Will walks through Gyde's acquisition model: buying quality MA brokerages and equipping them with a platform and support to drive organic growth post-acquisition. He contrasts this what agencies historically experienced in M&A: minimal resources post-transaction, team reorgs, and increased admin burdens. Gyde instead pitches itself as a long-term partner rather than a financial buyer.

The conversation shifts to the strategic value of the broker as carriers grapple with acquisition and retention. Will's view: the best brokers are already acting as trusted advisors beyond enrollment — helping members navigate pharmaceutical issues, find physicians, and manage the broader healthcare experience. He sees that role growing as MA benefits rationalize and get more complex to navigate independently.

The episode closes on his insurance unbundling thesis: as MA benefits become more focused on major medical expenses and supplemental coverage gets individualized, Will sees consumers needing comprehensive guidance across insurance, health, and wealth decisions — with Medicare as the entry point into a much broader relationship.

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Brought to you by:

Ursa Health: Helping value-based care organizations unlock the full value of their data. Learn more at ursahealth.com
 
Nashville Healthcare Sessions: join HTN and 1,400 execs from across the ecosystem Sep 13-15 in Nashville. Register at nashvillehealthcaresessions.com/register/

Referenced:

Gyde Health acquisition: https://www.gydehealth.ai/resources/gyde-acquires-we-know-medicare

Gyde Health: https://www.gydehealth.ai/

Will Johnson: will@guidehealth.ai

The good news: patients have largely been removed from balance billing. The harder news: the IDR arbitration process that replaced rate-setting has pushed prices to nearly 4x historical in-network rates in radiology, with those costs flowing to employers and likely eventually back to patients through higher premiums. Arbitration was always risky — it's opaque, and human arbitrators tend to be more sympathetic to physicians than insurers.

Loren walks through what may have been a cleaner approach: a benchmark price tying out-of-network payments to a percentage of Medicare, or regulating contract design directly by making it illegal for anesthesia and surgical groups to hold discordant network status from the hospitals they work in. Both solutions had appeal but neither got far in Congress.

On the near-term outlook, Loren is candid: no big picture changes are likely because the winners are concentrated — a handful of PE-backed emergency medicine and anesthesia groups dominating the IDR process — and the losers are diffuse. This dynamic makes congressional action very unlikely in the near term.

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Brought to you by:

Ursa Health: Helping value-based care organizations unlock the full value of their data. Learn more at ursahealth.com
 
Nashville Healthcare Sessions: join HTN and 1,400 execs from across the ecosystem Sep 13-15 in Nashville. Register at nashvillehealthcaresessions.com/register/

Referenced:

No Surprises Act: https://www.brookings.edu/articles/no-surprises-act-arbitration-databook/

Loren Adler, Brookings: https://www.brookings.edu/people/loren-adler/

Loren Adler on X: https://x.com/LorenAdler

Digital health continued pushing back on CMMI ACCESS rates, with Hinge Health CEO Daniel Perez issuing the most direct public rebuke yet. Kevin's read: CMMI set rates deliberately low to force a ground-up rebuild, publicly traded digital health companies are structurally ill-suited to participate, and the opportunity is best fit for companies building from a fundamentally different cost structure.

Kevin and Martin discuss the mixed signals emerging around healthcare AI adoption: OpenEvidence showing explosive clinician usage growth while Doximity and Health Catalyst struggle through the transition, alongside OpenAI and Anthropic launching consulting arms and Hippocratic AI publicly defending its traction amid growing scrutiny.

The US reimburses 88% of approved drug indications versus 30-40% in peer economies, illustrating the tradeoffs with healthcare costs in our country. Meanwhile, drug development TAMs are massive, exceeding that of even OpenAI. Kevin’s observation: we can and should be innovating here, but the healthcare cost debate must acknowledge that innovation comes with costs.

Guest: Loren Adler (Brookings Institution)
The No Surprises Act eliminated surprise bills, but the IDR arbitration process that replaced rate-setting has pushed prices to nearly 4x historical in-network rates — with those costs flowing to employers and eventually premiums. Loren's assessment: a benchmark price would have been cleaner, and a near-term fix is unlikely.

Guest: Will Johnson (Gyde)
Will, CEO of Gyde, joins to discuss Gyde’s growth via acquisitions of other MA brokerage agencies and how they integrate and support partners. He shares how they are incorporating AI, his perspective on the journey of the broker market, and the opportunity to go enrollment.

Guest: Jenny Schneider (Homeward)
Jenny Schneider from Homeward joins to discuss the $50B Rural Health Transformation Program and the challenges facing rural healthcare. The conversation covers the operational challenges states face in deploying funds, the $137B in projected rural cuts that exceed the investment, and why provider retention is the more pressing and underaddressed challenge.

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Brought to you by:

Ursa Health: Helping value-based care organizations unlock the full value of their data. Learn more at ursahealth.com
 
Nashville Healthcare Sessions: join HTN and 1,400 execs from across the ecosystem Sep 13-15 in Nashville. Register at nashvillehealthcaresessions.com/register/

Referenced:

MGB PCP backlash: https://www.bostonglobe.com/2026/05/09/business/mass-general-brigham-primary/

ACCESS pushback: https://www.statnews.com/2026/05/14/medicare-chronic-care-pilot-access-digital-health-tech/

No Surprises Act: https://www.brookings.edu/articles/no-surprises-act-arbitration-databook/

Loren Adler, Brookings: https://www.brookings.edu/people/loren-adler/

Loren Adler on X: https://x.com/LorenAdler

PhRMA report: https://cdn.aglty.io/phrma/Attachments/NewItems/PhRMA_OnePager_AccessToNewMedicinesReport_8.5x11_v3.2_Print%20(2)_20260512113247.pdf

Gyde Health acquisition: https://www.gydehealth.ai/resources/gyde-acquires-we-know-medicare

Gyde Health: https://www.gydehealth.ai/

Will Johnson: will@guidehealth.ai

OpenEvidence adoption: https://www.nbcnews.com/tech/tech-news/openevidence-ai-doctor-medical-physician-login-app-what-npi-uptodate-rcna341064

Homeward Health: https://www.homewardhealth.com/

Jenny Schneider: jschneider@homewardhealth.com

The conversation explores the broader prescribing ecosystem, including the limitations of legacy infrastructure, why “sending the XML document” is effectively a commodity, and how Photon is repositioning prescribing around the patient experience. Otto argues the real challenge begins after the prescription is written: pharmacy selection, insurance pricing, inventory availability, prior auth, and fulfillment.

Otto also discusses Photon’s go-to-market pivot toward health systems, where the company found stronger demand for pharmacy transparency and patient navigation. The discussion closes on why health systems increasingly operate around pharmacy economics, why pharmacy may become one of the most important patient engagement surfaces in healthcare, and how AI may further shift health systems toward medication-centered care models.

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The starting point is a simple observation: most healthcare risk is either mispriced or unpriced, and the incumbents who could theoretically fix it are structurally prevented from doing so because their business models depend on the mispricing. That creates an opening for a new category of companies that can quote a number, bear the risk, and stand behind their math.

Sean and Emre walk through how they think about this infrastructure layer, with dashboards and workflow tools on top and underwriting as the chassis underneath. RightWise, a portfolio company repricing pharmacy claims at the individual drug level for self-insured SMB employers, serves as a concrete illustration of their thesis.

The conversation also covers where else the thesis applies: ACOs, medical malpractice, surgical centers of excellence, and site of care arbitrage. On go-to-market, Sean and Emre explain why pharmacy is a cleaner starting point than medical, why SMBs are the right initial customer, and why focused execution beats trying to serve the whole market at once.

Sean and Emre wrap by underscoring that actuarial infrastructure is one of the more defensible investment categories in an AI world and what kind of founders Virtue wants to hear from.

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Patrick walks through the three types of special needs plans — D-SNP for dually eligible members, C-SNP for chronic conditions, and I-SNP for institutional settings — and why C-SNP has become the highest growth segment over the past two to three years. The P&L dynamics are part of the story: C-SNP reimbursement reflects more accurate risk capture and higher member engagement, which makes it an attractive product for plans navigating a difficult MA environment.

The conversation also explores the strategic tension between nationals and community health plans. Nationals can take a portfolio approach — using C-SNPs to differentiate in specific markets and generate higher margins. Community plans don't have that option. They've been rooted in their communities for 50 years and can't walk away from Medicare lines of business even when the economics are tough. Belong's role is helping those plans make special needs products sustainable.

The episode closes on broker relationships and year-round enrollment, where C-SNPs and D-SNPs give community plans a tool to build multi-decade broker relationships rather than competing on benefits alone during open enrollment.

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LifeStance serves over a million patients annually across 600 clinics and 33 states, with 8,300 employed clinicians. Dan walks through the growth algorithm: a confident organic engine running at mid-teens growth, complemented by tuck-in M&A to enter communities where LifeStance doesn't yet have a presence.

The conversation covers the national rollout of interventional psychiatry — TMS and Spravato — where payers are increasingly seeing the value for patients who have failed multiple antidepressants. Dan also shares how LifeStance is thinking about AI across four parts of the business, with the clearest ROI so far in back office functions like scheduling, intake, and revenue cycle.

On the commercial side, Dan discusses the shift from cash pay to insurance across behavioral health and LifeStance's goal of making the in-network experience indistinguishable from what patients believe they'd get by paying out of pocket. 

The episode closes on the progress of value-based care in behavioral health. While it's still early, LifeStance is preparing internally while embedding mental health into the physical health journey through referral partnerships with primary care offices, health systems, and at-risk VBC groups organizations further along the VBC journey.

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Q1 earnings broadly reinforced a shift away from hype narratives and toward operational execution across value-based care and healthcare services companies.

• Agilon: Stock jumped after a "turn the corner" quarter. The standout data point: new heart failure diagnoses occurring after hospital admissions reduced from 40-50% industry-wide to roughly 5%, reflecting stronger risk stratification and earlier intervention.
• Evolent: Continuing to build its oncology story — roughly 10% of the oncology market runs through Evolent today, with 50% still insourced by payers. Their thesis is that increasing complexity in oncology will push more payers toward outsourced specialty management.
• Privia: Continued its shared risk strategy with strong free cash flow and disciplined M&A patience. Management believes private-market provider enablement assets remain overpriced and are willing to wait for valuations to reset.
• Oscar: Strong quarter, with ACA enrollment attrition coming in materially better than worst-case scenarios. ICHRA and the new Lucy marketplace are the growth narratives beyond the ACA core, though Lucy still feels underdeveloped.

Zack Cooper published an op-ed in the New York Times arguing hospital market power is the primary driver of rising healthcare costs. The AHA responded, and Kevin and Martin's read is that the defensiveness itself is the signal. Recent consolidation in Minnesota and Missouri illustrates the core tension: economically problematic, but increasingly hard to avoid.

The CVS MinuteClinic / Mass General Brigham partnership gets a detailed look after Massachusetts regulators flagged a $40M annual cost increase. Most of it comes from 34,000 patients gaining a PCP for the first time — at $650 more per year in claims — plus convenience care now billing at MGB rates. A useful case study in the tradeoffs between expanding access and controlling cost.

Guest: Dan Ferris (LifeStance)
Dan discusses LifeStance's Q1 results, the return to tuck-in M&A after three years, the national rollout of interventional psychiatry including TMS and Spravato, and the accelerating shift from cash pay to insurance across behavioral health.

Guest: Patrick Foley (Belong Health)
Patrick explains why Medicare Advantage special needs plans — particularly C-SNPs — are becoming strategically important for both nationals and regional nonprofit health plans, and how SNPs enable tighter alignment between primary care, care management, and health plans while helping navigate difficult MA economics.

Guests: Sean Doolan &  Emre Karatas (Virtue VC)
Sean and Emre discuss Virtue's emerging thesis around a new actuarial infrastructure layer in healthcare, arguing that increasingly complex risk models, specialty benefit design, and value-based payment structures are creating demand for more sophisticated tooling beneath the surface of managed care markets.

Guest: Otto Sipe (Photon Health)
Otto makes the case that pharmacy is the most underutilized patient touchpoint in health systems — patients interact with pharmacy ten times more often than primary care. He walks through Photon's prescription price transparency model, the $16M raise, and why health systems thinking about patient LTV should be organizing around pharmacy cadence rather than medical claims.

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Referenced:

Zack Cooper NYT op-ed: https://www.nytimes.com/2026/05/04/opinion/health-care-hospitals-insurance.html

AHA response to op-ed: https://www.aha.org/news/blog/2026-05-06-setting-record-straight-three-ways-hospital-blame-narrative-gets-it-wrong

Virtue VC thesis: https://www.virtuevc.com/writings/hypothesis---a-new-actuarial-infrastructure-layer-is-emerging

CVS <> Mass General Brigham CMIR: https://masshpc.gov/publications/market-oversight-report/cmir-report-mass-general-brigham-and-cvs-minuteclinic-primary

Photon's funding announcement: https://photonhealth.com/blog/series-a-growth-in-darkness

Brian walks through the principles guiding the turnaround: income-adjusted premiums modeled on Medicare, benefit design that avoids penalizing members with chronic conditions, and a preferred provider strategy that uses the plan's purchasing volume to steer members toward better value. He emphasizes that these tools have existed for decades but have not been applied deliberately and with the member's financial interest as the north star.

The conversation also covers drug affordability, where Brian makes the case that FDA biosimilar regulation is a more effective and underappreciated lever than payment policy. Updating the pathway could make biologics cheap the same way generics made small molecules cheap, without undermining incentives for innovation.

The episode closes on the MA versus original Medicare cost debate. Brian's framework: the answer depends on which of three lenses you use, most people pick the one that gives them the answer they want, and the policy conversation would be better served by using all three.

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Drawing from research across more than 30,000 Americans, Natalie explains why affordability consistently emerges as the public’s top healthcare concern—not just because of medical bills, but because of the emotional stress, delayed care, and distrust the system creates. She walks through the policy solutions voters support most strongly, including prescription drug affordability, price transparency, site-neutral payments, and anti-competitive merger scrutiny. 

The conversation also explores the growing erosion of trust in healthcare institutions and the broader public backlash against a system increasingly perceived as prioritizing profits over patients. Natalie discusses why affordability reform is gaining traction in conservative states, how fragmented incentives make systemic change difficult, and why many organizations no longer have the leverage to independently reduce costs even when they want to. They also touch on AI in healthcare, where patients are simultaneously optimistic and deeply skeptical, with transparency and trust emerging as the key factors shaping adoption.

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Bryan walks through the original investment thesis: autologous ex vivo CAR-T therapy was producing remarkable efficacy in late-stage multiple myeloma, but everything else about the model was broken: six to seven week processing times, $220,000 cost of goods, and delivery restricted to academic medical centers. The bet was that Kelonia's in vivo platform, developed out of MIT and CNRS in France, could preserve the efficacy while eliminating the rest.

He describes the path to exit as anything but linear. The 2022 biotech financing freeze hit preclinical cell and gene therapy companies especially hard. Kelonia survived through pharma partnership deals with Astellas and J&J that funded operations without giving up the lead program, and by staying focused on getting to clinical data, which they achieved mid-2025.

The conversation closes with Bryan's honest read on the cell and gene therapy landscape: the $2M+ commercial launches have largely failed, the path forward is pricing in the $300-400K range, and the infrastructure required to deliver these therapies broadly is at least a decade away from where it needs to be.

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Topics discussed:

• What Eliana found working inside practices as a fractional CFO, and why finance kept surfacing as the hair-on-fire problem
• Addressing revenue cycle's root problem: the lack of a financial source of truth across EHRs, billing systems, clearinghouses, payer portals, and bank accounts
• Why Joyful shifted from selling software to owning the outcome end-to-end
• The distinction between AI services and AI agents, and where rules-based automation works versus where expertise is required
• The mechanics of working a denial, including ERAs, vague denial codes like CO-16, and the cross-system "detective work" involved
• The payer-provider dynamic and how AI is showing up on both sides
• Joyful's system-agnostic go-to-market and four-to-eight week implementation timeline
• The longer-term vision of integrating from payer contracts through to the bank account

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Q1 earnings covered Alignment Healthcare, Humana, Cigna, and Teladoc.

- Alignment Healthcare: Alignment raised guidance on revenue and membership despite its stock dropping on growth trajectory concerns. The most notable moment from the call: CEO John Kao said MA plans are paying hospitals exactly what they deserve to be paid, a direct statement that most people in the industry would only say off the record.
- Humana beat Q1 expectations and held guidance. CEO Jim Rechtin opened repeateadly with "We are right where we expected to be," signaling vindication after a rough stretch. The question is whether they can retain membership through the benefit cuts they're signaling for 2027.
- Cigna exited the ACA market and is exploring strategic options for Evicore.
- Teladoc showed signs of turning a corner after pivoting from subscription to insurance fee-for-service. Meanwhile, BetterHelp is generating $75M ARR, growing toward $125M ARR by year end and is generating 20% higher visit completion rates versus cash pay. It appears to be an undervalued asset for the organization, suggesting Teladoc itself is undervalued.

The CVS MinuteClinic / Mass General Brigham NPI deal was flagged by regulators to increase healthcare spending by at least $40M annually, a reminder that expanding access costs money, and health systems billing at hospital rates is a known problem with no easy political solution.

Nebraska is the first state to implement Medicaid community engagement requirements. Martin's observation: based on Nebraska's initial definition of medical frailty, as many as 50% of the Medicaid population may qualify for the exemption, raising questions about how meaningful the requirement will be in practice.

Guest: Eliana (Joyful Health)
Joyful Health recently announced a $17M Series A to build "financial infrastructure" for healthcare, addressing what they view as the root problem of revenue cycle, data fragmentation. They aim to address the costly, labor-intensive processes required to recover the 10-20% of revenue left on the table.

Guest: Bryan Roberts (Venrock)
Bryan discusses Venrock's thesis in seeding Kelonia, a gene therapy company recently acquired by Eli Lilly for $7B, what stood out about how Kelonia operated compared to most biotech companies, and his perspective on cell and gene therapy landscape and costs. 

Guest: Natalie Davis (United States of Care)
Natalie shares results on public trust in healthcare, illustrating the broad disapproval in US healthcare: 71% agree costs are unaffordable, 69% are unsure whether measures taken are meant to benefit patients, and most respondents make their recommended solutions to healthcare costs clear. She also discusses early results of public perception of AI in healthcare, suggesting a 50/50 split, with a desire for transparency and more time with providers.

Guest: Brian Miller (NC State Health Plan / Hoover Institution)
Brian pointedly describes the changes being made to turn around the NC State Health Plan: income-adjusted premiums, maxing out-of-pocket to avoid penalizing those with chronic conditions, and leveraging volume for steering and purchasing (Costco analogy). He also delves into biosimilar regulation as an underappreciated drug cost lever, and a nuanced framework for the MA versus original Medicare cost comparison.

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Referenced:

Anthropic: https://www.blackstone.com/news/press/anthropic-partners-with-blackstone-hellman-friedman-and-goldman-sachs-to-launch-enterprise-ai-services-firm/

Devoted: https://medcitynews.com/2026/04/ceo-of-for-profit-ma-plan-tells-cms-pay-us-less/?_bhlid=a2a53a17c3a7deac5a3afcbd556f7913be68c650ust 

Alignment: https://ir.alignmenthealth.com/events/event-details/alignment-healthcare-first-quarter-2026-earnings-call

Joyful Health: https://www.joyfulhealath.com/post/joyful-health-raises-22m-to-build-denial-intelligence-recovery-infrastructure

Mass General Brigham and CVS: https://medcitynews.com/2026/05/cvs-mass-general-brigham-primary-care-prices/

Kelonia: https://www.linkedin.com/feed/update/urn:li:activity:7452001270321643523/

Full earnings coverage: https://www.healthtechnerds.com/p/weekly-health-tech-reads-5-3-26

Public trust poll: https://unitedstatesofcare.org/wp-content/uploads/2026/04/Affordability-Poll-Polling-Memo.pdf

Medicaid work requirements: https://www.kff.org/medicaid/a-closer-look-at-the-work-requirement-provisions-in-the-2025-federal-budget-reconciliation-law/

Bold started with falls prevention and has expanded into chronic condition support, weight management, and musculoskeletal pain — delivered digitally and without requiring additional devices. The conversation covers how Bold thinks about behavior change, and why the platform is designed around member agency rather than clinical control.

The bulk of the discussion focuses on ACCESS. Amanda notes that hundreds of thousands of original Medicare members have expressed interest in Bold and been turned away — there was no payment pathway. ACCESS creates one. It also removes the provider referral requirement, which unlocks a channel Bold has been building toward with ACOs and provider groups who already advocate for exercise but couldn't realistically refer original Medicare members into the program.

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Patrick walks through how the 606 accounting change in 2019 reshaped the MA brokerage market by requiring brokers to recognize lifetime commission value upfront. Combined with rapid MA enrollment growth, this inflated EBITDA in ways that didn't reflect actual cash economics — drawing significant PE investment and driving a valuation bubble that eventually collapsed as carriers pulled back commissions and decommissioned plans.

Rebecca covers what the market looks like today: a tough AEP, significant churn, and carriers becoming increasingly selective about their broker relationships. The brokers that navigated this period successfully did so by focusing on long-term member retention over volume, generating their own leads, and engaging members throughout the policy lifecycle rather than at enrollment alone.

Looking ahead, Patrick and Rebecca describe a market moving toward product diversification, technology investment, and a fundamentally different value proposition — brokers as trusted, long-term partners for both carriers and members rather than high-volume enrollment engines. Rebecca flags one important gap: brokers are doing this value-add work, but nobody has figured out how to quantify it systematically for carriers yet.

Access the report here: https://bnco.com/insights/medicare-advantage-brokerage/

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The conversation centers on how Pair Team is thinking about CMMI ACCESS. Neil describes the rates as a feature, not a bug; CMS designed them to push participants to build sustainable, technology-driven models from the ground up. He discusses the role of AI in making 
mapping task automation over time, what that means for unit economics, and why channel partnerships with ACOs and PCPs are the right path to patient acquisition in this model.

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On demand, roughly one in four Americans is affected by a mental or behavioral health condition, and untreated costs extend well beyond direct care — unmanaged behavioral health issues exacerbate physical conditions and drive expensive downstream utilization including ED visits.

On supply, the picture is more nuanced than a simple shortage story. Psychiatry residency slots have grown 55% since 2018 and fill at 99%, suggesting insufficient positions rather than insufficient interest. Meanwhile, allied health providers and primary care physicians now prescribe two thirds of all behavioral health medications, reflecting how a non-specialized workforce is flexing into the gap.

The conversation also covers AI in behavioral health — where Alli draws a clear line between administrative use cases and the much harder clinical question — and a counterintuitive finding that D2C behavioral health care is on average more expensive for patients than traditional in-network care. Emerging treatments including TMS, psilocybin, and MDMA round out the discussion, where early signals from the Trump administration suggest growing appetite for research and regulatory flexibility.

Read the report here: https://www.trillianthealth.com/market-research/reports/2026-behavioral-health-report

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Alli Oakes, Chief Research Officer at Trilliant Health, breaks down their new behavioral health report — why $500B in untreated mental health costs dwarfs the $200B we spend treating it, where the supply-side gaps are most acute, and why D2C behavioral health is on average more expensive than traditional in-network care.

Neil Batlivala, CEO of Pair Team, walks through how Pair Team scaled to a thousand-person medical group serving high-needs Medicaid populations, the watershed moment with Flora, their AI care advocate, and the company's approach to the CMMI ACCESS Model — including why CMMI's rates are built bottoms-up from cost-to-deliver rather than value-delivered, and what that means for CAC and device cost economics.

Amanda Rees, CEO of Bold, makes the case for a device-agnostic, AI-first lifestyle change platform inside ACCESS, and why Bold's existing Medicare Advantage playbook on falls prevention and behavior change positions them differently than the MSK players that opted out.

Patrick Keavy and Rebecca Springer of Bailey and Company join to discuss the state of the Medicare Advantage brokerage market post-Medicarians — how 606 accounting reshaped the space from 2019 to 2021, why this AEP came in 20-30% south of expectations for many brokers, and why churn in the carrier base may actually be making high-quality brokers more valuable, not less.

Kevin and Martin close with the New York Times piece on Dr. Norman Rowe and the $440K breast reduction, the IDR arbitrator cottage industry now lobbying to entrench itself, the Doctronic-Utah Medical Board standoff on AI prescribing, the Washington state senator picking up the WISeR criticism, and Epic's growing role in AI adoption — and what it means when a B Epic product priced at $100K beats an A-minus startup product at $1M.

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Empassion CEO, Robin Heffernan, explains supportive care, distinguishing palliative care (any stage) from hospice (typically the last six months), and describes Empassion's model: contracting with payers so care is free to patients, curating a nationwide network of in-home providers, and using technology to coordinate care across teams in 45 states.

The conversation covers large quality variation across 5,000+ hospice agencies, Empassion Assured as a near-real-time CMS-metrics resource to identify good vs bad actors, and why hospice fraud persists given fast access and payment rules. 

Robin also discusses hospice being carved out of Medicare Advantage, why carving it in could improve oversight, and lessons from prior CMS efforts.

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He walks through what the team learned building a plan from scratch: that technology alone doesn't differentiate, that the employers most in need aren't startups but cost-pressured blue-collar businesses, and that the real opportunity was in powering the plans already winning on price rather than competing with them. 

The conversation covers how alternative health plans are beating traditional major health plans through reference-based pricing, direct primary care, and navigated cash pay, and why those plans needed an all-in-one TPA and platform to operationalize it.

Russell also discusses the $35M raise and the growing employer appetite for alternatives as healthcare costs continue to rise.

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The conversation covers how Withings became a Medicare Part B provider, what they've built on top of their connected device offering to participate in ACCESS, and why Patrick believes the program only works if participants coordinate care back to PCPs and ACOs rather than going at it alone.

Patrick also discusses patient choice as the most transformational design element of ACCESS, the fragmentation risk that comes with it, and how Withings is thinking about patient awareness and outreach as the program launches in July.

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The conversation covers how Abridge thinks about clinical intelligence as a reframe of clinical decision support. The old category was defined by rule-based alerts and popup fatigue. The new approach is contextual, surfacing cues grounded in medical literature without interrupting the clinical encounter. Shiv walks through a concrete cardiology example of how this works in practice.

He also discusses go-to-market strategy, why Abridge started with large health systems and IDNs, and how being embedded at that level creates the opportunity to collapse adjacent workflows like CDI and prior authorization rather than layering AI on top of them.

The conversation closes with where Shiv thinks AI impact shows up in healthcare, and why the gap between what clinicians feel and what the data shows is one of the most important problems the industry needs to solve.

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Neel walks through why the bundle is ending. Team-based care has made the original model increasingly difficult to administer, and the bundle was stifling innovation by failing to account for 40 years of technological change in maternity care. The unbundling is designed to be budget neutral, but budget neutral means some providers win and some lose, and the implications for rural practices and lower-risk pregnancies are real.

The conversation also covers what employers and brokers should expect, why purchasers whose populations skew higher risk could see cost increases of up to 10%, and why Neel thinks this is a "slow burn" story that the industry is only beginning to process.

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Neel Shah, Chief Medical Officer at Maven Clinic, breaks down the end of a 40-year global maternity payment bundle, what's driving the change, how it creates room for innovation in team-based care, and the cost and access implications for vulnerable populations.

Russell Pekala and Will Gillach from Yuzu walk through what the team learned building an alternative health plan from scratch and why they pivoted to become the TPA infrastructure powering them, covering how alternative plans are winning on price through reference-based pricing, direct primary care, and navigated cash pay.

Shiv Rao, CEO and Co-Founder of Abridge, discusses the company's expansion beyond AI scribing into clinical intelligence, anchored by a pre-visit, during-visit, and post-visit product framework and new evidence partnerships with JAMA and the NEJM.

Patrick, VP of Value-Based Care at Withings, closes with why a connected device company may be better positioned for CMMI ACCESS than pure digital health players, and how Withings is thinking about care coordination back to ACOs and PCPs as the program launches.

Kevin and Martin close with risk adjustment AI funding. Keebler Health raised $16M and Joyful Health raised $22M, and both signal where AI is driving productivity in healthcare today.

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Nancy Wang and Craig Allen, who lead strategy and actuarial at Sidecar, walk through how that model works, from the actuarial complexity of pricing every service and drug to the member education and behavior change required to make it work at the employer level.

The conversation covers why mid-market employers facing 40-80% rate increases are increasingly open to alternative plan designs, what 20% medical cost savings through consumerism looks like in underwriting, and why the Trump administration's proposed no-network ACA rule is less disruptive than critics suggest, given Sidecar operates as a fully ACA-compliant plan today without a traditional network.

They also touch on where the consumerism model could apply beyond the employer market, the shift in employer appetite from absorbing increases to demanding something different, and why the category of "alternative plan design" may not stay alternative for long.

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He outlines three converging themes: episode-based bundles—especially surgical/orthopedic—have shown savings (often from post-acute care); ACOs have struggled to operationalize bundles due to contracting, attribution, and reconciliation complexity; and specialists have largely remained outside value-based care. 

CARA aims to bridge these gaps by letting ACOs and specialists set up CMS-facilitated episode-based risk arrangements via a web-based portal, using predefined episodes or a customizable “max flex” option, while specialists continue billing fee-for-service and CMS performs retrospective reconciliation against target prices. 

The discussion also covers operational platform constraints, market-driven episode design, and the flow of funds in retrospective bundles.

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Conor and HTN cover today’s valuation dislocation amid AI uncertainty, slower deal processes and re-trading, niche investing themes in rev cycle and employer/payer services, and an exit market logjam from peak-era buys that may clear as return expectations reset.

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She explains SimpliFed’s insurance-covered care model across commercial, Medicaid, and TRICARE; its go-to-market strategy through health plans plus provider enrollment and integrations with OB/GYN workflows via an AI-enabled, interoperable maternal health operating system and native EMR. 

The conversation covers the “unbundling” of global maternity payments back toward fee-for-service, the trade-offs across access, quality, and cost, and why investing more in prenatal and postpartum care can reduce costly interventions. Ito outlines SimpliFed’s care team (IBCLCs, some NPs), studies on outcomes and cost reduction, and growth plans to support 5% of US births by 2026.

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Kevin and Gabe explored how inferred risk could level the playing field for groups with historically weak documentation — and how success in LEAD could open the door to testing the same approach in MA broadly. Gabe also flagged that organizations will be making enrollment decisions with less information than usual given the compressed timeline (application deadline: May 17; lock-in by early September).

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Kevin and Martin unpack the MA final rates reaction (2.48% and what it means for plans cutting benefits), break down ACO LEAD with Pearl Health's COO Gabe Drapos, and get the inside story on CARA, the specialist bundle component inside LEAD. Plus: Teladoc's activist investor drama, TrueHelm's growth equity thesis, Blues consolidation inadvertently accelerating, and SimpliFed's $10.8M Series A to extend from feeding support to OB care.

In this episode:

• MA final rates: 2.48%, benefit cuts, including BCBS MN beneficiaries losing Life Time memberships
• Pearl Health on ACO LEAD, AI-inferred risk, and what changes from REACH
• Manatt Health on CARA: how specialist bundles work inside LEAD
• Teladoc, BetterHelp, and the activist investor case for a PE buyout
• TrueHelm's Conor Green on health tech private markets and AI creating the most confusing environment in a decade
• Chapter's $100M raise, Blues consolidation, Function Health's Getlabs acquisition, Luminai raise + Cleveland Clinic partnership
• SimpliFed CEO Andrea Ippolito on their $10.8M Series A, expanding from lactation support to OB care, supported by AMA's vote to unbundle maternal care, and supporting 5% of US births

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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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