Relentless Health Value
EP503: Let's Go From Lazy PPO Networks to Smart Collaboration With Direct-to-Employer Specialty Care, With Ryan Wells; Leo Spector, MD, MBA; and Adam Stavisky
Why It Matters
Bridging the gap between plan sponsors and specialists could dramatically reduce healthcare waste, lower costs for employers, and raise care quality for patients. As self‑insured employers face rising expenses, the episode’s discussion of scalable, data‑backed direct contracting offers a timely roadmap for a more sustainable U.S. health system.
Key Takeaways
- •Direct contracts link employers to specialist providers, bypassing carriers.
- •Quality hinges on data accuracy and patient-reported outcomes.
- •Scaling requires new payment rails beyond fee‑for‑service.
- •Center of Excellence 3.0 envisions integrated, automated collaboration platform.
Pulse Analysis
The episode opens by exposing how traditional PPO networks leave self‑insured employers and specialist providers stranded on opposite sides of a congested healthcare road. Without direct dialogue, plan sponsors rely on carriers, ASOs, and TPAs, creating opaque pricing and variable quality. Guests argue that true collaboration—direct contracting—cuts through these layers, aligning purchasers with clinicians to drive value‑based care and reduce the administrative waste that inflates costs.
A central hurdle is defining and measuring quality. The panel highlights the need for robust data, including patient‑reported outcome measures (PROMs), to differentiate appropriate care from over‑utilization. Vendors now aggregate millions of claims to flag low‑performing physicians, but without outcome data the picture remains incomplete. Accurate metrics enable employers to avoid the bottom quality decile and incentivize specialists to adopt best‑practice pathways.
Scaling this model demands new payment rails beyond fee‑for‑service. The discussion walks through three Center of Excellence iterations: 1.0’s referral‑only model, 2.0’s expanded local networks still shackled by manual reconciliation, and 3.0’s vision of an integrated, automated platform. Companies like Health Here provide the digital bridge to automate contracts, data exchange, and risk adjudication, turning the “telephone game” into a seamless, transparent partnership. As the industry moves toward these smarter collaboration frameworks, employers can expect lower waste, higher quality, and a more predictable cost structure.
Episode Description
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
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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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