Relentless Health Value

In Episode 314, Stacey Richter talks with Sheldon Weiss, MD, former COO of a long-term care pharmacy, about the confoundingly messy pharmaceutical supply chain that skilled nursing facility patients depend on — and why it takes two pharmacies and a PBM to get a drug into a SNF resident's hands.

WHAT YOU'LL LEARN

✅ Why SNF residents often need both a wholesale pharmacy and a long-term care pharmacy, plus a PBM

✅ Why long-term care pharmacies don't negotiate directly with PBMs, and how volume drives pricing

✅ How overmedication happens in the long-term care pharmacy model, and how consultant pharmacists help prevent it

✅ Why adverse drug events are a leading reason SNF patients wind up in the ER

✅ Why people aging in place at home lack the kind of pharmacist oversight SNF residents get

WHY THIS MATTERS

SNF patients are often under the care of ten or more specialists prescribing medications with no visibility into what the others are prescribing, which is a big part of why adverse drug events are a leading cause of SNF-to-ER trips. A consultant pharmacist working alongside a medical director and director of nursing is a genuinely promising model for catching this kind of overmedication — but it only works if physicians actually listen to the pharmacist, and the same oversight simply doesn't exist for the much larger population aging in place at home.

=== LINKS ===

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🔗 Healthcare Industry Acronyms and Terms

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00:00 Introduction.

04:19 What's the role of a wholesale pharmacy in a SNF?

04:48 What's the connection between a wholesale pharmacy, a long-term care pharmacy, and a retail pharmacy?

07:00 Why does a SNF need two players? Why can't a long-term pharmacy also take on the role of the wholesale pharmacy?

09:43 Why don't long-term care pharmacies negotiate directly with PBMs?

10:02 "The key for … getting the best prices for medications is on volume."

10:11 Who are these wholesale pharmacies negotiating the best prices?

11:19 "The goal of driving health care costs down by helping out the residents is a good model."

13:43 "Ultimately the resident gets the same quality of medication, but yet it's at a much more reasonable price."

14:35 How does overmedication happen in the long-term care pharmacy model?

15:19 "The lower the amount of medicines, the less the chances of someone to become overmedicated."

17:50 "I would think that most of the time it's subtractive."

19:00 "The idea in health care should be and is … that we only prescribe medications that are necessary."

20:26 How does aging in place impact pharmacy?

22:11 "When you're aging at home, there's no one there looking out for you like a consultant pharmacist."

24:39 How do we make aging in place safer from a pharmacy perspective?

25:58 "Physicians are very intelligent, but they tend to know their medications in their field."

26:21 "Anything that increases the multidisciplinary approach model is going to benefit the patient."

27:10 "The cost of medicine and the outcome of medicine really don't equate."

In Episode 313, recorded live at the Health Rosetta Summit, Stacey Richter talks with Dan Strause of Hometown Pharmacy and Drew Leatherberry of Avergent about a collaboration model pairing local primary care teams with independent hometown pharmacies to deliver advanced, navigated chronic care.

WHAT YOU'LL LEARN

✅ Why keeping health care dollars local, rather than siphoned out by national players, matters for communities

✅ How pairing local PCP teams with local pharmacies creates a team-based advanced primary care model

✅ Why pharmacists are uniquely positioned to help patients manage chronic conditions, given how often patients visit

✅ Why pharmacists are motivated to help get patients off unnecessary medications, not just dispense more

✅ How unifying the patient health record across the collaboration supports better navigation and outcomes

WHY THIS MATTERS

Patients visit their local pharmacy roughly 35 times a year, which makes the pharmacist one of the most underused sources of expertise for managing chronic conditions. Because pharmacists are traditionally paid for the product they dispense rather than for their time and knowledge, this collaboration model between self-insured employers, local PCP teams, and independent pharmacies represents a genuine attempt to realign incentives around keeping patients healthy rather than just filling prescriptions — while keeping health care dollars circulating in the local community.

=== LINKS ===

🔗 Show Notes with all mentioned links: Episode Page

🔗 Healthcare Industry Acronyms and Terms

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00:00 Introduction.

05:02 What has Avergent's collaborative care model accomplished?

06:07 How did Drew and Dan connect?

07:08 "We realized that we were missing out [on] … how … to leverage the experience and the expertise of the pharmacist in driving better patient care."—Drew

07:31 Why would a pharmacy make it their goal to get their patients off their medications?

08:20 "Prescription medicine is the most expensive, most dangerous form of a plant."—Dan

08:39 "We believe we can help people by giving up prescription medicines."—Dan

08:45 Is a pharmacy equipped to create a personal relationship with their patients?

12:50 "It's a spin on traditional navigator-advocate-type roles."—Drew

16:15 What does helping the patient look like through this partnership program?

19:18 "We're really unifying the patient health record … and then … cross-referencing all those different data points … on a micro level [and] a macro level."—Drew

20:53 "Everyone is onboarded into the collaborative care model."—Drew

21:05 How does this collaborative care model cross the spectrum?

22:13 "Pharmacists are one of the unique professions that doesn't get paid for time and knowledge [but rather] because of the product they dispense."—Dan

23:06 "We can see the day where … patients will get a prescription from mail order but still need us."—Dan

25:46 "We would love to get paid to keep you healthy."—Dan

27:15 Why are pharmacists wanting to get patients off prescriptions, and how are they involved?

27:36 "In some cases, we are misapplying expertise that's sitting right in front of our face that can help us deliver a better patient outcome."—Drew

In Episode 312, Stacey Richter talks with Douglas Eby, MD, MPH, CPE, physician executive and VP of medical services at Southcentral Foundation, about the Nuka System of Care in Alaska — a relationship-based, community-centric health system that's achieved the Triple Aim at roughly half the average cost.

WHAT YOU'LL LEARN

✅ What the Nuka System of Care is, and how it was rebuilt from the ground up rather than incrementally patched

✅ Why relationship-based, non-transactional care and built-in behavioral health drive its results

✅ How advanced primary care and a multidisciplinary team reduce specialist referrals by 65%

✅ Why the workforce needs to look and feel like the community it serves

✅ Why 95% of what Nuka does is directly translatable to any location in the world

WHY THIS MATTERS

The Nuka System of Care, which serves Alaska Native and American Indian people, gets closer to the Triple Aim than almost anywhere else in the country: superior health outcomes at about half the average cost, with happy patients (or "customer owners") and happy clinicians. It didn't get there by tweaking a failing model — it rebuilt care around relationships, community, and a multidisciplinary team working at the top of their license. Dr. Eby argues the approach is almost entirely transferable elsewhere, which makes Nuka less a regional curiosity and more a blueprint most health systems have simply never looked at.

=== LINKS ===

🔗 Show Notes with all mentioned links: Episode Page

🔗 Healthcare Industry Acronyms and Terms

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00:00 Introduction.

03:52 What's the what and where of the Nuka System of Care?

04:49 What does the word Nuka mean?

05:25 "It's all built around this idea that we're raising … the ability for people to take control of their own health issues, and then we are just advisors … on that journey."

06:39 "The reason why people do pay attention to us is … the proof in the pudding."

09:09 What did the Southcentral Foundation do to create an ideal health system?

11:09 "It's access, it's relationship, it's partnering, it's being known … it's getting at the whole family and the whole person."

12:02 "There's two huge problems with modern medicine all across the world. One is how money is handled … [and the other] is this blind acceptance of the medical model."

14:14 "For 20 years, we've established a base of companionship and relationship."

16:06 What does advanced primary care look like?

19:25 How does this new style of chronic management work, and why does it get better results than Centers of Excellence and other health system models?

23:25 "We refer out to specialists 65% less often than we used to."

24:17 "It's a ballet; it's continual … all day, every day."

25:33 How big are the patient panels in this system?

28:49 "I would say that 95% of what we do here is directly translatable to any location in the world."

29:20 "Your workforce needs to look and feel like the community you're trying to influence."

32:12 "This is all designed and driven by the community that I am hired to support."

In Episode 311, Stacey Richter talks with Sumit Nagpal, CEO and founder of Cherish Health, about how aging in place is quietly turning into a business problem for fee-for-service providers, assisted living facilities, and SNFs.

WHAT YOU'LL LEARN

✅ What "health care is coming home" actually means for aging in place

✅ Why consumers and their families, not health systems, will be the first movers driving at-home care adoption

✅ Why our health care economy's incentives are fundamentally misaligned with proactive, preventive care

✅ Why FFS-dependent hospitals and SNFs have a business problem once predictive home monitoring reduces acute events

✅ What it will take to align incentives for at-home care to scale

WHY THIS MATTERS

Once families start installing monitoring technology to keep aging relatives safe at home, predictive and proactive care reduces acute events and changes who gets called when something does go wrong — not always an ambulance to the ER. That shift is a genuine business threat to FFS-dependent hospitals, assisted living facilities, and SNFs built around heads in beds. The first movers pushing this change won't be health systems acting against their own incentives; it will be families who can't afford, or don't want, to send a loved one to an institution.

=== LINKS ===

🔗 Show Notes with all mentioned links: Episode Page

🔗 Healthcare Industry Acronyms and Terms

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00:00 Introduction.

03:55 What does "health care is coming home" truly mean?

07:35 "It's not like we're cheese and we're aging in place. We're living. We're living our lives."

07:51 "Give us the ability to live where we want for as long as we want as safely as possible."

10:31 "The challenge with wearables beyond the initial cost is … you have to remember to wear them."

10:53 "The tech itself is not unreliable, but we as human beings are unreliable."

13:34 "The conversation typically begins with privacy and goes into other kinds of risks."

15:50 "Our health care economy is fundamentally misaligned."

17:57 "The incentives … today don't really enable this kind of proactive, preventive engagement."

23:30 How do we solve this cost problem at scale?

23:44 How do you align incentives for those that will care to solve these problems?

26:47 "I don't think that we're going to have mass, large-scale change in health care moving home until people are starting to adopt … these kinds of services in their homes."

In this "An Expert Explains" minisode, Stacey Richter talks with Ge Bai, PhD, CPA, associate professor at Johns Hopkins, about how GoodRx actually makes money — and why its savings only exist because of dysfunction in the pharmacy supply chain.

WHAT YOU'LL LEARN

✅ How GoodRx's business model differs from Amazon Pharmacy's

✅ Why cash-pay pharmacy prices are inflated in the first place, and how PBM contracts drive that

✅ How GoodRx contracts with a network of PBMs to secure lower prices for "cash-pay" patients

✅ Where the pharmacy itself fits into the GoodRx transaction

WHY THIS MATTERS

GoodRx looks to patients like a way to pay cash without a middleman, but Dr. Bai explains that it actually works by routing patients through a PBM network behind the scenes. The reason it saves people money at all is that PBM contracts require pharmacies to give PBM-network patients the best price, which leaves anyone walking in without a PBM card — the true cash-pay patient — paying inflated list prices. GoodRx's savings, in other words, are a symptom of a dysfunctional pricing structure, not a fix for it.

=== LINKS ===

🔗 Show Notes with all mentioned links: Episode Page

🔗 Healthcare Industry Acronyms and Terms

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00:00 Introduction

01:53 What's the difference between GoodRx and Amazon Pharmacy?

02:17 "GoodRx pharmacy makes money from one fact, and one fact alone."

03:43 "On the surface, it looks like the patients are paying cash without any middleman; but in reality, the patients are paying cash by using a network created by a PBM."

04:52 "GoodRx contracts with a network of PBMs."

06:06 Where does the pharmacy fit in this deal?

In Episode 310, Stacey Richter talks with Vikas Saini, MD, president of the Lown Institute, and Shannon Brownlee, senior vice president of the Lown Institute, about the 2020 Shkreli Awards — the annual top-10 list of the worst examples of profiteering and dysfunction in health care.

WHAT YOU'LL LEARN

✅ How the Lown Institute selects winners for its annual Shkreli Awards

✅ Why 2020's list is unique: every winner exploited the pandemic itself for profit

✅ How pharma companies developing COVID vaccines still made the list

✅ Why private equity's business model in health care is, at its core, profiteering

✅ Why the federal government took first place on this year's Shkreli Awards list

WHY THIS MATTERS

The Shkreli Awards, named for "pharma bro" Martin Shkreli, exist to call out health care profiteering that's often perfectly legal but still deeply unethical. As Dr. Saini and Shannon Brownlee point out, 2020's list stands out because every winner made a deliberate choice to treat a pandemic as an opportunity to exploit fear and anguish for profit. Every dollar earned without adding commensurate value back is, in their words, one more nail in the financially toxic coffin patients, employers, and taxpayers are stuck facing — and building a radically better health care system requires people to stop being shy about naming these issues publicly.

=== LINKS ===

🔗 Show Notes with all mentioned links: Episode Page

🔗 Healthcare Industry Acronyms and Terms

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00:00 Introduction.

02:51 "COVID was like … just a glare of x-ray that revealed everything … going on in the health care system."

05:14 "There's always profiteering whenever there's a buck to be made."

05:33 Is profiteering in the health care system deteriorating?

06:07 How did the winners of the 2020 Shkreli Awards get chosen?

07:18 "The categories that this falls into is really the stakeholders in health care."

08:11 What did Connecticut internist Steven Murphy, MD, do to earn his place at #8 on the awards list?

09:29 How did big pharma companies (some of which have been developing COVID vaccines) like Pfizer get on the Shkreli Awards list?

11:16 "We do have to start asking some hard questions about who is supposed to benefit from the … public funding that goes into these kinds of products—vaccines and drugs."

12:49 "The thing about private equity … is that the business model really is profiteering in health care."

19:43 Why did the federal government win the first place in the Shkreli Awards?

24:13 "Most of this is not illegal. It's merely unethical."

26:56 "There really is a radically better health care system that's possible, but we're not really going to get there if people are shy about talking publicly about some of these issues."

In Episode 309, Stacey Richter talks with Jeff Hogan, northeast regional manager for Rogers Benefit Group and president of Upside Health Advisors, about how fee-for-service providers are getting locked out of referral flows right now, as self-insured employers steer their plan members toward accountability and financial predictability.

WHAT YOU'LL LEARN

✅ What self-insured employers are doing right now to actively steer referral flows

✅ Why fee-for-service providers fear the informed health care consumer

✅ What employers actually mean by "value" coming out of COVID: accountability and predictability

✅ Why brick-and-mortar providers are realizing they need to up their game

✅ Why data has become critical to how employers manage their health care spend

WHY THIS MATTERS

Armed with claims databases and reports like RAND 3.0, employers can now see clearly which providers deliver accountability and financial predictability — and they're using that data to steer plan members accordingly. Slower-moving, FFS-centric providers, whether a large health system, urgent care center, or hospital-owned PCP, risk getting shut out of referral flows entirely. As Jeff Hogan puts it after 35 years in the business, this finally feels like an inflection point where health care can't go back to the fragmentation of fee-for-service.

=== 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.

01:43 What are self-insured employers doing right now to impact referral flows?

03:29 Are any virtual tech companies moving in on the local provider space?

07:46 "What we're trying to do … is to help the member have the best outcome."

10:32 "It's a continuum, if you will."

10:44 "There is a fairly significant gulf between providers … and, say, a COE [Center of Excellence]."

11:13 "What is value for employers coming out of COVID? Accountability and predictability."

13:40 What are second-order effects?

14:29 "People like and want better access."

14:46 "Fee-for-service providers fear the informed health care consumer."

22:19 "Many of the brick-and-mortar providers are realizing that they have to up their game."

24:52 "Things will change."

25:07 "People not only want convenience, but they want safety, they want data."

26:11 "We are at an inflection point … After 35 years in the business, I really finally feel like we've broken through."

27:31 "This requires people to really think; it requires employers to actually know what their biggest problems are."

29:53 "We can't go back to the fragmentation of fee for service."

30:25 "Data is critical."

In Episode 308, Stacey Richter talks with Mark Fendrick, MD, director of the University of Michigan Center for Value-Based Insurance Design, about two surprising insights into why value-based care so often fails to align incentives in the real world.

WHAT YOU'LL LEARN

✅ Why doctors get dinged on quality scores when their patients can't afford the follow-up care they're told to get

✅ Why cost sharing in most benefit designs is based on how expensive a service is, not how valuable it is

✅ Why that mismatch pushes patients toward cheap care instead of high-value care

✅ What V-BID's core pillars are for redesigning benefits around value

✅ Why aligning patient and provider incentives — not just cutting costs — is the real goal of value-based insurance design

WHY THIS MATTERS

Dr. Mark Fendrick, who coined the term Value-Based Insurance Design, argues that value-based care breaks down for a simple reason: benefit design and quality incentives often work against each other. A doctor tells a diabetic patient to get an eye exam, the patient can't afford it because of a high deductible, and the doctor gets penalized on quality metrics for an outcome the benefit design itself caused. Meanwhile, most cost sharing is tied to how expensive a service is rather than how valuable it is — pushing patients toward cheap, low-value care and away from expensive, high-value care. Fixing that misalignment, not just cutting costs, is what V-BID is built to do.

MENTIONED IN THIS EPISODE

🔗 Encore! EP176, with Dr. Robert Pearl

=== LINKS ===

🔗 Show Notes with all mentioned links: Episode Page

🔗 Healthcare Industry Acronyms and Terms

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00:00 Introduction.

03:53 Is back surgery high-value care?

04:46 If care is patient to patient, how is high-value care decided upon?

05:36 "Flintstones delivery: We have to move from the sledgehammer to the scalpel."

10:19 "Almost all of the services that we recommend to reduce cost sharing … do not save money."

11:36 "I didn't go to medical school to learn how to save people money."

16:14 "When a patient and their clinician agree … the patient should be able to get that [service] easily, and the clinician should be paid generously."

17:14 "When patients and providers are aligned, they do much better."

19:07 What services are deemed high value, and what services should be pre-deductible?

21:04 "Are primary care visits high value? … The answer is, it depends."

25:13 What are V-BID's core pillars to address value-based care?

27:24 How does Dr. Fendrick's method of value-based care and reimbursement actually enable better consumerism?

29:11 What do providers think about changing reimbursement on low-value and high-value care?

30:21 "We have incentives that are run amok."

31:34 Encore! EP176 with Dr. Robert Pearl.

32:12 "It's all about incentives."

33:05 "You do have the funding; you just have to have the courage."

In Episode 307, Stacey Richter talks with Loren Adler, associate director of the USC-Brookings Schaeffer Initiative for Health Policy, about the surprise billing legislation taking effect 1/1/22 — and what it means for providers, hospitals, self-insured employers, and patients.

WHAT YOU'LL LEARN

✅ How the new surprise billing law removes patients from the fight entirely, leaving them to pay only their normal co-pay or coinsurance

✅ How "baseball arbitration" resolves disputes between providers and insurers when they can't agree on a rate

✅ Why providers can't trigger arbitration more than once every 90 days for the same service

✅ How outlawing surprise bills could accelerate the shift toward bundled payments

✅ Why self-insured employer premiums are expected to drop about 1% as a result

WHY THIS MATTERS

Starting 1/1/22, patients are taken out of the surprise billing fight: if a provider sends a bill above what's in network, the patient still pays only their normal cost sharing, while the provider and insurer settle the rest through negotiation or baseball-style arbitration. Loren Adler unpacks who wins and who loses, why this could nudge the industry toward bundled payments and even single hospital bills, and why ground ambulances were left out of the legislation entirely.

=== LINKS ===

🔗 Show Notes with all mentioned links: Episode Page

🔗 Healthcare Industry Acronyms and Terms

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00:00 Introduction.

03:04 What is this surprise billing legislation?

04:27 What happens when a patient is sent a huge bill from the provider?

06:15 What is "the going rate"?

09:44 "If you weren't leveraging surprise billing beforehand, this law has no effect on you."

11:14 Will this legislation push the industry toward one hospital bill?

12:20 What will providers have to do if they don't like what insurance wants to pay them?

15:26 What is benchmark pricing?

17:37 "Fundamentally … it's really consumer groups and patient groups plus your self-insured employers … on one side and then provider groups on the other."

18:19 Is this surprise billing legislation a compromise?

19:48 "Arbitration really isn't meant to adjudicate every single claim."

20:11 "The idea is really to kind of push the facility … to negotiate and figure this all out."

20:50 Are hospitals being impacted by this bill?

24:56 What happens to providers who decide to send surprise bills anyway?

26:09 What are the implications of this legislation for self-insured employers?

28:48 Why have ground ambulances been left out of this surprise billing legislation?

32:23 "At the end of the day, I think this is a net positive for consumers and should be considered a win."

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

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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."