Relentless Health Value

The negative healthcare flywheel spins on one axle: employers buying discounts. Discounts create no incentive for health systems to control prices, no incentive to invest in primary care, and no way to know what anything actually costs. The flywheel just keeps spinning. In Part 2 of this conversation, Jonathan Baran turns it around — and the fix starts with employers refusing to buy discounts at all. In this Part 2 episode, Stacey Richter speaks with Jonathan Baran, co-founder and CEO of Self Fund Health, a Wisconsin-based health plan designed around the premise that employers should be buying healthcare, not insurance products built around discount arithmetic.

WHAT YOU'LL LEARN

✅ Why stopping the purchase of discounts is Step 1 — and not a theoretical idea: if employers demanded unit cost transparency instead of discount reports, the entire incentive structure downstream would begin to shift

✅ Why the most expensive thing in healthcare is the pen of the primary care doctor — and why independent, unconflicted direct primary care is the essential first move in any flywheel reversal, because trying to redirect a patient after they've already scheduled expensive care is too late

✅ How benefit design has to be realigned with actual unit costs — not in-network status — so that members have a financial reason to choose a $500 MRI over a $5,000 one, and why without this realignment, navigation alone cannot close the gap

✅ Why the broker's role needs to fundamentally shift from presenting health plan options to driving health outcomes — sitting with high-cost members, running education meetings on DPC and imaging access, and owning the results of the plan design choices they recommend

✅ How self-funded employers paying at time of service can eliminate prior authorization backlogs, denial follow-up, and 30-to-90-day accounts receivable from hospitals' cost structures — and what that kind of administrative simplification does to the unit cost of care

✅ Why EHR interoperability is not a technical problem — it is an incentive problem, and flipping the incentives would allow technology that already exists to start doing what patients, employers, and providers actually need it to do

WHY THIS MATTERS

Jonathan Baran's conclusion is worth sitting with: if the status quo guarantees higher costs and less control, it is not the safer option. Every employer that continues to buy discounts is spinning the flywheel one more turn. The reverse flywheel — better member health at the center, direct primary care, aligned benefit design, honest brokers, direct-contracting hospitals — is not theoretical. Purdue University and others in the Midwest are doing it. The question is whether enough employers decide to act before the next renewal shock.

MENTIONED IN THIS EPISODE

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

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

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

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

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

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

EP468 with Matt McQuide: Apple Podcasts | Spotify | Other Apps

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

LinkedIn post by Ramy Khalil, MD (link unavailable — original URL lost)

=== 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

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=== CONNECT WITH THE RHV TEAM ===

✭ LinkedIn ✭ Threads ✭ Bluesky ✭ X

00:00 Introduction.

05:23 Where to start in reversing the flywheel.

06:57 Why investing in primary care is pivotal to containing healthcare costs.

12:14 "The most expensive thing in healthcare is the pen of the primary care doctor."

13:04 How the role of the broker has to fundamentally change.

16:16 What will the single most challenging aspect of this restructuring become?

20:20 How self-funded employers can be amazing customers in containing the rising cost flywheel in healthcare.

22:56 How do EHRs and other medical record systems play into reversing the flywheel of rising healthcare costs?

24:59 Why is it important for employers to drive volume differently?

25:38 How Self Fund Health is helping in this regard.

A 9% healthcare renewal is celebrated as a good year. But 9% is three times the rate of inflation, and it's not going to doctors or nurses — physician compensation has been flat or declining, and nursing strikes are evidence enough of what's happening there. So where does the money go? Jonathan Baran has a very clear answer: it goes to the flywheel. And the flywheel starts with discounts. In this episode, Stacey Richter speaks with Jonathan Baran, co-founder and CEO of Self Fund Health, a Wisconsin-based health plan, about the cascade of perverse incentives that turns renewal season into an annual cost spiral — and how each stakeholder in the chain, from carrier to broker to employer to hospital to EHR vendor, is playing their role exactly as their incentive structure demands.

WHAT YOU'LL LEARN

✅ Why carriers benefit from rising premiums and have no structural incentive to control underlying healthcare costs — they earn a percentage of premiums and make money on float, so a higher premium base means higher revenue regardless of how efficiently care is delivered

✅ How the discount framework was engineered to create the illusion of cost control: an MRI with a list price of $10,000 discounted 46% looks like a win — until you realize the actual market rate is $500 to $600, and both carriers are selling the same fiction in different percentages

✅ Why buying insurance is fundamentally different from buying healthcare — and why employers who switch to self-funding without changing what they are actually purchasing will see the same costs under a different administrative structure

✅ How hospital systems use primary care acquisition not to invest in prevention but to control the referral funnel to profitable downstream services — and why after consolidation, the incentive flips to degrading primary care while maximizing high-margin procedures

✅ Why panel sizes of 2,000 to 5,000 patients and seven-minute average appointments are not accidents — they are the predictable outcome of an incentive structure that rewards throughput and downstream referrals, not prevention or chronic disease management

✅ How EHR systems function as digital moats for hospital revenue: data interoperability is a solved technical problem, but data leakage is patient leakage, and EHR vendors build for the executives who pay them, not for patients or clinicians

WHY THIS MATTERS

Follow the incentives and the behavior follows. Every stakeholder in this flywheel — carrier, broker, employer, hospital system, EHR vendor — is doing exactly what their incentive structure demands. That is why the flywheel keeps spinning despite decades of attempts to slow it. Part 2 of this conversation (EP483 Part 2) covers how to reverse it.

MENTIONED IN THIS EPISODE

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

LinkedIn post by Rina Tikia on self-funded plans (link unavailable — original URL lost)

=== 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.

08:46 Entering the health system "flywheel" at the renewal phase.

09:46 What goes on in the renewal season that contributes to the health system "flywheel"?

12:28 Why is the standard 9% increase in healthcare costs during renewal season actually problematic?

13:22 How does the purchase of discounts contribute to the skyrocketing cost of healthcare and distract from discussing the actually underlying cost of healthcare?

17:01 Why do employers need to learn to buy healthcare and not insurance?

23:18 Why are hospital executives incentivized to buy and own all of the primary care in a market?

26:35 How big electronic medical record systems play into this increase in healthcare costs.

28:27 Acquired podcast on one EHR system.

31:09 What needs to happen to reverse this flywheel of increasing healthcare costs?

When Stacey Richter and Jonathan Baran dig into the incentive structures driving healthcare costs, there is an important caveat: the individuals working inside large health systems, carriers, and benefit consulting firms are not the same as the organizations they work for. A C-suite decision to pursue margin at the expense of mission is not a democratic vote. Most people working inside these organizations don't fully know what's going on — and some are working against it every day. This short bonus clip, released alongside EP483 Part 1, is a plea on behalf of those people. Jonathan Baran, co-founder and CEO of Self Fund Health, makes the case that attacking stakeholders rather than incentive structures is both unfair and counterproductive — because we need the people inside these organizations to be part of the solution.

WHAT YOU'LL LEARN

✅ Why Jonathan Baran's goal is to name behaviors and incentives rather than attack individuals — because understanding why a stakeholder behaves a certain way is the prerequisite to changing anything about how the system works

✅ Why the majority of people inside large healthcare organizations do not actually understand the full impact of what their organization is doing — and why healthcare reform depends on more of them figuring it out

✅ Why identifying completely with the stakeholder you work for is an obstacle to improvement: if every critique of an organization's incentive structure is taken as a personal attack, the conversation about root causes can't happen

✅ Why the RHV tribe — the people inside these organizations who are trying against personal and professional odds to do better for patients — are the knights in this story, and why they deserve to be honored rather than lumped in with the organizations whose leadership may be making different choices

WHY THIS MATTERS

This clip pairs with EP483 Part 1 on the healthcare flywheel. The flywheel analysis names what the incentive structures are doing. This clip names what they are not doing: determining the intentions of every individual inside those organizations. Charlie Munger's quote cuts both ways. Show me the incentives, and you can explain the behavior. But the behavior of an organization is not the same as the values of every person in it.

MENTIONED IN THIS EPISODE

EP483 (Part 1) 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

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=== CONNECT WITH THE RHV TEAM ===

✭ LinkedIn ✭ Threads ✭ Bluesky ✭ X

00:00 Introduction.

03:11 A brief background on Jonathan and Self Fund Health.

04:24 Why is it imperative that individuals stop identifying wholly with the organization that they work with?

05:48 Why is it important to be direct and call out the behavior without calling out the individual?

Northeast Oklahoma beat out Colorado, Oregon, and New York to win a landmark federal competition for the Comprehensive Primary Care Initiative. The program worked — emergency room visits dropped, hospitalizations declined, patients loved it, doctors loved it, and primary care physicians earned tens of thousands in quality bonuses. Then a health system executive whispered a question that ended it: why would we want to keep people out of the emergency room? In this Summer Short, Stacey Richter speaks with Dr. Stan Schwartz, MD, co-founder of ZERO.health, about what happened to that CMMI program — and what it taught him about where change in American healthcare can and cannot originate.

WHAT YOU'LL LEARN

✅ How the Comprehensive Primary Care Initiative in northeast Oklahoma succeeded on every metric it set out to achieve — including reduced ER visits, reduced hospitalizations, integrated behavioral health, care guidance nurses, and risk stratification — and why it was shut down anyway

✅ Why the health system CEO's question — why would we want to keep people out of the emergency room when a third of hospital admissions come through it? — is not a villainous moment but a structurally rational one, and why that is the actual problem

✅ Why advanced primary care that keeps patients out of hospitals is a fundamentally different leg than the fee-for-service body it is attached to — and why that mismatch is not sustainable regardless of how well the program performs clinically

✅ Why commercially insured patients are the most financially attractive patients for providers — and why self-insured employers, who cover more Americans than any other single payer category, have more leverage than most of them realize

✅ Why Dr. Schwartz argues the change agent for American healthcare has to be the employer, not the health plan or health system — because employers are nimble, their members are desirable to providers, and collective action among employers creates market pressure that clinical organizations cannot ignore

WHY THIS MATTERS

The CMMI Comprehensive Primary Care Initiative story is a close cousin to the Dr. Scott Conard story from EP391 — another advanced primary care program that succeeded clinically and was shut down because success meant fewer profitable admissions. Both stories make the same point: you cannot fix healthcare with mission-driven programs that are inserted into a fee-for-service universe that is incentivized in the opposite direction. The fix has to start with who pays, not who provides.

MENTIONED IN THIS EPISODE

EP391 with Scott Conard, MD: Apple Podcasts | Spotify | Other Apps

EP438 with John Lee, MD: Apple Podcasts | Spotify | Other Apps

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

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

EP452 with Cora Opsahl: 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.

08:11 What was Dr. Schwartz's "Pelican Brief" moment?

09:09 How Dr. Schwartz's advanced primary care structure and health information exchange beat out competing states for CMMI funding.

12:53 What did "good" look like with this advanced primary care program?

16:57 What got Dr. Schwartz interested in employer-sponsored healthcare?

One carrier reported $4.8 billion in investment income in 2024. In 2025, United Healthcare recorded $151 billion in intercompany eliminations — payments from the insurance arm to subsidiaries it also owns. And as fee-for-service Medicare prices rise, Medicare Advantage capitation rates follow, creating a flywheel that rewards vertically integrated carriers for allowing underlying costs to climb. None of this is in the underwriting profit column. That's the point. In this episode, Stacey Richter speaks with Preston Alexander, who writes The Healthcare Breakdown at thehealthcarebreakdown.com, about three financial mechanisms that most plan sponsors and policymakers don't see — and why understanding them matters for anyone trying to understand why healthcare costs keep rising.

WHAT YOU'LL LEARN

✅ How float works: carriers collect premiums and record the amounts owed to providers as liabilities — but they hold the cash, and the longer they delay paying it out via denials, requests for more information, and timely-filing rules, the longer that money can be invested or used for acquisitions; at current interest rates, this is not a rounding error

✅ How intercompany eliminations work: when a carrier owns a medical practice, a PBM, or a pharmacy, it can pay that subsidiary above fair market value, inflating the medical loss ratio on the insurance side while capturing the excess on the care delivery side — shifting profit from the regulated insurance column to the unregulated healthcare column

✅ Why the $151 billion in United Healthcare intercompany eliminations in 2025 represents a structural conflict of interest for self-insured employers using that carrier as an ASO: the entity managing your plan dollars is simultaneously sitting on the other side of the provider negotiation, paying itself

✅ How Medicare Advantage upcoding and risk-score inflation generate above-cost capitation payments — and why those payments arrive upfront, creating the same float dynamic as commercial premiums, with the added incentive to delay care through the quarter

✅ Why large carriers are not structurally incentivized to reduce healthcare costs: higher underlying costs mean higher premiums, a larger float, more investment income, and higher capitation payments — every mechanism works better when costs are high

✅ What Preston Alexander's actual advice is for plan sponsors who now know all of this: find an unconflicted expert who builds health plans for employers, ask them pointed questions about what they have built and what it saved, and bring data — because anyone who cannot or will not produce data to support their claims is telling you something important

WHY THIS MATTERS

Preston Alexander closes with a line worth sitting with: our economy is not going to survive healthcare. The three mechanisms in this episode are not obscure accounting tricks — they are the structural financial incentives that explain why costs keep rising, why denials keep climbing, and why vertically integrated carriers grow larger every year. Understanding them is the first step toward being a more sophisticated buyer.

MENTIONED IN THIS EPISODE

Summer Shorts on pharma rebates, with Ann Lewandowski (episode removed from Libsyn feed — link unavailable)

EP478 (Part 1) with Andreas Mang and Jon Camire: 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.

08:29 What is float, and why is it a surprising way that carriers make money?

14:41 Why carriers really do denials and delays of payouts.

17:34 What are intercompany eliminations, and how do they make carriers more money?

22:21 How do carrier-owned pharmacies play into this?

23:19 How are carriers creating profit off of Medicare Advantage and Medicaid Advantage markets?

27:18 How the fee-for-service price increases affect Medicare prices.

28:12 Why aren't large insurance carriers motivated to make costs go down?

32:42 What is a potential way forward to fix the rising cost of healthcare?

33:36 As a plan sponsor, how do you address carriers making profit on your float?

36:34 "Our economy's not gonna survive healthcare."

Here is the central paradox of primary care: if you do it really well — evidence-based prevention, early intervention, curbing specialty volume — you cannibalize the very revenue stream that most consolidated health systems use to subsidize primary care in the first place. So why would a consolidated entity empower primary care to undermine its own major source of revenue? Stacey Richter calls this the Paradox of Primary Care, and she asks Dr. Tom X. Lee exactly what it takes to escape it. In this Take Two episode, Stacey revisits her conversation with Tom X. Lee, MD, founder of One Medical and Galileo (and co-founder of Epocrates), about how an independent primary care practice can survive — and even thrive — in the current healthcare economy without falling into that paradox or losing its mission to investor pressure.

WHAT YOU'LL LEARN

✅ Why Stacey calls it the Paradox of Primary Care — how doing primary care well reduces specialty revenue, creating a structural incentive for consolidated health systems to underfund the very practices they acquire

✅ Why CMS and commercial carriers continue to underpay independent primary care practices even while publicly championing their importance — and why that is, as Stacey puts it, "not tricky math"

✅ What Dr. Lee means by "enlightened leadership with a value mindset" — and why value is more about a mindset than a payment architecture, applicable even in a largely fee-for-service world

✅ Where the hidden waste in primary care actually lives — from 90-click EHR workflows to underutilized clinical talent doing work that a nurse navigator or technology could handle

✅ How to find the "productive middle" between human-centered care and operational efficiency — and why the best service organizations succeed by balancing those forces rather than choosing between them

✅ The mission vs. margin trade-off when professional capital (private equity, VCs, health system venture funds) enters the picture — and what degrees of freedom you give up when you take outside money to scale

WHY THIS MATTERS

Most primary care practices that have remained independent did so against the tide — and many eventually couldn't. CMS continues to follow RUC guidance on PCP rates while consolidated systems use specialty revenue to subsidize primary care on their own terms. The result is a shrinking pool of indie practices and a reinforcing cycle where the entities best positioned to deliver on primary care's promise are the ones being squeezed out. Dr. Lee's argument is that the paradox is not inevitable — but escaping it requires leadership that genuinely gives a damn, a value-focused mindset that doesn't depend on having the right contracts, and serious service operations discipline.

MENTIONED IN THIS EPISODE

EP438 with John Lee, 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

🎤 Listen on Apple Podcasts

🎤 Listen on Spotify

📺 Subscribe to our YouTube channel

=== CONNECT WITH THE RHV TEAM ===

✭ LinkedIn ✭ Threads ✭ Bluesky ✭ X

00:00 Introduction.

10:30 What is the paradox of primary care?

12:47 Why is it hard to run an independent primary care practice?

13:29 What are the barriers to running an independent primary care practice?

14:09 Can you have fee for service and value?

15:53 "Value is more about a mindset."

16:49 What hidden waste is there in a primary care practice?

18:36 What do you need to have a value-focused mindset?

20:41 Why does access precede quality?

22:40 What are the nuances of a service business that make them challenging for managers?

23:27 How do you find the balance between fee for service and value?

31:04 How can you invest in quality without a value-based contract?

33:09 How do you address the trade-off between fee-for-service finances and investing in value-based care?

34:26 Where is the "productive middle"?

35:18 Dr. Tom Lee's message to payers.

38:45 Dr. Tom Lee's message for policymakers.

Retail clinics have been a concept for 20-plus years — and by Dr. Tom X. Lee's assessment, they've largely failed to become what they promised. They're convenient vaccine shops and minor urgent care stops, but very few have become true longitudinal primary care destinations. In this bonus clip, Stacey Richter shares a sidebar conversation with Dr. Tom X. Lee, MD, founder of One Medical and Galileo — pulled from a longer conversation recorded the previous summer — that she describes as all the more relevant given recent RHV conversations about trust, mission, and margin. The discussion zeroes in on why access alone isn't enough, and what it actually takes to deliver on the promise of primary care.

WHAT YOU'LL LEARN

✅ Why retail clinics have succeeded as transactional urgent care and vaccine sites but have not delivered longitudinal primary care despite 20-plus years of trying

✅ How access and longitudinal care are fundamentally different things — and why confusing the two has led major retail players astray

✅ Why running a primary care service operation is not a second job: the underestimated operational complexity of delivering care as a core business

✅ How low reimbursement and high complexity overhead have diminished most primary care practices' ability to deliver on their original promise

✅ Why open access is an operational discipline — not a dollar problem — and why so few organizations actually execute it

WHY THIS MATTERS

Primary care's value proposition has always been delivering better outcomes at lower cost — but that only works if primary care is functioning as a true longitudinal relationship, not a transactional encounter. When retail giants like Walmart evaluated clinic square footage against tire sales, it revealed just how far most organizations were from treating care delivery as a core service operation. Dr. Lee's framing is a useful lens for anyone designing or funding primary care models: what is your definition of primary care, and are you actually delivering on it?

=== 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.

01:01 Why have retail clinics failed in being longitudinal primary care destinations?

01:32 Why access is an important factor, but not the only one.

02:10 Access vs. longitudinal care.

02:47 The challenges of operating a service operation within primary care.

03:47 What is a longitudinal primary care destination and why does it matter?

04:15 How is primary care not delivering on its promise?

04:27 How is the "promise of primary care" different than an urgent care or MinuteClinic?

"No margin, no mission" was coined by Sister Irene Kraus, a nun who ran a health system — and the spirit of the phrase is simple: if you can't sustain a viable business, you can't take care of patients. But somewhere along the way, as Stacey Richter puts it, enough people in healthcare seem to have adopted Jeff Bezos's inversion — "your margin is my mission" — and the phrase has become a rhetorical tool to legitimize something closer to profit extraction. In this episode, Stacey Richter speaks with Benjamin Schwartz, MD, MBA, SVP of Care Services and Strategy at Commons Clinic and a returning guest, about how to operationalize the balance between mission and margin in a $5 trillion industry riddled with perverse incentives, misaligned fiduciary responsibilities, and the ever-present temptation to drift.

WHAT YOU'LL LEARN

✅ Why Dr. Schwartz reframes the debate as profit vs. profiteering — and why that distinction is more useful than margin vs. mission when evaluating whether a healthcare organization is extracting value or creating it

✅ How mission drift happens gradually — illustrated by the example of virtual mental health companies that started with an access mission and ended up operating closer to pill mills because prescribing medications improved margin

✅ Why hospital consolidation is a case study in the slippery slope: organizations that consolidated in the name of integrated, cost-effective care wound up leveraging market power to raise prices instead

✅ Why value-based care has struggled to stick — including the measurement industrial complex, Goodhart's law, and the way outcome metrics systematically advantage well-resourced health systems over safety-net providers

✅ What dyad leadership actually requires — and why a clinical figurehead trotted out to wave at stakeholders is not a true dyad

✅ Why, at the end of the conversation, both Stacey and Dr. Schwartz land on trust as the variable that matters most: you cannot contract or measure your way into forcing someone who isn't inclined to do the right thing to do the right thing

WHY THIS MATTERS

Almost no entity in healthcare — not TPA or ASO leaders, not PBMs, not the boards of nonprofit health systems — has a legal fiduciary responsibility to patients or the communities they serve. In the absence of structural accountability, the balance between mission and margin comes down to the individuals making decisions. That's a precarious place to rest something as consequential as the health of a population. This episode is the second in Stacey's series on operationalizing mission — and it raises more hard questions than it answers, which is probably exactly right.

MENTIONED IN THIS EPISODE

EP400: Apple Podcasts | Spotify | Other Apps

EP474 with Yashaswini Singh, PhD: Apple Podcasts | Spotify | Other Apps

EP455 with Beau Raymond, MD: Apple Podcasts | Spotify | Other Apps

EP326 with Rishi Wadhera, MD, MPP: Apple Podcasts | Spotify | Other Apps

EP391 with Scott Conard, MD: Apple Podcasts | Spotify | Other Apps

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

EP475 with Peter Hayes: 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.

08:50 Sister Irene Kraus and the origin of no margin, no mission.

10:01 Margin and mission versus profit and profiteering.

13:01 What is the broad mission within healthcare?

14:12 What is mission drift within healthcare?

17:26 Why do we struggle with balancing margin and mission?

20:52 How does value vary?

23:53 What needs to happen to balance margin with mission?

28:29 Why does everything come down to trust?

32:21 What are the "vectors of change" to create balance between mission and margin?

A third of healthcare waste is someone else's profit. That profit buys a lot of influence — and it's one reason why doing the right thing for patients can get your face smashed against the wall inside a large healthcare organization. That's the real world Dr. John Lee is talking about in this episode, and his question is the one most mission-driven clinicians and operators eventually ask: now what? In this Take Two episode, Stacey Richter revisits her conversation with John Lee, MD — emergency physician, informaticist, and Chief Medical Information Officer — about how to maintain a sense of mission and avoid demoralization when you're working inside a system whose incentives are stacked against the very outcomes you're trying to achieve.

WHAT YOU'LL LEARN

✅ What cognitive dissonance looks like inside healthcare organizations — including the real-world example of a heart failure program that was shut down because it was too successful at reducing hospital admissions

✅ Why the system hasn't gamed most clinicians — it's gamed them: how RVU-driven comp models and hierarchical structures push good people into behavior they would never choose in a different environment

✅ Why the RaDonda Vaught case — a nurse criminally prosecuted after self-reporting a fatal medication error — illustrates exactly what happens when a system punishes transparency instead of using near-misses to prevent future harm

✅ Dr. Lee's boulder-and-pebbles framework: why one person cannot fix the dysfunction, but enough people removing enough pebbles will eventually start that boulder rocking

✅ Three practical strategies for working incrementally within a broken system: celebrate small wins, build technology and processes that support colleagues, and find like-minded people to serve as your sounding board and support network

WHY THIS MATTERS

The cognitive dissonance that builds up when mission and margin are out of alignment doesn't just demoralize clinicians — it drives them out of the profession or into a kind of learned helplessness. Stacey frames it plainly: you are what you won't do for money. But for the people inside large institutions who are not suffering from that dissonance, the question isn't philosophical — it's operational. This episode is a practical field guide for anyone who wants to keep moving the ball forward without waiting for wholesale systemic change that may not arrive anytime soon.

MENTIONED IN THIS EPISODE

EP391 with Scott Conard, MD: Apple Podcasts | Spotify | Other Apps

EP415 with Rob Andrews: Apple Podcasts | Spotify | Other Apps

EP326 with Rishi Wadhera, MD, MPP: Apple Podcasts | Spotify | Other Apps

EP431 with Kenny Cole, 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

🎤 Listen on Apple Podcasts

🎤 Listen on Spotify

📺 Subscribe to our YouTube channel

=== CONNECT WITH THE RHV TEAM ===

✭ LinkedIn ✭ Threads ✭ Bluesky ✭ X

00:00 Introduction.

08:05 What is cognitive dissonance relative to the healthcare industry?

09:23 What are the systems that start to bear down on individuals within the healthcare system?

12:27 "The system has almost gamed them."

15:44 How can alignment still be achieved in the face of cognitive dissonance?

20:43 Why does it take more than one person to solve the dysfunction in the healthcare system?

23:01 What are some little changes that can help change the cognitive dissonance in healthcare?

24:57 Why is a hierarchical healthcare structure not necessarily beneficial?

27:12 The RaDonda Vaught story.

34:30 "Be happy in the small things."

A lung transplant billed at $1.5 million. An organ charged at $676,000 when the legal maximum is $56,000. After a payment integrity review removed the ineligible charges, that bill came down to $290,000. That's not an edge case — for one plan with 55,000 members and $600 million in medical spend, a single year's audit identified $64 million in excessive charges on claims of $10,000 and above alone. In this episode, Stacey Richter speaks with Kimberly Carleson, CEO of US Beacon, about how hospital billing errors happen, why they persist, and what plan sponsors and hospital finance teams can do about it — including the legal rights most plan sponsors don't know they have.

WHAT YOU'LL LEARN

✅ The most common sources of hospital billing errors: documentation gaps, unbundling bundled codes, upcoding, duplicate charges, non-FDA-approved items, and time-based charges with no time documentation — plus why Kimberly believes most of this is not intentional, just a coordination failure in an understaffed and complex system

✅ What's legally not billable — including charging for an organ above the CMS-allowed amount, billing saline separately, charging for venipuncture, billing sterilization multiple times, or itemizing individual components (like screws) that are bundled into a surgical code

✅ How contracts can override CMS guidelines — and why this matters: if a carrier negotiates a line item for robotics (which is normally not legally billable), the contracted rate stands, even if the underlying charge would otherwise be impermissible

✅ The scale of the problem: 30% ineligible charges in-network after the discount, and 70% or above out-of-network — figures that help explain why five to ten percent of total hospital spend by plan sponsors may be attributable to billing inaccuracies

✅ Plan sponsor rights under ERISA and the Consolidated Appropriations Act: the right to the itemized bill and UB-04 before payment, the right to conduct audits, and why the clock on payment doesn't start until a clean claim is received

✅ Why a third-party claims audit is non-negotiable — including the example of a TPA that audited its own claims, found $21,000 in errors, then an independent auditor found over $400,000

WHY THIS MATTERS

Hospital charges make up roughly 50% of plan sponsor medical spend, and this episode makes clear that a significant portion of those charges may be ineligible under existing federal billing guidelines — regardless of what the network contract says. The practical implication is that payment integrity review isn't just a cost containment strategy; for self-insured employers, it's a fiduciary responsibility. And for hospitals looking to do direct contracting with plan sponsors, getting billing right before a sophisticated buyer with eyes on every line item is just table stakes.

MENTIONED IN THIS EPISODE

EP285 with Dawn Cornelis: Apple Podcasts | Spotify | Other Apps

EP370 with Erik Davis and Autumn Yongchu: Apple Podcasts | Spotify | Other Apps

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

=== LINKS ===

🔗 Show Notes with all mentioned links: Episode Page

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00:00 Introduction.

08:36 What's the magnitude of the lack of payment integrity within healthcare?

12:46 How is lack of coordination a main culprit of lack of payment integrity?

13:42 How does reading the records reveal whether health plans are being overcharged?

15:43 A real-world example of how reviewing the charges can drastically reduce your healthcare costs.

18:32 Do you have a right to a review of your claim?

22:08 How can contracts contradict what can legally be charged?

25:04 How can hospitals update their billing to have better payment integrity?

28:44 Advice for hospital executives and their finance teams.

29:03 Advice for plan sponsors.