Evan Richardson, Founder and CEO of Form Health, shares how his time at Castlight and Grand Rounds/Included Health shaped a thesis that higher-quality care drives better outcomes and lower long-term costs, and why he built Form Health to scale obesity medicine before Ozempic went mainstream. 

They dig into the real-world gap in GLP-1 outcomes and persistence without wraparound care, Form’s high-touch telemedicine approach, and how employers and payers are grappling with explosive demand, falling cash-pay prices via LillyDirect/NovoCare, and center-of-excellence models to control spend and prove ROI.

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They note that about half of U.S. children are covered by Medicaid/CHIP and describe how lower Medicaid reimbursement contributes to pediatric “care deserts,” worse access, and higher emergency and inpatient use. Glazier highlights rising prevalence of obesity, type 2 diabetes, metabolic syndrome, and behavioral health conditions including anxiety, depression, ADHD, and autism. 

Bluebird’s model emphasizes evidence-based, high-experience, whole-child care, supported by technology (Bluebird OS) for omnichannel access, hybrid virtual/in-person care, automation, and care pathways like asthma management. 

They discuss early-stage Medicaid value-based contracting focused on reducing avoidable utilization, state quality incentives, care coordination for complex kids, and plans for continued Florida growth and eventual multi-state expansion.

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Chris explains the roughly 40 bps increase, continued normalization of coding risk patterns, a delay in further model updates given V28’s early implementation, and the finalization of the unlinked chart review policy to curb risk-coding and revenue-cycle games. 

He frames “stability” as predictability for payers/providers and consistent choice and access for beneficiaries, while emphasizing program sustainability and a push to align growth with GDP. 

They discuss support for Medicare Advantage and broader accountable/value-based arrangements, cost control expectations for plans and providers, and an invitation for entrepreneurs and “insurgents” to enter the market and compete on cost-adjusted quality outcomes.

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As CMS pulls dollars out of the system, the key question becomes where that pressure lands—plans, providers, or beneficiaries—and Neil’s view is that the next phase will favor operators who can truly manage total cost of care rather than rely on favorable tailwinds. He shares how Greenbrook is approaching this moment with a full-risk, high-touch primary care model focused on seniors, built to perform under tighter margins and shifting incentives, and why periods of dislocation often create the best opportunities for disciplined, long-term builders.

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The conversation shifts to state Medicaid budget pressure, with Idaho and Colorado cutting provider reimbursements and limiting coverage programs, raising questions about payer profitability, consolidation, and regulator tradeoffs. 

Guests Neil Machhar (Green Brook Medical) and John Haskell (Sage Health) discuss full-risk primary care growth, payer relationships, and expanding into less-saturated markets. 

Quick deals: Avo MD, Yuzu Health, Jimini Health, Whoop, Noom, Jukebox/Braided, OpenLoop/Season, and Thatch/Venteur.

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Sam explains the difference between wraparound programs and clinician-led models that can diagnose and prescribe, noting GI access shortages and that many counties lack gastroenterologists. He describes Oshi’s virtual, nurse-practitioner-led care team—overseen by GI physicians and supported by dietitians, gut-brain specialists, and care coordinators—and how Oshi coordinates colonoscopy and other in-person procedures through referrals and partnerships. 

They discuss contracting lessons in commercial value-based arrangements, immediate cost savings from avoiding repeat workups and treat-and-release ER visits, strategies to build patient trust via testimonials and direct-to-consumer awareness, and plans to deepen local GI integration and use AI to improve efficiency and outcomes.

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Ben Kuhn, co-founder and CEO of Everbright Health, explains why these interventions haven’t become routine in independent practices: complex, frequently changing payer eligibility criteria, provider discomfort discussing specialized treatments, onerous prior auth, and the operational/compliance burden of running a new service line. 

Everbright Health positions itself as an AI-enabled MSO partner (not an acquirer), promising implementation in ~60 days by identifying eligible patients, managing education, prior auth/billing, and operations. The conversation also covers emerging therapies (psilocybin, PTSD treatment “Prism,” remote monitoring) and growing payer interest in outcomes/value-based models, citing data suggesting up to 50% total cost-of-care reductions when treatment resistance resolves.

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They discuss Thyme Care’s growth and care model: contracting with risk-bearing payers and entities to manage a claims-attributed oncology population, deploying a 500+ person wraparound care team to reduce avoidable acute care utilization, and partnering voluntarily with oncology practices on high-value drug interventions, waste minimization, and palliative/advanced care planning. 

Bradford also outlines contracting approaches using concurrent benchmarks and how Thyme Care uses AI mainly to automate back-office care workflows rather than patient-facing tools.

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Gray describes founding Ophelia after losing someone to overdose and argues MAT resembles long-term medication plus counseling but has been constrained by burdensome rehab-style requirements and limited prescribing capacity. Williams outlines his harm-reduction and research background and explains how new synthetic drugs, online access, and shipping have accelerated risk. 

They argue adoption lags due to fragmented care and Medicaid contracting, highlight Pennsylvania’s Center of Excellence as a workable reimbursement model, warn of SAMHSA and Medicaid funding pressures, and note how fee-for-service reimbursement limits innovation and AI adoption.

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A packed hour of health tech news: Kevin and Martin recap AHIP (the mood was grim), break down the MA final rates notice dropping any day now, and dig into the peptide/longevity boom reshaping consumer health. Plus two live guest interviews — Toyin Ajayi of Cityblock Health on why AI should be built for Medicaid first, not last, and Zach Kanter of Stedi on their $50M raise and what a billion claims a year looks like. Then a rapid-fire rundown of $581M in funding across 12 deals, including Qualified Health, Doctronic, eMed, and more.

In this episode:

• AHIP recap: MA gamesmanship, no-network plans, and the final rates notice
• Cityblock Health CEO Toyin Ajayi on AI + Medicaid
• Stedi CEO Zach Kanter on clearinghouses, Change Healthcare, and scaling to 1B+ transactions
• $581M in funding across 12 deals
• The peptide/longevity wave and what it means for health tech

Referenced this week: AHIP MMDC, CMS/CMMI, Stedi, Cityblock Health, Qualified Health, Thesis Care, Doctronic, eMed, Adonis, Blossom Health, Clasp, Dimer Health, Prax Health, Certuma, VITL

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They highlight widespread but shallow AI adoption which has the potential to widen gaps between best-in-class organizations that redesign processes, and laggards that “slap on” tools. 

They also discuss the finding that nearly 90% of providers expect labor costs per discharge to rise in 2026, driven by slow human/organizational change and persistent clinical labor pressures. 

They also discuss virtual care’s “next wave” as operationally embedded by specialty (e.g., behavioral health, OB/GYN, orthopedics), and growing payer-provider collaboration via specialty-focused risk/shared-savings models (e.g., kidney, cardiology) and improving interoperability as a path out of adversarial “bot vs bot” dynamics.

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Across the country, administrators, teachers, counselors, and perhaps if they’re lucky, a social worker or a nurse, find themselves helping students and their families navigate housing insecurity, hunger, and a healthcare system barely legible to people who do work in it for a living. Perhaps now more than ever, demand for mental health services is far outstripping supply making it harder for students and the adults who care for them to match kids with care.

I’ve got some personal experience with this from my time as a Teach For America corps member, which has made me especially interested in Marble Health’s mission and vision of personalized therapy for students. Here to talk about the realities of student mental health today, and how Marble Health is working with school counselors and Medicaid to meet this profound need, I’m excited to welcome Jake Sussman, cofounder and CEO of Marble Health.

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Ashul says their focus has been closing gaps in episodic, brick-and-mortar care by reaching patients at home, publishing outcomes, and now using AI to scale safely amid staffing constraints, including filtering remote monitoring data into actionable clinician decisions. 

They discuss Story Health by Innovaccer's partnership with Minneapolis Heart Institute/Allina to extend the CHAMP heart failure clinic model to rural and high-risk post-hospitalization patients, emphasizing workflow redesign and systemwide adoption. 

Ashul also covers Story’s fee-for-service and value-based economics, the CMMI ACO Access model’s promise and payment concerns, risks of fragmented care, and why AI’s cost-deflation impact will be gradual due to trust and technical limits.

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They’re joined by John Zutter, CEO of Lantern, who explains Lantern’s distributed “surgeons of excellence” approach versus traditional centers of excellence, its concierge patient experience, and how it selects providers using regulatory, clinical, appropriateness, and patient-reported outcomes data; he also shares context on Lantern’s $30M round and utilization-driven differentiation.

The episode also covers CMS remarks on steering beneficiaries toward accountable care relationships, early rollout challenges and backlash around Washington’s Wiser model and prior auth, a CMS timing change spurring state directed payment applications, and a funding/deal roundup including Doximity, Verily, Latent, Turquoise Health, Conduit Health, and Nadia Care, plus a stalled Qualtrics–Press Ganey deal due to debt markets.

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They discuss Medicaid as an under appreciated innovation lab, what makes pilots succeed or fail, and how state–managed care organization relationships have evolved into partnerships focused on accountability, risk, and care coordination—especially in Florida’s large managed-care program. 

Chris explains where value-based care works (defined populations, actionable data, simple contracts) and where it struggles (small cohorts, heavy admin burden), and how Medicaid-born models like telehealth and community-based care can diffuse into commercial and Medicare Advantage. 

He also offers guidance for policymakers, agencies, and startups: treat Medicaid as a platform, invest in data, reward outcomes, create safe pilot pathways, and lean into Medicaid rather than avoiding it.

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1. The US spends a lot more money than it takes in from tax revenue, quite a bit of which is on healthcare either through government funded programs or “tax expenditures” like the tax exclusion for employer sponsored programs
2. Like most services oriented professions, healthcare is subject to Baumol’s cost disease: “There is no technological change which can make an orchestra take less time to play a symphony - service industries don’t have the same productivity improvements as manufacturing industries” yet healthcare provider salaries need to rise despite the lack of productivity gains.
3. The American public isn’t inclined to pay more taxes or reduce service consumption or pay its healthcare providers less.

CMMI which was created by the Affordable Care Act to try and engineer some other, more palatable solution to this trilemma: i.e. “test innovative payment and service delivery models to reduce program expenditures under the applicable titles while preserving or enhancing the quality of care furnished to individuals under such titles.”

It would be charitable to call its record mixed with its portfolio netting out to cost the taxpayers much more money than it has saved. A few weeks ago, former CMMI senior adviser Ankit Patel wrote an article in Out Of Pocket called How to Fix CMMI Models which I thought was very good, and I was excited to welcome him to HTN radio to talk about it.

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He describes ending the Clear Pricing Project, arguing it raised costs despite showing members are highly price sensitive. The plan is boosting independent/rural primary care via networks paid ~160% of Medicare with reduced administrative burdens and shared savings, and is using Lantern to offer select elective surgeries at $0 member cost by shifting to much lower negotiated rates; 400 surgeries were completed with ~1,900 in the pipeline. Financially, projections improved toward a ~$450–$460M positive stabilization rate next year, with plans to expand “preferred provider” incentives across services.

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He outlines how CMMI kidney models have evolved from focusing on ESRD hospitalizations (CEC) to home dialysis and transplant incentives (ETC) and now earlier-stage CKD transitions (KCC), citing reported improvements like higher optimal starts, home dialysis use, and preemptive transplants, while noting open questions on cost effectiveness.

The conversation covers the growing landscape of kidney VBC operators beyond DaVita and Fresenius, the levers they use to manage total cost of care (care coordination, addressing social needs, avoiding hospitalizations), and early consolidation among providers. 

They discuss why the US lags in home dialysis, DaVita’s investment in home care (Elara), and how the dialysis bundled payment system may stifle innovation and the key areas to watch in policy and kidney drug development. 

The three part series on value-based kidney from Signals FS care can be found here: 
- Part 1: https://media.signalsfs.com/p/the-current-landscape-of-value-based
- Part 2: https://media.signalsfs.com/p/the-current-landscape-of-value-based-26d
- Part 3: https://media.signalsfs.com/p/the-current-landscape-of-value-based-1d4
- DaVita’s investment in Elara: https://media.signalsfs.com/p/brief-davitas-investment-in-elara

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The reality of caring for children with high medical complexity and the barriers their families face is under-discussed, and so is the hard problem of financing their care– it’s 6% of the population and 40% of the spend according to this note from the Children’s Hospital Association, and of that 40%, roughly half is on skilled nursing. It’s also important to keep in mind that ~50% of children’s healthcare is paid for through Medicaid and CHIP.

An interesting approach to delivering high quality care for these children is Prescribed Pediatric Extended Care, also known as PPEC. To talk about the unique challenges that high medical complexity kids face, the care they need, and his company’s approach to meeting those needs, we’re welcoming Jeffrey Soffen, CEO of Spark Pediatrics.

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• Universal Health Services announced it will acquire Talkspace to expand outpatient behavioral health and virtual care, raising questions about Talkspace’s largely non‑W2 therapist model and the modest premium paid. 
• Hims and Hers and Novo Nordisk unexpectedly reengaged after a broken partnership and lawsuit, with Hims curtailing compounded GLP‑1 advertising, Novo dropping its lawsuit, and Novo products expected on the platform, boosting Hims’ stock. 
• Wiley’s AI-focused earnings call and partnership with OpenEvidence (including equity)
• CMS action against Elevance over risk-adjustment submissions via encrypted USB drives
• Hospital operators’ revenue growth driven mostly by price and coding intensity
• Idaho legislation targeting a freestanding ER’s heavy use of the No Surprises Act IDR process
• Private-market deals for FindHelp and Greater Good Health
• The collapse of New Mountain’s planned “Thoreau” spinout
• Operational and financing challenges of scaling cell and gene therapies.

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The conversation covers state and federal roles, innovative payment models (including Louisiana’s earlier “Netflix model” for Hep C), operational challenges for providers and manufacturers, and the need for ecosystem-level public-private partnerships while warning against other payers shifting risk onto Medicaid.

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The conversation covers how TruMed decides what qualifies (clinical evidence in reputable journals), the role of letters of medical necessity via a compliant telemedicine process, and the goal of building a more “formulary-like” system for prescribing lifestyle interventions based on biomarkers and outcomes tracking.

Justin also addresses criticisms that HSAs favor higher earners, argue for prevention as a tool to reduce chronic disease costs, and compare U.S. healthcare incentives with Singapore’s Medisave approach, emphasizing that fixing lifestyle and environmental drivers of chronic disease is essential.

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They touch on Option Care’s Stelara biosimilar-driven margin compression, Fresenius’s improving value-based kidney care amid regulatory headwinds, and VBC updates from Agilon, Evolent, Privia, Clover, and Alignment, focusing on recontracting and risk transfer. 

Plus, UHS price-driven growth, skepticism about AI ROI, an Allina–Innovaccer/Story Health cardiology partnership, and rising attention to 340B financing and HHS’s rebate pilot.

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Kao explains Alignment’s provider-alignment model: guaranteeing PCP revenue via monthly payments, stratifying members so an interdisciplinary “Care Anywhere” team manages the highest-risk 10% at home, and sharing data back to physicians to improve outcomes and reduce avoidable hospitalizations. He discusses California-specific dynamics with IPAs, shared-risk arrangements, and global capitation, and contrasts these with expansion into new markets via clinically integrated networks and hospital systems. 

They address oncology as a specialty risk area, health system tensions around MA payment and claim edits, and CMS’s MA advance notice, emphasizing program integrity and the potential advantage for low-cost, clinically driven plans amid V28 and policy changes.

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Additional Context
Chris Klomp, the Medicare Director, made an interesting comment at the J.P. Morgan Healthcare conference earlier this year, sharing that CMS wants two types of Medicare: 1. Original Medicare in accountable care relationships; 2. Medicare Advantage, with Klomp noting that they renamed the internal team at CMS from Fee for Service Medicare to Original Medicare last month as a symbol of the focus.

Medicare Advantage has been getting most of the attention in healthcare policy worlds after the jaw-dropping Advance Notice from CMS, but in Martin's opinion what’s going on with Accountable Care Organizations deserves more attention. While MedPAC and the Better Medicare Alliance argue about whether MA actually saves money, the Medicare Shared Savings Program has a consistent track-record of real, albeit modest, savings.

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The conversation covers Jukebox’s operational model — building OT and contractor networks, partnering with plans on outcomes-based contracts, and delivering interventions that improve independence while preventing costly utilization. They also share real-world examples, lessons from working with Medicaid populations, and what’s next, including proactive monitoring and AI tools for care managers.

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They highlight what we learned from public companies this week including Grail’s stock drop after an NHS study missed its primary endpoint and reimbursement concerns; Talkspace’s shift from consumer to B2B; and Community Health Systems’ divestitures while also previewing Hims’ earnings and its acquisition of Eucalyptus. 

They discuss Scripps exiting Medicare Advantage after losing ~$75M and moving patients to traditional Medicare plus MedSup, contrasted with Cleveland Clinic expanding global cap lives. 

Looking ahead, they previewed upcoming earnings (Option Care, Fresenius, Acadia, Agilon, Teladoc, GoodRx, Privia, UHS, Clover, Alignment), flag HRSA’s renewed 340B rebate model discussions, and close with Inhabit Home Health & Hospice being acquired by Kinderhook for ~$1.1B amid MA contracting challenges and a broader theme of healthcare services companies considering going private.

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To discuss the current state of the Medicaid tech stack, how preparations for the January 1st 2027 implementation of community engagement requirements and twice yearly redeterminations is going, and alternatives to the Deloitte-Equifax “means-testing industrial complex” we’re joined by:

• Nikita Singareddy , CEO of Fortuna Health
• Luke Farrell, former USDS lead for benefits during the PHE unwinding, author of The Means-Testing Industrial Complex and Fellow at the University of Michigan’s Better Government Lab.

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