Relentless Health Value

In this milestone Episode 300, Stacey Richter talks with Bruce Rector, MD, biopharmaceutical policy advisor and health policy lecturer, about how to get the right drugs developed — and how to think differently about paying for them.

WHAT YOU'LL LEARN

✅ Why pharmaceutical companies have historically had little incentive to develop new antibiotics

✅ What orphan drugs are, and how the 1983 Orphan Drug Act reshaped drug development incentives

✅ The difference between "push" incentives (funding R&D costs upfront) and "pull" incentives (guaranteeing demand or revenue after launch)

✅ Why drugs don't behave like normal consumer products when there's no competition for a life-saving treatment

✅ What the "fire extinguisher" model and the subscription model offer as alternative ways to pay for drugs like antibiotics

WHY THIS MATTERS

Dr. Bruce Rector unpacks why the market alone often fails to produce the drugs society needs most, using antibiotics as the clearest case study: when resistant infections are rampant but pharma companies see nowhere to make money on new antibiotics, those drugs simply don't get developed. Push incentives fund research costs; pull incentives guarantee a return once a drug launches; and neither alone is enough. Rector's fire extinguisher and subscription payment models offer a different way to think about compensating pharma for drugs that society needs to have on hand, even if they're rarely used.

=== LINKS ===

🔗 Show Notes with all mentioned links: Episode Page

🔗 Healthcare Industry Acronyms and Terms

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00:00 Introduction.

05:58 What's the issue with innovation in the pharmaceutical space?

06:47 "The problem … everyone talks about is antibiotics."

07:38 What are pharmaceutical companies launching to drive value instead of antibiotics?

08:21 What are orphan drugs? And why is development incentivized for those drugs?

11:56 What are the differences between push incentives and pull incentives?

14:37 "The pharma company is all about how much money [the drug] can make once it hits the market."

16:28 "These contracts, they know once they hit the market, there's billions just waiting for them."

17:17 What are the biggest pull and push incentives in Pharma?

17:40 What are the push and pull incentives with antibiotics?

24:39 What's the fire extinguisher theory in Pharma?

In Episode 299, Stacey Richter talks with Alan Kaplan, MD, MBA, assistant professor of urology at Georgetown University and a practicing urologist, about why fee-for-service is a whole business model — not just a way to get paid — and what that means for specialists trying to evolve.

WHAT YOU'LL LEARN

✅ Why fee-for-service shapes how practices structure their entire business, not just how they bill

✅ Why FFS businesses have an inherent incentive to add labor rather than adopt labor-saving technology

✅ Why technology in health care has historically expanded the top line rather than making the bottom line more efficient

✅ What specialists need to be thinking about to stay relevant over the next five years

✅ Why the relationship between PCPs and the specialists they refer to matters more than ever

WHY THIS MATTERS

Dr. Alan Kaplan argues that fee-for-service isn't just a payment mechanism — it's a business model that shapes staffing, technology adoption, and strategy. Because FFS businesses only get paid when a human performs a billable service, they have little incentive to adopt technology that reduces billable hours, which is why health care technology has tended to expand revenue rather than cut costs. As capitated primary care and value-based models spread, specialists face a real strategic choice about how to evolve, and Dr. Kaplan makes the case that the relationships between PCPs and the specialists they refer to will be central to that transition.

MENTIONED IN THIS EPISODE

🔗 EP292, with Brian Klepper, PhD

🔗 EP219, with Arshad Rahim, MD, MBA, FACP

=== LINKS ===

🔗 Show Notes with all mentioned links: Episode Page

🔗 Healthcare Industry Acronyms and Terms

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00:00 Introduction.

03:51 Who are we actually discussing when we use the term specialist?

05:58 How does the PCP taking on more risk affect the specialists' path to value-based care (VBC)?

09:42 "Technology leads to … a reduction in labor burden … but in health care, that really hasn't been the case."

11:36 "Technology … in health care … has never really been about making the bottom line more efficient. It's been about expanding the top line."

13:39 What do specialists need to be considering if they want to stay relevant in the next 5 years?

14:27 EP292 with Brian Klepper, PhD.

16:53 Is there a future where specialists can transition from FFS to VBC while skipping the messy middle of a transition?

18:37 "The way we always did things is not the way that we have to always do things in the future."

25:20 "When all is said and done, the relationship between [PCPs] and the specialists that they refer … those relationships are really, really important."

26:14 EP219 with Arshad Rahim, MD, MBA, FACP.

28:13 What's going to be a big driver for providers to become more independent in the next 5 to 10 years?

In Episode 298, Stacey Richter talks with Don Fowls, MD, psychiatrist and health care consultant, about where value-based payments and behavioral health intersect — and why telepsychiatry has taken off so fast during COVID.

WHAT YOU'LL LEARN

✅ Why the debate over telehealth often glosses over what patients are actually being asked to get from a 7-minute specialist visit

✅ The difference between mental health and behavioral health, and why managing populations requires both

✅ What "good" looks like when payment is aligned with outcomes instead of volume

✅ The four pillars that become the outcomes framework for a managed population

✅ Why integrated data and industry stakeholder collaboration are essential to making value-based behavioral health work

WHY THIS MATTERS

Dr. Don Fowls pushes back on the idea that virtual care is inherently worse for patients who need connection, pointing out that we already lean on expensive fee-for-service specialists for brief visits that don't actually address an underlying epidemic of loneliness. Telepsychiatry has expanded access to mental and behavioral health services during COVID, and Fowls argues real progress requires integrating behavioral and physical health data and aligning payment with outcomes — not just adding more visits, virtual or otherwise.

=== 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.

03:27 Is telehealth here to stay?

06:16 "Now there's coverage in these medical clinics that there never was before."

07:38 "It's really trying to align the payment with the outcomes and services provided."

08:51 What does good look like?

12:06 "It's getting … plan and provider focused on achieving an outcome."

16:43 Do you really see outcomes change after implementing value-based payments?

17:40 "What are we really trying to achieve with this population? It's really four things. And these become … the pillars for outcomes."

23:29 "Right now, there's still way too much 'more is better.'"

24:16 "Well, that's great, but how did they do when they left? That's what you really want to know."

25:43 What are the three major data sets?

27:15 How is the pharmacy going to be impacted in mental and behavioral health moving forward?

28:05 "If you have data and facts behind you, it always helps."

In Episode 297, Stacey Richter talks with Jerry Durham, physical therapist and founder of The Client Experience Company, about how the front desk can make or break patient trust — and, potentially, outcomes.

WHAT YOU'LL LEARN

✅ Why the front desk often operates like a separate fiefdom, physically and culturally, from the rest of the practice

✅ The four phases of the "patient life cycle": marketing, engagement, provider interactions, and post-course of care

✅ Why the front desk carries most of the responsibility for phase two — the moment a patient first engages with a practice

✅ How front desk trust-building connects directly to patient outcomes, not just satisfaction scores

✅ The three distinct roles hiding inside what looks like one front desk job

WHY THIS MATTERS

Jerry Durham argues that physicians and nurses often get blamed (or credited) for the entire patient journey, when in reality the front desk shapes a huge part of whether a patient trusts and sticks with a practice. Trust drives outcomes, and a lack of trust is a documented factor behind disparities in outcomes across different patient populations. Treating the front desk as aligned with clinical goals, rather than a walled-off administrative function, is what turns good business practice into better patient care — and can even help reduce clinician burnout.

MENTIONED IN THIS EPISODE

🔗 EP228, with Julie Rish, PhD, from the Cleveland Clinic

=== LINKS ===

🔗 Show Notes with all mentioned links: Episode Page

🔗 Healthcare Industry Acronyms and Terms

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00:00 Introduction.

04:31 What is the patient life cycle?

05:33 What are the milestones of the patient life cycle? When does it start?

08:51 "This isn't a business solution; this is a patient-driven solution."

09:08 "What is best for the patient is best for business."

12:45 "The takeaway there is that your team members are all driving toward the same goal."

13:54 How does the front desk impact health outcomes?

16:00 What is the objective of a front desk to reduce provider burden?

20:38 "There's actually three roles at the front desk."

29:57 EP228 with Julie Rish, PhD, from the Cleveland Clinic.

In Episode 296, Stacey Richter talks with Vincent Rajkumar, MD, professor of medicine and practicing hematologist at Mayo Clinic, Rochester, about oncology FAQs covering telehealth, standardizing care, and drug prices.

WHAT YOU'LL LEARN

✅ How telehealth is reshaping oncology visits, and where it still falls short

✅ Why standardizing treatment pathways could help community oncologists keep pace with increasingly complex cancer care

✅ Why treatment pathways should be built by people without a financial stake in the outcome

✅ Why Dr. Rajkumar argues there are "no allies" in the fight for lower prescription drug costs

✅ Why cancer drugs behave like monopolies rather than products in a free market

WHY THIS MATTERS

Dr. Vincent Rajkumar, a leading voice on drug pricing and multiple myeloma treatment, walks through why cancer care has become so complex that community oncologists need standardized, conflict-free pathways to keep up, and why telehealth has a real but limited role to play in that complexity. He's especially blunt about drug pricing: unlike a car or a television, a cancer drug isn't something a patient can decide to live without, and when each drug functions as its own monopoly, normal market forces simply don't apply. Value-based pricing, he argues, isn't about putting a price on a life — it's about putting a price on what a drug is actually worth.

=== 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.

01:45 What is the perspective on telehealth and its impact on oncology?

03:50 "Cancer has become extraordinarily complex."

05:32 Is it possible to still have community oncologists in the advent of technology?

08:39 What's the viability for flat-fee reimbursement in oncology?

14:31 "The pathways should be designed and developed by people who don't have a financial stake [or] conflict."

18:34 "Part of the problem for physicians is, you want to deliver the best care."

21:23 "There are no allies in this fight for lower prescription drug costs."

23:18 "This is not like a television or a car where you can say you can live without it."

24:33 "It's absolutely not a free market."

25:35 "Each drug is a monopoly."

30:22 "When you do value-based pricing, you're not putting a price on anybody's life. You're only putting a price on what [a] drug is worth."

In Episode 295, Stacey Richter talks with Rebecca Etz, PhD, associate professor of family medicine and co-director of The Larry A. Green Center, about surprising insights into how primary care performance should actually be measured.

WHAT YOU'LL LEARN

✅ Why primary care remains one of the "best-kept secrets" of better health outcomes despite being chronically under-resourced

✅ Why measures that don't match the actual work of primary care are demoralizing to clinicians

✅ How financial incentives tied to the wrong targets distort what electronic medical records actually capture

✅ Why primary care is fundamentally a relational field, and what that means for measuring its value

✅ How primary care's performance measures held up during COVID, and where they broke down

WHY THIS MATTERS

Rebecca Etz and The Larry A. Green Center built 11 performance measures for primary care that are aligned across patients, clinicians, and payers — a rare feat, since PCPs already spend upwards of $40,000 a year of uncompensated time reconciling conflicting measurement standards. Etz argues that when the wrong things get measured, primary care's central strength — its relational, cognitive work of listening, thinking, and coordinating — gets systematically undervalued, and clinicians end up incentivized to paint an optimal picture in the record rather than actually deliver better care.

MENTIONED IN THIS EPISODE

🔗 EP270, with Dave Chase

🔗 EP272, with Guy Culpepper, MD

=== 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.

03:41 Why is primary care one of the "best-kept secrets" of better health outcomes?

08:38 "Measures are a form of communication."

08:51 "If the way that you are assessed does not actually match up with the work you do or what you find to be important, it's pretty demoralizing."

11:41 "It is the outcome of health care, but it is not the same thing as quality."

16:31 "It creates a financial incentive to hit a target by any means necessary."

18:06 "We incentivize people to have good outcomes, and what that means is that electronic medical records are no longer simply databases that tell us what the health of the population is. They are databases that tell us what is the optimal picture that a clinician is able to paint of their patients."

21:07 "Primary care is a relational field."

22:14 "How does this relate to cost and utilization?"

26:43 "I think we all know that fee for service is death."

27:11 How has the measure of PCPs in the time of COVID held up?

27:32 What measure performs worse in the time of COVID?

28:17 "Primary care is the place that everybody goes."

31:16 EP270 with Dave Chase and EP272 with Guy Culpepper, MD.

In Episode 294, Stacey Richter talks with Steve Schutzer, MD, physician executive for the orthopedic service line at Trinity Health of New England and medical director of the Connecticut Joint Replacement Institute, about building a Center of Excellence — a playbook for physician entrepreneurs.

WHAT YOU'LL LEARN

✅ Why competitive physician groups sometimes choose to band together despite being rivals

✅ Why even just going through the implementation process of a Center of Excellence (COE) yields unrecognized value

✅ How the savings from a COE actually break down: two-thirds from quality, one-third from price

✅ Why trust between physicians and hospital partners is the single most central issue in whether a COE succeeds

✅ Why actionable data — not just data — is essential, since physicians naturally distrust data

WHY THIS MATTERS

Dr. Steve Schutzer makes the case that physician entrepreneurship, not just digital health disruption, is one of the biggest opportunities in health care right now. Building a Center of Excellence requires an end-to-end care redesign and deep trust between physicians and hospital partners, but the payoff is real: most of the value comes from quality improvements, not just price. As fee-for-service faces an uncertain future, Schutzer argues physicians who organize around a COE model are well positioned for whatever comes next, COVID-driven disruption included.

=== 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.

03:22 Why would competitive physician groups gang together?

07:32 "Even if you never … bundle, going through the implementation process … will yield incredible unrecognized value."

08:49 "It demands an end-to-end care redesign process."

10:10 "The value of a COE is really unquestionable."

10:18 "For every dollar saved [in a COE], two-thirds was in the quality side, and one-third was in the price point."

14:05 "I'm talking about business relationships between the physicians … these are the most fundamental [relationships]."

15:23 "It is all about trust."

15:48 What is the most central issue as to why a COE does well or fails?

16:25 "It's not just data. It has to be actionable data because physicians naturally don't trust data."

21:54 "Employers are definitely taking note to patient-reported outcomes."

22:37 What is the seventh element that is necessary for a COE, and what is fundamental to that element?

23:27 Where will fee-for-service doctors be in 2 to 3 years?

24:45 "The only way that we can accrue the value that we deserve is through these types of relationships."

25:11 "The supreme motivator is opportunity."

27:01 How do physicians and providers begin a transformation of the marketplace they're in?

27:36 "What they need from us is product. They need products to disrupt the status quo."

30:26 "The problem is that there are vendors who are working at the margin."

In Episode 293, Stacey Richter talks with Dea Belazi, PharmD, MPH, president and CEO of AscellaHealth, about the escalating game theory battle among co-pay cards, co-pay accumulators, and co-pay maximizers.

WHAT YOU'LL LEARN

✅ How the "war of the co-pays" started when PBMs began demanding higher discounts from Pharma in exchange for lower patient co-pays

✅ Why pharma companies turned to co-pay discount cards to route around PBM leverage

✅ What co-pay accumulators and co-pay maximizers are, and how each escalates the fight differently

✅ Why this dynamic is far higher stakes on specialty drugs, where patients may have only one treatment option

✅ Why neither insurers nor pharma companies are truly innocent bystanders in what patients end up paying

WHY THIS MATTERS

Dea Belazi lays out an escalating game theory battle: PBMs use control over patient co-pays to extract discounts from Pharma, Pharma responds with co-pay discount cards to bypass PBMs, and PBMs counter with co-pay accumulators and maximizers that claw the value back. On expensive specialty drugs where patients may have only one viable option, this fight isn't academic — it determines whether people can actually afford care they're already paying premiums for. Belazi is careful to point out that both insurers, who set patient cost share, and pharma companies, who set drug prices, share responsibility for patients getting caught in the middle.

MENTIONED IN THIS EPISODE

🔗 EP241, with Vinay Patel

=== 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.

05:03 "The concept of co-pay accumulators wasn't just a … PBM thought, but it also came from their customers, whether it was health plans or employer groups."

10:00 "[This is] literally a math problem based on, 'Do I spend it now? Do I spend it later?'"

11:31 What reason do employers and payers have for doing this?

15:26 "This is another mechanism for payers to push down additional cost to both the patient and now the pharma company."

19:57 EP241 with Vinay Patel.

20:33 "I don't think accumulators are really forcing Pharma to be more competitive."

22:49 How co-pay maximizers are different from co-pay accumulators.

25:57 Who doesn't like co-pay accumulators and maximizers?

28:03 How patient advocacy groups are a different model.

30:14 What is the biggest challenge facing employers right now?

In this Episode 292, Part 2, Stacey Richter continues the conversation on Teladoc buying Livongo, speaking with Matt Anderson, MD, MBA, of Banner Health, and Brian Klepper, PhD, of Worksite Health Advisors, about what the merger means from the health system and employer points of view.

WHAT YOU'LL LEARN

✅ How a health system innovation leader views the Teladoc-Livongo combination and its competitive implications

✅ Why competition in health care is increasingly going to be about outcomes — or at least perceived outcomes

✅ Why so many organizations claim to deliver high-value care, when very few actually do

✅ Why the stakes have risen sharply for health systems and physicians of all types

✅ Why American health care has developed what Brian Klepper calls "a culture of excess"

WHY THIS MATTERS

Following Part 1's discussion of Teladoc buying Livongo, Matt Anderson and Brian Klepper widen the lens: this deal is just one entry in a much bigger wave of disruption, from Aetna-CVS to Walmart-Oak Street to Premise Health acquiring CareHere. The real competition ahead will be about who can prove they deliver genuinely better outcomes at lower cost, not just who has the best marketing. Both guests agree the stakes have never been higher for traditional health systems and physicians to demonstrate real, validated value rather than relying on a compelling pitch.

MENTIONED IN THIS EPISODE

🔗 EP252, with Chad Gray

=== 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.

05:06 What is the viewpoint about this merger from an MD, MBA in a health system?

06:30 "They're really starting to become someone who can provide that continuity of care in a way that I don't think anyone's really done before."—Matt

07:38 "When you are competing for patients, by definition you're competing for revenue."—Matt

10:09 "At baseline, their goal is to provide care but at the lowest cost possible."—Matt

12:17 What is a forward-thinking provider organization doing right now?

12:31 "This is going to be a space race for health care innovation right now."—Matt

15:43 "Sometimes it just comes down to the basics, and if you get the basics right, you can apply it in any situation."—Matt

16:29 What's forced the inertia in the industry to become action?

17:23 "Things are moving slowly but surely in the right direction, and that's something I've never seen during the course of my career."—Brian

19:56 "Everybody and his wooden-legged brother claims that they have a high-value service, but very few actually do."—Brian

21:13 "I think that the stakes have just gotten much higher for health systems … and physicians … of all types."—Brian

23:46 EP252 with Chad Gray.

25:12 "High-performance organizations represent a new paradigm in their niche."—Brian

25:35 "It speaks to the core problem of American health care, which is that we've developed a culture of excess."—Brian

27:42 Where's the top of the bell curve right now?

28:10 "A lot of this is driven by policy … and that has sort of rigged the game."—Brian

29:46 "There's a tipping point, and then everything really, really will change quickly."—Brian

In this Episode 292, Part 1, Stacey Richter talks with Bob Matthews, president and CEO of MediSync, and Dan O'Neill, MA, MS, about Teladoc buying Livongo — and what the merger means for providers, employers, and the market.

WHAT YOU'LL LEARN

✅ Why the Teladoc-Livongo merger is more than a deal — it's a bid for a $121 billion total available market

✅ How vertical integration in virtual care could disrupt the referral flow of traditional provider models

✅ Why "captive populations" are the real prize behind digital front doors

✅ Why consolidated health systems can charge 23% more without delivering better outcomes

✅ How this merger fits into a broader land grab for patients happening across the industry

WHY THIS MATTERS

Bob Matthews and Dan O'Neill unpack why Teladoc's acquisition of Livongo is a bigger deal than it looks: the combined company is explicitly targeting a $121 billion market and plans to cross-refer patients across conditions, from diabetes to musculoskeletal to behavioral health. That's a direct challenge to traditional referral flows and captive patient populations, especially in markets where consolidated health systems charge significantly more without better outcomes. As virtual care becomes a top priority for large employers, this kind of vertical integration could reshape who actually controls the patient relationship.

=== 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.

07:06 Are providers recognizing that Livongo is their competition?

08:32 Is this the beginning of the health care system in America being disrupted in a major way?

10:05 Where does the major disruptive potential lie with Livongo?

11:56 "The truth is that the local delivery system isn't doing a good job, and Livongo only has to do a better job."—Bob

14:55 What is MediSync?

15:46 Dan O'Neil speaks about the Teladoc-Livongo merger and what's going on right now.

16:08 "You have a blockbuster merger in the world of digital health or health tech."—Dan

17:03 How does this evolve?

18:16 "A vertical integration play in the virtual care space."—Dan

19:47 "They call it captive populations for a reason."—Stacey

23:59 "What you're seeing … is a different approach to … building, marketing, and delivering the service."—Dan

29:37 "Big mergers are always risky … that said … that is potentially a very significant move."—Dan