Relentless Health Value

This episode of Relentless Health Value features Dr. Kenny Cole from Ochsner Health System. The discussion emphasizes the critical role of trusted relationships and excellent primary care teams in keeping patients out of the emergency room, thus reducing healthcare costs.

Stacey Richter revisits this conversation to highlight the importance of care teams building trust with patients and the concept of primary care as an investment in health and wellness. The episode outlines four key points for delivering great primary care, including accountability for outcomes, belief in clinical goals, standardized care flows, and building patient trust.

Dr. Cole also discusses the real-world challenges and strategies for achieving clinical and financial success in primary care. The episode serves as a guide for plan sponsors, clinicians, and healthcare executives looking to improve primary care delivery and align it with financial viability. The discussion is further enriched with insights on digitizing care pathways and the importance of measuring and sharing best practices to achieve high standards of care.I

Stacey revisits, in a take two, this episode with Dr. Kenny Cole because she's listening to it this time with a new focus. That focus is the theme that keeps coming up over and over and over again on Relentless Health Value these past few months.

=== LINKS ===
🔗  Show Notes with all mentioned links:  
https://cc-lnk.com/EP473

✉️  Enjoy this podcast? Subscribe to the free weekly newsletter:
https://relentlesshealthvalue.com/join-the-relentless-tribe

🫙  Support the podcast with a small donation to the Tip Jar:
https://relentlesshealthvalue.com/join-the-relentless-tribe

🎤  Listen on Apple Podcasts  https://podcasts.apple.com/us/podcast/feed/id892082003?ls=1

🎤  Listen on Spotify  https://open.spotify.com/show/6UjgzI7bScDrWvZEk2f46b

📺  Subscribe to our YouTube channel   https://www.youtube.com/@RelentlessHealthValue

=== CONNECT WITH THE RHV TEAM ===
✭ LinkedIn   https://www.linkedin.com/company/relentless-health-value/
✭ Threads  https://www.threads.net/@relentlesshealthvalue/
✭ Bluesky   https://bsky.app/profile/relentleshealth.bsky.social
✭ X   https://twitter.com/relentleshealth/

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

10:52 EP412 with Robert Pearl, MD.

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

15:44 How do you scale clinical excellence?

18:18 EP315 with Bob Matthews.

19:12 EP242 with Marty Makary, MD.

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

22:33 EP427 with Rik Renard.

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

24:51 EP466 with Vivian Ho, PhD.

25:06 EP415 with Rob Andrews.

26:51 EP391 with Scott Conard, MD.

30:14 EP455 with Beau Raymond, MD.

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

In Episode 472, Stacey Richter speaks with Dr. Eric Bricker about the impactful strategies hospital systems use to maximize revenue from high-cost patients. They explore the financial complexities and contracting tactics that enable hospitals to profit significantly from a small percentage of high-cost claimants.

Key points include the negotiation of provider stop-loss contract provisions, strategic adjustment of charge masters, and the intentional steerage of patients to high-revenue service lines. This episode highlights the intricacies of hospital finance and the hidden mechanisms that drive healthcare costs for self-insured employers and other plan sponsors.

We could have 0.5% to 1% of total plan members costing upwards of 40% of total plan dollars. And I bring this up just to highlight the magnitude of the money here. In that show from last week, we take the issue of high-cost claimants from the standpoint of the plan sponsor.

Today, however, we’re gonna be looking at this from the standpoint of the hospital system. If we were to come up with a motto for the show today with Dr. Eric Bricker, it’s that all costs are somebody else’s revenue. And when it’s revenue and profit of the magnitude that we’re talking about with many high-cost claimants, it starts to be less of an accidental “Oh, wow! How did that CABG patient wind up in our clinic? What are the odds?” and more of a “Whoever is not steering patients is letting someone else with a big profit incentive lock down that steerage in deeply embedded ways.” 

=== LINKS ===
🔗  Show Notes with all mentioned links:  
https://cc-lnk.com/EP472 

📺 Dr. Bricker's AhealthcareZ Channel
www.youtube.com/@ahealthcarez 

✉️  Enjoy this podcast? Subscribe to the free weekly newsletter:
https://relentlesshealthvalue.com/join-the-relentless-tribe 

🫙  Support the podcast with a small donation to the Tip Jar:
https://relentlesshealthvalue.com/join-the-relentless-tribe 

🎤  Listen on Apple Podcasts  https://podcasts.apple.com/us/podcast/feed/id892082003?ls=1

🎤  Listen on Spotify  https://open.spotify.com/show/6UjgzI7bScDrWvZEk2f46b

📺  Subscribe to our YouTube channel   https://www.youtube.com/@RelentlessHealthValue 

=== CONNECT WITH THE RHV TEAM ===
✭ LinkedIn   https://www.linkedin.com/company/relentless-health-value/
✭ Threads  https://www.threads.net/@relentlesshealthvalue/
✭ Bluesky   https://bsky.app/profile/relentleshealth.bsky.social
✭ X   https://twitter.com/relentleshealth/

05:06 From a hospital revenue perspective, where do high-cost claimants fall?

08:45 How do hospitals structure their stop-loss provisions so that they ensure they’re always maximizing their revenue?

12:15 How hospitals acquire providers to steer as many patients as possible through specific service lines.

20:21 Why do carriers let hospitals get away with these rates and stop-loss negotiations?

21:06 How do Medicare Advantage and Medicare rates play into all of this?

22:00 What should a benefit consultant be doing here?

23:37 What are the keys to direct contracting?

27:21 Why is it important to get trusted relationships set up ahead of time?

28:04 The Company That Solved Health Care by John Torinus Jr.

29:23 What needs to be the clinical consideration for specialists?

30:46 What is the advantage that employers have in all of this?

33:06 Dr. Bricker’s video on 32 examples of healthcare deception.

Recently on Relentless Health Value, we’ve been tinkering around with a few recurring themes—recurring through lines—that are just true about American healthcare these days.

In this episode of Relentless Health Value, host Stacey Richter speaks with Dr. Christine Hale about high cost claimants and the implications for healthcare plans in 2025 and beyond. They discuss the importance of trust in patient care, the financial incentives behind patient steering, and the critical role of timely and comprehensive data analysis.

Dr. Hale emphasizes the need for an integrated approach to medical and pharmacy claims data to avoid expensive consequences and improve patient outcomes. She also shares strategies for plan sponsors to effectively manage high cost claimants through evidence-based care, appropriate treatment settings, and creative problem-solving, while underlining the importance of patient engagement and satisfaction.

Don't miss next week's episode with Dr. Eric Bricker for a deeper dive into these topics.

=== LINKS ===

🔗  Show Notes with all mentioned links:  

https://relentlesshealthvalue.com/episodes

✉️  Enjoy this podcast? Subscribe to the free weekly newsletter:

https://relentlesshealthvalue.com/join-the-relentless-tribe

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

https://relentlesshealthvalue.com/join-the-relentless-tribe

🎤  Listen on Apple Podcasts  https://podcasts.apple.com/us/podcast/feed/id892082003?ls=1

🎤  Listen on Spotify  https://open.spotify.com/show/6UjgzI7bScDrWvZEk2f46b

📺  Subscribe to our YouTube channel   https://www.youtube.com/@RelentlessHealthValue

=== CONNECT WITH THE RHV TEAM ===

✭ LinkedIn   https://www.linkedin.com/company/relentless-health-value/
✭ Threads  https://www.threads.net/@relentlesshealthvalue/
✭ Bluesky   https://bsky.app/profile/relentleshealth.bsky.social
✭ X   https://twitter.com/relentleshealth/

05:22 What is a high-cost claimant, and how is the definition changing?

07:42 Why buy-and-bill pharmaceuticals can be so costly for plan sponsors.

10:19 What are plan sponsors getting wrong about this situation?

11:28 What do you need as an employer to understand your plan data fully?

13:41 EP462 with Scott Conard, MD.

17:35 What are plan sponsors currently doing that they should not being doing?

19:54 Why starting small is important.

23:02 EP468 with Matt McQuide.

25:37 What are the steps employers should take to improve their high-cost claimant spend?

31:02 EP371 with Erik Davis and Autumn Yongchu.

33:46 EP467 with Stacey.

Recent past interviews:

Click a guest’s name for their latest RHV episode!

Nikki King, James Gelfand (Part 2), James Gelfand (Part 1), Matt McQuide, Stacey Richter (EP467), Vivian Ho, Chris Crawford (EP465), Al Lewis, Betsy Seals, Wendell Potter (Encore! EP384), Dr Scott Conard

In this episode, host Stacey Richter revisits a conversation with Nikki King, CEO of Alliance Health Centers, discussing the critical issues facing rural hospitals and healthcare systems. They delve into the impacts of Medicaid cuts, the financial struggles of rural hospitals reliant on commercial insurance, and potential solutions like freestanding emergency rooms, telehealth, and the expanded roles of nurse practitioners. 

The conversation also covers the complexities of maternity care and mental health services in rural areas, emphasizing the urgent need for systemic reforms to ensure equitable access to healthcare.

=== LINKS ===
🔗  Show Notes with all mentioned links:  
https://cc-lnk.com/EP470

✉️  Enjoy this podcast? Subscribe to the free weekly newsletter:
https://relentlesshealthvalue.com/join-the-relentless-tribe

🫙  Support the podcast with a small donation to the Tip Jar:
https://relentlesshealthvalue.com/join-the-relentless-tribe

📺  Subscribe to our YouTube channel   https://www.youtube.com/@RelentlessHealthValue

🎤  Listen on Apple Podcasts  https://podcasts.apple.com/us/podcast/feed/id892082003?ls=1

🎤  Listen on Spotify  https://open.spotify.com/show/6UjgzI7bScDrWvZEk2f46b

=== CONNECT WITH THE RHV TEAM ===
✭ LinkedIn   https://www.linkedin.com/company/relentless-health-value/
✭ Threads  https://www.threads.net/@relentlesshealthvalue/
✭ Bluesky   https://bsky.app/profile/relentleshealth.bsky.social
✭ X   https://twitter.com/relentleshealth/

08:14 How dire is the rural hospital situation right now?

08:33 How could freestanding ERs be a potential solution for rural hospitals?

09:56 Advice from CHQPR: Rural hospitals should not be forced to eliminate inpatient care.

11:22 Why is broadband a roadblock to telehealth as a solution for rural health access?

14:52 What are other potential rural health access solutions?

15:37 The “hot potato” of nurse practitioners in the healthcare world.

16:34 “The number of residencies for physicians each year is not increasing, but the population … is increasing.”

20:28 EP312 with Douglas Eby, MD, MPH, CPE, of the Nuka System of Care.

22:00 What’s the issue with maternity care in rural America?

24:09 “As healthcare becomes more and more specialized, [the] ability to treat high-risk cases is better, but access gets worse.”

27:57 How is mental health care affected in rural communities?

28:29 “Rural communities are trying very hard to hang on to what they have.”

29:52 “When you look at the one market plan that’s available in a rural community, you probably can’t afford it.”

31:37 What’s the single biggest challenge to moving to a model that incentivizes keeping people healthy?

32:32 “The easiest low-hanging fruit … is having national Medicaid and have that put under the same hood as Medicare.”

In part 2 of episode 469, host Stacey Richter discusses the implications of Medicare site neutral payments and Health Savings Account (HSA) reforms with James Gelfand, president and CEO of the ERISA Industry Committee (ERIC). 

The episode details how plan sponsors should adapt to Medicare's site neutral payment policies aimed at curbing hospital consolidation and inflated prices through facility fees and markups. Gelfand provides insights into how HSA reforms currently in Congress could expand the scope of preventive care covered before deductibles are met, benefitting both employers and employees. 

The conversation also touches on the challenges high deductible health plans pose and the potential benefits of codifying recent IRS guidance to allow greater flexibility in pre-deductible coverage. The discussion underscores the importance of plan sponsors staying ahead of Medicare policies to avoid higher costs.

=== LINKS ===

🔗  Show Notes with all mentioned links:  
https://relentlesshealthvalue.com/episodes

✉️  Enjoy this podcast? Subscribe to the free weekly newsletter:
https://relentlesshealthvalue.com/join-the-relentless-tribe

🫙  Support the podcast with a small donation to the Tip Jar:
https://relentlesshealthvalue.com/join-the-relentless-tribe

🎤  Listen on Apple Podcasts  https://podcasts.apple.com/us/podcast/feed/id892082003?ls=1

🎤  Listen on Spotify  https://open.spotify.com/show/6UjgzI7bScDrWvZEk2f46b

📺  Subscribe to our YouTube channel   https://www.youtube.com/@RelentlessHealthValue

=== CONNECT WITH THE RHV TEAM ===

✭ LinkedIn   https://www.linkedin.com/company/relentless-health-value/

✭ Threads  https://www.threads.net/@relentlesshealthvalue/

✭ Bluesky   https://bsky.app/profile/relentleshealth.bsky.social

✭ X   https://twitter.com/relentleshealth/

05:42 What does Medicare site-neutral payments mean?

08:59 How do markups play into the dynamics here?

09:52 Upcoming episode with Christine Hale, MD, MBA.

10:36 What does the “narrow” start for these changes mean?

11:42 What action steps should plan sponsors be taking?

13:01 What options do plan sponsors have in highly consolidated markets?

14:27 EP371 with Erik Davis and Autumn Yongchu.

14:53 EP448 (Part 1 and Part 2) with Shawn Gremminger.

15:46 Will this bill potentially make changes to HSA plans?

17:40 Why has the thinking behind healthcare usage changed since the inception of HSAs?

18:42 INBW41 with Stacey.

23:24 How are preventive care and first-dollar coverage connected within the context of HSAs?

25:48 Why would it be difficult to completely get rid of a high-deductible health plan and offer HSAs without them?