In Episode 306, Stacey Richter talks with Ge Bai, PhD, CPA, associate professor at Johns Hopkins, about Amazon's pharmacy business — and a mind-blowing PBM contracting term that keeps cash-pay prices tethered to third-party payer rates. WHAT YOU'LL LEARN ✅ Why Amazon's pharmacy model is best understood as a combination of GoodRx and mail-order pharmacy ✅ Why a PBM contracting term keeps pharmacies from selling drugs to cash-pay patients for less than what payers pay ✅ What options self-insured employers now have with Amazon Pharmacy ✅ Whether Amazon is likely to disrupt the traditional pharmacy rebate system ✅ Why cutting out the PBM entirely is harder than it sounds in a third-party payer system WHY THIS MATTERS Ge Bai, an accounting researcher turned health care pricing expert, walks through why Amazon needs a PBM at all for cash-pay patients and unpacks a little-known contracting term: pharmacies generally can't sell a drug to a cash-pay patient for less than the price a PBM pays for it, with coupons like GoodRx as the one workaround. That detail shapes how self-insured employers should think about Amazon Pharmacy, what it might mean for rebates, and why real change in drug pricing requires more than one new market entrant. === 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 🎤 Listen on Spotify === CONNECT WITH THE RHV TEAM === ✭ LinkedIn ✭ Threads ✭ Bluesky ✭ X 00:00 Introduction 03:27 Why is Amazon in the pharmacy space a big deal? 04:03 "I view Amazon Pharmacy as a combination of GoodRx and mail-order pharmacy." 05:07 What's the difference between Amazon and other pharmacies? 06:14 Why does the third-party payer health care system keep Amazon from cutting out the PBM? 07:49 "We don't have insurance companies, we don't have PBMs." 09:21 "Who's really using prescription drugs? The majority is Medicare patients." 11:46 Is Amazon doing anything innovative in the pharmacy space? 12:37 What options do self-insured employers have now with Amazon? 14:42 Why employees and employers might choose to use Amazon Pharmacy over other mail-order pharmacies. 21:27 Will Amazon affect pharmacy rebates? 25:28 "Fundamentally, employers want to have more power in the whole process." 27:41 What should you be doing as a self-insured employer? 28:58 "If we do not put out effort to make the private market work, then the next option would be single payer."

In Episode 305, Stacey Richter talks with Darrell Moon, CEO of Orriant, about the 1% most expensive claimants who rack up massive fee-for-service bills year after year without ever actually getting better — and what behavioral science reveals about why. WHAT YOU'LL LEARN ✅ Why the same high-cost claimants keep reappearing year after year without improving ✅ How loneliness and low self-esteem drive some patients to become "hyper-users" of health care ✅ Why a perverse incentive can form when someone's identity becomes wrapped up in their health issues ✅ How to distinguish a true hyper-user from someone with a legitimately complex chronic condition ✅ Why building self-esteem, not just adding more medical appointments, actually improves outcomes for this population WHY THIS MATTERS Darrell Moon and his team at Orriant noticed that certain high-cost patients kept generating expensive care year after year without ever getting better — and traced it back to loneliness, low self-esteem, and low self-efficacy that no amount of specialist visits could fix. When someone's identity becomes their myriad of health issues, they can develop a perverse incentive not to follow medical advice, since getting better would mean losing that identity. Helping these patients requires behavioral science, not more tests, and it means asking two simple questions to identify future high-cost claimants early: how's your health, and how's your social experience? === 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 🎤 Listen on Spotify === CONNECT WITH THE RHV TEAM === ✭ LinkedIn ✭ Threads ✭ Bluesky ✭ X 00:00 Introduction 03:11 What do CEOs want out of the health care system? 04:52 Is it a good strategy to focus on high-cost claimants? 07:04 Who are the people year over year that wind up in the high-cost claimant pool? 07:50 "Really, you have to get to the crux of the problem, which is … they've become a victim … to the health care system." 08:16 Who are these "hyper-users" and how do we define them? 11:35 "Getting that person to have a regular relationship with someone isn't the hard part; the hard part is then helping them to build their self-esteem." 13:20 "That's the key to building self-esteem—is helping people accomplish what's most important to them." 14:57 Why helping a patient not to view themselves as a victim helps them manage their care better. 17:45 "It's often less the training and the right personality of the person." 18:54 Do health outcomes correlate with the self-esteem of the patient? 19:28 "If you want to identify future claims, ask people two questions: 1) Tell me about your health … and 2) Tell me about your social experience." 21:21 "They're the customer/owner of their own health." 24:23 "How do you help not just the 1% but everybody [in health care]?" 27:16 "The ideal environment is to have a massively powerful primary care team." 27:47 "Having an influence on that person and what they do and how they behave is more important than getting the diagnosis right." 29:34 "It's not about just when [people] reach out … but [getting] people to reach out early."

In this "An Expert Explains" minisode, Stacey Richter talks with Steve Blumberg, MBA, VP of practice transformation at GuideWell Health, about Humana's 2020 Value-based Care Report — and why a headline-grabbing 0.4% savings number doesn't tell the whole story. WHAT YOU'LL LEARN ✅ What Humana's 2020 Value-based Care Report actually found about cost savings ✅ Why outcomes, not just raw cost differences, are the more meaningful measure ✅ Whether value-based care outperformed fee-for-service during COVID ✅ Why value-based care's impact needs to be evaluated over time, not in a single snapshot ✅ Why there's no single solution that will save health care 10% overnight WHY THIS MATTERS A widely circulated blog post seized on Humana's finding that its value-based care program saved just 0.4% over its non-VBC program, treating it as a damning verdict on value-based care itself. Steve Blumberg, who has worked VBC delivery on both the provider and payer side, argues that's the wrong lens: cost is only part of the story, outcomes matter just as much, and value-based care's real impact only shows up when you look at it over time rather than expecting a single silver-bullet solution to cut costs by 10%. === 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 🎤 Listen on Spotify === CONNECT WITH THE RHV TEAM === ✭ LinkedIn ✭ Threads ✭ Bluesky ✭ X 00:00 Introduction 02:11 Does value-based care really reduce cost, according to the Humana report? 03:02 Why we should look at outcomes and not just raw costs. 04:06 Is the impact of a value-based model that much better than a fee-for-service model during COVID? 04:38 "At the end of the day, I think … the lack of a cost difference is notable, but one must think there's more to it than that." 05:44 "You have to look at these things over time." 06:02 "I think in health care we've been looking for the 'what will save 10%' solutions … and there's just no such animal."

In Episode 304, Stacey Richter talks with Steve Blumberg, VP of practice transformation for GuideWell Health, about his move from provider-side population health work to the payer side — and what it takes for a "payvider" organizational structure to actually drive Triple Aim results. WHAT YOU'LL LEARN ✅ How thinking like a payer changes the way you build a primary care practice ✅ Why access to longitudinal data gives payviders a potential edge over siloed entities ✅ What "practice transformation" actually means on the ground ✅ Why Steve argues it's not about control, but about connection with the patient across their continuum of care ✅ Why employers and consumers are increasingly trading broad-network choice for an assurance of quality WHY THIS MATTERS Steve Blumberg spent a decade on the provider side of population health and value-based care before moving to GuideWell Health, the payer side. That vantage point from both sides raises a real question: can a combined payer-provider structure actually improve care, or is it just an "HMO in drag"? Blumberg's answer centers on connection over control — curated networks and continuity of care that let primary care do its most effective work, even as payers and providers historically pull in different directions. === 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 🎤 Listen on Spotify === CONNECT WITH THE RHV TEAM === ✭ LinkedIn ✭ Threads ✭ Bluesky ✭ X 00:00 Introduction 03:30 How does thinking like a payer change the way you build out a primary care provider practice? 04:37 "When I was on the provider side, I definitely worried about the total cost of care … but making the products affordable was … someone else's concern." 09:12 How would you define practice transformation? 13:29 "We're curating networks." 16:56 "If they come to the market, they'll be hard to ignore." 17:38 How integrated is the physicians network? 18:35 "Control isn't the right word … it is the connection with the patient … that's where we think the most effective primary care takes place." 18:59 Where does attempting team-based care fall apart the most? 21:25 Are employers trading out for an assurance of quality?

In Episode 304, Stacey Richter talks with Steve Blumberg, VP of practice transformation for GuideWell Health, about his move from provider-side population health work to the payer side — and what it takes for a "payvider" organizational structure to actually drive Triple Aim results. WHAT YOU'LL LEARN ✅ How thinking like a payer changes the way you build a primary care practice ✅ Why access to longitudinal data gives payviders a potential edge over siloed entities ✅ What "practice transformation" actually means on the ground ✅ Why Steve argues it's not about control, but about connection with the patient across their continuum of care ✅ Why employers and consumers are increasingly trading broad-network choice for an assurance of quality WHY THIS MATTERS Steve Blumberg spent a decade on the provider side of population health and value-based care before moving to GuideWell Health, the payer side. That vantage point from both sides raises a real question: can a combined payer-provider structure actually improve care, or is it just an "HMO in drag"? Blumberg's answer centers on connection over control — curated networks and continuity of care that let primary care do its most effective work, even as payers and providers historically pull in different directions. === 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 🎤 Listen on Spotify === CONNECT WITH THE RHV TEAM === ✭ LinkedIn ✭ Threads ✭ Bluesky ✭ X 00:00 Introduction 03:30 How does thinking like a payer change the way you build out a primary care provider practice? 04:37 "When I was on the provider side, I definitely worried about the total cost of care … but making the products affordable was … someone else's concern." 09:12 How would you define practice transformation? 13:29 "We're curating networks." 16:56 "If they come to the market, they'll be hard to ignore." 17:38 How integrated is the physicians network? 18:35 "Control isn't the right word … it is the connection with the patient … that's where we think the most effective primary care takes place." 18:59 Where does attempting team-based care fall apart the most? 21:25 Are employers trading out for an assurance of quality?

In this Encore episode, Stacey Richter talks with AJ Loiacono, CEO of Capital Rx, about pharmaceutical contracting, PBMs, pharmacies, employers, and the HHS rebate proposal aimed at eliminating kickbacks to middlemen. WHAT YOU'LL LEARN ✅ What the HHS proposal to eliminate rebate safe harbor actually changes ✅ Why swapping the term "rebate" for "charge-back" matters, and how point-of-sale charge-backs would work ✅ Who the potential players are in paying pharmacies under a new model: PBMs, wholesalers, switches, banks/fintech, government contractors ✅ Why PBMs have strong incentives to maintain the status quo ✅ Why pay-to-play formulary access is so hard to escape, even under a new rule WHY THIS MATTERS AJ Loiacono unpacks the hidden machinery behind pharmacy adjudication just as HHS was finalizing a rule to eliminate the safe harbor protecting drug rebates in Medicare Part D, worth $39.8 billion in 2019 alone. Renaming a rebate a "charge-back" and moving it to the point of sale sounds simple, but it reshuffles who controls the payment workflow and who gets to take a cut. Understanding that dark, messy middle matters regardless of whether this specific HHS rule survives, because the incentives it's trying to fix aren't going away. === 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 🎤 Listen on Spotify === CONNECT WITH THE RHV TEAM === ✭ LinkedIn ✭ Threads ✭ Bluesky ✭ X 00:00 Introduction 03:03 HHS's plan to remove safe harbor from the rebates that Pharma pays to PBMs to buy their way onto formularies. 03:13 Creating more transparency by eliminating the anti-kickback. 03:58 What the anti-rebates process flowchart looks like. 04:20 Changing the term from "rebate" to "charge-back." 04:25 Charge-back at the point of sale rather than post-adjudication. 04:37 How putting the pharmacy in the middle of the transaction changes everything. 05:36 "From a cash flow perspective, this matters."—Stacey 07:18 "Who is in charge of this payment workflow?" 09:25 "Why the switch?" 10:56 The potential players in the role of paying pharmacies: PBMs, wholesalers, the switches (McKesson), banks/fintech, government contractors. 12:04 The likelihood that this will spill over into commercial medicine. 14:11 Why PBMs want to maintain the status quo, and how that works. 15:44 "Where there's variability, there's variable profitability." 17:28 How do you check that the patient is getting the charge-back amount they deserve? 18:28 Is it still possible to pay to be on a PBM's formulary? 19:16 Can you ever get away from the pay-to-play formulary? 22:31 "If you think about it, who's writing the checks at the end of the day?" 22:59 What questions should employers be asking right now? 25:20 The problem with implementing HHS's primary goal. 30:51 "Really what we should be focusing on is, 'What are we solving for?'" 32:26 Capital Rx and what they do.

In this inbetweenisode, Stacey Richter pulls together the wisdom of Relentless Health Value guests from throughout 2020 to reveal a common thread running through nearly every conversation about fixing health care. WHAT YOU'LL LEARN ✅ Why patients so often fall through the cracks when their providers, payers, and PBMs aren't "singing off the same sheet of music" ✅ The difference between vertical and lateral/horizontal collaborations in health care ✅ Why so many solutions to health care's problems already exist — they just haven't been broadly adopted ✅ What the essential ingredients of a successful cross-organization collaboration are ✅ Why 2020's guests kept landing on the same answer: collaboration, not more silos, is the path forward WHY THIS MATTERS Stacey set out to find a common thread of wisdom across a year's worth of RHV guests, and found one: patients suffer most when the organizations meant to serve them — providers, payers, PBMs — operate in their own silos instead of collaborating. Pulling together voices from across 2020, from health system innovation to payer strategy to patient advocacy, the throughline is the same: real transformation depends on organizations finding ways to work together, vertically and horizontally, rather than each optimizing for itself. MENTIONED IN THIS EPISODE 🔗 EP298, with Don Fowls, MD 🔗 EP283, with Sylvia Romm, MD, MPH 🔗 EP251, with Kimberly Noel, MD 🔗 EP259, with Rahul Dubey 🔗 EP255, with Richard Zane, MD 🔗 EP248, with Mark Blum 🔗 EP253, with George Mathew, MD 🔗 EP229, with Alex Fair 🔗 EP294, with Steve Schutzer, MD === 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 🎤 Listen on Spotify === CONNECT WITH THE RHV TEAM === ✭ LinkedIn ✭ Threads ✭ Bluesky ✭ X 00:00 Introduction 01:18 Don Fowls, MD, from EP298. 02:47 What will it take to get to a place where the triple or quadruple aim is met? 03:07 Sylvia Romm, MD, MPH, from EP283. 05:37 "I'd say there's two kinds [of collaborations]: There's the vertical kind … but also lateral or horizontal."—Stacey 06:19 Dr. Kimberly Noel from EP251. 07:46 Rahul Dubey from EP259. 08:57 Richard Zane, MD, from EP255. 10:04 Mark Blum from EP248. 10:34 Conversation with David Contorno and Emma Fox from E Powered Benefits. 11:44 "We are human; we do serve ourselves."—Rahul Dubey 14:56 "In so many cases, the solution already exists. … It's just that the solution has not been adopted broadly."—Dave Chase from Health Rosetta 15:52 George Mathew, MD, from EP253. 17:21 Alex Fair from EP229. 19:29 What are the essential ingredients of a collaboration? 19:37 Steve Schutzer, MD, from EP294. 20:29 Dave Dierk, co-president of Aventria Health Group, shares a few thoughts on this matter. 21:45 "I think it's a pretty sound assumption that we all should probably be contemplating how we can better collaborate."—Stacey 24:04 "There's a great willingness to work together and find new solutions to provide better patient care because there's a need for it."—Dave Dierk

In Episode 303, Stacey Richter talks with Anna Kaltenboeck, senior health economist and program director for the Drug Pricing Lab at Memorial Sloan Kettering, about QALYs — the "ruler" used to measure the value of a drug so society has a consistent benchmark for what to pay. WHAT YOU'LL LEARN ✅ What a QALY (quality-adjusted life year) actually measures and why it exists ✅ The three components that go into a QALY calculation: added survival, quality of life, and societal willingness to pay ✅ Why willingness to pay varies by both country and condition ✅ What role ICER plays in producing independent QALY-based drug assessments ✅ Where value-based pricing fits into the broader QALY framework WHY THIS MATTERS Anna Kaltenboeck breaks down QALYs as a kind of universal ruler for drug value — a way to make an apples-to-apples comparison so that a dollar of value means the same thing across different drugs and different patients. The calculation combines how much a drug extends survival, how it affects quality of life, and how much society is willing to pay for that improvement. It's an imperfect tool, and not everyone agrees on how well it works, but it gives patients, payers, and pharma a shared framework for asking whether a drug's price actually matches the benefit it delivers. === 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 🎤 Listen on Spotify === CONNECT WITH THE RHV TEAM === ✭ LinkedIn ✭ Threads ✭ Bluesky ✭ X 00:00 Introduction 03:56 What is a QALY? 05:28 "You don't get marks; it's the treatment that gets the marks." 09:13 What is willingness to pay? 10:52 "What we pay for drugs should be reflected in societal preference." 12:29 Does Pharma fear the QALY? 15:38 "At the end of the day, the ideal here is simply to be able to quantify 'This is what we're going to pay for this additional benefit that we're going to provide for patients.'" 17:09 "When you meet that price, patients should be getting access to that product." 19:27 What are the significant advances being seen with QALYs and drug development? 21:23 "The challenge is when the price is so much higher than those benchmarks." 22:27 How do we use the QALY as a tool? 25:56 Where does value-based pricing fall in the world of QALYs?

In Episode 302, Stacey Richter talks with Blake McKinney, MD, ER physician and cofounder/CMO of CirrusMD, about what's really wrong with the way we argue about telehealth — and why the site of care matters far less than the agency behind it. WHAT YOU'LL LEARN ✅ Why telehealth "failures" are often really failures of the surrounding care ecosystem, not the modality itself ✅ Why familiarity is a more powerful force than convenience when it comes to patient behavior ✅ Why continuity-based telemedicine tends to outperform one-off virtual visits ✅ The four-step care delivery process — assessment, diagnosis, treatment plan, implementation — and the "pre-step" Dr. McKinney adds ✅ Why implementation is really about follow-up, and why doctors crave resources to support it WHY THIS MATTERS Dr. Blake McKinney argues that most complaints about telehealth actually point to flaws in the surrounding care ecosystem — missed follow-ups, no access to labs or imaging, lack of continuity — not flaws in virtual care itself. A single patient visit, virtual or in person, is a tactic, not a care pathway. What actually determines outcomes is whether the provider behind the camera has the agency, data, and infrastructure to guide a patient through a defined treatment journey, which is why continuity-based telemedicine can perform just as well as, or better than, in-person care. === 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 🎤 Listen on Spotify === CONNECT WITH THE RHV TEAM === ✭ LinkedIn ✭ Threads ✭ Bluesky ✭ X 00:00 Introduction 06:53 "Regardless of the availability of convenient options, there is one force more powerful than convenience, and that is familiarity." 09:01 "Telemedicine that is continuity based is going to be better medicine fundamentally." 13:21 "The fundamentals of medicine are the same, and the standard of care is the same, whether the care is in person or in clinic." 15:16 What's the underlying determinant of patient success? 16:08 "When it comes to the 'What's next,' doctors love resources." 16:52 How is telemedicine lacking in resources? 18:42 "Implementation to me is, first and foremost, about follow-up." 23:10 "There's a place for automations. My prime directive … is to build trust." 25:13 "The best adaptive interview that you can create is human to human."

In this Encore episode, Stacey Richter talks with Ashok Subramanian, CEO and founder of Centivo, about why high-deductible health plans have not delivered the high-quality, cost-effective care their advocates promised. WHAT YOU'LL LEARN ✅ Why the consumerism bet behind high-deductible plans hasn't panned out as intended ✅ Why patients overwhelmingly follow their provider's recommendation rather than shopping around ✅ Why a patient's entry point into the health system shapes everything that follows ✅ What it takes to build a high-value specialist network instead of a sprawling one ✅ Why primary care teams, not patients, are best positioned to drive down total cost WHY THIS MATTERS The theory behind high-deductible health plans was that shifting cost burden onto patients would push them to shop for higher-quality, lower-cost care and prices would fall. Ashok Subramanian argues that theory hasn't held up: most patients aren't equipped to evaluate medical recommendations, so they simply follow what their provider tells them to do. That means the real lever for a high-value health system isn't patient shopping behavior — it's building a strong, curated primary care network that steers patients toward high-value specialists and away from a needlessly sprawling one. === 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 🎤 Listen on Spotify === CONNECT WITH THE RHV TEAM === ✭ LinkedIn ✭ Threads ✭ Bluesky ✭ X 00:00 Introduction 02:58 Background for this conversation—the entry point for where a patient enters the health system. 03:56 "Broad open-access, on-demand health care simply doesn't work." 04:18 "What people really do do is they listen to their provider." 04:47 Putting more emphasis on the primary care team, as opposed to putting the burden on the employee. 05:01 High-deductible plans as blunt instruments. 05:20 Creating transparency around pricing, and the reality behind this. 05:38 "People aren't very good at [discerning] low-value care from high-value care." 06:57 Why people don't challenge their doctors. 07:06 The primary care physician (PCP) as the gateway into the health care system. 07:45 Two reasons why health care is so tricky. 09:09 "There is no single awesome source of data." 11:00 What is the PCPs' charge? 11:43 PCPs as the change agents in health care for employers. 14:47 How do you discern who the high-value specialists are? 15:15 Building the network right the first time and making it dynamic. 17:05 Narrow networks and what's important to focus on. 19:03 Redefining "access." 19:22 "None of us need 40,000 doctors in our network." 21:57 Driving better total cost. 25:02 Negotiating with the biggest health care players and operating a network with or without them.