Relentless Health Value

In this episode, Stacey Richter talks with Mark Blum, executive director of America's Agenda, about how uniting labor and employers could stand against rising health care costs.

WHAT YOU'LL LEARN

✅ Why deductibles are rising at eight times the rate of inflation

✅ How America's Agenda used a "reverse auction" to save New Jersey unions $1.6 billion on pharmacy benefits

✅ How to design a purchaser contract that eliminates hidden pricing in PBM contracting

✅ Why PBMs resist these kinds of reforms

✅ How labor-owned direct primary care can improve outcomes while reducing costs

WHY THIS MATTERS

Mark Blum makes the case that instead of employers and unions fighting each other over cost shifting at the bargaining table, they should unite against the actual drivers of rising health care costs—excess middleman profit, private equity extraction, and a system that rewards volume over value. His concrete example, a reverse-auction PBM contract that saved New Jersey unions $1.6 billion over three years, shows what's possible when purchasers negotiate collectively and demand transparent terms.

MENTIONED IN THIS EPISODE

🔗 EP241, with Vinay Patel

=== LINKS ===

🔗 Show Notes with all mentioned links: Episode Page

🔗 Healthcare Industry Acronyms and Terms

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00:00 Introduction.

03:17 Employers and unions—combining forces.

04:04 Rising deductibles at eight times the rate of inflation.

04:40 Creating and sharing savings, rather than fighting over cost shifting.

05:45 Working with New Jersey unions to have meaningful reduction in pharmacy benefits manager (PBM) spend—New Jersey Education Association (NJEA); Communications Workers of America (CWA); American Federation of State, County and Municipal Employees (AFSCME); Patrolmen's Benevolent Association (PBA); among others.

07:57 Finding the next PBM to serve all these people in New Jersey using a "reverse auction."

09:04 Designing a purchaser contract to eliminate hidden pricing in PBM contracting.

16:20 "There is no reason other PBMs couldn't participate in reverse auctions like this."

16:35 How reverse auctions like America's Agenda's auction in New Jersey are possible in virtually every state.

17:58 "The big obstacle to doing this … is that the PBM industry is remarkably profitable."

19:25 Tactics among PBMs—Vinay Patel discusses in EP241.

20:26 Why PBMs don't want to see this change.

21:51 "What stops them from reducing reimbursements to community pharmacies?"

22:05 "Best-in-class terms can build in requirements that PBMs may not spread price."

24:37 America's Agenda's transformation of direct primary care.

26:56 America's Agenda's biggest innovation in labor direct ownership of direct primary care.

28:24 Aligning the interests of patients and physicians.

29:46 The big crisis in American health care—rising costs.

In this episode, Stacey Richter talks with John Gorman, CEO and chairman of Nightingale Partners, about quality measures, Medicare Advantage (maybe for all), and price gouging.

WHAT YOU'LL LEARN

✅ How Medicare Advantage and fee-for-service Medicare value-based care measures compare, and whether the weighting is legitimate

✅ Why half of the Medicare Advantage star rating is attributable to member experience

✅ How Medicare Advantage could plausibly expand into a "Medicare Advantage for all" model

✅ Why a more rigorous antitrust approach to hospital mergers could help curb price gouging

✅ John Gorman's advice for independent physicians and rural hospitals navigating this landscape

WHY THIS MATTERS

John Gorman doesn't claim Medicare Advantage is problem-free—coding gamesmanship, wasteful quotas, and restrictive networks are all real issues. But he makes the case that MA's trajectory, combined with insurance carrier profitability and consolidation pressure, is reshaping how rural hospitals and independent physicians need to think about scale and negotiating leverage. His blunt advice to smaller providers: get bigger and more sophisticated in the value you bring, because there's strength in numbers when you're not adapting fast enough to survive.

MENTIONED IN THIS EPISODE

🔗 EP202, with Frazer Buntin

🔗 EP219, with Arshad Rahim

=== LINKS ===

🔗 Show Notes with all mentioned links: Episode Page

🔗 Healthcare Industry Acronyms and Terms

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

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=== CONNECT WITH THE RHV TEAM ===

✭ LinkedIn ✭ Threads ✭ Bluesky ✭ X

00:00 Introduction.

01:37 The quality measures being used to assess value.

04:00 "Half of the rating is attributable to the member experience."

04:29 Are the ways that FFS and Medicare Advantage value-based care measures are weighted legitimate?

07:59 Insurance carrier profitability.

08:33 Medicare for all to Medicare Advantage for all—how John sees this morphing into the future.

11:07 Is insurance profitability at the expense of the rest of the country?

13:47 "A more rigorous antitrust approach to hospital mergers would certainly help."

15:10 "Get bigger and get more sophisticated in … the value you bring to the table."

16:49 "There's always strength in numbers."

20:35 EP202 with Frazer Buntin.

23:28 "If you're not adapting, you're dying in this environment if you're a hospital."

24:37 John's advice to rural hospitals.

27:44 EP219 with Arshad Rahim.

28:27 What Nightingale is and what they do.

In this health care podcast, I speak with John Gorman, who is a government-sponsored health programs guru. He’s also the founder of a newly minted organization called Nightingale that (spoiler alert) we discuss toward the end of our conversation. I just want to interject right here that I, for one—but I’m sure John would agree—do not believe that Medicare Advantage (MA) is, as is, perfectly terrific and devoid of problems.

There are, of course, well-known issues with coding, the whole exaggerated diagnoses for higher reimbursements thing … then there’s the whole potentially wasteful quotas payments and the restrictive networks of doctors cited issues. We don’t get into these during our conversation, focusing instead on comparing MA to FFS (fee-for-service) Medicare.

From there, we get into advice for independent physicians in rural hospitals and then we wind up at price gouging by nonprofit hospitals. John’s points are insightful as always, and I guarantee he will give you a lot to think about.

You can learn more and connect with John on LinkedIn.

John Gorman is the founder and former executive chairman at Gorman Health Group (GHG). For 22 years he led the development of the industry’s leading consulting practice and several entrepreneurial ventures in government health programs. John’s work focuses on Medicare Advantage, Medicaid, and Accountable Care Act strategy, governance, and social determinants of health. John considers himself a defender and fixer of health insurance coverage, especially Medicare, Medicaid, and subsidized individuals served by health plans. He has strong opinions and relies on evidence and sound policy. Prior to founding GHG in 1996, he was appointed by President Clinton as the first assistant to the director of the Health Care Financing Administration’s (now Centers for Medicare and Medicaid Services) Office of Managed Care.

Why EHR Infrastructure Comes First for Health Tech Innovation, With Pam Arora (EP246)

Even Visionary Health IT Initiatives Need a Rock-Solid EHR Foundation. Episode 246.

Telemedicine in schools and patients' homes, medication-adherence chips on transplant capsules, voice and GPS pilots — Children's Health in Dallas has an ambitious health IT roadmap. In this episode, Stacey Richter talks with Pam Arora, SVP and CIO at Children's Health in Dallas, about what it actually takes to run visionary initiatives like these while still keeping the fundamentals — EHR upgrades, security patches, virtual desktops — running smoothly.

WHAT YOU'LL LEARN

✅ How Children's Health in Dallas is piloting integrated telemedicine in schools and in patients' homes

✅ How the health system is monitoring medication adherence for transplant patients by putting chips on the capsules themselves

✅ Why Pam Arora says visionary initiatives like these only work on top of a capable, robust EHR infrastructure — not instead of one

✅ Why relentless attention to the specific details of what patients and families actually want and need underlies the whole strategy

WHY THIS MATTERS

It's tempting to talk about health IT innovation as if voice technology, GPS, and adherence chips are the interesting part and the EHR is just plumbing. Pam Arora's point is the opposite: none of the visionary work is possible without getting the unglamorous infrastructure right first, which means CIOs have to fund and prioritize both at once, not sequence one before the other.

=== LINKS ===

🔗 Show Notes with all mentioned links: Episode Page

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=== CONNECT WITH THE RHV TEAM ===

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In this health care podcast, Pam Arora, SVP and CIO at Children’s Health in Dallas, talks about the work she and her team are doing. Spoiler alert: It’s pretty visionary. They have integrated telemedicine solutions in schools and in patients’ homes. They’ve also been monitoring adherence to vital transplant meds by putting chips on the capsules. They have initiatives happening with voice and GPS technology. I asked Pam what it takes to get all of this done while, at the same time, balancing the usual suspects—the EHR upgrades, the security patches, the virtual desktops, the inevitable panic of the month.

Pam explains her answer far more eloquently than I’m going to be able to recap here, but in a nutshell, she says it’s all about getting the fundamentals right. A hospital, a health system, needs a capable, robust EHR infrastructure that really works. She further adds that attaining that infrastructure takes a lot of things, but one of them is a relentless attention to the details, particularly the details around what exactly and specifically patients and their families want and need.

I met Pam at the NODE.Health conference earlier this year in New York City.

You can learn more at childrens.com or onTwitter at @ChildrensTheOne.  You can also connect with Pam on Twitter at @pkarora.

Pamela Arora serves as senior vice president, information services, and chief information officer (CIO) and is responsible for directing all efforts of the information services groups in the organization. Her oversight encompasses systems and technology, health information management, and health care technology management and support.

Why Al Lewis Calls Traditional Wellness Programs "Health Care Done to Employees, Not for Employees" (EP245)

Arithmetically Impossible: A Reckoning for the Wellness Industry. Episode 245.

Traditional "to employee" wellness programs are, in Al Lewis's words, health care done to employees rather than for employees — mandatory, often stick-dressed-as-carrot, and generally touted for cost savings that don't hold up under scrutiny. In this episode, Stacey Richter talks with Al Lewis, cofounder and CEO of Quizzify, about why so many employer wellness programs stay in place despite being suboptimal on cost, quality, and satisfaction, and what it will take for the market to finally reward the solutions that actually work.

WHAT YOU'LL LEARN

✅ Why traditional wellness programs persist even when they're "heartily suboptimal" — because everybody in the supply chain, from vendors to brokers, is still making money off them

✅ Why re-educating an employer about an underperforming wellness program is often seen as too time-consuming or risky for brokers to bother with

✅ Why Al Lewis has earned the nickname "troublemaker-in-chief" of the wellness industry for his rigorous, often unpopular analysis

✅ How Quizzify, Al Lewis's company, teaches employees to get the care they need while avoiding the "care" they don't — and how its claims have been independently validated by the Validation Institute

WHY THIS MATTERS

Employers are getting wiser about a lot of things right now, and wellness programs may be next on the list. As lawsuits move forward and research piles up showing many programs don't deliver on their promises, the real question is whether legacy vendors can compete with solutions employees actually want to use — or whether the market finally starts rewarding what works over what's always been sold.

=== LINKS ===

🔗 Show Notes with all mentioned links: Episode Page

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=== CONNECT WITH THE RHV TEAM ===

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In this health care podcast I speak with Al Lewis. He’s been called both “the founding father” of disease management, and he’s also been called the “troublemaker-in-chief” of the wellness industry. His integrity and commitment and rigorous analytical approach is open and shut. Al is the author of two books. He’s also the CEO of Quizzify, a company and an approach that teaches employees how to get the care they need while avoiding the “care” they don’t.

A Playbook for Jumbo Employers on Fixing Health Care Benefits, With Lee Lewis of the Health Transformation Alliance (EP244)

The Three-Chapter Playbook Jumbo Employers Are Using to Fix Health Benefits. Episode 244.

The Health Transformation Alliance (HTA) is a group of 50 major corporations that have banded together with one goal: fix a broken health care system. In this episode, Stacey Richter talks with Lee Lewis, the newly minted chief strategy officer at the HTA, about the three-chapter playbook he uses to improve health care benefits for large employers — a playbook built around the idea that employers and employees can both come out ahead at once.

WHAT YOU'LL LEARN

✅ Why Lee Lewis says fixing employer health benefits is like having your cake and eating it too — employers save money while employees get better care and spend less time navigating the health care system alone

✅ The first chapter of Lee's playbook, the "how": the administrative superstructure underlying a benefits plan

✅ The second chapter, the "what": drug spend and how care is delivered for high-cost clinical conditions like musculoskeletal and cardiometabolic disease

✅ The third chapter, the "who": where employees get steered for care, with an emphasis on primary care providers

WHY THIS MATTERS

Jumbo employers have leverage that smaller purchasers don't, and the HTA was built to use it collectively across 50 major corporations. Lee Lewis's three-chapter framework — how, what, and who — gives any employer, provider, consultant, carrier, or pharma company that gets paid by jumbo employers a concrete structure for thinking about where the real savings and quality gains actually come from.

=== LINKS ===

🔗 Show Notes with all mentioned links: Episode Page

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

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=== CONNECT WITH THE RHV TEAM ===

✭ LinkedIn ✭ Threads ✭ Bluesky ✭ X

In this health care podcast, I speak with Lee Lewis, who is the newly minted chief strategy officer at the Health Transformation Alliance, otherwise known as the HTA. The HTA is a group of 50 major corporations that have come together in an alliance to do one thing: fix our broken health care system.

Who Wins and Who Loses in the Snowball of Drug Pricing Proposals Coming Out of Washington, With Josh LaRosa (EP243)

Will All the Drug Pricing Reform Proposals in Washington Actually Stick — or Just Blow Over? Episode 243.

Big vested interests always want to maintain the status quo, and the drug supply chain is no exception. So here's the $106-billion-a-year question: will the wave of drug pricing proposals moving through Washington and state legislatures in 2019 actually change anything, or are Big Pharma, PBMs, and insurance carriers well girded enough to withstand them? In this episode, Stacey Richter talks with Josh LaRosa, MPP, policy associate at Wynne Health Group, to get up to speed on what's actually being proposed and what it means for the drug supply chain.

WHAT YOU'LL LEARN

✅ Whether health care legislation has reached an inflection point, and what obstacles stand in the way of Congress actually passing anything

✅ Which proposed measures are most likely to pass — and which would be most disruptive to the drug supply chain if they did

✅ How a catastrophic benefit proposal and the International Pricing Index Model would work, and why they'd have some of the greatest industry impact

✅ How the FTC could bring transparency to PBM contracting by mandating what's actually in those contracts

✅ Why brand and generic manufacturers face different pressures — and what generic reform would need to break down

WHY THIS MATTERS

It's easy to lose track of the sheer number of drug pricing proposals moving through Washington at any given moment, and just as easy for stakeholders with the most to lose to run out the clock waiting for public attention to move on. Understanding which proposals have real teeth — and which are more bark than bite — is the first step for anyone trying to figure out how the drug supply chain might actually change.

=== LINKS ===

🔗 Show Notes with all mentioned links: Episode Page

✉️ Enjoy this podcast? Subscribe to the free weekly newsletter

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

🎤 Listen on Apple Podcasts

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=== CONNECT WITH THE RHV TEAM ===

✭ LinkedIn ✭ Threads ✭ Bluesky ✭ X

00:00 Introduction.

01:48 This conversation happened at the end of August 2019.

02:32 Are we at an inflection point with health care legislation?

05:10 What obstacles stand in the way of seeing any legislation passed by Congress?

06:14 Most likely to happen and most disruptive among the health care measures being proposed.

09:03 The catastrophic benefit and how it works.

16:34 International Pricing Index Model.

20:12 The two areas that would have the greatest impact on the industry, if they transpire.

21:07 Federal Trade Commission (FTC), PBMs, and drug pricing.

21:46 Mandating PBM contracts, and what it would take at the FTC.

22:27 Bringing transparency to the forefront of PBM contracting.

27:10 Brand manufacturers vs generic manufacturers.

28:05 Breaking down barriers in generic reform.