 "There actually might be systematic and structural ways that the healthcare system might say … we're not interested in taking care of you." —Dr. Lypson

16:51 "The incentive to have a good outcome is not there; the incentive to have another visit is there." —Dr. Lypson

17:49 "The only indictment I have on the fee-for-service system is that it's gotten us to where we are right now." —Dr. Lypson

18:41 "If you don't have any connection in that system, even the provider trying to … provide a good outcome might be disconnected because the system is not in place to … connect the dots." —Dr. Lypson

19:28 What are the must-haves for a value-based system that create the patient outcomes we need?

19:51 What is a whole health model?

25:31 Why we need to fix the structural issues if we want to fix health.

26:00 Why a patient's bias is the one we want in the room.

27:36 Stacey's conclusion on this week's episode.

The Line Between Fair Profit and Profiteering in Medicare Advantage

There's a simple test for telling a fair profit from profiteering in Medicare Advantage: does the carrier make more money when the patients it serves are worse off? In this episode, Stacey Richter talks with Betsy Seals, co-founder of Rebellis Group and a Medicare Advantage consultant making her third appearance on the show, about how vertically integrated carriers shift costs onto self-insured employers' commercial rates, why MA plans can end up paying providers they own more than independent practices, and the back-to-basics strategy Seals recommends for any MA plan that wants to make money the right way.

WHAT YOU'LL LEARN

✅ How vertically integrated carriers negotiate the lowest possible Medicare Advantage rates with consolidated health systems, then let those systems make up the difference by raising commercial ASO rates — a cost-shifting pattern research puts at 4.7% above what employers would otherwise pay

✅ Why Medicare Advantage carriers that own provider organizations have a financial incentive to pay those owned providers more than independent practices, since MA rate increases are pegged to fee-for-service benchmarks

✅ How Goodhart's Law shows up in STARS and other quality measures — once a measure becomes the target, it stops reliably reflecting genuine member health improvement

✅ The back-to-basics strategy Betsy Seals recommends for Medicare Advantage plans: don't get caught with your hand in the cookie jar, focus on the beneficiaries you actually serve well, and use STARS and clinical programs to genuinely improve health rather than to check boxes

✅ Why squeezing independent primary care practices on reimbursement can ultimately raise the total cost of care for everyone, even though it looks like savings in the short term

WHY THIS MATTERS

Medicare Advantage runs on taxpayer dollars, and it's the care seniors, family members, and friends depend on. When the financial incentive flips — when a plan makes more money the worse its members do — that's profiteering, not business. Seals's back-to-basics framework offers a way to tell the difference, and a roadmap for plans willing to make a fair profit instead.

MENTIONED IN THIS EPISODE

EP481 with Benjamin Schwartz, MD, MBA: Apple Podcasts | Spotify | Other Apps

EP495 with Mick Connors, MD: Apple Podcasts | Spotify | Other Apps

Video : Eric Bricker, MD, on the financial performance of the U.S. healthcare system

EP463 with Betsy Seals: Apple Podcasts | Spotify | Other Apps

EP482 with Preston Alexander: Apple Podcasts | Spotify | Other Apps

EP462 with Scott Conard, MD: Apple Podcasts | Spotify | Other Apps

Article : STAT, "Trump Goes Soft on Medicare Advantage Medical Underwriting," by Bob Herman

=== LINKS ===

🔗 Show Notes with all mentioned links: Show Notes

✉️ Enjoy this podcast? Subscribe to the free weekly newsletter

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

🎤 Follow us on Apple Podcasts

🎤 Follow us on Spotify

📺 Subscribe to our YouTube channel

=== CONNECT WITH THE RHV TEAM ===

✭ LinkedIn ✭ Threads ✭ Bluesky ✭ X

TIMESTAMPS

00:00 Introduction to this episode.

01:25 How Medicare Advantage is relevant to everyone.

06:15 A preview of today's conversation.

07:49 The "state of the state" of Medicare Advantage plans.

09:32 Does Medicare Advantage's losses matter to the patients?

10:29 A recap of Betsy's insights so far.

11:19 The underlying strategic through line that needs to be considered.

13:04 The impact of Goodhart's Law.

14:12 What the players that are succeeding right now are doing.

14:22 The first pillar of a back-to-basics strategy: Don't get caught with your hand in the cookie jar.

16:50 Why short-term strategies don't work.

18:26 Stats report on prior authorizations serving the beneficiary.

19:38 Why prior authorization needs change.

21:28 The better strategy to use.

23:17 The second pillar of a back-to-basics strategy: Focus on the beneficiaries you actually serve well.

24:37 What it looks like to implement this focus on the beneficiaries you serve well.

25:29 How special needs plans play into this.

27:43 The third pillar of a back-to-basics strategy: Think about how STARS in clinical programs improve health.

30:04 The ethical component to implementing a Medicare Advantage program.

31:04 Betsy's advice for independent practices dealing with prior authorizations.

34:08 Betsy's final notes for all players impacted by what's currently happening.

The 7.7% Wake-Up Call: A Roadmap to Align Finance Teams With Benefit Design, With Patrick Nelli (EP509)

The Seven-Step Roadmap That Gets CFOs to Stop Being Passive Price Takers on Health Benefits. Episode 509.

As a companion to last week's CEO-focused episode, Stacey Richter talks with Patrick Nelli — CEO of Aligned Marketplace and a former CFO himself — about how to bring finance teams into health benefits strategy using their own language. Patrick lays out a seven-step roadmap, starting with forecasting healthcare trend at an accurate 7.7%-or-higher rate rather than the CPI, to show finance teams exactly why the status quo is financially untenable.

WHAT YOU'LL LEARN

✅ Why healthcare inflation structurally outpaces the Consumer Price Index, driven partly by Baumol's cost disease — healthcare's low productivity gains force price increases just to keep pace with salaries in higher-productivity sectors

✅ Patrick Nelli's seven-step roadmap: stop the renewal surprise, confront an accurate trend, offer a win-win alternative to the status quo, lean into proven strategies like advanced primary care, align incentives and safeguards, optimize contracting, and steer and tier

✅ Why setting next-year forecasts at a real 7.7%-or-higher trend (two to three points above CPI) is the fastest way to get a finance team to find its own "why" for changing the health plan

✅ How direct contracting with independent practices fits into a finance-team-aligned contracting strategy, and why risk-stratifying and steering members to high-value organizations matters most for rising-risk populations

✅ Why advanced primary care keeps surfacing as the proven strategy to bend the cost curve, and what a plan sponsor's next step looks like once it commits to that model

WHY THIS MATTERS

Finance teams often forecast health benefits using the Consumer Price Index, but healthcare costs have been running two to three points above CPI for years — meaning the status quo is already financially untenable even before considering the human cost. Speaking to CFOs in their own language, with real numbers and a concrete roadmap, is what turns finance from a passive price taker into an active partner in fixing the health plan.

MENTIONED IN THIS EPISODE

EP504 with Ryan Jacobs: Apple Podcasts | Spotify | Other Apps

Take Two: EP341 with Gary Campbell: Apple Podcasts | Spotify | Other Apps

EP492 with Sam Flanders, MD, and Shane Cerone: Apple Podcasts | Spotify | Other Apps

INBW46 with Stacey: Apple Podcasts | Spotify | Other Apps

EP391 with Scott Conard, MD: Apple Podcasts | Spotify | Other Apps

Summer Short with Stan Schwartz, MD: Apple Podcasts | Spotify | Other Apps

Study: Milbank Memorial Fund on the role of primary care

EP466 with Vivian Ho, PhD: Apple Podcasts | Spotify | Other Apps

EP464 with Al Lewis: Apple Podcasts | Spotify | Other Apps

EP503 with Ryan Wells; Leo Spector, MD, MBA; and Adam Stavisky: Apple Podcasts | Spotify | Other Apps

EP430 with Barbara Wachsman: Apple Podcasts | Spotify | Other Apps

=== LINKS ===

🔗 Show Notes with all mentioned links: Episode Page

✉️ Enjoy this podcast? Subscribe to the free weekly newsletter

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

🎤 Listen on Apple Podcasts

🎤 Listen on Spotify

📺 Subscribe to our YouTube channel

=== CONNECT WITH THE RHV TEAM ===

✭ LinkedIn ✭ Threads ✭ Bluesky ✭ X

00:00 Introduction to this episode.

02:48 Roadmap Step 1 highlights.

03:07 Roadmap Step 2 highlights.

03:49 Roadmap Step 3 highlights.

04:15 Roadmap Step 4 highlights.

04:27 Roadmap Step 5 highlights.

04:58 Roadmap Step 6 highlights.

05:37 Roadmap Step 7 highlights.

06:28 Introduction to the conversation with Patrick Nelli.

06:36 Step 1 to Patrick's roadmap: Open the conversation.

07:57 What Patrick thinks is sometimes missing in health benefits.

09:07 What finance teams need in order to change their behaviors.

09:53 What Baumol's cost disease is.

12:18 The second item stacked against employers: Being price "takers."

13:49 The percent inflation employers should expect if they follow the status quo.

16:54 Proven strategies to bend the health benefits finance curve.

20:18 How employers and plan sponsors can bend the cost curve.

21:47 The two distinct business models that finance teams need to consider when setting up their health benefits model.

24:53 A quick reminder of high-cost spending within health plans.

25:59 What finance teams need to hear right now to understand why disrupting their health benefits plan is worth it.

27:45 The next step when an employer recognizes that they should seek out an advanced primary care option for their members.

30:27 Next steps after an employer enlists an advanced primary care system and aligns values and incentives in their benefits plan.

34:26 A last word to benefit teams working with finance teams.

35:08 How Aligned Marketplace fits into this entire conversation.

Why Self-Insured CEOs Won't Take Bold Action on Health Benefits, With Lee Lewis (EP508)

The Three False Dogmas Keeping CEOs From Fixing Their Health Plan. Episode 508.

In the show's first-ever Ask Me Anything episode, Stacey Richter puts a listener's question to Lee Lewis, chief strategy officer and GM medical solutions at the Health Transformation Alliance: why do so few self-insured CEOs take bold action on their health benefits strategy? Lee walks through three false dogmas, four external pressures, and the C-suite math behind a real acquisition where better-managed benefits alone created a quarter billion dollars of instant equity value nobody had priced in.

WHAT YOU'LL LEARN

✅ The three false dogmas that keep CEOs stuck in the herd: health benefits are a fixed expense, saving money hurts people, and fixing healthcare is never worth the risk or disruption

✅ How one acquired company's better-managed health plan — $2,300 less per employee per year, with better benefits — created over a quarter billion dollars of unpriced equity value in an M&A deal

✅ The four external reasons C-suites avoid action: circles CEOs travel in with health system leaders, "balance of trade" threats and promises, personal incentives like trips and perks from status quo vendors, and a blind spot to how a $5,000 deductible lands very differently on a $25-an-hour employee

✅ Why perverse incentives baked into C-suite compensation at health systems make it structurally hard for consolidated systems to accept change

✅ Lee Lewis's concrete advice for benefits teams working under a risk-averse C-suite, and his direct advice to any CEO listening

WHY THIS MATTERS Health benefits sit as one of the largest line items on a corporate balance sheet, and the false belief that fixing them is too risky or too disruptive keeps plan sponsors leaving real money and real employee health outcomes on the table. Understanding the dogmas and the external pressures behind CEO inertia is the first step to breaking it.

MENTIONED IN THIS EPISODE

EP500 with Stacey: Apple Podcasts | Spotify | Other Apps

EP466 with Vivian Ho, PhD: Apple Podcasts | Spotify | Other Apps

EP404 with Suhas Gondi, MD, MBA: Apple Podcasts | Spotify | Other Apps

EP506 with Jerry DiMaso: Apple Podcasts | Spotify | Other Apps

EP501 with Ivana Krajcinovic, PhD: Apple Podcasts | Spotify | Other Apps

LinkedIn Post by Patrick Moore

EP488 with Mark Cuban and Cora Opsahl: Apple Podcasts | Spotify | Other Apps

=== LINKS ===

🔗 Show Notes with all mentioned links: Episode Page

✉️ Enjoy this podcast? Subscribe to the free weekly newsletter

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

🎤 Listen on Apple Podcasts

🎤 Listen on Spotify

📺 Subscribe to our YouTube channel

=== CONNECT WITH THE RHV TEAM ===

✭ LinkedIn ✭ Threads ✭ Bluesky ✭ X

00:00 Introduction to this episode.

00:43 Ask Me Anything Question 1: Why don't more self-insured executives take bold action toward their benefits strategy?

03:09 A summary of the three dogmas covered in the following conversation.

05:53 A look ahead at next week's episode.

06:36 An introduction to today's guest, Lee Lewis.

08:23 Why there is an aversion to digging into health benefits for some executives.

09:43 The first dogma: Healthcare costs are fixed expenses.

09:56 The second dogma: Saving money in healthcare hurts people.

12:01 The third dogma: Fixing healthcare is never worth the effort.

12:26 How these dogmas trickle down to HR teams.

13:47 Anecdote: One company that turned down saving $50 million and why.

16:28 A quick reminder about the context behind where CEOs' mindsets are.

17:10 The kinds of employers HTA seeks out.

20:03 The power of C-suites in health systems.

21:42 Why a CEO may pull the plug on health plan/health benefit improvements.

22:37 An anecdote about Lilly cancelling their health plan.

23:21 Items that CEOs need to be thinking about.

26:32 A summary of why CEOs should care about their health benefits costs now.

29:02 How do personal incentives play into CEOs' decisions about health benefits?

30:44 Another quick reminder about C-suites.

31:53 Why perverse incentives make it difficult for C-suites to accept change.

33:28 Why the salary gap plays into health benefit decisions in a perverse way.

36:13 Lee Lewis's advice to people in benefits who are aligned to the mission.

40:06 Lee Lewis's advice for CEOs.

4 Core Concepts to Buy or Deliver the Highest-Value Healthcare, A Review With 15 Experts (EP507)

Buy Healthcare, Not Insurance: A Through-Line Review of the Four Concepts Behind High-Value Care. Episode 507.

Stacey Richter pulls together clips from 15 past guests to lay out the four core concepts for buying or delivering the highest-value healthcare: buy healthcare (not just insurance), avoid the myth that less expensive automatically means lower quality, consider direct contracting between plan sponsors and clinicians, and make sure whatever you're buying or delivering is actually high value.

WHAT YOU'LL LEARN

✅ Why health insurance is not healthcare, and why buying the two as if they were the same thing costs plan sponsors billions of dollars a year

✅ Why there is often no correlation between price and quality — sometimes less expensive care is higher quality, and low-quality care can be the most expensive care regardless of its price tag

✅ Why direct contracting between plan sponsors and clinicians helps eliminate low-value middlemen and opens the door to real collaboration on integration and shared goals

✅ Why "buy the highest-value healthcare" is a genuine north star rather than a slogan — and what plan sponsors should hold their direct-contracting partners accountable for delivering

✅ A sneak peek at the new Relentless Health Value Chatbot, trained on the show's 500-plus guests, that Stacey used with a light touch while building this episode

WHY THIS MATTERS The Relentless Tribe moves fast, covering a lot of ground episode to episode — so this through-line review exists to make the big points stick: buy healthcare, not insurance; don't assume price and quality trade off against each other; use direct contracting to get plan sponsors and clinicians talking directly; and hold whatever you buy or deliver to a real standard of value.

=== LINKS ===

🔗 Show Notes with all mentioned links: Episode Page

✉️ Enjoy this podcast? Subscribe to the free weekly newsletter

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

🎤 Listen on Apple Podcasts

🎤 Listen on Spotify

📺 Subscribe to our YouTube channel

=== CONNECT WITH THE RHV TEAM === ✭ LinkedIn ✭ Threads ✭ Bluesky ✭ X

00:00 Introduction to this episode and guests.

01:38 The four core concepts to buy or deliver highest-value healthcare: a summary.

06:01 An exciting show announcement.

07:32 Core Concept 1: Why buy highest-value healthcare, not "best" coverage?

11:28 Core Concept 2: Will employers fall victim to the myth of inexpensive care?

13:00 Why better-quality care vs. more affordable care is a false choice.

17:09 Core Concept 3: Direct contracting.

17:58 Why demand curve matters in healthcare cost.

22:08 How Centers of Excellence play into all of this.

22:54 Core Concept 4: How do you conceive of and buy high-value healthcare?

23:48 The value equation in healthcare.

25:35 What is value?

28:20 What whole-person care looks like.

30:24 Relentless Health Value Chatbot sneak peek announcement.

32:14 Coming up: looking at the episodes ahead.

Price Transparency Data: How Employers, Shareholders, and Clinics Use It, With Jerry DiMaso (EP506)

The Price Transparency Arms Race: What Self-Insured Employers and Clinics Can Both Do With the Data. Episode 506.

Health price transparency data isn't just a compliance exercise anymore — it's becoming a competitive weapon for plan sponsors, shareholders, and clinics alike. Stacey Richter talks with Jerry DiMaso, co-founder and CEO of Payerset, about how self-insured employers can use hospital and carrier transparency files to benchmark against competitors, catch overpriced billing codes, and expose "discount shell games," while independent clinics use the same data to level an historically asymmetric market.

WHAT YOU'LL LEARN

✅ How plan sponsors can use an EIN to look up their own or a competitor's negotiated rates and carve-outs, exposing which companies in their industry are quietly getting better pricing

✅ Why the "discount shell game" is exposed by transparency data — a TPA's claimed 90% discount can be checked against real negotiated rates instead of taken on faith

✅ How plan sponsors can direct their TPA to renegotiate rates, implement service carve-outs and direct contracts, and calculate objective savings instead of relying on vendors to grade their own homework

✅ How independent clinics use the same rate data to benchmark reimbursement, discover new payer contracts they didn't know existed, and defend their prices during negotiations using quality metrics

✅ Why identifying high-cost billing codes matters — including the kind of million-dollar infusion overpayment discussed in the recent episode with Ivana Krajcinovic, PhD

WHY THIS MATTERS Health benefits are often the second-largest line item on a corporate balance sheet, yet most plan sponsors have never checked whether they're paying more than their competitors for the exact same care. Price transparency data turns that blind spot into an "arms race" — plan sponsors can benchmark and negotiate harder, while independent clinics can use the same data to keep from being squeezed out by consolidated health systems that would otherwise inherit all their volume, and all their pricing power.

MENTIONED IN THIS EPISODE

EP472 with Eric Bricker, MD: Apple Podcasts | Spotify | Other Apps

EP503 with Ryan Wells; Leo Spector, MD, MBA; and Adam Stavisky: Apple Podcasts | Spotify | Other Apps

LinkedIn Post by Chris Deacon

LinkedIn Post by Andrew Tsang

LinkedIn Post by Pearly Chen

EP489 with Dan Greenleaf: Apple Podcasts | Spotify | Other Apps

EP501 with Ivana Krajcinovic, 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

🎤 Listen on Apple Podcasts

🎤 Listen on Spotify

📺 Subscribe to our YouTube channel

=== CONNECT WITH THE RHV TEAM === ✭ LinkedIn ✭ Threads ✭ Bluesky ✭ X

00:00 Introduction to this episode.

00:50 How does transparent pricing data fit into the "inches all around us"?

03:13 A quick overview of what plan sponsors do with these price transparency insights.

05:52 The specific ways that clinical organizations can leverage price transparency data.

08:13 How price transparency infrastructure started and how it's grown to where we are now.

09:21 What are the insights that can be gleaned from the price transparency data available?

10:01 How price transparency data is a treasure trove for self-insured employers.

11:21 How employers can utilize this transparency data.

14:48 How employers can help TPAs negotiate.

15:18 Why employers should be thinking about carving out services.

16:21 Why employers need to direct contract.

17:38 A quick summary of advice for plan sponsors.

19:32 How rates get set and how small providers can see this and benefit from it.

20:55 How small providers can use rate transparency to negotiate better rates.

25:46 Have prices increased due to price transparency?

29:25 Why price transparency makes it more important to eliminate lazy networks.

31:10 What is the transparency arms race, and what is happening because of it?

34:39 What Payerset does.

Time-Driven Costing and the Operative Value Index for Surgical Care, With Ahilan Sivaganesan, MD (EP505)

Why "Value Equals Outcomes Over Cost" Doesn't Work Until You Can Actually Measure Both. Episode 505.

What if the only way to know who's delivering high-value surgical care is to actually calculate it, instead of guessing? Stacey Richter talks with Ahilan Sivaganesan, MD—known as Dr. Siva—a practicing neurosurgeon with the Hospital for Special Surgery in Naples, Florida, and Head of Quality and Value at Mishe Health, about the Operative Value Index (OVI): a common mathematical framework, built on time-driven activity-based costing (TDABC) and condition-specific patient-reported outcomes, that finally lets self-funded employers and health systems quantify value instead of guessing at it.

WHAT YOU'LL LEARN

✅ Why most hospitals and surgeons have no real idea what it actually costs to deliver a given episode of surgical care—a "complete guessing game" that becomes a serious business risk as procedural bundles expand

✅ How the Operative Value Index (OVI) combines time-driven activity-based costing (TDABC) with condition- and procedure-specific patient-reported outcomes into a single quantified value metric

✅ Why appropriateness, not just surgical skill, is the true foundation of quality—and how measuring conservative, non-surgical care can finally reward the right clinical decision instead of just surgical volume

✅ How Dr. Siva's "bubble chart" visualizations let self-funded employers compare surgeons, practices, and health systems on value at both the procedural and diagnosis level, risk-adjusted for confounders

✅ Why physicians can't reasonably be asked to take on risk-based payment models until they understand their own true costs of care

✅ Why Dr. Siva sees a "Google moment" coming for health systems still maximizing fee-for-service volume instead of competing on quantified value

WHY THIS MATTERS Across the $5.6 trillion healthcare sector, both halves of the value equation—outcomes and cost—are effectively question marks: costs get rolled up into vague, triangulated numbers while outcomes get broken down to the level of a single blood test. Without quantified outcomes and unit-level costs, no one can actually identify where high-value care exists, let alone pay for it in a way that isn't a built-in perverse incentive. As Dr. Siva puts it, health systems that keep maximizing fee-for-service volume are Yahoo laughing at Google, right before the world changed underneath them.

MENTIONED IN THIS EPISODE

EP434 with Benjamin Schwartz, MD, MBA: Apple Podcasts | Spotify | Other Apps

EP326 with Rishi Wadhera, MD, MPP: Apple Podcasts | Spotify | Other Apps

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

Article: by Dana Prommel Strauss

EP449 with Marty Makary, MD, MPH: Apple Podcasts | Spotify | Other Apps

EP503 with Ryan Wells; Leo Spector, MD, MBA; and Adam Stavisky: Apple Podcasts | Spotify | Other Apps

EP501 with Ivana Krajcinovic, PhD: Apple Podcasts | Spotify | Other Apps

EP398 with Jacob Asher, MD: Apple Podcasts | Spotify | Other Apps

Substack post by John Lee, MD

Essay by Dr. Siva

=== LINKS ===

🔗 Show Notes with all mentioned links: Show Notes

✉️ Enjoy this podcast? Subscribe to the free weekly newsletter

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

🎤 Follow us on Apple Podcasts

🎤 Follow us on Spotify

📺 Subscribe to our YouTube channel

=== CONNECT WITH THE RHV TEAM ===

✭ LinkedIn ✭ Threads ✭ Bluesky ✭ X

00:00 Introduction to this episode.

00:38 The goal of this episode.

01:28 What the Operative Value Index (OVI) is.

02:04 A quick episode overview.

04:44 How this episode came about.

09:24 How Dr. Siva got involved in the research around outcomes and costs.

11:51 How the value equation doesn't add up to true quality.

14:12 What measuring quality across the entire care journey means.

16:07 Why appropriateness is the foundation of quality.

19:08 Why practicing clinicians need to be thinking about the true costs of delivering care.

21:20 Time-driven activity-based costing (TDABC).

23:44 The two things that must be known for value-based care to succeed.

27:09 A quick summary of the conversation thus far.

30:42 The power of transparency in Dr. Siva's bubble plots.

34:05 Why these bubble plots work not just at the procedural level but at the diagnosis level, too.

37:28 The "big blue ocean" opportunity for forward-looking providers.

40:37 The incredible opportunity for entities and groups that can help provide the infrastructure needed for this value index.

43:19 Last thoughts by Dr. Siva on TDABC and competition on value.

A Roadmap Through the Perverse Incentives Blocking Advanced Primary Care, With Ryan Jacobs (EP504)

Why Evidence-Backed Primary Care Still Can't Scale, and a 3-Step Roadmap to Get Around It. Episode 504.

Why isn't advanced primary care (APC) everywhere, if the evidence for it is this strong? Stacey Richter talks with Ryan Jacobs, SVP of Strategy and Partnerships at Marathon Health, about the two root causes blocking APC from scaling—conflicting fiduciary duties and what Jacobs calls "the black box of complacency"—and the three-step roadmap he uses to help plan sponsors and clinicians get around both.

WHAT YOU'LL LEARN

✅ Why conflicting fiduciary duties push hospital boards and payers to keep driving volume, even when advanced primary care would improve outcomes and lower costs

✅ How the "black box of complacency" lets consolidated health systems and lazy networks do nothing and still keep their volume, since innovators usually lose to the status quo, not to a better competitor

✅ Ryan Jacobs' three-step roadmap: perform a reality-based assessment, anticipate the stakeholders' math, and build strategic conclusions such as direct contracting

✅ Why frustrated self-insured employers are increasingly going direct to APC organizations themselves instead of waiting on payers or health systems to change

✅ Why ER spend now tops out at roughly 6% of total plan costs for self-insured employers, and how limited primary care access feeds that number

✅ Why direct contracting for APC works by connecting the plan sponsor directly to the clinicians providing care, cutting out the conflicted middle

WHY THIS MATTERS Advanced primary care has a robust evidence base—it improves outcomes and lowers costs—yet it still isn't everywhere, because the incentives of the largest players in a nonfunctioning healthcare market run the other way: health systems and payers get bigger by driving volume, not by keeping people out of the hospital. As Ryan Jacobs puts it, plan sponsors and clinicians who don't follow the dollar and anticipate that reality will keep losing to complacency rather than to a better competitor.

MENTIONED IN THIS EPISODE

SUMS5 with Jacob Asher, MD: Apple Podcasts | Spotify | Other Apps

EP483 (Part 1 and Part 2) with Jonathan Baran: Part 1 Apple Podcasts | Spotify | Other Apps; Part 2 Apple Podcasts | Spotify | Other Apps

EP465 with Chris Crawford: Apple Podcasts | Spotify | Other Apps

EP391 with Scott Conard, MD: Apple Podcasts | Spotify | Other Apps

EP436 with Elizabeth Mitchell: Apple Podcasts | Spotify | Other Apps

EP398 with Jacob Asher, MD: Apple Podcasts | Spotify | Other Apps

EP286 with John Rodis, MD, MBA: Apple Podcasts | Spotify | Other Apps

EP438 with John Lee, MD: Apple Podcasts | Spotify | Other Apps

=== LINKS ===

🔗 Show Notes with all mentioned links: Show Notes

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🫙 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 A refresher on advanced primary care (APC).

02:36 Why APC isn't everywhere.

04:39 The problem of complacency in the healthcare system.

05:27 Ryan Jacobs' roadmap.

08:59 The pitfalls of advanced primary care.

09:58 What primary fiduciary responsibility means.

10:51 Growth on the payer side.

13:27 The reality of the healthcare system in the United States.

14:11 The flywheel created by the tension within the healthcare system.

15:51 The tension between APC's goals and fiduciary responsibility.

17:52 The black box of complacency.

20:05 What's driven most of the change in the advanced primary care space.

21:01 What would happen if there was a functioning market in healthcare.

21:52 Why complacency may be a rational move in healthcare.

23:22 A roadmap to success in advanced primary care.

23:55 Step 1: Follow the money.

24:50 Step 2: Someone's gonna do math.

25:17 What strategic thinking looks like as an employer.

28:34 Step 3: Proceed based on strategic conclusions.

30:20 How self-insured employers have created their own market.

31:07 The strategic decision for physicians wanting to create change.

32:25 A reiteration of the episode's discussion.

33:49 Better payment structures.

Listener Insights on Better Decisions, Price Transparency, and PBM Spread Pricing Tricks (INBW46)

Why "Insight Is Common, Execution Is Rare" Is the Whole Game in Fixing Healthcare. Episode INBW46.

In this inbetweenisode, Stacey Richter spotlights two Relentless Tribe members whose LinkedIn posts crystallized something she'd been trying to say all season: that healthcare doesn't lack frameworks or commentary, it lacks better decisions. Along the way she walks through real examples of how spread pricing gets disguised as "profit" or a "discount," why avoiding disruption can itself become the most disruptive choice a health plan makes, and a listener-built interactive map of ten years of Relentless Health Value episodes and themes.

WHAT YOU'LL LEARN

✅ Why Stacey believes "insight is common, execution is rare" — and how better, more informed decisions, not better frameworks, are what actually move healthcare outcomes

✅ How self-insured employers and their shareholders can use price transparency data to catch site-of-care overpayments before they show up on the balance sheet

✅ Real-world tricks used to reclassify spread pricing as "profit" or a "discount" — from PBM-owned pharmacies getting preferred volume to consultant fee arrangements

✅ Why avoiding the word "disruption" can itself create disruption, when a lazy network leaves members functionally uninsured or bankrupt

✅ A listener-built interactive map of ten years of Relentless Health Value episodes, guests, and themes — and what the most-repeated words since 2014 reveal about the industry's stuck patterns

WHY THIS MATTERS

Better decisions — not better frameworks or more commentary — are what actually change outcomes in a healthcare system that Stacey describes as so financialized, with so much regulatory capture and vertical integration, that surface-level transparency can still hide an arbitrage underneath. Making good decisions requires both transparent data and the knowledge to interpret it, since a "negotiated rate" or a "no spread" claim can look clean while still not adding up. As Stacey puts it, "Knowledge isn't just power. It's really fiduciary armor in a health system built on mystery and margin."

MENTIONED IN THIS EPISODE

LinkedIn Post by Ken Wosczyna

SUMS8 with Larry Bauer, MSW, MEd: Apple Podcasts | Spotify | Other Apps

SUMS7 with Keith Passwater and JR Clark: Apple Podcasts | Spotify | Other Apps

EP501 with Ivana Krajcinovic, PhD: Apple Podcasts | Spotify | Other Apps

EP472 with Eric Bricker, MD: Apple Podcasts | Spotify | Other Apps

LinkedIn Comment by Craig Herndon

LinkedIn Post by Michelle Bernabe, RN

EP500 with Stacey Richter: Apple Podcasts | Spotify | Other Apps

EP503 with Ryan Wells, Leo Spector, MD, MBA, and Adam Stavisky: Apple Podcasts | Spotify | Other Apps

Website : RHV Universe interactive map, by Michelle Bernabe, RN

EP480 with Kimberly Carleson: Apple Podcasts | Spotify | Other Apps

=== LINKS ===

🔗 Show Notes with all mentioned links: Show Notes

✉️ Enjoy this podcast? Subscribe to the free weekly newsletter

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

🎤 Follow us on Apple Podcasts

🎤 Follow us on Spotify

📺 Subscribe to our YouTube channel

=== CONNECT WITH THE RHV TEAM ===

✭ LinkedIn ✭ Threads ✭ Bluesky ✭ X

00:00 Introduction: trying something new with this inbetweenisode.

03:08 The power of the C-suite versus the decision power of workers.

04:00 The power of actuaries to align with values.

04:50 Rate criticals for fixing the nonexistent healthcare market.

06:56 Why you can't fix what you don't understand.

10:44 Why avoiding disruption and problems with access can create disruption and problems with access.

15:56 Looking ahead: topics future episodes will be covering.

19:22 Check out this episode's sponsor.

Direct-to-Employer Specialty Care and Centers of Excellence 3.0, With Ryan Wells, Leo Spector, MD, and Adam Stavisky (EP503)

Why Self-Insured Employers and Specialists Need to Start Talking Directly Instead of Through a Lazy Middle. Episode 503.

Self-insured employers and the specialists who actually deliver care sit on opposite ends of a long, crowded road—with carriers, ASOs, TPAs, and consolidated health systems clogging up the middle. Stacey Richter talks with Ryan Wells, founder and CEO of Health Here; Leo Spector, MD, MBA, CEO of OrthoCarolina; and Adam Stavisky, a board member at Omada Health and former SVP of U.S. Benefits at Walmart, about what it actually takes to bring those two ends together through direct contracting and smart collaboration.

WHAT YOU'LL LEARN

✅ Why self-insured employers and specialists—the two ends of the healthcare "road"—rarely talk directly, with carriers, ASOs, TPAs, and consolidated health systems clogging the middle

✅ Why "disruption analyses" trap traditional carrier networks into keeping every doctor in-network, even when that means highly variable quality and safety sit side by side

✅ Why patient-reported outcomes are largely missing from most quality data, and how appropriateness—not just surgical skill—has to anchor any real comparison between clinicians

✅ How direct contracting has evolved from Centers of Excellence 1.0 (fly to a brand-name hospital) to 2.0 (scaled but still riding fee-for-service rails) to an emerging 3.0 model built on new infrastructure

✅ Why benefit design and value-based contracts are "peanut butter and jelly"—without aligned incentives like waived cost-sharing, a direct-contracting program gets built and nobody uses it

WHY THIS MATTERS

Self-insured employers and the specialists actually delivering care are natural allies on cost and quality, but the rails of the healthcare system were built for fee-for-service, not for direct collaboration between the two. Left alone, that gap defaults to lazy networks, where price and quality are highly variable within the same plan and carriers compete only on discounts, not outcomes. Bridging it, as this conversation lays out, requires new infrastructure, better data on appropriateness and outcomes, and benefit design that actually rewards patients for using it.

MENTIONED IN THIS EPISODE

EP294 with Steve Schutzer, MD: Apple Podcasts | Spotify | Other Apps

Take Two: EP398 with Jacob Asher, MD: Apple Podcasts | Spotify

EP501 with Ivana Krajcinovic, PhD: Apple Podcasts | Spotify | Other Apps

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

=== LINKS ===

🔗 Show Notes with all mentioned links: Show Notes

✉️ Enjoy this podcast? Subscribe to the free weekly newsletter

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

🎤 Follow us on Apple Podcasts

🎤 Follow us on Spotify

📺 Subscribe to our YouTube channel

=== CONNECT WITH THE RHV TEAM ===

✭ LinkedIn ✭ Threads ✭ Bluesky ✭ X

00:00 Introduction.

00:32 Collaboration as the next breakthrough innovation.

02:24 A summary of the upcoming conversation.

05:45 A summary of where we are and what the future looks like.

06:24 A relevant post from Jonathan Baran.

08:12 The conversation with Ryan Wells, Dr. Leo Spector, and Adam Stavisky: collaboration from the standpoint of a specialist.

12:22 The pitfalls of data accuracy and defining what quality means from the POV of a self-insured employer.

15:36 Defining quality and data accuracy from the POV of a physician.

15:57 How do you measure outcomes when assessing quality and looking at the available data?

22:06 Scale and operationalization: How do we do it?

27:00 Shout-out to OrthoForum.

30:30 How things could be better.

33:29 One last complication and how to structure benefit design to align incentives.

35:33 What an "anti-cricket" program looks like.

37:34 How do we operationalize benefit design and aligned incentives?

39:39 What we're seeing today in Centers of Excellence 2.0.

41:47 What Adam wants to make clear in all of this.