Episodes

  • EP507: 4 Core Concepts to Buy or Deliver the Highest-Value Healthcare—A Review

    EP507: 4 Core Concepts to Buy or Deliver the Highest-Value Healthcare—A Review
    Apr 16 2026
    Look, we wonks, meaning you and me, you're listening to this, so I am on to you. But we wonks in the Relentless Tribe, we move like lightning on Relentless Health Value. We tend to cover lots of ground pretty fast. So, sometimes I like to, with great intention, sum up what's been said—really lock into the big revelations, the big points made, the through lines. For a full transcript of this episode, click here. If you enjoy this podcast, be sure to subscribe to the free weekly newsletter to be a member of the Relentless Tribe. I like to do this so that points stick in my mind and I remember them and can build on them later. I am thinking you like this, too, because actually our through line shows in the past have been pretty popular. But this, today, is not your average through line show. I am trying something new and actually playing clips of earlier episodes so that you can recall what a guest may have said exactly and specifically and also really see the ways that episodes may interlock. So, to that end, let me just get to it and tell you the four core concepts to buy or deliver the highest-value healthcare that we will cover today. Core Concept 1: Buy healthcare. And by the way, health insurance is not healthcare. Jonathan Baran talks about that, and then Cynthia Fisher, Mark Newman, and Justin Leader cover the why, which is billions of dollars. Core Concept 2: When buying said healthcare, avoid the myth of less expensive healthcare. What is the myth of less expensive healthcare? Well, there's a lot of them, actually. One myth is that low price means low quality. Wrong. Most of the time there is actually no correlation between price and quality, but sometimes less expensive is higher quality. Also, low quality can be the most expensive care irrespective of the cost. Also, the same exact healthcare service or product can cost wildly different prices. Just keep that in mind. You'll hear Elizabeth Mitchell; Sam Flanders, MD; Shane Cerone; Jerry DiMaso; Ivana Krajcinovic, PhD, talk about this, this whole idea of when buying healthcare, avoid the myth of less expensive healthcare. Core Concept 3: So, of course, at this point, direct contracting enters the building. Because direct contracting between ultimate buyers of healthcare (meaning plan sponsors like self-insured employers etc.) and the actual purveyors of healthcare (meaning clinicians) is a fairly obvious strategy if we're going to try to get high quality at a fair price. I mean, get the beginning and the end of the road together. When you do that, it not only can spotlight—and thereby help eliminate—who might be low value that's sitting in the middle of the road collecting tolls like a toll booth, but it also enables collaboration in other ways, really, between the ultimate purchasers and the ultimate deliverers of care. Because there can be conversations about integration. There can be goals and then work out issues together, right? Collaboration is the next breakthrough innovation. So, that's our Core Concept 3: Consider direct contracting or even just, you know, as a start, go talk to, if you're a self-insured employer or you're a purveyor of care, go just find somebody to have a conversation with. Go talk to each other. Just have a chat. And I might include pharmacies, actually, in that mix. It's amazing what can happen, actually, when those buying care and selling care sit in the same room. In this number three core concept, consider direct contracting, we hear again from Ivana Krajcinovic but then also from Ryan Jacobs, Adam Stavisky, and then lastly, we have a quote from Ryan Wells. Core Concept 4: When direct contracting, or otherwise purchasing healthcare, buy the highest-value healthcare. How is that for an aspirational goal? But really, what do you want a direct contract for? What do you want your partners to be accountable to deliver? And what's rolled up into all of that? What is value? What is value, right? We go there, and when I say we, I mean we hear from Mick Connors, MD; Dr. Siva, otherwise known as Ahilan Sivaganesan, MD; and then we have Kenny Cole, MD, to bring us home. We finish up really at a very human level for why all of this matters. So, in summary, here's our four concepts. When you buy healthcare, buy healthcare. Focus on what you're actually getting for your money and how you are buying it. When you do that, direct contracting starts to make some sense. Just make sure the care that you are buying is truly high value. That's the whole shebang in a nutshell. One more thing before we kick into this. So, yeah, while I was quietly contemplating the vast universe of things gone wrong and right in the healthcare sector, Tom Nash, our producer extraordinaire, wandered in and asked me to try out his new Relentless Health Value Chatbot that he's been working on possibly 18 hours a day, including weekends ever since the incident with Michelle Bernabe and the AI futurist philanthropist, which you can hear all about ...
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    34 mins
  • EP506: How Other Employers, Shareholders, and Clinics Are Using Price Transparency Data—And It's an Arms Race, With Jerry DiMaso

    EP506: How Other Employers, Shareholders, and Clinics Are Using Price Transparency Data—And It's an Arms Race, With Jerry DiMaso
    Apr 9 2026
    So, we have a few miniseries afoot here on Relentless Health Value right now, and one of them is "The Inches That Are All Around Us"—finding the hidden fees, the hidden friction for plans and members and clinics themselves a lot of times in those inches. For a full transcript of this episode, click here. If you enjoy this podcast, be sure to subscribe to the free weekly newsletter to be a member of the Relentless Tribe. So, how does transparent pricing data fit in here? Well, you can use it to find inches. They are all around us. You can see it in this data. So, we talk about self-insured employers, plan sponsors, and their perspective on this price transparency data first in the conversation that follows. And then we get into the perspective of the provider organization or the clinic. Let's take this from the top. Plan sponsors such as self-insured employers or unions can gain three very interesting and maybe underappreciated insights from this price transparency data. Not limited, of course, to these three insights, but these were the three that Jerry DiMaso talked about; and I lasered in on them with very single-minded ambition. Okay … so, here's the three insights of interest to plan sponsors. (1) Benchmarking against a plan sponsor's competitors. We often forget about this, that every self-insured employer is actually a company trying to sell something, probably with competitors. You can search for your own plan or a competitor's plan using an EIN to compare rates, specific carve-outs, and identify if there are other companies in the same industry that are receiving better pricing. Considering that paying for health benefits is often the second-biggest line item on many corporate balance sheets, I wonder how long it's going to take for some activist shareholder group to figure out that they can find evidence of avoidable overspending. Especially because of our number two insight here, which is (2) you can use this data to identify high-cost codes. Plan sponsors can pinpoint specific billing codes where they are paying way too much. And right now (maybe you are, too) but I am thinking about the examples of infusions given in the recent episode with Ivana Krajcinovic, PhD (EP501) and that Brian Cotter talks about all the time. Also Nate Walker. Plans paying a million dollars too much for some infusion. That would be a crazy thing for a corporate shareholder to figure out and bring up at some, I don't know, shareholder meeting or earnings call, right? (3) Exposing the, I'm gonna call it, "discount shell game." This data allows plan sponsors to see through stuff like gross aggregated discounts. They can verify if a TPA's, I don't know, 90% discount is actually real savings. Okay … so, what does one then do with these insights once found? Jerry DiMaso, again, my guest today in the conversation that follows, talks through these at some length; but here's the very top line. First thing a plan sponsor can do is use this information to direct TPA negotiations. Plan sponsors can get their TPA to go back to providers and negotiate better rates. I did not know that. Number two thing that a plan sponsor can do with this information: Implement service carve-outs and direct contracts. Employers can identify expensive outliers and then steer and tier and maybe direct contract with specialized providers or Centers of Excellence as a result of that knowledge. As a second bit to this, not to be underestimated, this data allows for objective calculation of savings a lot of times from, you know, direct contracts or other initiatives so that plan sponsors don't have to rely on vendors to grade their own homework, as they say. Plan sponsors can start to do their own math. And here's the last thing that we discuss in the episode that follows that a plan sponsor can do with this price data: Model alternative plan types. Right? You can analyze whether switching from a PPO to an HMO or some other alternative model would save money while actually maintaining access to the same providers that employees are already using. Okay … so, now and in the conversation that follows, at this moment, we pivot to clinical organizations and how they can use this information. And by the way, although what we talk about next is of great interest to clinical organizations, lots of this is also still relevant to self-insured employers because, right, any ultimate purchaser does not want the independent practices to go outta business. So, helping them make sure that they can stay in business is in everyone's best interest. I talk about this coming up with Patrick Nelli from Aligned Marketplace, and I talked about it with Dan Greenleaf from Duly in an episode. Indie practices are just cheaper than consolidated health systems. If they go out of business, now all of the volume goes to consolidated health systems who now well and truly have a monopoly and all the glorious, unchecked pricing opportunities that go along with that. Anyway. ...
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    36 mins
  • EP505: The Death of the "What Is Value" Guessing Game for Clinical and Plan Decision-Makers Ready to Move On, With Ahilan Sivaganesan, MD

    EP505: The Death of the "What Is Value" Guessing Game for Clinical and Plan Decision-Makers Ready to Move On, With Ahilan Sivaganesan, MD
    Apr 2 2026
    Stacey Richter interviews neurosurgeon Dr. Ahilan Sivaganesan (Dr. Siva) about replacing vague healthcare "value" claims with quantified outcomes and unit-level costs, introducing his Operative Value Index (OVI). They discuss how hospitals often lack true internal episode costs and how common quality metrics miss patient-reported outcomes and appropriateness across the full care journey. Using time-driven activity-based costing (TDABC) and condition- or procedure-specific patient-reported outcomes, OVI creates a common mathematical language to compare surgeons, practices, or health systems, risk-adjust for confounders, and support steering/tiering and direct contracting for self-funded employers. Siva describes transparency via bubble charts that spur clinician behavior change without new incentives and argues this infrastructure is essential as bundled payments and risk-based arrangements expand, framing a "Yahoo vs Google" shift from fee-for-service volume to measurable value. === LINKS === 🔗 Show Notes with all mentioned links: https://cc-lnk.com/EP505 ✉️ 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= 🎤 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/ 00:00 Introduction to this episode. 00:38 The goal of this episode. 01:28 What the Operative Value Index (OVI) is. 02:04 A quick episode overview. 04:23 EP434 with Benjamin Schwartz, MD, MBA. 04:44 How this episode came about. 09:24 How Dr. Siva got involved in the research around outcomes and costs. 11:51 How the value equation doesn't add up to true quality. 14:12 What measuring quality across the entire care journey means. 15:00 EP326 with Rishi Wadhera, MD, MPP. 15:08 EP295 with Rebecca Etz, PhD. 16:07 Why appropriateness is the foundation of quality. 19:08 Why practicing clinicians need to be thinking about the true costs of delivering care. 21:20 Time-driven activity-based costing (TDABC). 23:44 The two things that must be known for value-based care to succeed. 24:06 Article by Dana Prommel Strauss. 27:09 A quick summary of the conversation thus far. 30:42 The power of transparency in Dr. Siva's bubble plots. 32:39 EP449 with Marty Makary, MD, MPH. 34:05 Why these bubble plots work not just at the procedural level but at the diagnosis level, too. 36:13 EP503 with Ryan Wells; Leo Spector, MD, MBA; and Adam Stavisky. 36:21 EP501 with Ivana Krajcinovic, PhD. 36:30 EP398 with Jacob Asher, MD. 37:28 The "big blue ocean" opportunity for forward-looking providers. 38:52 Substack post by John Lee, MD. 40:37 The incredible opportunity for entities and groups that can help provide the infrastructure needed for this value index. 41:42 Essay written by Dr. Siva. 43:19 Last thoughts by Dr. Siva on TDABC and competition on value.
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    44 mins
  • EP504: A Back-to-Basics Roadmap Through the Perverse Incentives to Advanced Primary Care, With Ryan Jacobs

    EP504: A Back-to-Basics Roadmap Through the Perverse Incentives to Advanced Primary Care, With Ryan Jacobs
    Mar 26 2026
    Why Advanced Primary Care Doesn't Scale: Conflicting Incentives, Complacency, and a 3-Step Roadmap Stacey Richter interviews Ryan Jacobs (SVP Strategy and Partnerships, Marathon Health) on why evidence-backed advanced primary care (APC)—focused on managing risk, improving outcomes, and lowering costs—still isn't widespread. They argue APC struggles to scale due to two root barriers: conflicting fiduciary duties (health systems and payers driven by volume, "heads in beds," and market-power growth, while APC keeps patients out of hospitals) and a "black box of complacency," where innovators often lose to the status quo because dominant organizations can rationally avoid investing without gaining share. Jacobs offers a three-step roadmap: perform a reality-based assessment by following the money and identifying who is financially harmed by prevention; anticipate stakeholders' math by framing value as CFOs, benefits leaders, and plan sponsors do; and proceed from strategic conclusions such as direct contracting to bypass misaligned intermediaries. === LINKS === 🔗 Show Notes with all mentioned links: https://cc-lnk.com/EP504 ✉️ 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/ 00:00 A refresher on advanced primary care (APC). 02:36 Why APC isn't everywhere. 04:39 The problem of complacency in the healthcare system. 05:27 Ryan Jacobs' roadmap. 08:59 The pitfalls of advanced primary care. 09:58 What primary fiduciary responsibility means. 10:51 Growth on the payer side. 11:51 SUMS5 with Jacob Asher, MD. 12:36 EP483 (Part 1 and Part 2) with Jonathan Baran. 12:48 EP465 with Chris Crawford. 13:27 The reality of the healthcare system in the United States. 14:11 The flywheel created by the tension within the healthcare system. 15:25 EP391 with Scott Conard, MD. 15:51 The tension between APC's goals and fiduciary responsibility. 17:52 The black box of complacency. 19:25 EP436 with Elizabeth Mitchell. 20:05 What's driven most of the change in the advanced primary care space. 20:54 EP398 with Jacob Asher, MD. 21:01 What would happen if there was a functioning market in healthcare. 21:41 EP286 with John Rodis, MD, MBA. 21:52 Why complacency may be a rational move in healthcare. 22:41 EP438 with John Lee, MD. 23:22 A roadmap to success in advanced primary care. 23:55 Step 1: Follow the money. 24:50 Step 2: Someone's gonna do math. 25:17 What strategic thinking looks like as an employer. 28:34 Step 3: Proceed based on strategic conclusions. 30:20 How self-insured employers have created their own market. 31:07 The strategic decision for physicians wanting to create change. 32:25 A reiteration of the episode's discussion. 33:49 Better payment structures.
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    34 mins
  • Insights to Outwit the Hot Mess of the Non-Healthcare Market

    Insights to Outwit the Hot Mess of the Non-Healthcare Market
    Mar 19 2026
    In this Inbetweenisode, Stacey shares listener feedback and reflects on making better decisions in employer-sponsored healthcare, spotlighting LinkedIn posts by Ken Wosczyna and Michelle Bernabe. Ken argues Relentless Health Value moves from theory to practical transformation by sharpening judgment, which Stacey ties to how millions of workplace decisions shape the healthcare system and how actuaries and executives can align choices with values. Stacey emphasizes that good decisions require both transparency and understanding, previewing an upcoming episode with Jerry DiMaso about using transparency files to compare what peer companies pay, and citing examples of misleading "transparency" through complex contracting and financialization (e.g., CABG pricing and PBM tactics). She also questions what "disruption" means when the status quo already harms access. Stacey highlights direct contracting, Centers of Excellence, and upcoming advanced primary care episodes. === LINKS === 🔗 Show Notes with all mentioned links: https://cc-lnk.com/INBW46 ✉️ 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/ 00:00 Introduction: trying something new with this inbetweenisode. 01:29 "Insight is common. Execution is rare.": a LinkedIn post from Ken Wosczyna. 03:02 SUMS8 with Larry Bauer, MSW, MEd. 03:08 The power of the C-suite versus the decision power of workers. 03:45 SUMS7 with Keith Passwater and JR Clark. 04:00 The power of actuaries to align with values. 04:50 Rate criticals for fixing the nonexistent healthcare market. 05:50 EP501 with Ivana Krajcinovic, PhD. 06:56 Why you can't fix what you don't understand. 07:46 EP472 with Eric Bricker, MD. 09:27 A comment from Craig Herndon. 10:44 Why avoiding disruption and problems with access can create disruption and problems with access. 12:22 A LinkedIn post from Michelle Bernabe. 12:26 EP500 with Stacey. 15:56 Looking ahead: topics future episodes will be covering. 16:07 EP503 with Ryan Wells; Leo Spector, MD, MBA; and Adam Stavisky. 17:08 A Web site/app for Relentless Health Value episodes. 18:24 EP480 with Kimberly Carleson. 19:22 Check out this episode's sponsor.
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    20 mins
  • EP503: Smart Collaboration With Direct-to-Employer Specialty Care, With Ryan Wells; Leo Spector, MD, MBA; and Adam Stavisky

    EP503: Smart Collaboration With Direct-to-Employer Specialty Care, With Ryan Wells; Leo Spector, MD, MBA; and Adam Stavisky
    Mar 12 2026
    Episode 503 of Relentless Health Value features Stacey Richter with Adam Stavisky, Dr. Leo Spector (OrthoCarolina), and Ryan Wells (Health Here) discussing how self-insured employers and specialists rarely connect directly due to intermediaries and fee-for-service "rails." They outline three common pitfalls when bridging this gap: defining and measuring quality and appropriateness (limits of claims data and missing patient-reported outcomes), achieving scale across geographies and specialties, and ensuring benefit design and incentives so members actually use direct-contracting programs. The conversation frames the evolution of Centers of Excellence from 1.0 (travel to brand-name hospitals) to 2.0 (more local but administratively manual) to 3.0 (new infrastructure enabling direct, efficient contracting). Health Here is described as a digital bridge to support payment and communication pathways and reduce administrative waste. === LINKS === 🔗 Show Notes with all mentioned links: https://cc-lnk.com/EP503 ✉️ 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/ 00:00 Introduction. 00:32 Collaboration as the next breakthrough innovation. 02:24 A summary of the upcoming conversation. 05:45 A summary of where we are and what the future looks like. 06:24 A relevant post from Jonathan Baran. 08:12 The conversation with Ryan Wells, Dr. Leo Spector, and Adam Stavisky: collaboration from the standpoint of a specialist. 12:22 The pitfalls of data accuracy and defining what quality means from the POV of a self-insured employer. 15:36 Defining quality and data accuracy from the POV of a physician. 15:57 How do you measure outcomes when assessing quality and looking at the available data? 21:45 EP294 with Steve Schutzer, MD. 22:06 Scale and operationalization: How do we do it? 27:00 Shout-out to OrthoForum. 29:58 Take Two: EP398 with Jacob Asher, MD. 30:13 EP501 with Ivana Krajcinovic, PhD. 30:30 How things could be better. 33:29 One last complication and how to structure benefit design to align incentives. 35:33 What an "anti-cricket" program looks like. 37:24 EP308 with Mark Fendrick, MD. 37:34 How do we operationalize benefit design and aligned incentives? 39:39 What we're seeing today in Centers of Excellence 2.0. 41:47 What Adam wants to make clear in all of this.
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    46 mins
  • EP502: How Some Pretty Wild Medicare Fraud Sabotages ACOs and Also Independent Practices and Could Cost Plan Sponsors Such as Self-insured Employers a Lot of Zeros Downstream, With Brian Machut

    EP502: How Some Pretty Wild Medicare Fraud Sabotages ACOs and Also Independent Practices and Could Cost Plan Sponsors Such as Self-insured Employers a Lot of Zeros Downstream, With Brian Machut
    Mar 5 2026

    Episode 502 features Stacey's conversation with Brian Machut (Alliant Health) on how widespread Medicare fee-for-service fraud is inflating costs and undermining ACO shared savings in MSSP and ACO REACH. ACOs uncovered major urinary catheter fraud in 2023 tied to codes A4352/A4353, totaling about $3.5B, with some beneficiaries billed for items never received (including a case shared by Dr. Tara Lagu).

    CMS created a "SAHS" (significant, anomalous, highly suspect) process to remove certain suspect costs, but benchmark effects can unevenly impact ACOs; catheter fraud is still projected at $3–$3.5B in 2025. The episode also highlights rapidly growing "skin substitute" spending projected at $13–$15B in 2025; CMS did not classify 2024 skin substitute costs as SAHS, leaving them in ACO performance calculations.

    Machut explains this fraud and missed CMS trend projections can reduce provider earnings, discourage participation in value-based care, and potentially drive cost shifting into higher commercial rates—affecting plan sponsors such as self-insured employers.

    === LINKS ===
    🔗 Show Notes with all mentioned links:
    https://cc-lnk.com/EP502

    ✉️ 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/
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    00:00 One way hackers are using medical data to commit Medicare fraud.

    01:49 What today's conversation with Brian Machut entails.

    02:16 The downstream impact that this Medicare fraud can have.

    03:30 A brief outline of how plan sponsors can be affected by this Medicare fraud.

    06:38 What does a value-based actuary do?

    08:04 The conversation with Brian Machut: What caused his team to look into DME costs and uncover Medicare fraud?

    08:46 How much did this fraud scheme cost organizations in 2023?

    09:57 How this data was tracked down and uncovered.

    11:13 How fee-for-service ACOs work, and why this Medicare fraud affected the ACOs' shared savings.

    12:46 The two codes that were the target of this fraud.

    15:13 Across the U.S., how much money in 2023 did this fraud, waste, and abuse cost, and what was done about it?

    16:14 The framework that was created to combat this fraud spend.

    17:49 Why the CMS decision to pull those expenditures negatively affected some ACOs.

    20:17 Where things stand now with this catheter fraud.

    21:33 Why this fraud is still able to happen.

    22:19 Is this a use case for prior authorizations?

    23:49 How this Medicare fraud affects self-insured employers and what they should keep in mind.

    25:12 What is the correlation to employee affordability?

    27:08 A cost that dwarfs the catheter Medicare fraud.

    28:21 A brief summary of skin substitutes.

    29:32 What SAHS means, and how CMS uses it to calculate an ACO's shared savings.

    31:21 Why CMS chose not to classify skin substitutes as SAHS.

    33:26 Why this fraud affects ACOs' prospective trend pricing risk.

    36:40 Why these fraud cases make participating in ACO programs less appealing to provider organizations.

    38:28 Medicare Advantage Advance Notice for 2027.
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    39 mins
  • EP501: Speaking of Infusions, Do You Want to Pay $135 or Do You Want to Pay $13,560 for the Exact Same Drug? With Ivana Krajcinovic, PhD

    EP501: Speaking of Infusions, Do You Want to Pay $135 or Do You Want to Pay $13,560 for the Exact Same Drug? With Ivana Krajcinovic, PhD
    Feb 26 2026
    Episode 501 of Relentless Health Value features Stacey Richter interviewing Ivana Krajcinovic, outgoing Vice President of Healthcare Delivery at Unite Here Health, about extreme and persistent price variation for medical infusions as evidence of a "no market" in healthcare. They cite examples where the same chemotherapy drug (Oxaliplatin), long off patent, cost Medicare about $35 (or $185 for a series), an independent practice about $135, but a hospital in Chicago charged $13,560 and a hospital in Monterey billed $90,000 for a series—markups described as up to nearly 500x and far beyond Medicare. The discussion highlights how these prices create major member affordability problems through co-insurance and reduce funds available for wages, with one Monterey analysis showing nearly $1 million in annual savings by moving just two patients to an independent oncology practice. They argue that functioning markets would rationalize prices and that carrier networks often fail as a demand curve, showing apathy and relying on broad "discount" negotiations even when prices differ by hundreds of times, including cases within the same health system. Krajcinovic describes a roadmap to fight back: drill into claims data, push back on providers and networks, use benefit design to steer site of care, carve out utilization management and case management to support member navigation, and pursue direct contracts with independent practices. They also discuss the "whack-a-mole" dynamic of hospital pricing and the value of collective action, media attention and regulatory forums such as California's Office of Health Care Affordability. === LINKS === 🔗 Show Notes with all mentioned links: https://bit.ly/Episode501 ✉️ 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 📺 Subscribe to our YouTube channel https://www.youtube.com/@RelentlessHealthValue 🎤 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/ 00:00 $135 vs $13,560: How infusion drug prices play into the "Inches All Around Us" series. 02:02 How infusion drug pricing fits into the "No Market" series. 03:19 A roadmap and more episodes on this topic. 04:36 Introducing this week's expert, Ivana Krajcinovic, PhD. 05:10 A must-read Bloomberg News article on infusion pricing. 05:33 An overview of what to expect from this episode. 06:54 The first tell of the infusion nonmarket. 07:41 The price variations that Ivana has seen in the infusion nonmarket. 11:39 How hospital spend affects wage increases affects patients and employees twice over. 12:04 EP373 with Cora Opsahl. 13:43 The second tell of the infusion nonmarket. 14:33 Take Two: EP398 with Jacob Asher, MD. 14:55 EP483 with Jonathan Baran. 16:15 Why networks are apathetic to this pricing discrepancy. 17:55 The factors that play into the nonmarket issue of infusion drug pricing variations. 18:26 EP475 with Peter Hayes. 19:18 EP370 with Erik Davis and Autumn Yongchu. 19:45 Are pricing discrepancies easy to spot? 22:38 Where we have power in a nonmarket situation. 23:22 A recap of the advice in the show so far. 23:39 EP493 with John Quinn. 23:41 EP496 with Mark Newman. 25:51 How you place pricing pressure on an entity. 28:47 EP482 with Preston Alexander. 29:34 How an improved market creates time for better care coordination. 30:52 EP486 with Stan Schwartz, MD. 33:23 The fourth part of the roadmap. 36:41 EP492 and EP490 with Sam Flanders, MD, and Shane Cerone. 36:49 Why serving the community and being fiscally responsible should go hand in hand. 38:05 EP500 with Stacey.
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    40 mins