Relentless Health Value

The myth is that we have a functioning marketplace. We don't. We don't have a broken market — it's closer to a nonexistent market. That's Shane Cerone speaking, a former CEO of multiple hospital systems, and it is the central argument of this episode: the pricing crisis in American healthcare isn't being solved because the foundational premise — that market forces are constraining hospital prices — is false. Stacey Richter speaks with Shane Cerone and Dr. Sam Flanders, MD, both now at Kada Health, who together ran Beaumont Hospital Royal Oak at approximately 150% of Medicare while achieving national quality and safety rankings, about the three myths that keep health systems and employers from confronting what is actually driving costs.

WHAT YOU'LL LEARN

✅ Why the healthcare market is not broken but nonexistent: hospitals do not compete on price or quality for patients, carriers cannot create competition that does not exist, and the absence of real transactions means supply and demand curves have nothing to equilibrate — welcome to 37% renewals

✅ Why Dr. John Rodis's experience is the proof: as CEO he drove his hospital's Leapfrog safety rating from a D to an A and received zero volume reward — no additional patients steered to him, no better carrier rates — because there is no mechanism in the current system to reward quality or efficiency

✅ Why razor-thin hospital operating margins are not automatically evidence of financial hardship: without competitive pricing pressure, organizations that spend every dollar they are given will always show thin margins, and the two explanations — genuine cost pressure versus spending without constraint — are impossible to separate

✅ Why the data already refutes the "hospitals can't survive below 200% of Medicare" claim: Kada Health has published a list of over 20 nationally ranked hospitals operating at or below 200% of Medicare, and Beaumont Hospital Royal Oak ran at roughly 150% with top-decile quality ratings for seven consecutive years

✅ Why lowering prices and raising quality are not a tradeoff — they move together: a finding backed by the work of W. Edwards Deming and the Toyota model, where process discipline that reduces waste also reduces defects, and the frontline improvements that lower cost simultaneously improve safety and reliability

✅ Why pricing as a percent of Medicare reference-based model is the only path to simplicity legible enough for physicians, patients, and employers to actually make decisions — and why the current mess of negotiated rates is by design, not by accident

WHY THIS MATTERS

This is the problem show. The solutions show is EP492. Listen to both. As Shane Cerone puts it, we have been focused for decades on controlling volume and utilization while doing nothing about price. Until price is addressed in a functioning market structure — where employers negotiate directly, where quality and cost are visible, and where high-value providers are actually rewarded — the flywheel keeps spinning in the wrong direction.

MENTIONED IN THIS EPISODE

EP466 with Vivian Ho, PhD: Apple Podcasts | Spotify | Other Apps

EP486 with Stan Schwartz, MD: Apple Podcasts | Spotify | Other Apps

EP488 with Mark Cuban and Cora Opsahl: Apple Podcasts | Spotify | Other Apps

EP286 with John Rodis, MD, MBA: Apple Podcasts | Spotify | Other Apps

EP472 with Eric Bricker, MD: Apple Podcasts | Spotify | Other Apps

=== 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

📺 Subscribe to our YouTube channel

🎤 Listen on Apple Podcasts

🎤 Listen on Spotify

=== CONNECT WITH THE RHV TEAM ===

✭ LinkedIn ✭ Threads ✭ Bluesky ✭ X

00:00 Introduction.

10:08 Why we need to focus on prices in healthcare.

11:50 The first myth that holds change back: the healthcare "market."

15:51 The reality behind why there is no functional market in healthcare.

17:11 Why price simplicity is so important.

19:31 How there is pricing failure while hospitals are still facing razor-thin margins.

22:11 The second myth: Can a hospital survive on Medicare rates alone?

25:21 What is the best hospitals can achieve?

26:01 List of hospitals recognized as national leaders for care quality and affordability.

29:23 The third myth: When you lower prices, do you get lower quality?

33:11 Why a decentralized approach at improvement is the way to lower cost and raise quality.

One third of adults in this country are delaying or forgoing care due to cost. Financial toxicity is clinical toxicity. And yet the standard assumption in healthcare is that affordable prices and financial sustainability are in fundamental tension with each other. Dan Greenleaf's argument — backed by the operating results of Duly, a 1,800-clinician multispecialty group in Chicago — is that they are not. In this Part 2, Stacey Richter speaks with Dan Greenleaf, CEO of Duly Health and Care, a six-time CEO with three public companies and three PE-backed organizations under his belt, about how Duly generates margin by achieving its mission rather than despite it — and why physician compensation adjusted for inflation is down 36% over 25 years while the competitors he names are sitting on tax-exempt balance sheets of $6 to $24 billion.

WHAT YOU'LL LEARN

✅ How Duly's operational model generates margin: 65% of primary care referrals stay in-network, 76% of specialist-to-ambulatory-surgery-center referrals are captured, and the group's 30 lab sites, 6 ASCs, 16 imaging centers, 11 immediate care centers, and 100 infusion chairs allow it to deliver care at roughly 30% less than institutional competitors — every patient kept in network is a mission win and a margin win simultaneously

✅ Why 600 of Duly's 1,800 physicians are shareholders and 40% of the company is physician-owned — and how aligned financial incentives change the organizational psychology in ways that matter for both culture and operational performance

✅ How five of eleven Duly board seats are held by physicians — and why that governance structure is what actually operationalizes the "dyad leadership" concept that most organizations talk about but few sustain at the board level

✅ How ambient AI scribing reduced physician administrative burden by four and a half hours per week per physician while improving patient experience scores by five percentage points — and what that means for clinician retention and the margin case for mission-aligned technology

✅ Why Dan Greenleaf's framing for capital partners is performance-based rather than mission-based: he competes against organizations with $10 to $24 billion on their balance sheets and his credibility with Ares, his capital partner, comes from a track record of operational performance, not from making the moral case for value-based care

✅ Why the fee-for-service versus value-based care debate misses the point — the real problem is institutional pricing, and every patient Duly keeps out of a hospital system charging 9 to 12 times more is a concrete affordability and quality win regardless of payment model

WHY THIS MATTERS

The mission show is EP489 Part 1. This is Part 2. Dan Greenleaf's central argument is that the successful care models are those that create value inherently — and that reducing friction for patients and reducing friction for clinicians, pursued relentlessly, produces both better outcomes and sustainable margin. The organizational structures that make this possible — physician ownership, physician board seats, aligned incentives, transparent mission metrics — are not incidental to the financial model. They are the financial model.

MENTIONED IN THIS EPISODE

EP466 with Vivian Ho, PhD: Apple Podcasts | Spotify | Other Apps

EP462 with Scott Conard, MD: Apple Podcasts | Spotify | Other Apps

Summer Shorts episode with Stan Schwartz, MD: Apple Podcasts | Spotify | Other Apps

EP460 with Rushika Fernandopulle, MD: Apple Podcasts | Spotify | Other Apps

EP445 with Tom X. Lee, MD: Apple Podcasts | Spotify | Other Apps

EP407 with Vivek Garg, MD, MBA: Apple Podcasts | Spotify | Other Apps

=== 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

📺 Subscribe to our YouTube channel

🎤 Listen on Apple Podcasts

🎤 Listen on Spotify

=== CONNECT WITH THE RHV TEAM ===

✭ LinkedIn ✭ Threads ✭ Bluesky ✭ X

00:00 Introduction.

09:56 How does Dan achieve his mission given the realities of margin?

14:49 How Duly Health's approach and incentives differ from other health systems.

18:50 How having physicians on the hospital board greatly improves margin and mission.

20:04 How Dan explains his approach to his capital partners.

22:23 Fee for service vs. institutional care.

Hospitals have increased their prices 256% over the last 20 years while physician compensation adjusted for inflation is down 36%. The average American family of four now spends $24,000 a year on healthcare — up from $6,000 in 2000 — while wages have risen far more slowly. Dan Greenleaf's argument is that in this environment, focusing on mission is not a financial sacrifice. It is a competitive advantage. In this episode, Stacey Richter speaks with Dan Greenleaf, CEO of Duly Health and Care, a large multispecialty group in Chicago, about how Duly defines and measures mission across four concrete quadrants — affordability, access, consumer experience, and quality — and why achieving those quadrants reduces friction for patients and clinicians in ways that also produce financial sustainability. The margin show is EP489 Part 2.

WHAT YOU'LL LEARN

✅ Why affordability is the foundational mission quadrant: Duly's MRI costs $500 versus $4,500 at a Chicago hospital system, colonoscopies are $10,000 less, and the group estimates it saves employers, unions, and taxpayers in excess of $1 billion — likely closer to $2 billion — in the Chicago market alone

✅ How co-insurance math makes affordability a direct patient health issue: a $4,500 MRI at 20% co-insurance is $900 out of pocket versus $100 at Duly — and that $800 difference is the difference between patients seeking or delaying necessary care

✅ Why access at two days average wait time versus eight to sixty days at Chicago hospital systems is both a mission priority and a cost issue: an Avalere study found Duly Medicare fee-for-service patients had 15% fewer hospital admissions and 13% fewer ER admissions than comparable populations

✅ How Duly measures consumer experience with 50,000 Press Ganey survey responses per quarter and a net promoter score of 74 — above the 70 threshold for world-class, and compared to a 46 national hospital average — with price transparency explicitly built into the consumer experience definition

✅ Why Duly's prostate biopsy positive rate of 77% versus a national average of 25% is a proxy for diagnostic discipline — every unnecessary biopsy is both a quality failure and a financial harm to the patient

✅ How outbound activation campaigns for lung screening, colonoscopies, mammograms, and diabetic screening — work Duly does without getting paid for it — have detected hundreds of early-stage lung cancers and led to outcomes like a 25-day diagnosis-to-therapy timeline that Dan Greenleaf says nobody else achieves

WHY THIS MATTERS

Dan Greenleaf's framing is direct: there are only three ultimate payers in healthcare — taxpayers, employers and unions, and patients themselves — and everyone else is a middleman. The communities where Duly serves 40 to 50% of patients rank among the healthiest in the country. That is not incidental. When a clinical organization actually defines what mission means, measures it the way it measures any strategic priority, and builds operations around reducing friction for patients and clinicians, the mission and the margin move in the same direction.

MENTIONED IN THIS EPISODE

EP466 with Vivian Ho, PhD: Apple Podcasts | Spotify | Other Apps

EP488 with Mark Cuban and Cora Opsahl: Apple Podcasts | Spotify | Other Apps

EP388 with Merrill Goozner: Apple Podcasts | Spotify | Other Apps

EP464 with Al Lewis: Apple Podcasts | Spotify | Other Apps

EP467 with Stacey: Apple Podcasts | Spotify | Other Apps

LinkedIn post by Patrick Moore (link unavailable — original URL lost)

EP481 with Benjamin Schwartz, MD, MBA: Apple Podcasts | Spotify | Other Apps

=== 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

🎤 Listen on Spotify

📺 Subscribe to our YouTube channel

=== CONNECT WITH THE RHV TEAM ===

✭ LinkedIn ✭ Threads ✭ Bluesky ✭ X

00:00 Introduction.

08:32 What should mission be in multispecialty?

08:54 Are mission and margin mutually exclusive?

10:47 What are the four "vectors" of Dan's mission?

11:32 Why does affordability matter?

13:32 Who are the three payers in the marketplace?

19:19 How does access play into mission?

22:56 Why price transparency is important to consumer experience.

High deductible health plans were supposed to give patients skin in the game. What they actually did was create a class of functionally uninsured Americans — because if your deductible is more than you have in your bank account, your insurance is worthless. And then there's the second layer: self-insured employers hired armies of consultants and middlemen to navigate the complexity, which made the complexity worse. In this episode, Stacey Richter speaks with Mark Cuban, founder and CEO of Mark Cuban Cost Plus Drugs, and Cora Opsahl, Health Fund Director of the 32BJ Health Fund, about the two well-intentioned solutions that have arguably made American healthcare worse — and what direct contracting, transparent pricing, and a healthcare CFO can actually do instead.

WHAT YOU'LL LEARN

✅ Why high deductibles function as a payroll deduction for employees and a cash addition for insurance companies — with 40% of Americans holding $400 or less in savings, a $1,500 deductible is functionally equivalent to a $10 million deductible for a large portion of the workforce

✅ Why high deductibles shifted cost onto providers: hospitals now take on deductible financing risk, CFOs report 50% nonpayment rates on patient balances, and the fastest-growing private equity healthcare investment area is revenue cycle management — which Mark Cuban calls proof of system failure

✅ What 32BJ Health Fund did when it removed a hospital from its network that was generating millions in excess charges: members got the biggest raise they had ever received and the fund got a premium holiday — with almost no member complaints because access to high-quality care was preserved

✅ How Mark Cuban's direct contracting model works: cash up front, no employee deductible, no pre-authorization risk, no underpayment risk, no collection risk — and providers are willing to offer their cash price or Medicare reference-based pricing in exchange for all of that

✅ Why Mark Cuban believes every company with 500 or more employees can afford to hire a dedicated healthcare CFO or CEO at around $150,000 and see an immediate return — because most C-suites have no idea how much money they are leaving on the table

✅ Why power in the current system sits with hospital C-suites and large insurance companies, not with patients, employers, or independent providers — and why Cora Opsahl frames the goal as making healthcare prices transparent and simple enough to pay with a chicken

WHY THIS MATTERS

The conversation lands on a point that is both obvious and radical: healthcare on the business side has only three questions — how much does it cost, how do you pay for it, and who takes the risk for nonpayment? The current system has buried all three under layers of administrators, opaque contracts, and misaligned incentives. Direct contracting, transparent pricing, and a serious commitment to managing health benefits as the large spend category they are can answer all three. The rest is theater.

MENTIONED IN THIS EPISODE

EP482 with Preston Alexander: Apple Podcasts | Spotify | Other Apps

EP486 with Stan Schwartz, MD: Apple Podcasts | Spotify | Other Apps

EP425 with Marshall Allen: Apple Podcasts | Spotify | Other Apps

EP436 with Elizabeth Mitchell: Apple Podcasts | Spotify | Other Apps

EP480 with Kimberly Carleson: Apple Podcasts | Spotify | Other Apps

EP372 with Cora Opsahl: Apple Podcasts | Spotify | Other Apps

EP452 with Cora Opsahl: Apple Podcasts | Spotify | Other Apps

EP419 with Andreas Mang: Apple Podcasts | Spotify | Other Apps

EP483 (Part 1) with Jonathan Baran: Apple Podcasts | Spotify | Other Apps

EP483 (Part 2) with Jonathan Baran: Apple Podcasts | Spotify | Other Apps

EP453 with Claire Brockbank: Apple Podcasts | Spotify | Other Apps

EP484 with Dave Chase: Apple Podcasts | Spotify | Other Apps

EP485 with Cristin Dickerson, MD: Apple Podcasts | Spotify | Other Apps

EP487 (Part 1) with Kevin Lyons: Apple Podcasts | Spotify | Other Apps

EP466 with Vivian Ho, PhD: Apple Podcasts | Spotify | Other Apps

=== 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

🎤 Listen on Apple Podcasts

🎤 Listen on Spotify

📺 Subscribe to our YouTube channel

=== CONNECT WITH THE RHV TEAM ===

✭ LinkedIn ✭ Threads ✭ Bluesky ✭ X

00:00 Introduction.

06:25 What was the original rationale behind high deductibles?

07:38 How high deductibles are creating a class of functionally uninsured people.

10:20 "We're using health insurance as a proxy for healthcare." —Mark

12:30 How providers are now in the debt collecting business rather than the healthcare business.

15:16 "We have a fundamental reasonability problem." —Cora

18:25 Direct contracting versus self-funded employers.

23:53 Why the current system doesn't allow the accountability that is needed.

26:34 How direct contracting gives strength back to independent practices that high deductible plans take away.

27:46 Who pays, what's the price, and where does the power lie?

34:45 How it comes down to power and leverage when controlling healthcare costs.

38:35 Why putting together a network and just buying healthcare—not discounts—is not as difficult as it seems.

40:10 Why we need to stop talking about disruption and start talking about change.

47:40 Why it's the incentives that are different between American hospitals and hospitals in a single-payer program.

50:25 The main takeaways from the conversation.

51:08 Why you can't fix the problems in healthcare without transparency.

The New Jersey state employee health plan is projected to cost $3.5 billion in 2026 — with no medical director employed by the state and no unconflicted experts at the negotiating table. Kevin Lyons, a former police detective and executive director of labor employee benefits at the New Jersey State Policemen's Benevolent Association, which represents 33,000 members, is trying to change that. In Part 2 of this two-part episode, he explains how he uses detective training to follow the healthcare dollar. Part 1 covers the three structural barriers driving up public sector healthcare costs: profit defends profit, lack of unconflicted expert representation, and industry influence over the media. This episode is the practical advice half.

WHAT YOU'LL LEARN

✅ Why statement analysis is Kevin Lyons's most useful detective tool in healthcare vendor meetings: bad actors leave holes in their answers, sidestep questions, and retreat to "it's proprietary" — and that retreat is the X marking the spot

✅ How to treat a vendor's refusal to answer as equivalent to pleading the Fifth: if they don't give you the answer, your job is to go find it — the omission tells you where to look

✅ Why preparation is the prerequisite: if you walk into a TPA or vendor presentation without doing your homework, you will follow their path instead of yours, and they are counting on that

✅ Why "disruption" is a shutdown word — Kevin Lyons's counterpart at 32BJ, Claire Brockbank, confirms it is the status quo's go-to move to stop anyone pushing for change — and why learning to recognize it and push through it matters

✅ What the actual scale of the NJ public sector problem looks like: the KFF average family plan cost is $25,000 in member contribution alone, with towns and the state picking up the remaining share — for a total family plan cost Kevin Lyons estimates at $67,000

WHY THIS MATTERS

Kevin Lyons's advice is deceptively simple: be fearless, speak truth to power, follow the money, and never let a good crisis go to waste. The people on the other side of the table have every incentive to keep plan sponsors in the dark and every tool to do it. The only counter is preparation, persistent questioning, and the willingness to treat a non-answer as a confession.

=== 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

🎤 Listen on Spotify

📺 Subscribe to our YouTube channel

=== CONNECT WITH THE RHV TEAM ===

✭ LinkedIn ✭ Threads ✭ Bluesky ✭ X

00:00 Introduction and Episode Overview

00:25 Recap of Part One: Barriers to Reducing Healthcare Costs

03:01 Introducing Kevin Lyons: Detective Skills in Healthcare

03:52 Detective Techniques Applied to Healthcare

06:41 Challenges and Solutions in Healthcare Transparency

12:15 Final Thoughts and Acknowledgements

13:10 Closing Remarks and Podcast Information

The New Jersey PPO family plan cost $67,000 in 2026 — having almost doubled in five years, with a 37% rate increase proposal for that year alone, cumulating to 115% over five years. State workers including teachers, police officers, and public employees are paying roughly $25,000 of that themselves. And the state has no medical director, no unconflicted experts at the table, and a legislature whose campaign contributions run heavily toward the very carriers and hospital systems driving the increases. In this episode, Stacey Richter speaks with Kevin Lyons, a former police detective and executive director of law enforcement labor employee benefits at the New Jersey State Policemen's Benevolent Association (NJ State PBA), which represents 33,000 members, about three structural barriers that keep the public sector from getting better, more affordable healthcare — and why they are so hard to dismantle.

WHAT YOU'LL LEARN

✅ Why profit defends profit in the public sector: healthcare industry campaign contributions to legislators are second only to real estate, those legislators oversee the contracts with those same companies, and the more money those companies make from the status quo, the more they can spend protecting it

✅ Why the NJ state health plan covering roughly 800,000 lives has no medical director and employs no pharmacists — and how this vacuum gets filled by the contracted partners, who then effectively audit themselves and negotiate on behalf of the entity that pays them

✅ How a real-world prior authorization fight over proton vs. photon therapy for a member with brain cancer — where the state sent a pediatrician to argue the commission's position — illustrates what happens when no unconflicted clinical expertise sits on the purchaser's side

✅ Why the lack of willingness to pay for unconflicted talent at the state level is a self-defeating strategy: the right person at $250,000 annually could save ten times their salary — but the system defaults to career bureaucrats supervised by politicians who are not incentivized to know what they don't know

✅ Why media sponsorship by incumbent TPAs and carriers completes the circle: the same entities being investigated sponsor the coverage, and union publications advertising those same TPAs make member education nearly impossible

✅ What Kevin Lyons brings to the negotiating table from detective training — and why Part 2 covers how he uses those skills to follow the healthcare dollar once he identifies where the answers are being hidden

WHY THIS MATTERS

As Kevin Lyons puts it: unions can't tax their members to fund a PAC at the scale carriers and hospitals fund lobbying. The financial asymmetry is foundational to the problem. When the people whose job is to advocate for the plan's members are outgunned financially, politically, and informationally, the flywheel keeps spinning. The barriers are real. The question is whether enough people who understand them will push loud enough and long enough to change it.

MENTIONED IN THIS EPISODE

EP483 (Part 1) with Jonathan Baran: Apple Podcasts | Spotify | Other Apps

EP483 (Part 2) with Jonathan Baran: Apple Podcasts | Spotify | Other Apps

=== 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

🎤 Listen on Spotify

📺 Subscribe to our YouTube channel

=== CONNECT WITH THE RHV TEAM ===

✭ LinkedIn ✭ Threads ✭ Bluesky ✭ X

00:00 Introduction to Episode 487

00:33 Viral Video and Metaphor for Healthcare

04:48 Healthcare Costs and Union Challenges

07:32 Interview with Kevin Lyons Begins

08:17 Why is it important to "dig in" right now on health benefit cost increases?

08:39 Barriers to Affordable Healthcare

10:16 The first barrier to better health benefits: profit defending profit.

10:54 Profit Defense and Political Influence

16:38 Why "throw money at the problem" isn't a real solution.

18:31 The second barrier: why a lack of employed experts costs more money.

18:59 Government Inefficiencies and Conflicts of Interest

25:58 The third barrier: media sponsorship from incumbents prevents change.

26:19 Media Influence and Public Perception

30:23 Conclusion and Teaser for Part Two

A 23-year-old roofing laborer paid $125 for a comprehensive metabolic panel — a test available directly for $6.52. That is not a healthcare problem. That is a pricing failure. And it is the origin story of ZERO.health, a direct contracting platform that gets plan members access to high-quality providers for $0 out of pocket using bundled payments. In this episode, Stacey Richter speaks with Dr. Stan Schwartz, MD, co-founder of ZERO.health, who has been building and operationalizing direct contracting arrangements since 2014, about how bundled payments actually work in practice — what providers get, what employers get, what members get, and specifically how to solve the logistics problems that have sunk other direct contracting attempts.

WHAT YOU'LL LEARN

✅ How ZERO's bundled payment model works: a five-star Medicare hospital in Tulsa performs outpatient gallbladder surgery for $5,641 all-in — covering anesthesia, surgeon, hospital, and recovery room — compared to roughly $8,000–$10,000 through a typical claims process, with the employer covering 100% so the member pays zero

✅ Why Dr. Schwartz's mantra is "if you can schedule it, you can put a price on it" — and how this applies not just to major surgeries but to lab tests, imaging, and routine services where spread pricing adds unnecessary cost on top of already inflated prices

✅ Why the utilization concern is asking the wrong question: good evidence shows that prior authorization impedes necessary care more often than unnecessary care — and the greater financial risk for most plans is members not getting care they need, not members overconsumption

✅ How ZERO solves the double-billing and administrative chaos problem: everything is pre-arranged through personal health assistants, providers send a simple invoice or claim directly to ZERO, the member pays nothing at point of service, and double billing is easy to catch because members know they should owe zero

✅ Why Surgery Center of Oklahoma, one of ZERO's earliest providers, runs at a 10-to-1 clinical-to-administrative staff ratio versus the industry average of 2-to-1 — because bundled, direct-paid care eliminates collections, accounts receivable, and coding complexity

✅ How ZERO tracks utilization and improves it over time: in year one, roughly 30% of ZERO-eligible services actually go through the ZERO program; by years two and three, the best-performing companies reach 70% — and the gap is monitored through ongoing claims review and targeted member outreach

WHY THIS MATTERS

So much of what we call healthcare expense is pricing failure — something that should cost $7 is billed at $100, spread through an insurance mechanism, and processed with administrative overhead that can reach 30% of total plan spend. Direct contracting with bundled payments is not a new idea, but operationalizing it — training providers, educating members off open enrollment cycle, tracking missed opportunities in real time — is where most attempts fall apart. Dr. Schwartz has been doing this for over a decade. This episode is the how.

MENTIONED IN THIS EPISODE

EP480 with Kimberly Carleson: Apple Podcasts | Spotify | Other Apps

EP420 with Ge Bai, PhD, CPA: Apple Podcasts | Spotify | Other Apps

EP436 with Elizabeth Mitchell: Apple Podcasts | Spotify | Other Apps

EP475 with Peter Hayes: Apple Podcasts | Spotify | Other Apps

EP477 (Through Line Show) with Stacey: Apple Podcasts | Spotify | Other Apps

=== 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

🎤 Listen on Spotify

📺 Subscribe to our YouTube channel

=== CONNECT WITH THE RHV TEAM ===

✭ LinkedIn ✭ Threads ✭ Bluesky ✭ X

00:00 Introduction.

07:59 How did ZERO.health start?

11:04 Why does the emotional energy behind understanding how the problem of healthcare affects individuals matter in changing healthcare?

12:45 "If you can schedule it, you can put a price on it."

18:21 How do employers ensure that patients and clinicians are coordinated and on board with direct contracting within their health plans?

22:52 Why is it important that this direct contracting system isn't mandatory for health plan members?

24:50 How does direct contracting affect excessive utilization?

27:29 Why is it important that your plan benefits benefit health?

29:39 Why is it important to educate not only members but also providers who agree to participate in the program?

31:06 "It's all about simplicity."

33:11 How do you ensure plan members use the service after it is installed?

Imaging costs 6 to 11% of total plan sponsor spend — and that figure requires aggregating CPT codes, contrast charges, professional services, and facility fees, many of which are split across different code categories in ways that make the true total hard to see. The same MRI that costs $5,000 at a hospital system might cost $300 to $500 at a freestanding imaging center of equivalent quality. And prior authorization for imaging, per a study by the American College of Radiology, does not reduce the number of scans performed — it only delays care. In this episode, Stacey Richter speaks with Dr. Cristin Dickerson, MD, founding partner of Green Imaging, an $18 million physician-led radiology network, about why direct contracting for imaging is one of the highest-leverage moves a plan sponsor can make — and how to actually do it, including when to go around the TPA entirely.

WHAT YOU'LL LEARN

✅ How hospital revenue codes allow imaging claims to bypass standard CPT-based claims adjudication — the Osceola County school district case found one CT scan billed at over $50,000 using hospital revenue codes rather than CPT codes, escaping standard review entirely

✅ Why 62% of Texans are delaying or forgoing care because they can't afford it — and how direct contracting with zero member cost-sharing can solve an access problem while the employer still saves money, as the City of Plano health plan discovered

✅ Why prior authorization for imaging delays care without reducing utilization, per the American College of Radiology — and how radiologist-specific protocols (such as clarifying whether contrast is truly needed, which eliminates unnecessary contrast in roughly 30% of chest CT orders) do more to control appropriate use than prior auth

✅ Why TPAs often cannot or will not facilitate direct imaging contracts — because of carrier contract clauses, competing internal vendors, or referral fee arrangements — and how approximately 80% of Green Imaging's larger employer clients simply go around the TPA and contract directly

✅ How employers can execute a direct imaging contract without TPA involvement: under HIPAA's omnibus rule, employers can withhold PHI from carrier network partners and pay cash, Green Imaging sends a single invoice with all data needed for stop-loss compliance, and there is no repricing or prior auth complexity

✅ Why the "down the hall" referral habit is weakening as patient bills get larger — doctors often cannot estimate what imaging costs at their affiliated hospital, and patients are increasingly aware of the risk of an unexpectedly large bill

WHY THIS MATTERS

When a plan sponsor pays for imaging through a traditional claims process, they are paying whatever the system decides — which can include misapplied codes, facility fees, contrast charges in separate buckets, and RBP fees that sometimes exceed what the provider actually received. Direct contracting strips all of that away. The price is set in advance, the member pays nothing, the provider gets paid quickly without collections overhead, and the employer saves money. The model works. The barriers are real but navigable.

=== 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

🎤 Listen on Spotify

📺 Subscribe to our YouTube channel

=== CONNECT WITH THE RHV TEAM ===

✭ LinkedIn ✭ Threads ✭ Bluesky ✭ X

00:00 Introduction and Episode Overview

00:31 The Case for Direct Contracting in Imaging

01:43 Real-World Examples and Challenges

04:47 The Importance of Data and Transparency

08:49 Interview with Dr. Kristen Dickerson

12:39 Barriers to Direct Contracting

24:05 Overcoming Barriers and Final Thoughts

33:22 Conclusion and Contact Information

PBGH member employers collectively spend over $350 billion a year on healthcare. And per Elizabeth Mitchell, 30% of that spend disappears in the middle — not reaching providers, not improving health — just gone into administrative spread, misaligned fee structures, and the cost of a system that was never designed to pass money through efficiently. That number is not speculation. It is what she observes across her member organizations. In this Take Two episode, Stacey Richter revisits a conversation with Elizabeth Mitchell, President and CEO of the Purchaser Business Group on Health (PBGH), about why health plan and TPA inertia is arguably a bigger problem than employer inertia — and what employers who are done waiting are actually doing about it.

WHAT YOU'LL LEARN

✅ Why a TPA's job should be exactly three things — pay claims, provide transparent data, negotiate contracts — and how the moment health plans start layering in care management services and carve-outs, they retain more of the money and make it harder for employers to work directly with the providers they want

✅ How one employer discovered they were paying five times the hospital's published price for a service, sought a refund directly from the hospital, and had their own health plan try to block the transaction — because the health plan's network rate was higher than the direct price

✅ What happens when employers direct contract without a TPA in the middle: in every case PBGH has tracked, employers see a 10 to 30% reduction in total cost of care, better access, better patient experience, and better outcomes

✅ How the Consolidated Appropriations Act (CAA) changed employer accountability: employers can no longer say "my consultant recommended it" — they are held to an expert standard, they are entitled to their data, and the liability is personal and organizational

✅ Why a 4.7% price markup appears when hospitals are in a TPA's Medicare Advantage network — TPAs negotiate commercial clients to pay higher rates so their MA members pay lower rates, which is not in the interest of commercial plan participants

✅ What PBGH did when three jumbo employers issued a direct RFP for high-quality whole-person primary care: providers literally asked "what do you mean, there's no health plan?" — and then the RFP was wildly successful, because providers and employers want the same things

WHY THIS MATTERS

As Elizabeth Mitchell puts it, having a health plan in the middle between an employer and a provider is like being at the UN with a bad translator. The plot gets lost. The money gets lost. And for decades, employers had no way to verify what was actually happening because they couldn't get the data. That is now changing. The employers who are using it are seeing results. The question is whether enough of them move fast enough to create a market that makes inertia an unviable strategy.

MENTIONED IN THIS EPISODE

EP408 with Chris Deacon: Apple Podcasts | Spotify | Other Apps

EP427 with Rik Renard: Apple Podcasts | Spotify | Other Apps

=== 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

🎤 Listen on Spotify

📺 Subscribe to our YouTube channel

=== CONNECT WITH THE RHV TEAM ===

✭ LinkedIn ✭ Threads ✭ Bluesky ✭ X

00:00 Introduction.

08:06 What is the overarching context for health plans in healthcare purchasing?

11:31 Why is it important to reestablish a connection between the people paying for care and people providing care?

13:47 What are the needs of a self-insured employer when managing employee benefits?

19:00 Is it doable for employers to set their own contracts?

21:24 Is transparency presumed?

22:39 Will the new transparency upon us actually expose wasted expense?

25:58 "This is not about individual bad actors. … The systems … that is not aligned."

27:39 Are there providers who want to work directly with employers?

30:53 Why is it important that incentives need to be aligned?

33:51 What's missing from the conversation on changing health plans?

Across the country, self-insured employer teams are waking up to the fact that "I trusted my consultant" is not a legal defense. Not under ERISA. Not under the Consolidated Appropriations Act. And the lawsuits — J&J, Wells Fargo, Tiara Yachts versus Blue Cross Blue Shield of Michigan, Osceola County — are making it impossible to ignore. In this episode, Stacey Richter asks Dave Chase, co-founder and CEO of Health Rosetta, to answer the three most burning questions plan sponsors are asking right now: how to verify a benefits advisor actually works for you, how to avoid personal liability when TPA contracts have hidden conflicts, and how to tell if pharmacy costs are being systematically inflated despite PBM guarantees.

WHAT YOU'LL LEARN

✅ The four canaries in the coal mine of trust for any benefits advisor: comprehensive compensation disclosure with no excuses, full data and reporting access, real experience with high-performance health plan components, and a meaningful share of their book of business with independent plan administrators

✅ Why unfettered access to claims data is the single most predictive factor of a high-performance health plan — confirmed by a Tufts University study of 2,000 to 3,000 Health Rosetta plan grade reports — and why being blocked from that data is a near-certain sign you are being overcharged

✅ How spread pricing works on the medical side: the Tiara Yachts lawsuit documents Blue Card claims being repriced out-of-network to inflate so-called savings, with the carrier collecting fees larger than what was actually paid to the provider

✅ Why pharmacy guarantees can hide systematic overcharges: PBMs have created approximately 50 different revenue streams, rebate guarantees often retain manufacturer revenue, and without net cost disclosure after all fees, the numbers that appear favorable on paper conceal the actual extraction happening in the background

✅ What the Ann Lewandowski whistleblower case revealed: one EBC's TPA arm took $20 million in client pharmacy rebates and funneled them into their executive bonus pool — not a single client discovered this without the whistleblower

✅ What Health Rosetta and Nautilus Health Institute have open-sourced for free: an advisor RFP template, a TPA contract template, a data platform, and a PBM Field Guide — tools that represent approximately $4 million in direct investment, available at nautilushealth.org

WHY THIS MATTERS

The retirement industry went through this same reckoning 15 to 20 years ago. The status quo players disappeared and a completely different set of market leaders emerged. Dave Chase argues the same thing is happening now in employer-sponsored health benefits — and the employers who act on these three questions before the lawsuits find them are the ones who will come out ahead, with better health outcomes for their members and meaningfully lower costs.

MENTIONED IN THIS EPISODE

EP478 with Andreas Mang and Jon Camire: Apple Podcasts | Spotify | Other Apps

EP453 with Claire Brockbank: Apple Podcasts | Spotify | Other Apps

EP433 with Justin Leader: Apple Podcasts | Spotify | Other Apps

EP436 with Elizabeth Mitchell: Apple Podcasts | Spotify | Other Apps

EP483 (Part 1) with Jonathan Baran: Apple Podcasts | Spotify | Other Apps

EP457 with Cynthia Fisher: Apple Podcasts | Spotify | Other Apps

Summer Short with Elizabeth Mitchell: Apple Podcasts | Spotify | Other Apps

EP365 with Scott Haas: Apple Podcasts | Spotify | Other Apps

EP397 with Paul Holmes: Apple Podcasts | Spotify | Other Apps

EP465 with Chris Crawford: Apple Podcasts | Spotify | Other Apps

EP429 with Luke Slindee, PharmD: Apple Podcasts | Spotify | Other Apps

EP476 with Ann Lewandowski: Apple Podcasts | Spotify | Other Apps

=== 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

🎤 Listen on Spotify

📺 Subscribe to our YouTube channel

=== CONNECT WITH THE RHV TEAM ===

✭ LinkedIn ✭ Threads ✭ Bluesky ✭ X

00:00 Introduction.

06:36 What questions does a plan sponsor need to ask their consultant, EBC, or broker to ensure they are protecting the interest of the plan sponsor?

11:03 How can plan sponsors avoid personal liability when their TPA has hidden conflicts of interest?

11:40 Tiara Yachts v. Blue Cross Blue Shield of Michigan lawsuit.

16:18 The Marshall-Hickenlooper bill called the Price Tags Act.

17:36 How do plan sponsors figure out if they are being overcharged for pharmacy benefits?

28:38 Where to find open-source resources to help guide plan sponsors with making better health plan decisions.

29:47 How the open-source trend is growing for health transparency.

30:48 What to look forward to at RosettaFest.