In Episode 459, host Stacey Richter speaks with healthcare attorney Bill Sarraille about co-pay maximizers and accumulators, mechanisms designed to extract maximum co-pay support dollars from pharmaceutical companies.

They discuss the financial implications for patients, plan sponsors, and pharmacy benefit managers (PBMs), emphasizing the legal and ethical issues and potential patient harm due to high out-of-pocket costs and surprise expenses.

Sarraille provides five key pieces of advice for plan sponsors and highlights the importance of transparency and proper utilization management to minimize patient access problems and legal risks. Listen or read the show notes on our site for the full list.

(continued below the links)

=== LINKS ===

🔗 Show Notes with all mentioned links:
https://cc-lnk.com/EP459

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Co-pay maximizers and accumulators are programs designed to capture maximum co-pay assistance from phara. Maximizers spread pharma co-pay support evenly throughout the year, ensuring plan sponsors benefit while, in theory, patients face minimal costs. More on how that can go wrong in the episode.

Accumulators, however, design their plan to deplete pharma dollar support quickly, surprising patients with significant out-of-pocket expenses mid-year when they go visit the pharmacy.

These programs usually exclude pharma assistance dollars from deductibles, potentially causing financial hardship because when pharma is paying your co-pay, those payments don't count against your deductible.

09:31 What should plan sponsors be aware of right now?

14:01 What is the justification for maximizers, and why is this at odds with the purpose of insurance?

18:05 Where does the issue of “fairness” land within cost containment?

20:00 Brian Reid’s LinkedIn post on insurance company access challenges.

21:30 What are the real legal issues presented by some of these co-pay maximizers and co-pay accumulator programs?

27:06 How are these programs creating perverse incentives?

29:28 EP450 with Marilyn Bartlett, CPA, CGMA, CMA, CFM.

32:16 “If you’re covered by the ACA, I think this is unlawful.”

32:57 What advice does Bill have in regard to these programs?

33:49 What potential litigations does Bill see coming in the near future in regard to these co-pay maximizers and co-pay accumulator programs?

In this Inbetweenisode titled 'End of Year Wrap Up and My Personal Charter Encore,' Stacey Richter extends heartfelt thanks to listeners and healthcare workers for their dedication.

She reflects on the challenges of maintaining personal integrity in a profit-driven healthcare system and introduces her personal charter. This charter, focused on ensuring net positive outcomes for patients, acknowledges that achieving transformational change in healthcare requires a collective effort.

Stacey discusses the complexities of balancing ethical decisions, financial constraints, and the broader impact on patient care, urging others to reflect on their own guiding principles.

Here's her manifesto which she is now calling her Personal Charter below which she breaks down in this podcast episode:

"If the thing results in a net positive for patients, then I will do it. The timeframe is short-term or medium-term. And the assumption is that it will take a village and I am not alone in my efforts to transform healthcare or do right by patients."

=== LINKS ===

🔗 Show Notes with all mentioned links: https://cc-lnk.com/INBW41

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06:52 “It’s a zero-sum game.”

07:02 Is the amount of profit fair?

07:13 What is an inescapable fact of the healthcare industry?

07:30 What does the financialization of healthcare mean?

07:55 Why does the self-interest in healthcare matter?

09:54 “It’s basically up to us as individuals to do the right thing.”

13:39 What is the first part of Stacey’s personal charter?

13:54 How does Stacey calculate the net positive of an impact?

14:17 What are two major upsides/downsides that Stacey contemplates?

17:08 Why are incremental change and disruptive change not mutually exclusive?

21:16 “I always try to keep in mind that it will take a village.”

22:55 Why finger pointing is killing innovation in healthcare.

Are you on the board of directors of a company? Or are you a shareholder of a publicly traded company? Or are you a CEO or a CFO or in-house counsel who reports to a board of directors or these shareholders? Well, this show is for you.

And it’s about how the healthcare industry has become financialized at the same time that providing health benefits has become the second-biggest line item after payroll for most companies. We talked about that in a recent encore with Mark Cuban (EP418) also, as well as the show with Cora Opsahl (EP452) and Claire Brockbank (EP453) from 32BJ.

In this encore episode of 'Relentless Health Value,' Stacey Richter interviews Andreas Mang from Blackstone about the financialization of health benefits for boards of directors and C-suites of self-insured employers.

They discuss the unseen financial layers in healthcare benefits and how companies can save significantly while improving employee satisfaction and health.

=== LINKS ===

🔗 Show Notes with all mentioned links: https://cc-lnk.com/EP458

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04:55 Why Andreas starts every conversation with the question, “How’s your healthcare company?”

07:38 Why is it important, as a self-insured employer, to treat your business as a small healthcare company?

09:16 Why is it unnatural for companies to be providing health insurance?

10:47 What can be achieved when there is alignment between employers and insurers?

12:41 What things can a company do to reduce spend by 10%?

14:14 Why is it better to have CFO engagement in the benefits plan throughout the year?

16:25 Why does self-insurance save 5% to 9% for companies automatically?

18:14 “The funding isn’t a healthcare thing; it’s a CFO thing.”

18:27 Why is it vital to have a reliable, trustworthy broker?

25:12 When is the last time your company has RFP’d their health plan?

27:39 Why does changing a health plan feel scary but is necessary?

28:31 What is a dependent eligibility audit?

31:20 Why are employers better together?

34:34 How do employers truly get a flat-fee model with brokers?

In Episode 458 of Relentless Health Value, host Stacey Richter speaks with Dr. Komal Bajaj about innovative strategies for addressing staffing shortages in the healthcare sector. They explore the importance of cultural alignment within organizations, emphasizing trust and shared values to retain staff.

Dr. Bajaj shares surprising findings from surveys indicating that healthcare workers are motivated by the goal of providing high-quality, planet-friendly care. The discussion highlights the interconnectedness of environmental sustainability and healthcare quality, presenting tangible ways to engage and empower healthcare workers while addressing both local community health and broader environmental concerns.

The episode underscores the strategic importance of aligning organizational goals with the aspirations of the workforce to foster trust and mitigate staffing shortages.

Stacey's guest today is Dr. Komal Bajaj. Dr. Bajaj is an ob-gyn who serves as the chief quality officer for a couple of hospitals in the Bronx, New York, that are part of the municipal health system of New York. She also now serves as medical director of sustainability for the municipal health system NYC Health + Hospitals.

=== LINKS ===

🔗 Show Notes with all mentioned links:
https://cc-lnk.com/EP458

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08:20 How do we quantify the issue of staffing shortages?

11:18 Why do we need to look at the root cause of the shortages?

11:51 Deloitte survey on staffing shortages.

11:54 Why is trust one of the core problems when it comes to staffing shortages?

13:59 “Healthcare workers have choice.”

15:34 What are the strongest correlations that influence healthcare workers’ desire to stay?

18:17 What things give healthcare workers the most pause?

19:36 The U.S. Department of Health and Human Services Health Sector climate pledge.

20:20 The Commonwealth Fund survey on what health systems can do to address climate change.

22:29 What do we do about sustainable, climate-friendly healthcare being a driving factor in staffing?

27:28 How do you meet the desires of healthcare workers where they’re at?

In this episode of 'Relentlessly Seeking Value,' host Stacey Richter is joined by healthcare entrepreneur Cynthia Fisher to discuss the crucial issue of medical spread pricing and the need for contract transparency.

Fisher explains how hidden fees and spread pricing by middlemen are leading to substantial overcharges for employers and patients in the U.S. healthcare system. The conversation delves into recent lawsuits that highlight these practices, the legislative strides made to enforce price transparency, and how transparency can potentially transform the industry.

Look, this is a thing now, medical spread. And similar to how PBM spreads adds up to millions, billions of dollars, medical spread is not change in the couch cushions. Did you see the lawsuit against Cigna? Cynthia Fisher mentions it in the conversation that follows. Spoiler alert, here’s the numbers: Self-insured employer paid $4 million for a claim.

There’s a slide on this Cynthia Fisher gave me, by the way, if you want to see all this written out. So, the employer pays $4 million. The provider was paid—drumroll, please—$876,000. I’m pausing so that sinks in: $4 million paid by the employer; $876,000 of that makes it across the trench to the provider.

To view the meme we created for how carriers are learning to do spread pricing from the PBMs, visit our show notes page below. (continued after the links below)

=== LINKS ===
🔗 Show Notes with all mentioned links:
https://cc-lnk.com/EP457

✉️ Enjoy this podcast? Subscribe to the free weekly newsletter:
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Fisher emphasizes the importance of employers and unions demanding accountability, using existing laws to unveil true pricing, and advocates for a revolution in healthcare to ensure fair, equitable, and transparent billing. Insights are also shared from industry experts who were previous guests including Chris Deacon, Justin Leader, and Andreas Mang. You can find the links in the show notes on our site.

09:03 What is the goal of PatientRightsAdvocate.org?

10:28 Is American competitiveness being affected by healthcare spend?

13:47 Why is transparency a root cause to healthcare costs?

15:11 What’s going on across the country to empower transparency in healthcare?

19:31 “I think people are fed up.”

21:22 The Cigna lawsuit in California.

26:36 How do employers navigate contracts against anti-steering?

28:54 EP419 with Andreas Mang.

29:33 EP452 with Cora Opsahl and EP453 with Claire Brockbank.

29:45 EP433 with Justin Leader.

You can learn more at PatientRightsAdvocate.org.

In this encore episode, Mark Cuban discusses his insights and experiences on disrupting the healthcare and pharmacy benefits landscape with Stacey Richter. This show from last year was one of the most popular episodes of the past year. And it’s also extremely relevant right now, given all of the PBM (pharmacy benefit manager) goings-on, as well as ongoing litigation like the J&J lawsuit, etc. Listen to the show with Julie Selesnick (EP428) for more on that one.

You can find the show notes with all links mentioned and a transcript on our episode page.

If you enjoy this podcast, be sure to subscribe to the free weekly newsletter to be a member of the Relentless Tribe.

Joined by Ferrin Williams from Scripta, Cuban stresses the importance for CEOs and CFOs of self-insured companies to get actively involved in their healthcare plans to avoid overpaying. The conversation tackles the opaque practices of PBMs, the financialized nature of the healthcare industry, and introduces Mark Cuban's Cost Plus Drugs model which aims for transparency and cost reduction.

Key topics also include the potential legal implications for employers, the importance of trust in healthcare transactions, and the real-world savings and benefits achievable with greater involvement and transparency in healthcare management.

What do all of these numbers have in common: $140,000, $3 million, $35 million, and $3 billion?

These are all actual examples of how much employers, unions, and some public entities saved on healthcare benefits for themselves and their employees. The roadmap to saving 25% on pharmacy spend and/or 15% on total cost of care in ways that improve employee health and satisfaction always begins when one thing happens. There’s one vital first step.

That first step is CEOs and/or CFOs or their equivalents roll up their sleeves and get involved in healthcare benefits.

Read the full article/show notes with all the mentioned links here:
https://cc-lnk.com/Encore418

06:29 What was Mark Cuban’s own journey as a self-insured employer with Cost Plus Drug Company?

07:44 What did Mark find when he decided to go through and look through his company’s benefit program?

09:12 “When you think it through, you start to realize that money is being spent primarily by your sickest employees.” —Mark

10:02 How do you get CEOs and CFOs of self-insured employers to realize that their sickest employees are the ones subsidizing their checks?

13:00 What is the role of insurance in healthcare?

14:30 “If you can’t convince them, confuse them and hide it.” —Mark

15:24 The reality behind getting a rebate check.

16:21 Why are rebates going away, and why isn’t that changing PBM earnings?

19:05 How do you get CEOs and CFOs to dig into their benefits plan?

20:59 Does morally abhorrent move the needle?

21:33 “What we’re trying to do is just simplify the [healthcare] industry.” —Mark

24:19 What’s been changing in consumer behavior?

25:04 “Transparency is a huge part of building that trust.” —Ferrin

25:19 Why CEOs and CFOs really have the power to change healthcare.

32:29 What are Cost Plus Drugs’ plans to expand?

39:21 Where is the future of the prescription drug market going?

42:09 What will happen to the prescription drug market in 10 to 20 years?

48:40 The wake-up call self-insured employers should be acknowledging now.

52:02 Where is the real change in the healthcare industry going to come from?