Relentless Health Value

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

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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

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=== CONNECT WITH THE RHV TEAM ===

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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

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=== CONNECT WITH THE RHV TEAM ===

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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 Chris Sloan, associate principal at Avalere Health, about how Medicare Part D plans became addicted to drug rebates — and what happens to premiums, PBMs, and pharma pricing if a proposal to eliminate those rebates actually takes effect.

WHAT YOU'LL LEARN

✅ Why rebates are such a big part of how Medicare Part D actually functions

✅ How rebates flow between PBMs and manufacturers, and how list prices factor in

✅ Why killing pharma rebates would likely raise everybody's insurance premiums under the current model

✅ Why PBMs and health plans oppose eliminating rebates while pharma supports it

✅ How large PBMs can create perverse incentives that push manufacturers to raise list prices

WHY THIS MATTERS

A reboot of a proposal to eliminate pharma manufacturer rebates to Part D plans and PBMs was set to take effect 1/1/2022, and Chris Sloan breaks down what's actually at stake: removing rebates could upend the historically opaque middle layer of drug pricing, but the immediate effect — under how the system is built today — is that premiums go up. That tension is exactly why PBMs and health plans line up against the proposal while pharmaceutical manufacturers back it.

=== 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

02:35 "Rebates are a really big part of Medicare Part D."

02:49 What the "follow the dollar" looks like in this scenario.

04:14 How rebates between PBMs and manufacturers work, and how list prices play into this.

05:31 How this system can hurt the patient, and how this new proposal works to change that.

06:42 Pricing a product as a PBM.

08:06 The total dollar value of PBM rebates.

10:50 Do we know how much PBMs are making in incentives?

13:29 Are PBMs helping or hurting the process?

16:18 Why pharmaceutical manufacturers may be more compelled to raise their prices thanks to large PBMs.

17:13 Perverse incentives in the system.

17:57 "At the end of the day, PBMs are still going to be employed by health plans."

18:56 How a new model is combating the perverse incentive that raises prices for patients.

22:11 The trade-off involving premium prices in this new proposal.

24:38 "We're not talking astoundingly large amounts of money."

25:12 Why PBMs and health plans are against this proposal.

26:02 Why Pharma is for this.

26:51 The perverse incentives for health plans.

28:39 The benefit of Part D.

29:25 The advantage of huge rebates.

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

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=== CONNECT WITH THE RHV TEAM ===

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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

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=== CONNECT WITH THE RHV TEAM ===

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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

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=== CONNECT WITH THE RHV TEAM ===

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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

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=== CONNECT WITH THE RHV TEAM ===

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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

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=== CONNECT WITH THE RHV TEAM ===

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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.

In Episode 301, Stacey Richter talks with Jeff Leibach, MBA, director at Guidehouse's Healthcare Practice, about the three CMS transparency rules reshaping hospital and payer pricing — and what they mean for patients, employers, and providers heading into a new administration.

WHAT YOU'LL LEARN

✅ What the three CMS transparency rules require of hospitals and payers, and how they build on each other

✅ Why the hospital chargemaster-posting rule turned out to be mostly useless in practice

✅ How the new machine-readable negotiated-rate files change what patients and employers can see

✅ Why employers may gain new leverage once pricing becomes transparent

✅ Why the administrative burden of complying with these rules is real, and where opposition is coming from

WHY THIS MATTERS

Jeff Leibach walks through three CMS transparency rules as three steps on a ladder: hospital chargemaster posting, machine-readable negotiated rate files for providers, and a more comprehensive payer rule requiring price-shopping across all sites of care. Combined with rules like ONC TEFCA that make patient data more portable, these changes make it easier for patients and employers to price shop and easier for employers to narrow networks — pushing commoditized providers to compete harder on outcomes and experience, not just brand.

=== LINKS ===

🔗 Show Notes with all mentioned links: Episode Page

🔗 Healthcare Industry Acronyms and Terms

✉️ Enjoy this podcast? Subscribe to the free weekly newsletter

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

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=== CONNECT WITH THE RHV TEAM ===

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00:00 Introduction.

05:31 What are the two pieces to the new transparency rule going into effect on January 1, 2021?

06:58 "Any negotiated rate … is required to be disclosed."

07:43 What's the payer rule, and how does it differ from the hospital rules?

10:24 Where are direct comparisons going to come in most useful with transparency rules?

11:16 How does CMS intend these rules to be used?

14:34 "I anticipate employers having a newfound power here."

17:27 Why is there opposition to transparency in health care?

18:27 "The administrative burden is real."

21:03 "I think commoditized is a word we're going to hear a lot more."

22:55 Where is CMS headed under a Biden administration?

26:22 What barriers can tech help break down, and what other opportunities are there for tech right now?

28:49 What should payers be preparing for right now?