Relentless Health Value

In Episode 322, Stacey Richter talks with Monica Lypson, MD, MHPE, vice dean for education at Columbia University Vagelos College of Physicians and Surgeons, about cherry picking, lemon dropping, and other lessons value-based care needs to learn to serve underserved communities well.

WHAT YOU'LL LEARN

✅ How perverse incentives in value-based care can worsen known health care disparities

✅ What cherry picking and lemon dropping mean, and why they're a real risk in VBC models

✅ Why fee-for-service isn't a real alternative, even with all of VBC's flaws

✅ What a "whole health" model of care actually requires

✅ Why a national framework is necessary to enable local value-based initiatives

WHY THIS MATTERS

Value-based care has real, serious problems worth taking seriously — but the answer isn't to throw it out and go back to fee-for-service, which got health care to where it is today. Dr. Lypson argues that critical thinking about VBC's flaws should inform creative solutions: closing loopholes that let people game the system, building equity into the framework from the start, and creating a national structure flexible enough to let local communities and their partners actually solve problems together.

=== LINKS ===

🔗 Show Notes with all mentioned links: Episode Page

🔗 Healthcare Industry Acronyms and Terms

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=== MENTIONED IN THIS EPISODE ===

🔗 EP319 (Apple) / EP319 (Spotify) with Grace Terrell, MD

🔗 EP312 (Apple) / EP312 (Spotify) with Douglas Eby, MD, MPH, CPE

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00:00 Introduction.

04:08 Is value-based care good for underserved communities?

05:09 "If you create perverse incentives, you actually might make known health care disparities worse … to meet the demands' value."

06:29 "There actually might be systematic and structural ways that the health care system might say … we're not interested in taking care of you."

07:12 "The incentive to have a good outcome is not there; the incentive to have another visit is there."

08:33 "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."

08:55 "The only indictment I have on the fee-for-service system is that it's gotten us to where we are right now."

09:30 What are the must-haves for a value-based system that creates the patient outcomes we need?

09:58 What is a whole health model?

10:43 EP319 with Grace Terrell, MD.

11:08 EP312 with Douglas Eby, MD, MPH, CPE.

16:25 "We want to move money around with the accountability of the patient outcome. We want to be responsible stewards of that dollar."

17:14 What does it mean to keep an equity framework?

20:48 Do we know the impact of independent physicians closing their offices?

25:20 What do we need to be mindful of when constructing a value-based system of care?

27:52 "The large health care system needs their community partners at the table."

In Episode 321, Stacey Richter talks with Rich Klasco, MD, chief medical officer at Motive Medical Intelligence, about how to identify low-value care and get physicians, patients, and payers on the same page about what actually counts as appropriate care.

WHAT YOU'LL LEARN

✅ Why patients often struggle to recognize high-value versus low-value care

✅ How looking at practice-pattern data and outlier physicians can surface low-value care

✅ Why payers are often well positioned to understand what high-value care really looks like

✅ The difference between cost cutting and true utilization optimization

✅ How teams can build consensus and move forward on delivering appropriate care

WHY THIS MATTERS

Everyone agrees in theory that health care should deliver only high-value care, but the wheels fall off once you try to define, in practice, what counts as low-value. One reliable approach: look at practice-pattern data across a specialty, find the outliers, and simply show physicians where they stand — often enough to change behavior on its own. Combined with published guidelines and real-world evidence, this kind of data-driven approach offers a genuine path toward identifying appropriate care without a fight.

=== LINKS ===

🔗 Show Notes with all mentioned links: Episode Page

🔗 Healthcare Industry Acronyms and Terms

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00:00 Introduction.

03:31 How do you define high-value care?

04:40 How do we define what isn't appropriate care?

05:26 Why aren't patients good at recognizing high-value care?

07:02 "He was in the 'more is more' school of medicine, which is always wrong."

11:54 Are payers good at identifying high-value care?

13:41 Why are payers so adept at understanding what high-value care really is?

15:53 "It's not just cost cutting; it's utilization, optimization of resources."

16:02 "This is, again, an innovation of appropriateness."

18:38 "We have to deal with the world that we have in front of us now."

19:55 How do we get everyone on the same page about high-value and appropriate care?

24:16 How does a team recognize the path forward for appropriate care?

In this sidebar episode, Stacey Richter continues her conversation with David Carmouche, MD, executive vice president of value-based care and network operations at Ochsner, about the challenges health systems face trying to collaborate and strike risk-share agreements with pharmaceutical manufacturers.

WHAT YOU'LL LEARN

✅ Why creating collaboration between health systems and Pharma has been so difficult

✅ How weighing a more expensive drug against downstream episode-of-care costs complicates these deals

✅ Why assembling enough patients to make a pharma risk-share agreement worthwhile is a real structural challenge

✅ How payer and PBM plan design further narrows the pool of patients eligible for these arrangements

WHY THIS MATTERS

When a pharma company says its drug will save money downstream through avoided complications or better outcomes, testing that claim through a risk-share agreement means assembling enough patients on the same payer and the same PBM plan design to make the numbers work. That layered dependency — health system, payer, and PBM all needing to line up — helps explain why direct value-based contracts between health systems and pharma manufacturers remain rare, even when everyone agrees on the goal.

=== LINKS ===

🔗 Show Notes with all mentioned links: Episode Page

🔗 Healthcare Industry Acronyms and Terms

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=== CONNECT WITH THE RHV TEAM ===

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00:00 Introduction

01:57 Why has creating collaboration across Pharma been difficult?

03:10 "Is it better over an episode of care to add a more expensive drug … or would we be better served using less expensive drugs?"

03:51 Why has it been difficult for health systems to execute agreements directly with pharma companies?

04:36 "The question is really just whether or not there's enough value that's created to make it worth our while."

In Episode 320, Stacey Richter talks with Christian Milaster, founder of Ingenium Digital Health Advisors, about why treating telehealth versus in-person care as a winner-takes-all fight misses the point — and why telehealth is best understood as a clinical tool, not a rival care setting.

WHAT YOU'LL LEARN

✅ Why telehealth is best understood as a clinical tool, not competition for in-person care

✅ The biggest mistake provider organizations are making with telehealth right now

✅ Why organizational change management is essential to incorporating telehealth well

✅ How organizations can use telehealth strategically to redesign care delivery workflows

✅ Why digital inclusion is itself a social determinant of health

WHY THIS MATTERS

Asking whether telehealth or in-person care is "better" is like asking whether an X-ray or an MRI is better — the right tool depends on the patient and the clinical pathway, decided before you pick the setting, not after. Post-pandemic demand for telehealth is reshaping how patients, especially commercially insured ones with real choice, evaluate their providers, but it's worth remembering that the very patients telehealth was meant to serve — those with transportation or access barriers — are sometimes the least able to take advantage of it due to gaps in internet access and digital literacy.

=== LINKS ===

🔗 Show Notes with all mentioned links: Episode Page

🔗 Healthcare Industry Acronyms and Terms

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=== CONNECT WITH THE RHV TEAM ===

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00:00 Introduction.

06:53 What's the biggest mistake provider organizations are making in regard to telehealth right now

08:50 Is there a downside to not investing more in telehealth?

12:28 "There's no more geographic boundaries."

15:25 What's a provider organization's first step in making telehealth a cornerstone of care?

17:20 Why is organizational change management essential to incorporating telehealth?

19:00 "Everybody involved in the in-person care experience needs to be involved and play a role in the virtual care experience as well."

19:22 What does the patient flow look like for organizations that do telehealth well?

21:12 How does an organization use telehealth as a strategic tool?

23:55 "Telehealth gives us an opportunity to redesign the workflow of the care delivery experience."

24:38 How is the provider reimbursed in telehealth?

26:29 "It's really about the outcomes and it's about value-based care … when I can just wield telemedicine … as a clinical tool."

28:19 "Telemedicine … is vital for value-based care; it's vital for better patient outcomes."

In Episode 319, Stacey Richter talks with Grace Terrell, MD, CEO of Eventus WholeHealth, about bringing advanced, whole-person primary care into skilled nursing and assisted living facilities — and why fee-for-service gives these facilities zero financial incentive to improve.

WHAT YOU'LL LEARN

✅ Why advanced primary care models are rarely applied to the most vulnerable patients in facilities

✅ Why fee-for-service gives skilled nursing facilities no real financial incentive to improve care

✅ What whole-person, integrated care actually looks like inside a long-term care facility

✅ Why this population often doesn't respond well to typical specialist-prescribed medications

✅ What integrated care requires: information access, communication, and understanding what the patient wants

WHY THIS MATTERS

Skilled nursing and assisted living facilities get paid a set Medicare/Medicaid rate whether the care is excellent or mediocre, so there's little built-in financial incentive to improve — and these facilities have been chronically underfunded and heavily regulated for years, then hit hard by COVID. Dr. Terrell's work at Eventus shows that bringing the same whole-person, integrated primary care principles that work in the community into these facilities can genuinely improve outcomes for some of health care's most medically vulnerable patients.

=== LINKS ===

🔗 Show Notes with all mentioned links: Episode Page

🔗 Healthcare Industry Acronyms and Terms

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=== CONNECT WITH THE RHV TEAM ===

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00:00 Introduction.

04:09 "The industry itself is in a real pickle."

04:49 What are the fiscal opportunities that a SNF might have in a value-based care model?

09:34 What's the basic principle that needs to be true to provide the best care possible in a SNF environment?

11:05 How does whole-person care work?

15:51 "It does require integrative care; it does require somebody … to be steering the ship."

18:53 "This population doesn't necessarily do well with the typical medications that are prescribed … by a specialist."

20:49 "Most of us in health care … don't have the opportunity to build something from the ground up. You have to work in the system that you're in."

23:10 "More and more people are thinking about integrative models of care."

27:50 "Integrated care is very much based on … access to information, access to communication capabilities, the ability to know what the patient wants, … and the skills to actually provide them good care."

29:27 "Once you get past critical thinking and get into … creative thinking, you'll find that there's just a ton of folks out there who want to be with you, who want to create with you."

In Episode 318, Stacey Richter talks with Troy Larsgard, category manager of pharmaceuticals at Johns Hopkins Medicine, about what a great strategic collaboration between Pharma and a health system actually looks like — from the point of view of the person pharma reps most want to meet.

WHAT YOU'LL LEARN

✅ Why a health system's level of centralized decision-making shapes how Pharma should approach it

✅ The difference between a strategic model and a purely transactional, tactical model

✅ Why early, frequent, transparent communication builds more trust than a "boots on the ground" rep strategy

✅ How drugs actually get onto formulary, and how physicians learn about it

✅ What "partnership" really means to a health system, versus what pharma companies often assume it means

WHY THIS MATTERS

Practicing medicine without pharmaceuticals doesn't work, so figuring out how providers and Pharma collaborate well matters a great deal — and that sweet spot exists somewhere between blocking every pharma rep at the door and outright conflicts of interest. Troy Larsgard's insight, that pharma companies who meet health systems where they actually are outperform those clinging to legacy transactional approaches, applies just as much to medical device makers and digital health vendors trying to work with health systems.

=== LINKS ===

🔗 Show Notes with all mentioned links: Episode Page

🔗 Healthcare Industry Acronyms and Terms

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=== CONNECT WITH THE RHV TEAM ===

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00:00 Introduction.

04:16 What's the rationale behind trimming the supplier list for pharmacists?

05:35 What's the difference between a strategic model and a tactical model?

06:49 "A lot of effort goes into developing drugs and bringing them to market, but sometimes the thought of how to interact with the health system beyond that isn't always thought out."

09:06 "I think there's opportunity to be more seamless."

10:48 "Those who inform early, often, and are transparent … save much more face."

11:04 What do account managers need to know about health systems and vice versa for them to work together?

14:15 How do drugs on formulary fall into these pharma/health system collaborations?

16:46 How do physicians know when a drug is on formulary?

19:32 Are downstream medical costs being assessed?

21:29 Why would a health system choose to collaborate with a pharmaceutical company in this system?

22:31 "What does partnership mean to you?"

26:15 "Outcomes-based contracts sometimes are called risk share, and I like to joke sometimes it's all risk, no share."

In Episode 317, Stacey Richter talks with Josh LaRosa, MPP, policy director at Wynne Health Group, about how drug pricing reform quietly ended up tucked inside the federal infrastructure bill — and the three major ways the government might try to capture Medicare drug savings.

WHAT YOU'LL LEARN

✅ Why drug pricing reform showed up as a funding source in the infrastructure bill

✅ The three major approaches Congress is weighing to capture Medicare drug savings

✅ What "inflation rebates" are, and how they'd apply to both Medicare Part D and Part B drugs

✅ Why HHS negotiating drug prices directly remains such a politically charged option

✅ What might be coming from the Executive Branch, including a possible Most Favored Nation rule reboot

WHY THIS MATTERS

Drug pricing reform is being discussed as a literal funding mechanism for roads and bridges, which tells you something about how seriously Washington is weighing it right now. Between inflation rebates that could hit both Part D and the often-far-more-expensive Part B oncology drugs, and the long-simmering possibility of direct HHS price negotiation, the shape of this legislation could have a real impact on Medicare spending and, by extension, everyone whose costs are influenced by federal drug pricing policy.

=== LINKS ===

🔗 Show Notes with all mentioned links: Episode Page

🔗 Healthcare Industry Acronyms and Terms

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=== CONNECT WITH THE RHV TEAM ===

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00:00 Introduction.

02:56 Where are we on drug pricing reform in legislation?

05:06 What things have the greatest potential for consideration on drug pricing reform legislation?

06:07 How is the Part D benefit design and reform shaping up?

07:55 Who is one of the largest offenders of high federal spending?

09:15 Who is going to pay in the reform of the catastrophic pricing phase?

12:04 What are inflation rebates?

15:36 "The interesting part of the inflation rebates … is that it not only … had these inflation rebates as applying to … Medicare Part D drugs but also Medicare Part B … drugs."

16:20 How likely is this reform?

18:43 What's happening on the regulatory and administrative side of drug pricing?

24:23 When will we start to see what the White House intends to do about drug reform pricing?

In Episode 316, Stacey Richter talks with David Carmouche, MD, executive vice president of value-based care and network operations at Ochsner Health, about what a large provider organization actually wants and needs from commercial payers and self-insured employers.

WHAT YOU'LL LEARN

✅ The four things that have to come together for meaningful value-based care creation

✅ Why payer-provider-employer partnerships may be the most important collaborations for value

✅ Why health systems want to grow their commercial market share

✅ Whether competition among health systems is moving upstream

✅ Why collaboration skills are essential to any organization's transition away from fee-for-service

WHY THIS MATTERS

Dr. Carmouche flips the usual script on this show: instead of employers explaining what they need from providers, a large health system explains what it needs from commercial payers and employers to make value-based care work. His four ingredients — willingness to change, the ability to affect payment, access to data, and some control over steering patients — put employers and payers squarely at the center of provider transformation. The broader lesson applies well beyond Ochsner: no organization can transition to value without knowing how to collaborate and share the rewards with everyone else in the ecosystem.

=== LINKS ===

🔗 Show Notes with all mentioned links: Episode Page

🔗 Healthcare Industry Acronyms and Terms

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=== CONNECT WITH THE RHV TEAM ===

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00:00 Introduction.

04:15 Who needs to be working together to create value-based success?

04:31 "I think the most important partnerships that are likely to lead to value are those between payers or purchasers … and providers."

04:45 What four things have to come together for meaningful value?

06:02 "We're focusing specifically on payer employers today. We think that's where there's the biggest opportunity."

07:23 What's the overarching reason for health systems to want to grow their commercial market share?

14:00 Is the competition moving upstream?

16:20 "In all honesty, we're competing for pieces of the business."

16:23 What's the ultimate competition?

18:36 "There is a consumer experience that is available inside these … collaborative efforts."

20:53 "We really haven't changed the paradigm of benefit design as it comes to drugs."

In Episode 315, Stacey Richter talks with Bob Matthews, president and CEO of MediSync, about the unglamorous secret to making technology actually improve patient outcomes: process.

WHAT YOU'LL LEARN

✅ Why technology alone can't improve outcomes without a process framework around it

✅ Why quality of care regresses to the mean without standardized care processes

✅ How great performers achieve consistency through process, whether or not they realize it

✅ Why team-based care requires a shared playbook of processes

✅ What business reasons are driving practices to level up chronic care management right now

WHY THIS MATTERS

Medical knowledge doubles roughly every 73 days, with 800,000 journal articles published annually — no human, and no piece of technology on its own, can keep up without a framework for using it. Process is what lets a provider organization incrementally improve care instead of watching quality drift back to average, and it's what separates consistently great performers from those coasting on individual talent. It's an unglamorous truth that gets lost in the excitement over flashy new health tech.

=== LINKS ===

🔗 Show Notes with all mentioned links: Episode Page

🔗 Healthcare Industry Acronyms and Terms

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=== CONNECT WITH THE RHV TEAM ===

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00:00 Introduction.

04:47 How do you address concerns about chronic care costs?

06:15 What are the disjunctures in the health system?

07:01 "Very few organizations today know how to do a great job in managing [chronic care]."

09:58 "Some medical group organizations … put the pressure on, but they don't offer much help."

10:09 "There's something inherently difficult about the work, or we wouldn't have this problem."

10:44 What is the increasing pressure on practices to manage chronic conditions?

11:51 "We just simply cannot afford to get the outcomes we need with the system we have."

13:37 "The pressure to improve outcomes is just really now starting to heat up."

14:00 What things need to be focused on to improve outcomes?

17:32 "The only thing you get rewarded for is speed."

19:20 "Just because you start the journey doesn't mean that you're going to succeed."

23:18 "Complexity can only be mastered with process."

25:38 "We do need to work on ways to help patients want to take their own medicines."

29:21 Who is MediSync?

In this "An Expert Explains" minisode, Stacey Richter talks with Douglas Eby, MD, MPH, CPE, VP of medical services at Southcentral Foundation's Nuka System of Care, about the single piece of advice self-insured employers most need to hear: access and trust are what actually reduce downstream costs.

WHAT YOU'LL LEARN

✅ Why access to a trusted care team is the key lever for reducing downstream health care costs

✅ How restricting patient access can counterintuitively drive up utilization and spend

✅ Why trust between patients and their care team replaces the need for more testing and follow-up visits

✅ What self-insured employers should look for when selecting a provider network

WHY THIS MATTERS

When patients don't trust that they can get access to care when they need it, they behave like people stocking up before a shortage — grabbing every test or follow-up they can while they have the chance. Dr. Eby's experience at the award-winning Nuka System of Care suggests that combining real access with genuine trust between patients and their care team does more to reduce unnecessary utilization than restricting access ever could, a lesson self-insured employers should keep in mind when selecting their network.

=== LINKS ===

🔗 Show Notes with all mentioned links: Episode Page

🔗 Healthcare Industry Acronyms and Terms

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=== CONNECT WITH THE RHV TEAM ===

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00:00 Introduction

03:19 "The employer is the total-cost provider."

03:23 "The people who don't like us are people who are trying to make profits … extremely high use of high-end medicine."

03:47 "Health care, for chronic disease management, should be provided when, where, and how the person on the receiving side wants and needs it."

07:05 "People think demand is driven by … paranoia … but when you replace all of that by trust … that's a massive replacement for all of that other stuff."