Relentless Health Value

So much can be said about pharma rebates — or, as Stacey Richter puts it after this conversation, monies received back from manufacturers, or post-sale concessions — that the word "rebate" itself has become linguistic gymnastics. Some of these dollars don't always get called a rebate, and some wind up in the pocket of the PBM/GPO or the TPA/EBC instead of the plan sponsor — allegedly, per the whistleblower case in which $27 million of someone else's rebates is alleged to have ended up in an executive bonus pool (hear that story on EP476 with Ann Lewandowski). Much has already been said on Relentless Health Value about pharma rebates, with Scott Haas, Mark Cuban, Chris Sloan, Pramod John, PhD, and Paul Holmes, among others, so this Summer Short instead rounds up what's being written about rebates right now, then digs into a nuance that gets little attention: how rebate-driven contracts can block the very pharmacogenomic testing that would otherwise catch a mismatched medication before it causes harm.

An article by Austin Chelko notes that per-employee rebates paid to employers have nearly tripled since 2017, yet total drug costs have still risen almost 24% over that same period — because, as Chelko writes, rebate-driven contracts block employers from pursuing lower-cost generics and biosimilars, incentivize PBMs to support clinically immaterial patent extensions, and let PBMs hit whatever guarantee they set for a given employer through formulary changes, cross-subsidized guarantees, and MAC manipulation (hear more on this from Chris Crawford on EP465). Rebate deals also routinely push genetic testing off the table: a manufacturer's rebate is often tied to a drug's existing FDA label, so a plan that starts limiting prescribing based on a pharmacogenomic test beyond what that label allows can forfeit the rebate entirely. In this Summer Short, Stacey Richter returns to a conversation with Ann Lewandowski, a nationally recognized healthcare executive last heard on EP476 discussing a pharma rebate whistleblower case, about exactly that rock-and-a-hard-place choice, and what it costs plan sponsors and patients alike.

WHAT YOU'LL LEARN

✅ What a pharmaceutical rebate actually is — a post-sale concession granted a specific exemption from the anti-kickback statute (the "Safe Harbor") — and why "rebate" is really just one of roughly 50 different classifications of post-sale money flows, per Texas's insulin-pricing lawsuit

✅ Why rebates remain a black box: pharma classifies rebate amounts as trade secrets, and even the PBM-reporting laws that exist (like Minnesota's) only require aggregated, unnamed disclosure

✅ How a "direct to label" rebate agreement can block pharmacogenomic (PGx) testing: manufacturers tie rebates to a drug's existing FDA label, so a plan that adds prescribing limits based on genetic testing beyond that label forfeits the rebate entirely

✅ Why that trade-off has real clinical stakes: one study found pharmacogenomic testing can reduce emergency department visits for medication interactions by 42% — yet PGx testing and rebate-chasing are often mutually exclusive under current contracts

✅ The "rock and a hard place" this creates for plan sponsors trying to build a value-based formulary: forgo the rebate and pay list price, or keep the rebate and risk prescribing a drug that a genetic test would have flagged as ineffective or harmful for that patient

✅ Why biosimilars and other low-list-price alternatives may offer a way out: they remove the choice between chasing a rebate and prescribing based on a patient's actual biochemistry and genetics

WHY THIS MATTERS

Ann Lewandowski's closing point reframes the stakes beyond the clinical: plan sponsors that let a rebate keep someone on the wrong medication don't just risk an ER visit, they can also end up paying for the long-term disability that follows when an employee is on a drug that was never going to work for them in the first place. As Peter Hayes has separately pointed out, rebates directed back to a plan sponsor to lower premiums for everyone amount to a regressive tax on sicker patients who are paying list price for the medications they actually need — and with roughly half of Americans already skipping essential medications over affordability, that trade-off compounds costs for everyone down the line.

MENTIONED IN THIS EPISODE

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

EP353 with Pramod John, PhD: Apple Podcasts | Spotify | Other Apps

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

EP426 with Nina Lathia, RPh, MSc, PhD: 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.

07:24 What is a pharmaceutical rebate?

08:15 Why are pharma rebates so opaque?

09:52 Texas lawsuit on insulin pricing.

10:18 Why is focusing on a singular type of concession difficult with current pharma rebate structures?

14:29 How does pharma genomics testing affect pharma rebates?

Stop-loss carriers shoot for 30 to 40% margins on the policies they sell. That figure came from the CEO of a large stop-loss carrier, in what Andreas Mang describes as a moment of weakness. If you're a self-insured employer and you haven't been actively marketing your stop-loss coverage every year, you may be paying hundreds of thousands — or millions — of unnecessary dollars for too much insurance, or the wrong kind. In this second conversation, Stacey Richter speaks with Andreas Mang, Senior Managing Director at Blackstone and CEO of Equity Healthcare, and Jon Camire, Managing Director, CFO of Equity Healthcare, and actuary, about the advanced considerations in stop-loss coverage for high-cost claimants — the contract provisions most plan sponsors overlook, the eligibility gaps that surface at the worst possible moment, and how to use a panel approach to let market forces work in your favor.

WHAT YOU'LL LEARN

✅ Why contract type matters more than price: the difference between a 12-15 and a 12-24 runout period — and why a plan with 200 employees could find itself fully on the hook for a NICU baby born December 30th if it chose the cheaper option without understanding what it was buying

✅ Four contract provisions to negotiate or demand: no new lasers once the policy is written, renewal caps on year-over-year premium increases, mirroring provisions (the stop-loss contract must mirror the medical plan's coverage), and an adequate runout period

✅ Why eligibility audits are non-negotiable: stop-loss carriers are meticulous about eligibility when a million-dollar claim comes in — and across dozens of companies, Jon Camire finds that 2 to 3% of dependents on a plan are typically ineligible

✅ The most common mistake: being either too conservative (overpaying year after year for coverage you don't need) or too price-focused (buying gaps into your coverage) — and why stop-loss decisions are too often the last, most rushed purchase in an already exhausted benefits cycle

✅ What a panel approach is and why it works: a panel of 9 to 10 stop-loss carriers competing annually for a large block of premium keeps the pencil sharp, ensures consistent contract terms, and captures carriers that may be aggressive in the market in a given year

✅ Know how everyone is getting paid — your consultant, the collective, and the stop-loss carrier — because stop-loss commissions are not reported on 5500s, and there is room for questionable behavior that won't surface unless you ask

WHY THIS MATTERS

Stop-loss coverage is a risk management tool first and a cost center second — but too many plan sponsors treat it as the last line item in an already locked budget. For clinical organizations serving high-cost claimants, this episode matters in a different way: it explains how your plan sponsor customers ensure they can pay you when a catastrophic claim arrives, and what happens when those structures have gaps. This is the 201-level conversation; EP478 is the 101-level conversation.

=== 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.

07:47 What are the best practices for plan sponsors to use for stop-loss coverage?

10:11 What are the "unknown unknowns" within stop-loss coverage?

15:25 What are some policy provisions that plan sponsors should be aware of?

19:02 Why is it so important to do eligibility audits?

20:41 What are some common mistakes made with stop-loss coverage among the self-insured?

23:21 What's a panel approach, and why is it important for negotiating stop-loss coverage?

The weekly claims wire looks like a payment for medical and pharmacy claims. But tucked inside that same wire, invisible to most plan sponsors, are fees that have nothing to do with the care your members received. One multi-employer fund reduced its $13 million in annual spend by $1.5 million just by getting better eyes on what was flowing through. Another plan's network-approved auditor found $21,000 in errors — and charged $25,000 to find them. An independent auditor then found more than 20 times that amount. In this Take Two episode, Stacey Richter revisits her conversation with Justin Leader, President and CEO of BenefitsDNA, about the five fees buried in TPA claims wires that most self-funded plan sponsors are paying without knowing it — and what to do about it.

WHAT YOU'LL LEARN

✅ Shared savings fees: what plan sponsors are actually paying when a TPA negotiates an out-of-network discount, accesses a Blue Card network, or recovers an overpayment it made — including the perverse situation where a TPA can charge a fee to correct its own billing mistake, with some contracts allowing fees as high as 50% of "savings" against an undefined baseline

✅ Prior authorization fees: why charging a plan sponsor a separate fee to conduct prior authorization may amount to charging for doing the job the admin was already hired to do — and why delayed or denied prior auths can generate more fee revenue than approvals

✅ Prepayment integrity fees: 85 to 90% of claims are auto-adjudicated, and carriers sometimes agree in provider contracts not to review claims prepayment — meaning errors get let through intentionally or not, with more money made catching them post-payment than preventing them up front

✅ Pay and chase fees: when a provider overbills and the TPA goes back to recover the overpaid amount, the plan gets charged a percentage of the recovered dollars — on top of whatever the TPA already charged to adjudicate the claim incorrectly

✅ TPA adjudication itself: how auto-adjudication software checks eligibility, prior auth, and plan design without human review — and why "we pay claims accurately and timely" is a near-meaningless guarantee if you can't define what a clean claim is or access the data to verify it

✅ Medical spread pricing as a bonus category: the DOL v. BCBS of Minnesota lawsuit and the concept that what a plan sponsor pays for a service may exceed what the provider actually receives — with the difference flowing somewhere else entirely

WHY THIS MATTERS

Julie Selesnick has said it plainly: it is the very definition of a fiduciary breach to have the same entity auditing claims also processing them. Getting gag clause language out of your contracts is a useless exercise, as Karen Handorf puts it, if you don't look at the data to figure out how it's hurting the plan and its participants. For self-funded employers, this episode is a field guide to asking the right questions of your TPA — and understanding why the answers have been so hard to get.

MENTIONED IN THIS EPISODE

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

EP428 with Julie Selesnick: Apple Podcasts | Spotify | Other Apps

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

EP379 with AJ Loiacono: 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.

06:56 How is the claims wire typically explained to a plan sponsor?

10:49 What is the whole point of self-funding?

10:58 Why is it so vital to understand what you're paying for?

11:53 What are the five "buried" items that wind up in these claims wires?

12:12 What is a shared savings fee?

16:14 "Rates are important, but so are your rights."

20:13 What's going on with prior auth fees?

22:44 What is prepayment integrity?

27:29 What is pay and chase?

30:58 What is a TPA claim review?

34:45 Is there medical claim spread pricing?

Stop-loss is one of the most important buying decisions a self-insured employer makes — and it's almost always the last one, made when everyone is exhausted and ready to just be done. That combination has produced some expensive disasters. This episode is the 101 that makes sure you don't create one. Stacey Richter speaks with Andreas Mang, Senior Managing Director at Blackstone and CEO of Equity Healthcare, and Jon Camire, Managing Director, CFO of Equity Healthcare at Blackstone, and actuary, about what stop-loss coverage actually is, how individual and aggregate policies work, and — most importantly — why a laser claim is not always the bad news it sounds like.

WHAT YOU'LL LEARN

✅ What stop-loss is: a form of reinsurance that protects self-insured employers from catastrophic individual claims or aggregate plan-year overruns — and why it remains one of the few pieces of health coverage that still meets the true definition of insurance: low-probability, high-cost events

✅ How individual stop-loss works: a plan deductible (called an attachment point) is set based on company size — roughly $75K–$125K for a ~400-person employer, up to $750K–$1M for a ~5,000-person employer — above which the stop-loss carrier absorbs the cost; companies at roughly 10,000 employees can consider eliminating individual coverage entirely

✅ How aggregate stop-loss works: set at approximately 125% of expected annual plan costs, it caps total plan-year exposure; typically purchased by smaller employers and dropped around 1,000 employees; hits approximately once every 100 years, per a stop-loss administrator's own estimate

✅ What a laser claim actually is — and why accepting one can be the right financial move: a laser pulls a known high-cost individual out of the risk pool and assigns a higher deductible; the alternative is the carrier simply buries the cost in the premium at a higher margin, leaving the employer paying more with less transparency

✅ Why stop-loss is a CFO decision, not just an HR decision: it is a risk management tool that directly affects cash flow — a $500,000 claim is catastrophic for a plan running $200,000 a month in claims; irrelevant to one running $10 million a month

✅ The one rule to rule them all: get a highly experienced, unconflicted broker or employee benefit consultant who specializes in plans your exact size — and know exactly how they are compensated, because the math of self-insurance gets complicated fast and the stop-loss decision is where the real damage happens when it goes wrong

WHY THIS MATTERS

When a self-insured employer goes without the right stop-loss structure — or over-insures out of first-year nervousness and spends millions more than necessary — it can turn the entire economics of self-insurance upside down. This episode is Part 1 of a two-part series. Part 2 (EP479) covers the specific contract provisions, eligibility audit failures, and purchasing mistakes that produce those bad outcomes.

MENTIONED IN THIS EPISODE

EP420 with Ge Bai, PhD, CPA: 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.

07:24 What is stop-loss?

08:27 What is reinsurance?

10:10 Why has stop-loss been a barrier for smaller companies going self-insured?

13:55 Why self-insurance needs to be a joint decision between finance and HR.

15:38 What is aggregate versus individual within stop-loss?

19:51 Why is it important for companies to choose the right level of stop-loss coverage?

21:29 What is a laser claim?

29:28 Why is it important to know what your brokers are getting paid on your stop-loss policies?

"The very real impact of trust, or lack of trust, which may come from too little antitrust." That line, from Dr. Mick Connors, is the through line of this episode — and it connects patients who don't take prescribed medications because they trust their neighbor more than their doctor, to clinicians who are leaving the workforce because they don't trust their employers, to medical students who won't enter primary care or pediatrics because they can't count on mission or margin. EP477 is a solo through-line episode where Stacey Richter synthesizes listener contributions and insights from prior RHV episodes into one clear argument: trust is not soft or secondary. It is step one. Skip it, and you will be mopping up the floor while the faucet is still running.

WHAT YOU'LL LEARN

✅ Why trust is the precondition for almost everything else in healthcare — care gap closure, member navigation, high-cost claimant management, and pop health interventions all fail without a foundation of patient and member trust; as Denise Wiseman put it after the Kenny Cole episode, "it's a critical lever for better health outcomes and smarter system design"

✅ How antitrust behavior produces distrust at scale: consolidated systems, private equity ownership, and misaligned incentives corrode clinician trust in their employers — with 74% of physicians now employed by corporate or hospital systems, the distrust ripples directly into patient care

✅ Why Goodhart's Law destroys trust-based outcomes: when biometric scores become the quality metric, the trusted relationship that actually produces better biometrics gets cut out of the process as seemingly optional — and outcomes get worse

✅ Adam Grant's givers, takers, and matchers framework applied to healthcare: whoever is doing the taking may win a few in the short term, but in a long game, reputation catches up — and the most successful collaborators are the ones who can be trusted to give even when they know they won't get anything in return

✅ Why the Relentless Health Value community is uniquely positioned: givers and giver-matchers who show up week after week to build a better system are, per Adam Grant's research and per Viktor Frankl's observations on purpose and survival, also the ones most likely to prevail — and to live longest

✅ A bonus add-on accompanies this episode: a clip from Stacey's conversation with Charles Green of Trusted Advisor Associates, author of The Trusted Advisor, on how trust is actually earned — and how to rebuild it once it's lost

WHY THIS MATTERS

Stacey closes the episode with a direct message to the Relentless Health Value tribe: you are smart to be here. Not because of the show, but because of the way you think — focused on what patients and members need, committed to doing the work, and trustworthy enough to be the kind of collaborator others want to work with. In a system corroded by misaligned incentives and earned distrust, that is not nothing. It is, in fact, the only way anything actually changes.

MENTIONED IN THIS EPISODE

Bonus Add-on to EP477 with Charles Green: Apple Podcasts | Spotify | Other Apps

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

EP473 with Kenny Cole, MD: Apple Podcasts | Spotify

EP295 with Rebecca Etz, PhD: Apple Podcasts | Spotify | Other Apps

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

=== LINKS ===

🔗 Show Notes with all mentioned links: Episode Page

🔗 Bonus Show — Show Notes: 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.

00:47 What is the new, emerging through line becoming apparent in healthcare?

07:06 Why does trust grow through proximity, and why do providers need to integrate this into care models?

07:59 Why antitrust is so prevalent in healthcare.

10:00 What are two main contributors to the lack of primary care doctors?

13:27 Why collaboration builds trust.

Healthcare is one of the hardest industries in which to build trust — conflicts of interest are baked into the economics, relationships have become transactional, and transparency is the exception rather than the default. So what does it actually take to earn it? This bonus add-on to EP477 revisits a conversation Stacey Richter recorded ten years ago with Charles Green, founder of Trusted Advisor Associates and author of The Trusted Advisor — a book he had already spent 15 years researching and teaching when the interview originally aired. The clip is, as Stacey says, a masterclass on what trust means and how to earn it.

WHAT YOU'LL LEARN

✅ Four organizational trust principles that apply directly to healthcare relationships: client focus (orienting toward the other party, not yourself), collaboration (operating as if you are genuinely on the same team), long-term orientation (thinking about what would happen if this interaction repeated 10 times, not just once), and transparency as the default rather than obfuscation

✅ Why healthcare makes all four of these hard: zero-sum incentives undermine collaboration, fee-for-service structures reward transactions over relationships, and opacity is often the deliberate strategy — but Charles Green's argument is that those stuck in the zero-sum game need to collaboratively think their way out of it, because both parties are getting harmed by it

✅ Why trust repair has to start at the individual level, not the institutional level — and why individual behavior has an outsized impact even in the most broken organizational contexts; you don't have to wait for the CEO or a new incentive structure to start behaving in trustworthy ways

✅ Why leadership is a force multiplier specifically for trust: leaders who admit they don't know something, who listen to subordinates, who display empathy — their behavior cascades through organizations in ways that no mission statement ever does; as Green puts it, walk the talk turns out to be much more powerful in trust than almost anything else

✅ The one practical step anyone can take this afternoon: practice listening as a form of paying attention — not to extract information, but as a form of respect and curiosity toward another person; the reciprocal response it generates is the foundation of every trusted relationship

WHY THIS MATTERS

Trust in healthcare is not primarily a systemic problem waiting for a systemic fix. It is the sum of individual interactions, accumulated over time, between people who choose whether to focus on the other party or on themselves. Charles Green's framework makes clear that the behaviors that build trust — client focus, collaboration, long-term thinking, transparency — are also the behaviors that make healthcare work. And the behaviors that destroy trust are, not coincidentally, exactly the ones that have made it so expensive and so fragmented.

=== 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.

01:45 Four trust principles that can help you earn your clients' trust and come off as more trustworthy from first impressions onward.

04:31 Charles's words of wisdom for rebuilding lost trust.

05:46 Where does trusted leadership start?

06:38 Why trust in leadership is about embodying trust in actions, not words.

07:26 Why does personality have an outsized impact in leadership and trust?

08:21 "If we want to improve our trust, we just simply need to work on ourselves."

08:56 Why listening with a sense of curiosity and respect drives reciprocal behavior and improves trust.

09:14 What is the best technique to immediately improve your trust relationship?

An EBC Allegedly Pocketed $27 Million of Client Pharma Rebates. Here's What Happened Next.

An employee benefit consultant where 61% of revenue allegedly came from keeping clients' pharma rebates — undisclosed, in violation of the Consolidated Appropriations Act of 2021, funneled into the executive bonus pool. When the compliance officer raised the alarm and eventually disclosed to a plan sponsor, he was fired. That firing is what made this a whistleblower case. Stacey Richter speaks with Ann Lewandowski — nationally recognized healthcare executive and whistleblower known for Lewandowski v. Johnson & Johnson — about the pharma rebates case, what it means for plan sponsors, and what to do if you are an employee watching something like this unfold.

WHAT YOU'LL LEARN

✅ The anatomy of the case: an EBC's TPA arm allegedly kept client pharma rebates — 61% of revenue — without disclosing them as required by the CAA, funneled them into the executive bonus pool, and fired the compliance officer who tried to make the disclosures; originally filed in Maryland state court, moved to federal court because it involves ERISA, with the Department of Labor now working alongside plaintiff's counsel

✅ Why Form 5500 disclosure templates matter: a vague statement like "may from time to time receive third-party compensation" satisfies the letter of the law while hiding everything; Ann's advice is to use your own template with black-and-white line items so the vendor either discloses or actively lies

✅ What a qui tam lawsuit is: qui tam provisions allow private individuals to sue on behalf of the government and collect a portion of the recovery — the upside most employees don't think about when weighing whether to come forward

✅ The Upjohn warning: when a company's lawyers interview employees about potential wrongdoing, those lawyers represent the company, not the employee — the company can waive privilege and share what was said with the DOJ; every employee must understand this before speaking

✅ Ann's practical advice: document everything, don't depend on others to protect you, and consult an ERISA attorney — the DOJ's 2016 sentencing guidelines mean individuals with knowledge of wrongdoing can be personally prosecuted, not just the company

✅ Compliance as the organizational immune system: you can tell everything about a company by whether it treats a concern raised by the compliance officer as a vaccine or an invader to be eliminated

WHY THIS MATTERS

Trust but verify — and as W. Edwards Deming put it, in God we trust, all others must bring data. For plan sponsors, this is a guide to defensive plan sponsorship. For employees watching the wrong things happen around them: the risk of not whistleblowing, of being on the wrong side of the table when someone else does, is just as real as the risk of coming forward.

MENTIONED IN THIS EPISODE

EP379 with AJ Loiacono: Apple Podcasts | Spotify | Other Apps

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

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.

08:10 What does it mean to be a whistleblower?

09:05 What's happening in the current whistleblower case about pharma rebates?

14:24 What are the disclosure requirements, and how does this affect contracts in healthcare?

15:11 The 5500 form.

16:46 Why having a "defensive health plan" is important.

17:31 Matt Ohrt's post about healthcare's soul.

17:42 Michelle Bernabe's post about how healthcare has lost its heart.

18:15 Why "trust and verify" is important when building contracts and relationships in healthcare.

18:42 Quote by W. Edwards Deming.

21:35 How has this case moved from state to federal court?

23:30 Whistleblower case on generic drug collusion.

24:01 What is a qui tam lawsuit?

28:08 What is an Upjohn warning and the issue of corporate Miranda rights?

30:01 What is Ann's advice to employees who might be whistleblowers?

33:31 What are some red flags that employees should look for to understand what kind of company they work for?

Something shifted after the assassination of UnitedHealthcare CEO Brian Thompson. As Peter Hayes puts it, we've reached a "force majeure of bridges too far" — obvious, over-the-line activities that offend normal people's sense of justice. In this episode, Stacey Richter speaks with Peter Hayes, retired president and CEO of the Healthcare Purchaser Alliance of Maine and former director of associate health and wellness at Hannaford Supermarkets, about why he believes healthcare is finally at an unprecedented tipping point. Hayes identifies three forces now braiding together: changing public opinion, price and quality transparency, and regulation — specifically the Consolidated Appropriations Act. Individually, none is new. But their convergence, Hayes argues, has created an inexorableness that something's got to give.

WHAT YOU'LL LEARN

✅ Why the Brian Thompson assassination served as a pressure-cooker moment — and why 60% of Americans carrying medical debt means public anger has now reached a genuine critical mass

✅ How price transparency is exposing a system where the cash price beats the insurer-negotiated rate 60% of the time — including one Maine hospital where a knee replacement costs $15,000 cash versus $45,000 through insurance

✅ Why the Consolidated Appropriations Act is the regulatory earthquake: for the first time, C-suite executives and boards face personal and corporate fiduciary liability if they fail to use employee benefit dollars prudently — and why consultants who take 30–40% in undisclosed back-end revenue flows from health plans are now exposed

✅ How the U.S. pays four times more for healthcare than other industrialized countries while averaging a life expectancy of 78 — six years behind European nations at 84 — and why Leapfrog data showing C-or-lower hospitals carry an 88% higher fatality risk makes this an urgency issue, not just a cost issue

✅ Why the eroded trust among patients, physicians, and clinicians is the central unifying force — and how states acting as regulatory laboratories (eight states now pursuing hospital price controls, eleven with prescription drug affordability boards) are the most likely path to restoring it

WHY THIS MATTERS

Healthcare costs roughly four times more in the U.S. than in other industrialized countries, and 30 to 40% of that spending goes not to care but to intermediaries, administration, and margins. The forces Peter Hayes describes — public fury, price transparency, and fiduciary accountability under the CAA — are not new in isolation, but their convergence is. As Hayes frames it, the braiding together of these three forces has created a trifecta that is difficult to reverse, even if individual lawsuits fail and individual reforms stall. The question is no longer whether something gives, but when.

MENTIONED IN THIS EPISODE

EP458 with Komal Bajaj, MD: Apple Podcasts | Spotify | Other Apps

EP358 with Wayne Jenkins, MD: Apple Podcasts | Spotify | Other Apps

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

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

EP455 with Beau Raymond, 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.

05:28 What things are adding to the urgency in this moment of healthcare?

05:55 The three things that have brought us to a tipping point in healthcare.

07:05 Why is now the real moment for this tipping point?

13:01 Article by (and tribute to) Uwe Reinhardt.

13:27 Hospital ratings by The Leapfrog Group.

16:29 How is regulation changing in healthcare?

21:48 How the "trifecta" of change is working together to create this movement of change in healthcare.

23:54 What do we need to look at to address the problems pushing this change in healthcare?

30:04 Why is federal and state collaboration going to be important to this healthcare change?

What Private Equity Actually Does to Your Healthcare Costs, Doctors, and Community

Private equity has invested over $1 trillion in U.S. healthcare in the past decade — from neonatal services to nursing homes — and most plan sponsors and patients don't know it's happened until the downstream effects are already deeply pervasive. In this episode, Stacey Richter speaks with Yashaswini Singh, PhD, MPA, healthcare economist and assistant professor of health services, policy, and practice at Brown University School of Public Health, whose peer-reviewed research appears in Health Affairs, NEJM, and JAMA. As Dr. Singh puts it: if you've seen one private equity acquisition, you've seen one private equity acquisition. The sector-specific playbooks are the key to understanding what's coming — and knowing them is power.

WHAT YOU'LL LEARN

✅ The two core PE profit levers — increasing negotiated prices and cutting staffing — and why reducing physician time with patients often triggers a cascade of higher-cost diagnostic imaging and procedures with unclear patient benefit

✅ How real estate leasebacks work in hospital and nursing home acquisitions: PE buys the facility, immediately acquires the underlying real estate, then leases it back to the entity — stripping its most valuable asset and explaining how Hahnemann Hospital in Philadelphia and the Steward Health Care saga in Massachusetts unfolded

✅ Why physician practice roll-up consolidation is the other dominant playbook: PE gradually acquires smaller practices under a platform umbrella to build regional market share, then uses that leverage to negotiate price increases of 10 to 25% from commercial insurers depending on the clinical area

✅ What Dr. Singh's Health Affairs study found: physician turnover jumps from 4% to over 20% in the three years following a private equity acquisition — and why noncompete clauses with geographic radii as wide as 100 miles can force physicians to leave states entirely

✅ The three policy levers that could actually work: antitrust enforcement through the DOJ, FTC, and state attorneys general for consolidation concerns; updated corporate practice of medicine doctrines for physician autonomy concerns; and ownership transparency requirements, which Dr. Singh calls the lowest-hanging fruit

WHY THIS MATTERS

If plan costs in a local market suddenly spike 15 to 25%, Stacey's advice is to check who just rolled up the physician practices in that area. The problem isn't that private capital is inherently wrong — healthcare is increasingly capital-intensive and money is required. The problem, as Dr. Singh frames it, is that PE firms are not here to look out for patient wellbeing. If that is a side effect of the strategies they deploy to serve their investors, fine. But when left unchecked, the incentives are misaligned with the core mission of healthcare: to care for people. That argument, as Dr. Adam Brown writes, is not speculative.

MENTIONED IN THIS EPISODE

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

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

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

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

EP460 with Rushika Fernandopulle, 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.

05:53 What is the tension between business and medicine?

07:05 What is the impact of private equity on healthcare?

08:46 How does healthcare change when private equity invests in medical facilities?

10:54 What are the intuitive impacts of private equity in healthcare?

12:28 What are the less intuitive effects of private equity on healthcare?

14:15 What are the misconceptions about private equity investors acquiring healthcare facilities?

16:17 The Steward saga.

16:24 The death of Hahnemann Hospital in Philadelphia.

19:27 Are there any positive outcomes to private equity investment in healthcare?

22:55 Is there ever a need for private investment in healthcare?

25:40 How do the changes private equity firms create affect patients?

27:20 Study in Health Affairs on physician turnover rates following private equity acquisitions.

29:30 How can private equity disrupt physician employment as well?

34:13 What remedies might there be for consolidation in healthcare and private equity investing in medicine?

I'm revisiting, in a Take Two, this episode with Dr. Kenny Cole because I'm listening to it this time with a new focus — the theme that keeps coming up over and over on Relentless Health Value these past few months: if care teams don't build a trusted relationship with plan members and patients, then in a moment that really matters, the patient will suboptimally wind up in the ER. Across an entire plan sponsor's member population, all these pilgrimages to the ER come at great cost — ER spend is about 6% of average plan spend. As Denise Wiseman, PhD, MBA, CPXP, put it on LinkedIn, "Primary care is absolutely an investment in health and wellness, not a cost…Trust is the foundation. Without trusted relationships between patients and care teams, we're not investing—we're just reacting." Dr. Kenny Cole of Ochsner Health System joins Stacey Richter again for a conversation that has lessons for plan sponsors, clinic managers, and anyone trying to reinvent a business model so that best-practice clinical pathways and financial viability actually align.

WHAT YOU'LL LEARN

✅ Why clinical teams have to deliver care in such a way that they are accountable for the outcomes generated — not just activity, but the actual result

✅ Why clinical teams need to see with their own eyes and believe that a clinical goal that's been set is actually achievable before they'll commit to it

✅ Why care flows are critical: getting everyone on the same page about what best-practice care looks like, then operationalizing how that clinical excellence gets achieved day to day

✅ Why building trust with patients and connecting with them cannot be underestimated — and why care flows need to both standardize care for speed and ease and facilitate the patient relationships that make that care stick

✅ How Dr. Cole splits his own week — seeing patients one day and serving as system VP the other days — to design and develop new care models, including Ochsner 65 Plus, built around aligning clinical outcomes with financial viability

WHY THIS MATTERS

This concept — a trusted relationship with a primary care team — can feel soft and squishy, and it's easy for someone looking at a spreadsheet to cross it off as wasted time. But without it, good primary care falls victim to the very real perverse incentives to drive commercial ER volume or volume to high-revenue service lines. If plan sponsors don't get their members a trusted advisor who will be there for them when it matters, someone else is going to steer that member — based on their own financial incentives, not the patient's. Dr. Cole's work at Ochsner is a real-world example of what it takes for primary care to live up to its potential as an investment rather than just another line-item cost.

MENTIONED IN THIS EPISODE

EP412 with Robert Pearl, MD: Apple Podcasts | Spotify | Other Apps

EP315 with Bob Matthews: Apple Podcasts | Spotify | Other Apps

EP242 with Marty Makary, MD: Apple Podcasts | Spotify | Other Apps

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

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

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

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

EP455 with Beau Raymond, 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.

07:35 Is there an optimal care pathway where there might be a lot of treatment variability?

12:32 Why is it important to start with the end in mind?

15:44 How do you scale clinical excellence?

21:29 Why is it important simply to demonstrate what's possible for better health outcomes?

23:18 How do we reinvent the business model of healthcare?

34:22 Dr. Cole is published in various healthcare journals; check out his most recent article.