Episode Resources:

• AHealthcareZ
• DOJ Antitrust Lawsuits Against NY-Presbyterian and OhioHealth
• KFF Issue Brief on Provider Consolidation
• Overview of the No Surprises Act Dispute Resolution Process

When it comes to negotiating healthcare payments, fairness is an illusion. It is entirely a game of market power. In this episode, Dr. Eric Bricker returns to unpack the massive impact of health system consolidation on specialist stipends, facility fees, and the everyday reality of patient care. You’ll walk away with a crystal-clear understanding of the hidden financial levers driving up healthcare costs and how recent Department of Justice lawsuits could disrupt the entire industry.

Dr. Anthony Paravati and Dr. Amar Rewari join Dr. Bricker to examine the aggressive all-or-nothing contracting tactics that mega hospital systems use to monopolize markets and artificially inflate facility fees. The trio dissects the controversial world of specialist stipends, revealing how workarounds to the Stark Law and the influx of private equity are radically transforming physician compensation. They also debate whether the push for value-based care within Medicare Advantage is a genuine cost-control solution or just a cynical strategy by the government to shift the burden of rationing care to insurance carriers. You won't want to miss Dr. Bricker’s surprisingly radical framework for how doctors can collectively reclaim their agency and finally outmaneuver corporate administrators. 

If you want to stay ahead of the curve on the business of medicine, be sure to subscribe to the podcast and leave a review!

Episode Resources:

• The Great Obamacare Enrollment Fraud Report
• Report on Medicaid Financing Reform and Provider Gimmicks

U.S. healthcare spending accounts for nearly a fifth of our GDP, yet systemic failures and physician burnout continue to reach historic highs. In this episode of Value Health Voices, Dr. Amar Rewari and Dr. Anthony Paravati sit down with Brian Blase, President of the Paragon Health Institute, to unpack the massive legislative shifts inside the newly passed One Big Beautiful Bill Act. Clinicians and healthcare leaders will walk away with a clear understanding of how new federal policies are fundamentally altering healthcare economics, Medicaid funding, and everyday clinical practice.

We explore the structural forces driving hospital consolidation, examining how government-subsidized demand and restricted supply have inadvertently inflated costs across the entire sector. Brian breaks down the controversial "legalized money laundering" of Medicaid provider taxes and reveals why enforcing site neutrality and Medicare payment reform could be the ultimate weapons against hospital monopolies. The conversation also tackles the heated debate over Medicaid work requirements, exposing staggering data on ACA exchange "phantom enrollees" that challenges the structural integrity of subsidized coverage. Will pushing for consumer-driven healthcare and expanding HSAs finally force high-priced providers to compete, or simply shift the burden to vulnerable patients?

If you want to stay ahead of the curve on healthcare policy and economics, be sure to subscribe to Value Health Voices and leave us a review.

Episode Resources:

• Official Website for Claimable
• Marshall Allen’s Official Website and "Never Pay the First Bill"
• NBC News: How AI Helps Patients Fight Insurance Denials
• STAT News: Investigation into UnitedHealth’s "nH Predict" Algorithm

When a health insurance company denies life-saving medical care, it isn’t just a bureaucratic hurdle—it’s a hidden public health crisis that costs lives. In this episode of Value Health Voices, Dr. Amar Rewari and Dr. Anthony Paravati sit down with Time 100 Health List honoree Warris Bokhari, founder of Claimable, to expose the shocking reality behind the nearly one billion medical denials issued every year. Listeners will learn exactly how to fight back against predatory insurance tactics and successfully overturn wrongful claim rejections, especially in high-stakes fields like oncology.

Drawing from his insider experience at Anthem and Apple Health, Warris pulls back the curtain on how insurers use proprietary AI algorithms and fabricated terms like "medically unnecessary" to boost profits at the expense of patient care. The conversation explores the heavy toll of prior authorization and utilization management, the disturbing conflict between fiduciary responsibility and clinical ethics, and how Claimable operates as the "TurboTax for health insurance appeals" to wage asymmetric warfare against corporate giants. Warris also reveals a brilliant, legally-backed framework for using ERISA laws and employer liability to force insurers into approving delayed treatments, but you'll have to listen to find out the single most important step every patient must take within 48 hours of receiving a denial letter.

Don't let a devastating insurance denial dictate your health journey. Hit play to arm yourself with these essential medical advocacy tools. Be sure to subscribe to Value Health Voices, leave us a review, and check the show notes for a direct link to Claimable and other critical resources mentioned in this episode.

Episode Resources:

• Healthcare in Action Official Website
• Dr. Sachin Jain on The Ethical Erosion of American Healthcare
• Details on SCAN Health Plan’s $250 Million Legal Victory
• SCAN Affirm Member Guide for LGBTQ+ Seniors

American healthcare doesn’t have a payment crisis; it has a profound leadership crisis. In this episode, Dr. Sachin Jain, President and CEO of SCAN Group, dismantles the broken culture of modern medicine and reveals how his non-profit Medicare Advantage organization is successfully flipping the script on senior care. Tune in to discover actionable strategies for aligning clinical integrity with financial sustainability, empowering you to drive meaningful change within your own health system. 

Dr. Jain takes us under the hood of SCAN’s explosive growth, explaining why delegating full financial risk to provider groups is the ultimate antidote to the toxic cycle of traditional utilization management. He introduces his fascinating framework of "soft UM," challenging the industry's obsession with superficial quality metrics and exposing the "ethical erosion" plaguing profit-driven hospital boards. From designing hyper-targeted health plans for diverse populations to navigating the controversial debate over health systems dropping Medicare Advantage contracts, this conversation pushes boundaries and redefines the social determinants of health. Can we rely on corporate giants to save value-based care, or does the true solution lie in the hands of courageous, disruptive physician leaders? 

If you’re ready to stop accepting the status quo and start leading with impact, hit subscribe and leave us a five-star review. Be sure to check the show notes for more information on SCAN Health Plan and additional resources on the future of healthcare innovation.

Episode Resources

• Free Case Evaluation Form for Interested Providers and Physicians to Connect with an Attorney
• Gilbert LLP
• MultiPlan
• CMS: No Surprises Act
• Department of Labor: ERISA
• UnitedHealthcare

A single intermediary company touches an estimated 80% of all out-of-network medical claims in the United States, yet most doctors have never even heard of it. To help us understand the massive MultiPlan lawsuit, we sit down with Matt Lavin, a partner at Gilbert LLP and the lead antitrust attorney at the center of the battle. He breaks down how this obscure pricing system might be quietly draining hundreds of billions of dollars from American medicine.

Throughout the episode, Lavin explains the exact mechanics of how commercial health insurance companies process out-of-network claims and why the system is drawing scrutiny from the Department of Justice. He reveals how proprietary algorithms are allegedly used to aggressively suppress healthcare reimbursement rates, creating massive fees for insurers while leaving providers struggling and patients stuck with the balance. We also unpack the hub-and-spoke cartel theory that forms the foundation of this case, detailing the real-world financial impact on rural hospitals and private practices.

If you are an independent physician dealing with unpredictable revenue or a practice manager trying to make sense of mysteriously slashed payments, this episode is for you. You will walk away with a clear understanding of the hidden corporate forces driving down your revenue and practical advice on how to audit your past claims to protect your business.

About Matt Lavin:

Matt Lavin is a partner at Gilbert LLP’s Washington, D.C. office. He has successfully resolved countless reimbursement disputes with commercial payors such as Aetna, Anthem, AmeriHealth, Ambetter, Beacon, Centene, HealthNet, Humana, Cigna, UnitedHealthcare, HealthNet, Magellan, and many Blue Cross Blue Shield entities and Blue Card Network plans. Matt has experience with practically every aspect of the business of healthcare and revenue cycle management and has handled suits against “cost-containment” vendors, like MultiPlan, that egregiously underprice the value of out-of-network claims.

Episode Resources:

• Learn more about Quest Diagnostics
• Explore Quest's Consumer-Initiated Testing

How does a flawed government policy threaten the very foundation of modern medicine? Nearly every clinical decision, from a routine check-up to advanced cancer treatment, begins with data from a lab test. But the system that determines the value and payment for these critical services is under threat. In this episode, we explore the complex world of clinical laboratory services policy and payment with an unparalleled expert, Dr. Yuri Fesko, Chief Medical Officer of Quest Diagnostics. We uncover how a poorly designed law could cripple patient access to testing, especially in rural communities, and stifle the life-saving innovation happening in diagnostics.

This deep-dive conversation with Dr. Yuri Fesko breaks down the most pressing issues facing clinical laboratories today. We start with the Clinical Laboratory Fee Schedule (CLFS) and the disastrous impact of the Protecting Access to Medicare Act (PAMA). Dr. Fesko explains how PAMA’s flawed data collection, which surveyed only the largest, most efficient labs, has led to proposed reimbursement cuts of up to 15% annually, threatening the viability of smaller hospital and independent labs across the country. We then discuss the bipartisan RESULTS Act, a proposed solution to create a more accurate and equitable system. The discussion also tackles the immense administrative burden of prior authorization for lab testing, a major friction point for clinicians that delays diagnoses and care. We explore how technology, like Quest’s adoption of the Epic EMR system, aims to streamline this broken process. A significant portion of our conversation focuses on the challenges surrounding reimbursement for advanced diagnostics. Dr. Fesko provides a fascinating look into cutting-edge innovations like Minimal Residual Disease (MRD) testing in oncology, a revolutionary tool that can detect trace amounts of cancer DNA in the blood to help guide treatment decisions and avoid unnecessary, toxic chemotherapy. We also navigate the intricate landscape of laboratory-developed tests (LDT) regulation, weighing the pros and cons of proposed FDA oversight versus the existing accreditation framework. Finally, we touch on patient-centric improvements like price transparency, the power of lab data in public health initiatives, and the critical importance of interoperability in ensuring patients own and control their health records. This episode is an essential guide to understanding the policy, payment, and innovation that will define the future of diagnostic medicine.

About Our Guest:

Dr. Yuri Fesko is the Chief Medical Officer of Quest Diagnostics. With a background in internal medicine, hematology, and oncology, Dr. Fesko leads Quest's medical groups, payer access and reimbursement strategies, and research activities. He brings a unique perspective from the front lines of both clinical practice and the leadership of one of the world's largest laboratory services companies, offering deep insights into the regulatory and financial pressures impacting patient care and diagnostic innovation.

Timestamps:

(00:00) Why Lab Testing is the Foundation of Medicine

(05:43) The Clinical Laboratory Fee Schedule (CLFS) Explained

(09:22) PAMA: A Flawed Law Threatening Lab Services

(14:51) The RESULTS Act: A Bipartisan Fix for PAMA

(18:24) The Burden of Prior Authorization for Lab Testing

(26:07) Improving the Patient Experience with Price Transparency

(30:56) Innovation: Reimbursement for Minimal Residual Disease (MRD) Testing

(41:52) The Complex Regulation of Laboratory-Developed Tests (LDTs)

(46:15) Big Data: How Lab Results Shape Public Health

(55:49) Future Risks & Opportunities for Clinical Labs

Episode Resources:

• Learn from Dr. Seheult on his YouTube Channel
• Explore MedCram's Health Optimization Courses (CME available)
• Watch the Guy Foundation's Autumn Series on Light & Health
• Read the Glen Jeffery study in Nature Scientific Reports
• Explore the Swedish study on sun exposure and all-cause mortality

Could a simple, free resource dramatically reduce hospital stays and save the healthcare system billions? In this episode, we explore the powerful clinical case for sunlight therapy with one of the most respected medical educators online, Dr. Roger Seheult. He begins with the astonishing story of a 15-year-old boy given two days to live due to a flesh-eating fungal pneumonia, who made a miraculous recovery after one simple request: to go outside. This episode confronts the "magical thinking" skepticism head-on, presenting a data-driven argument that hospitals and policymakers can't afford to ignore.

We're joined by Dr. Roger Seheult - a quadruple board-certified physician in pulmonary, critical care, and sleep medicine, and the founder of Medcram - to dissect the science behind sunlight and infrared light. Dr. Seheult breaks down the groundbreaking randomized controlled trials, including recent studies in Nature, that demonstrate the profound link between infrared light and mitochondrial function. Learn how specific wavelengths of light can pass through the human body, making our cellular batteries (mitochondria) more efficient, boosting ATP production, and impacting the root cause of many chronic diseases. This robust photobiomodulation evidence suggests we've overlooked a fundamental element of human health.

The discussion pivots from cellular mechanics to systemic impact, focusing on the staggering potential for reducing hospital length of stay. Dr. Seheult cites multiple studies showing that patients exposed to more sunlight or targeted infrared light are discharged 3-4 days earlier - a reduction of over 30%. We analyze the immense financial implications, calculating potential savings of $5,000-$7,500 per admission for hospitals operating on bundled DRG payments. The episode tackles the practical and bureaucratic hurdles, from the inertia of hospital administration to the need for a new light therapy reimbursement policy. We explore actionable pathways for change, including updates to CPT codes, integration into CMMI value-based care models, and the power of the HCAHPS patient satisfaction survey to drive adoption. This conversation makes a compelling case that adopting light therapy isn't just good medicine; it's a financial and ethical imperative.

About Our Guest:

Dr. Roger Seheult is a quadruple board-certified physician (Internal Medicine, Pulmonary Diseases, Critical Care Medicine, and Sleep Medicine) and an Associate Clinical Professor at the UC Riverside School of Medicine and on faculty at Loma Linda University. As a critical care doctor, he sees the sickest patients in the hospital, which pushed him to explore foundational health principles that could pull patients back from the brink. He is the co-founder of MedCram, a leading online medical education platform with millions of viewers, where he excels at explaining complex medical topics in a clear and accessible way.

Timestamps:

(00:00) A Miraculous Recovery: The Case of the Boy with a Flesh-Eating Fungus

(02:49) The Science and Finance of Light Therapy

(03:55) Deep Dive: A 15-Year-Old's Fight Against Fungal Pneumonia

(11:10) The Clinical Case for Light Therapy: Examining the Evidence

(15:22) How Infrared Light Boosts Mitochondrial Function

(19:51) Sunlight Exposure, All-Cause Mortality, and Global Health Patterns

(26:40) The Financial Impact: Reducing Hospital Length of Stay by 30%

(31:28) Practical Implementation: How to Prescribe Light Therapy in a Hospital

(34:40) Overcoming Barriers: The Financial and Logistical Case for Change

(44:14) Pathways to Reimbursement: New Policy and Payment Models

(47:35) Rediscovering Old Wisdom: The History of Heliotherapy

(56:21) Actionable Resources & How to Get Involved

Episode Resources:

• Learn about the California Medical Association (CMA)
• Explore the AMA's Resources on the Corporate Practice of Medicine
• Access the CMA's Model Medical Staff Bylaws
• AMA Venture capital and private equity investment snapshot
• AMA Legislative approaches to curb corporate influence in health care
• Read about SB 306 (Prior Authorization Reform)
• Follow Dr. Shannon Udovic-Constant on LinkedIn

In this pivotal episode of Value Health Voices, we explore how physician advocacy in California is at the forefront of a nationwide battle for the soul of healthcare. California’s health system is facing its biggest stress test in a generation, with looming federal budget cuts under HR1 threatening to pull tens of billions from Medi-Cal, the state's healthcare backbone for 1 in 3 residents. How can doctors protect patient care and their own professional autonomy when faced with unprecedented financial and corporate pressures?

Our guest, Dr. Shannon Udovic-Constant, immediate past president of the California Medical Association (CMA), provides a masterclass in turning crisis into opportunity. She reveals the strategies the CMA is deploying to defend the future of medicine, offering actionable insights for physicians everywhere who feel powerless against a broken system. This is a must-watch for any healthcare professional wondering how to reclaim their voice and drive meaningful change.

This episode unpacks the core challenges and solutions shaping modern medicine. We dive deep into the devastating Medi-Cal cuts and HR1 impact, which could strip coverage from millions and close rural hospitals. Dr. Udovic-Constant explains how the CMA successfully passed a provider tax initiative (Proposition 35) to boost reimbursement rates, a critical victory now grandfathered in despite federal changes. This proactive approach to physician advocacy in California serves as a model for other states.

We also confront the alarming rise of private equity in healthcare and its corrosive effect on physician autonomy. Dr. Udovic-Constant explains the importance of the corporate practice of medicine doctrine, a legal shield designed to prevent corporate interests from interfering with clinical decisions. She provides practical steps physicians can take, from structuring better contracts to utilizing the CMA's model staff bylaws, to protect the physician-patient relationship from profit-driven motives. We connect this corporate pressure directly to the epidemic of physician burnout and collective action, reframing burnout not as a personal failing, but as a symptom of a system that needs fixing. Dr. Udovic-Constant argues that proactive, aspirational engagement in organized medicine is the most potent antidote.

Finally, we celebrate tangible legislative wins that demonstrate the power of organized medicine. Learn about the landmark California prior authorization reform bill (SB 306), which aims to cut administrative red tape by eliminating prior authorizations for services that are almost always approved. We also discuss new guardrails for AI in healthcare (AB 489), ensuring transparency when patients interact with chatbots instead of clinicians. Through these examples, this episode highlights a clear path forward, showcasing why effective physician advocacy in California is not just about defense—it’s about building a better, more sustainable, and physician-led future for healthcare.

About Our Guest:

Dr. Shannon Udovic-Constant is a board-certified pediatrician in San Francisco and the 156th Immediate Past President of the California Medical Association (CMA), the largest state medical association in the country. A passionate advocate for children's health, equity in care, and physician leadership, she has been instrumental in shaping policies to protect patients and empower doctors across California.

(Timestamps / Chapters):

(00:00) Intro: California's Healthcare System Faces a Generational Crisis

(04:19) The CMA: A Bridge Between the Bedside and the Legislature

(07:32) A State-Level Victory: Boosting Medi-Cal Reimbursement Rates

(12:54) Defending Physician Autonomy Against the Corporate Practice of Medicine

(16:28) The Data Behind California’s Healthcare Pressures

(21:06) How Physicians Can Regain Power Through Contracts and Bylaws

(24:36) The Looming Threat: How HR1 Cuts Endanger Medi-Cal

(30:40) Legislative Victories: Tackling Prior Authorization and AI Deception

(38:05) Transforming Physician Burnout into Proactive Advocacy

(43:55) Final Thoughts: The Future of Healthcare is Physician-Led

Join us as we separate fact from fiction in the world of medical AI. Dr. Sanjay Juneja, a medical oncologist and VP of Clinical AI Operations at Tempest, shares his journey from social media educator to a trailblazer in health technology. We dive deep into how AI can address the "unwarranted variation in care" that leads to inconsistent patient outcomes across the country. Dr. Juneja explains how machine learning models can analyze vast datasets to find novel insights, much like Google's AlphaGo made a move in the game of Go that was inconceivable to human grandmasters. This episode explores the incredible potential of the future of AI in healthcare, from AI scribes developed to combat AI and physician burnout to new diagnostic tools that can predict hyperglycemic events from the sound of your voice or determine a tumor's molecular features from a simple pathology slide.

However, the conversation doesn't shy away from the serious challenges ahead. We confront the "garbage in, garbage out" problem, discussing how biases in training data can lead to flawed or inequitable conclusions. A core part of our discussion focuses on the critical need for validating AI models in medicine before they are widely deployed, ensuring that these powerful tools are both safe and effective. We also explore the nuanced impact of AI and the doctor-patient relationship, debating whether an algorithm can truly be more empathetic than a human physician and what happens to trust when patients suspect their doctor's messages are AI-generated. Finally, we unpack one of the biggest hurdles to adoption: the issue of liability for AI in healthcare. When an AI model makes a mistake, who is responsible—the developer, the hospital, or the clinician who acts on its recommendation? This is a must-watch for any clinician, patient, or technologist seeking to understand the real-world implications of AI in oncology today and in the near future.

About Our Guest:

Dr. Sanjay Juneja (@TheOncDoc) is a triple board-certified medical oncologist who has become a leading global authority on the application of AI in medicine. He serves as the Vice President of Clinical AI Operations at Tempest, is a contributing writer for Forbes, and was credentialed by Harvard Medical School's inaugural "AI in Healthcare" executive program. Through his massive social media presence and podcast, Dr. Juneja has a unique talent for simplifying complex medical and technological topics for a broad audience.

Timestamps / Chapters:

(00:00) Introduction: Separating Hype from Reality in AI and Oncology

(02:41) From Social Media Influencer to AI Trailblazer: Dr. Juneja's Journey

(06:14) Tackling Unwarranted Variation in Cancer Care with AI

(10:35) The Devil's Advocate: Bias, "Garbage In, Garbage Out," and AI's Flaws

(19:10) Real vs. Hype: Current AI Applications Changing Medicine Now

(24:22) Systemic Hurdles: Data Privacy, Reimbursement, and AI Adoption

(33:30) Can an AI Be More Empathetic Than Your Doctor?

(41:35) AI in the Clinic: Improving Workflow and Reducing Physician Burnout

(47:15) Who's to Blame? Unpacking the Liability of AI in Healthcare

(52:06) The 2-to-5-Year Future of AI in Oncology

Episode Resources:

• Follow Dr. Sanjay Juneja on LinkedIn
• Follow Dr. Sanjay Juneja on Instagram
• Follow Dr. Sanjay Juneja on TikTok
• Follow Dr. Sanjay Juneja on YouTube
• Check out Dr. Juneja's Podcast

We connect the dots between the federal shutdown, expiring ACA enhanced premium tax credits, clandestine pharmacy benefit manager (PBM) practices, and Medicare's latest payment cuts. Why can't Washington compromise, and who is feeling the most pain? We explore the real-world consequences, including delays for companies seeking approvals for new drugs and devices, the degradation of hospital payer mix due to rising uninsured rates, and the political maneuvering that leaves everyday Americans caught in the middle. This discussion on US healthcare policy challenges uncovers the systemic dysfunctions, from legislative gridlock to the "wrecking ball" approach to policymaking that prioritizes disruption over stability.

This episode provides a comprehensive breakdown of the most pressing issues in healthcare today. We uncover the truth behind Pharmacy Benefits Managers (PBMs) and the bipartisan push for PBM reform, exposing their fundamental conflicts of interest, the dirty tricks of "spread pricing" on generic drugs, and why their business model drives up costs for everyone. We also analyze the controversial Medicare efficiency adjustment included in the latest Medicare Physician Fee Schedule—a "lazy" blanket cut that penalizes specialists and creates further uncertainty in the medical technology market. If you want to understand the forces driving up your insurance costs and creating chaos in the US healthcare system, this is a must-watch conversation that unpacks the complex US healthcare policy challenges we all face.

About Our Guest:
Matt Wetzel is an attorney and Partner at Goodwin Procter LLP, based in Washington D.C. He is a leading expert in medical device and healthcare regulation, working with numerous biotech, medtech, and digital technology companies. As a seasoned health policy commentator, Matt provides deep insights into the administrative and regulatory hurdles impacting the healthcare industry, from the FDA and CMS to the NIH.

Timestamps:
(00:00) Introduction: A System in Crisis
(01:55) The Government Shutdown's Widespread Impact on Healthcare
(05:05) How the Shutdown Halts FDA Approvals for New Drugs & Devices
(09:25) The Crushing Weight of Uncertainty on the Healthcare Business Community
(11:34) The Looming Expiration of ACA Enhanced Premium Tax Credits
(14:28) Why Can't Congress Agree on Extending ACA Subsidies?
(20:09) The Hidden Bureaucracy Driving Up Health Insurance Costs
(26:15) Decoding PBM Reform: Conflicts of Interest and Hidden Costs
(33:24) The PBM Conflict of Interest: Serving Two Masters
(37:50) PBM Trick Explained: What is "Spread Pricing"?
(41:00) The "Halloween Surprise": Unpacking the Medicare Efficiency Adjustment
(49:09) What's Next? Biotech, National Security, and Future Healthcare Legislation

Learn More From Our Guest / Episode Resources:

• Learn more about Matt Wetzel's work at Goodwin Procter LLP

Why? Because rebates are just one of five profit driving "tricks" PBMs use to quietly inflate your drug costs.

In this episode, Dr. Anthony Paravati breaks down the real money flow behind prescription drug pricing, how a system designed to reduce costs does the exact opposite

You'll learn:

• The 7-player money map that explains where every healthcare dollar really goes

• The 5 PBM "tricks" that turn generics into goldmines

• How "spread pricing" means employers (and ultimately you) pay huge markups on actual drug cost

• Why regulatory capture keeps this system legal

• And why this reform moment in Washington matters right now

If you're an employer, benefits consultant, or policymaker, this episode will change how you see pharmacy costs forever.

If you're a patient, you'll finally understand why your prescriptions keep getting more expensive.

Because every dollar diverted to middlemen is a dollar not going to care, wages, or innovation.

🎧 Listen now to understand the role PBMs have played to drive annual healthcare spend in the US to a ridiculous $4 trillion.

Joined by two of the nation's leading experts on the topic, we dissect the complex mechanics of the 340B drug pricing program and the powerful financial incentives that drive it. We explore how the program has grown exponentially, fueled by rising drug costs and the explosion of 340B contract pharmacies. This discussion sheds light on the central question: who benefits from the 340B program? Our guests break down how pharmacy benefit managers (PBMs) and major chains like CVS and Walgreens have become major players, diverting funds that were meant for patient care. We provide a clear, step-by-step example of how the money flows for a single prescription, revealing the winners and losers in this system.

A significant focus of our conversation is on 340B in oncology, where high-cost drugs create enormous financial spreads for participating hospitals, often without any direct savings for the cancer patient. This raises critical questions about whether the program encourages the use of more expensive drugs and consolidates cancer care into large hospital systems. We also dive deep into the push for 340B program reform, covering the recent Senate hearings, the legal battles over state laws restricting manufacturers, and the debate over moving oversight from HRSA to CMS. We analyze proposals like a rebate model and increased transparency requirements to understand what the future may hold for this vital, yet deeply flawed, healthcare program.

About Our Guests:

Ted Okon: As the Executive Director of the Community Oncology Alliance (COA), Ted Okon is a nationally recognized voice on the policy and politics of cancer care. He is a frequent presence on Capitol Hill, advocating on critical issues like drug costs, Medicare reimbursement, and the changing economics of oncology.

Amanda Smith: Amanda is Counsel at K&L Gates in their healthcare and FDA practice, with a specialized focus on the federal 340B drug pricing program. She advises clients on complex regulatory, legislative, and litigation matters related to the program and previously served as a healthcare law clerk for the U.S. Senate Committee on Finance.

Timestamps / Chapters: (00:20) Understanding the 340B Drug Pricing Program (07:24) How the 340B Program Really Works (09:29) Who Truly Benefits from 340B Discounts? (12:03) The Financial Impact: How 340B Influences Drug Prices (16:33) Navigating the Regulatory Landscape: HRSA's Role and Limitations (22:03) The Rise of 340B Contract Pharmacies & PBM Influence (25:26) The Legal Battleground: State Laws and Lawsuits (30:21) FOLLOW THE MONEY: A $10,000 Drug Example (36:11) Hospital Eligibility and the Lack of Transparency (44:26) The Future of 340B Program Reform: Rebates, CMS Oversight & More (59:45) PREDICTIONS: What Will 340B Look Like in 2 Years?

Learn More From Our Guests / Episode Resources:

• Learn more about the Community Oncology Alliance (COA)
• Learn more about K&L Gates' Healthcare Practice
• Subscribe to our channel
• Follow us on TikTok
• Follow us on LinkedIn

Meagan shares her journey from oncology business consulting to national advocacy, shaped by her own personal experience with cancer care. With two-thirds of U.S. cancer programs in its network, ACCC plays a pivotal role in driving change across the oncology landscape.

In this episode, we discuss:

• Why personal experience can reshape how we design cancer care

• Strategies to address workforce shortages through empowerment

• Using technology to amplify—not replace—clinical teams

• Building upstream cancer care capacity to improve community health

• Making value-based care real in oncology practices

• Interoperability and integrated models for better patient outcomes

• The role of diversity in improving adherence and patient engagement

Key Takeaways

• Workforce empowerment is essential to meet rising patient needs.

• Technology should act as a force multiplier for clinicians.

• Patient-centered care must be prioritized at every level.

• Interoperability and upstream investment are critical for sustainable oncology systems.

About the Guest Meagan O'Neill is the Executive Director of ACCC, which represents more than two-thirds of U.S. cancer programs. She previously worked in oncology business consulting and brings both professional and personal perspectives to driving systemic change in cancer care.

Chapters 00:00 – Introduction to ACCC and Meagan O'Neill 04:58 – A Personal Cancer Journey 12:11 – Workforce Empowerment in Oncology 20:19 – Building Capacity in Cancer Care 25:25 – Patient-Centered Care 26:12 – Data-Driven Approaches 28:10 – Expanding Capacity with Nursing and APPs 30:37 – Leveraging Technology 34:36 – Navigating Claims and Denials 37:18 – Interoperability and Integrated Care 39:02 – Tailoring Oncology Models 43:09 – Telehealth and E-Consults 45:39 – Designing Future Oncology Care 51:35 – Reflections on ACCC's 50th Anniversary

Keywords ACCC, cancer care, oncology, workforce empowerment, technology in healthcare, patient experience, healthcare systems, cancer treatment, healthcare innovation, patient-centered care, value-based care, interoperability, nursing, APPs, telehealth

As a solo practice physician treating cancer patients while leading the nation's largest physician organization, Dr. Mukkamala provides unique insights into the policy battles affecting healthcare delivery. The conversation covers prior authorization barriers that delay cancer care, the Medicare payment crisis with 25 years of declining physician reimbursement, and the collapse of independent medical practices due to site neutrality issues.

Dr. Mukkamala also addresses Medicare Advantage's aggressive denial tactics, the physician workforce shortage, and dangerous trends toward independent nurse practitioner practice without physician oversight. The discussion includes the AMA's role in CPT coding and RUC valuation, as well as Dr. Mukkamala's personal cancer journey and its impact on his advocacy for NIH research funding.

This episode reveals how physician advocacy organizations fight for both healthcare providers and patients as the system faces mounting pressures. Dr. Mukkamala's dual perspective as practicing physician and cancer patient offers invaluable insights into what's really happening in American healthcare.

About the Guest: Dr. Bobby Mukkamala is President of the American Medical Association, a practicing otolaryngologist in Flint, Michigan, and graduate of University of Michigan Medical School. He previously served on the AMA Council on Science and Public Health while maintaining his solo practice.

Value Health Voices makes healthcare policy and finance accessible through engaging discussions with industry leaders, policymakers, and practitioners working to transform care delivery.

Key Topics Covered:

• Critical APC "crosswalk" methodology issues affecting new treatment delivery codes
• CMS's new "efficiency adjustment" reducing procedural service payments by 2.5%
• Transition from survey-based valuations to hospital cost data methodology
• Image guidance and port film bundling into treatment delivery codes
• Surface radiation therapy coding updates and valuation changes
• RUC committee dynamics and specialty representation challenges
• Strategic considerations for the comment period ending September 12, 2025

Technical Analysis: Dr. Sameer Keole (ASTRO President) and Dr. Brian Lally (ACRO President) and Drs Paravati and Rewari explain how CMS may have assigned new radiation therapy codes to incorrect ambulatory payment classifications. The analysis suggests CMS deleted separate IMRT codes but may not have recognized that IMRT services are now bundled into new level 2 and level 3 treatment codes, potentially resulting in significant undervaluation.

Policy Context: The discussion examines how radiation oncology's 21% decline in relative value over 20 years, combined with these proposed changes, affects practice sustainability. Freestanding centers face particular challenges with a 32% reimbursement reduction since 2015.

About Our Guests: Dr. Sameer Keole serves as President of ASTRO and practices radiation oncology in Arizona. Dr. Brian Lally is President of ACRO and practices at an academic center in South Carolina. Both provide extensive expertise in healthcare policy and specialty society leadership.

This focused analysis provides healthcare leaders with essential technical information for participating in the rulemaking process.

Note: This is a condensed version of our full Episode 18 analysis, focusing specifically on radiation oncology implications.

Subscribe & Connect: Follow Value Health Voices Podcast for healthcare policy analysis. Find us on YouTube, LinkedIn, and all major podcast platforms.

Episode Tags: Medicare physician fee schedule, HOPPS, radiation oncology, ASTRO, ACRO, APC crosswalk, efficiency adjustment, CMS proposed rule, treatment delivery codes, comment period, healthcare policy analysis, specialty medicine, supercut

Key Topics Covered:

• CMS's new "efficiency adjustment"—a 2.5% reduction to work RVUs for procedural services
• New treatment delivery codes and potential APC "crosswalk" issues in radiation oncology
• Budget neutrality's role in specialty medicine reimbursement competition
• The shift from survey-based valuations to hospital cost data methodology
• Practice expense changes affecting technical component payments
• RUC committee dynamics and specialty representation challenges
• 34-year evolution of the RVU system and its impact on different specialties

Critical Policy Analysis: The episode examines how CMS assigned new radiation therapy codes to ambulatory payment classifications, potentially using incorrect methodologies that may not account for IMRT services bundled into new level 2 and level 3 codes. Our expert guests explain why radiation oncology has experienced a 21% decline in relative value over two decades while primary care increased 38%.

About Our Guests: Dr. Sameer Keole serves as President of the American Society for Radiation Oncology (ASTRO) and is a practicing radiation oncologist in Arizona. Dr. Brian Lally is President of the American College of Radiation Oncology (ACRO) and practices at an academic center in South Carolina. Both bring extensive experience in healthcare policy and specialty society leadership.

This executive briefing provides physicians and healthcare leaders essential context for the 60-day comment period ending September 12, 2025, and explores strategies for effective advocacy during the rulemaking process.

Subscribe & Connect: Follow Value Health Voices for comprehensive healthcare policy analysis. Find us on YouTube, LinkedIn, and all major podcast platforms.

Episode Tags: Medicare physician fee schedule, MPFS, HOPPS, efficiency adjustment, radiation oncology, ASTRO, ACRO, CMS proposed rule, RUC committee, budget neutrality, APC methodology, conversion factor, practice expense, healthcare policy analysis, specialty medicine, procedural services

This powerhouse leader, former Advisory Board Company executive who worked with 4,500+ healthcare organizations and 200,000+ leaders, breaks down the urgent shift happening in healthcare funding. With 10,000 baby boomers daily moving from private insurance to Medicare, operating margins are shrinking fast.

Key Topics Covered:

• Why "grateful patient" programs heal faster than traditional medicine
• How behavioral health donations surged 500% since COVID
• Why 100% leadership giving is non-negotiable for foundation success
• How AI is revolutionizing donor identification while respecting patient privacy
• Mobile clinics funded by donors serving vulnerable populations
• Alice's game-changing advice: "No doctor should ever ask for money—but opening gratitude conversations makes patients heal faster"

From her 20+ years leading healthcare transformation to guiding foundations that collectively raise $11 billion annually, Alice provides the roadmap hospitals need as federal funding disappears.

About Our Guest: Alice Ayres has served as President and CEO of AHP since 2018, recognized as one of Non-Profit Times Power and Influence Top 50 in 2024. She previously led strategic marketing for The Advisory Board Company, creating strategy sessions for 150+ leading healthcare providers worldwide. She holds an MBA from Northwestern Kellogg and brings deep healthcare industry knowledge to philanthropy leadership.

Subscribe & Connect: Follow Value Health Voices for insider healthcare finance strategies. Find us on YouTube, LinkedIn, and all major podcast platforms.

Episode Tags: healthcare philanthropy, hospital funding, grateful patient programs, healthcare finance, Alice Ayres, AHP, medical fundraising, healthcare donations, Medicaid cuts, hospital charity care, healthcare leadership, nonprofit management

This internal medicine physician and founder of AHealthcareZ (400+ healthcare finance videos, 100,000+ subscribers) delivers his signature straight-talk analysis on what will be the most earth-shattering healthcare legislation in decades. Dr. Bricker exposes how this bill would strip Medicaid coverage from 11-16 million Americans while dismantling the state funding mechanisms that keep safety-net hospitals alive.

Dr. Bricker and the VHV guys discuss:

• How "provider tax safe harbors" being cut from 6% to 3% will trigger massive prior authorization increases
• Why hospital systems will face a "double squeeze": less Medicaid revenue AND higher debt refinancing costs
• The brutal politics behind using patient care as a "political pawn" to fund tax cuts
• How charity care programs could become the only lifeline for millions of Americans
• Why even Republican senators are questioning these Medicaid cuts

Dr. Bricker's urgent message to physicians: "The age of passivity is over. No one is coming to save you or your patients." He provides concrete actions healthcare professionals can take locally while this legislative earthquake unfolds in Washington.

From work requirements that target caregivers to state-directed payment caps that will bankrupt safety-net hospitals, this episode breaks down thousands of legislative pages into what every healthcare leader needs to know before the Senate votes.

Subscribe to Value Health Voices for critical healthcare policy analysis. Check out Dr. Bricker's AHealthcareZ YouTube channel for his complete healthcare finance education library.

Chapters:

00:00 The $3.3 Trillion Healthcare Bill: An Overview

02:05 GOP Budget Reconciliation Bill: Key Healthcare Proposals

03:45 The Human Cost: Real Stories from Safety-Net Hospitals

07:23 Work Requirements: Who Really Gets Hurt

10:53 The Great Medicaid Funding Squeeze: Provider Taxes Under Attack

18:03 State-Directed Payments: The End of Hospital "Scavenger Hunts"

23:33 Political Power and Healthcare: The Real Game Being Played

29:02 The Double Squeeze: Medicaid Cuts + Rising Interest Rates

31:35 Taking Action: What Physicians Can Do Right Now

37:27 Hospital Innovation: Learning from Ochsner's Success Model

44:49 The Future of Healthcare Finance: Reasons for Optimism

Keywords: #Medicaidcuts, #budgetreconcilation #Senatebill, #CongressionalBudgetOffice #Medicaid #providertaxes #statedirectedpayments #workrequirements, #safetynethospitals healthcare finance #DrEricBricker #AHealthcareZ

Discover why Medicaid isn't actually one program but 50+ different state systems with wildly different funding mechanisms. Dr. Bricker exposes how provider taxes, DSH payments, and state-directed payments create a $80 billion federal funding ecosystem—and why only sophisticated hospital systems with armies of consultants can navigate it successfully. You'll learn why California gets 50% federal matching while Mississippi receives 77%, how children's hospitals depend on Medicaid for half their revenue, and why some suburban systems can ignore Medicaid entirely while urban academic centers live or die by these payments.

Known for his viral whiteboard videos that deconstruct the US healthcare system, Dr. Bricker delivers essential insights every healthcare leader needs to understand the financial forces reshaping American healthcare. This eye-opening conversation explains why administrative complexity has become a competitive advantage—and what it means for patient care.

Subscribe to Value Health Voices for expert healthcare policy analysis. Check out Dr. Bricker's AHealthcareZ YouTube channel for his complete healthcare finance library.

Chapters:

00:00 Understanding Medicaid: A Complex Landscape

02:12 The Mechanics of Medicaid Funding

05:41 Provider Taxes and Their Impact

10:01 Disproportionate Share Hospital Payments

17:22 State-Directed Payments: Variability and Controversy

20:16 Expansion vs. Non-Expansion States

24:22 The Role of Managed Care Organizations

28:40 Challenges in Accessing Care for Medicaid Patients

32:35 Understanding the Complexities of Healthcare Funding

36:56 The Scavenger Hunt for Revenue in Healthcare

39:48 The Friction in Healthcare Administration

Keywords: Medicaid, healthcare finance, health policy, state funding, provider taxes, DSH payments, state-directed payments, expansion states, healthcare access, revenue generation

Chapters

00:00 Introduction to Healthcare Economics and MedPAC

02:56 The Evolution of Health Economics

06:05 Unique Challenges in Healthcare Markets

09:11 Moral Hazard and Insurance Dynamics

12:10 The Role of Technology in Rising Costs

15:10 Understanding MedPAC's Function and Influence

18:01 MedPAC Recommendations and Their Impact

22:16 The Complexity of Medicare Payment Systems

25:07 Challenges in Hospital Profitability

28:20 The Future of Payment Models in Healthcare

38:16 Geographic Variation in Medical Practice

39:15 Alternative Payment Models and Pricing Issues

46:53 The Rise of Medicare Advantage

55:20 Future of Medicare and Healthcare Reform

About:

Value Health Voices is a podcast redefining conversations around health policy and healthcare finance, delivering accessible and expert-driven discussions on the topics shaping the future of healthcare. Hosted by Dr. Anthony Paravati and Dr. Amar Rewari, the podcast explores how regulations, emerging technologies, and financial pressures impact patient care, provider operations, and healthcare systems. With their combined experience as radiation oncologists and healthcare leaders, they break down complex topics like Medicare reimbursement, artificial intelligence in healthcare, and prior authorization in ways that are actionable and engaging. Each episode features insights on legislative efforts, best practices for providers navigating policy changes, and trends shaping the future of value-based care, empowering listeners with knowledge they can use immediately.

Connect with Value Health Voices on:

Apple Podcasts: https://tinyurl.com/VHV-apple

Spotify: https://tinyurl.com/VHV-Spotify

Amazon music: https://tinyurl.com/VHV-amazon

LinkedIn: https://tinyurl.com/VHV-Linkedin

To truly understand healthcare in the U.S., an understanding of CPT and RUC is fundamental.

In this special episode of Value Health Voices, we flip the script—Dr Anthony Paravati interviews co-host Amar Rewari, a nationally recognized expert in the CPT development process and the RUC (Relative Value Scale Update Committee). This is your backstage pass to the invisible forces that decide how doctors are paid, which services get valued, and why the U.S. healthcare system rewards what it does.

In this episode, we unpack:

• What the CPT process really is—far beyond billing codes

• How the RUC committee wields extraordinary influence over payment policy

• The lifecycle of a medical service's valuation—from clinical utility to reimbursement

• How these processes directly affect hospital strategy, service line planning, and physician compensation

No deep dive into CPT and RUC is complete without exploring the critiques—many of which are long-standing and still unresolved:

• Specialty Bias: Procedural specialties often dominate the RUC, leading to higher valuations for procedures and lower ones for cognitive services like primary care.

• Lack of Transparency: Decision-making behind closed doors fuels frustration and distrust, especially among non-physician stakeholders.

• Inertia and Inequity: Efforts to revalue services often move at a glacial pace, creating systemic lag between innovation and payment.

We challenge assumptions, unpack the politics, and explore what meaningful reform could look like.

Whether you're a hospital executive, a health policy analyst, a medical director, or a clinician trying to understand your paycheck, this episode gives you what textbooks and boardrooms don't: a clear, actionable understanding of the CPT and RUC systems and how they quietly influence everything from your budget to your workforce strategy.

You'll walk away with:

• A framework to think critically about reimbursement strategy

• Insight into why your specialty is—or isn't—being adequately valued

• Clarity on how to engage with these systems to advocate for fairer healthcare

Keywords: CPT process, RUC committee, physician reimbursement, healthcare payment reform, US healthcare finance, healthcare policy podcast, Medicare valuation, specialty society lobbying

takeaways

• Dr. Nikore's journey from software development to healthcare entrepreneurship.
• The importance of home-based care in improving patient outcomes.
• Home Care Hub aims to create smaller, community-based care homes.
• Metrics such as decreased readmissions are crucial for success.
• Regulatory challenges vary significantly across states and provinces.
• Advocacy for policy changes is essential for funding alternative care models.
• The future of healthcare will involve more personalized and accessible care options.
• Data collection from home care can drive better patient outcomes.
• Entrepreneurship in healthcare requires resilience and adaptability.
• Mentorship and networking are key for aspiring healthcare entrepreneurs.

Chapters

00:00 Introduction to Home-Based Care Innovations 01:39 The Journey of Dr. Vipan Nikore 10:15 Exploring Home Care Hub 17:13 Metrics and Outcomes in Home Care 20:29 Navigating Regulatory Challenges 22:34 Navigating Regulatory Challenges in Healthcare Innovation 23:49 Advocating for Alternative Care Models 25:05 The Importance of Personalized Care 26:20 Addressing Loneliness and Social Isolation 27:42 Leveraging Technology in Home Care 29:39 Policy Advocacy for Healthcare Solutions 32:18 The Role of Data in Improving Outcomes 33:03 Envisioning the Future of Home Healthcare 36:12 The Entrepreneurial Journey in Healthcare 39:16 Advice for Aspiring Healthcare Entrepreneurs

In this episode of Value Health Voices, Dr. Anthony Paravati and Dr. Amar Rewari sit down with Ned Laubacher, CEO of Health Spectrum Advisors and an expert in direct-to-employer contracting, to break down: ✅ The shift toward self-insured models and employer-driven health benefits ✅ The role of quality metrics and shared savings in employer-provider contracts ✅ How data transparency is transforming healthcare finance and cost control ✅ The impact of legislation on employer health plans ✅ Common pitfalls in direct contracting and how to avoid them

💡 Key Takeaways: 🔹 Self-insured employers have more control over healthcare costs and provider networks 🔹 Direct contracts with health systems help improve cost transparency and health outcomes 🔹 Employers must take a proactive role in healthcare policy to navigate complex regulations 🔹 PBMs and cost-plus drug models are playing an increasing role in employer-led health plans 🔹 Analytics & data-driven decision-making are the future of value-based care

Takeaways

Matt Wetzel is a lawyer specializing in medical technology and life sciences. The JPMorgan Healthcare Conference is a key networking event in the industry. The Trump administration is focused on efficiency in healthcare regulation. NIH has implemented a cap on indirect costs for grants. There is a debate within the industry about the appropriateness of indirect cost caps. Medicaid spending is a politically sensitive issue that may face cuts. The FDA's regulatory environment is evolving, with potential for increased efficiency. Personnel changes in government can significantly impact healthcare policy. The media often sensationalizes healthcare regulatory changes. Understanding the details of regulations is crucial for stakeholders.

Chapters

00:00 Introduction to the Regulatory Landscape 04:53 Insights from the JPMorgan Healthcare Conference 10:16 Changes in NIH Grant Funding 20:33 Medicaid Spending and Work Requirements 24:03 Understanding Federal Health Programs 28:24 Navigating Regulatory Challenges 32:47 The Strategic Landscape of Healthcare Policy 38:23 The Future of Leadership in Healthcare 42:59 Key Takeaways for Navigating Change

Chapters

00:00 Introduction to Medicare Cuts 03:47 Understanding the RVU and Conversion Factor 09:18 The Impact of Legislation on Physician Payments 14:13 The Role of MACRA and Future Considerations 19:40 The Broader Implications for Patient Care

Chapters

00:00 Introduction 03:24 Early Career and Background on RFK Jr. 04:23 Vaccine Controversies and Scientific Denialism 14:36 Agricultural Policies, Raw milk and Health Implications 17:18 Wellness and Chronic Disease Management 25:29 The Influence of Pharmaceutical Lobbying 27:45 Pharmaceutical Benefit Managers and Drug Pricing 29:31 Fluoride in Water: A Complex Debate 32:25 CPT Codes and the RUC: The Role of the AMA in Healthcare 36:16 Navigating Bureaucracy: Challenges Ahead for RFK Jr. 38:09 Summary

• Medicare Advantage offers lower premiums, appealing to budget-conscious seniors.
• The program is administered by commercial insurance companies, not the government directly.
• Narrow networks in Medicare Advantage can limit provider choices for seniors.
• Seniors with lower incomes are more likely to choose Medicare Advantage.
• Insurance companies benefit from risk adjustment payments for sicker patients.
• Quality bonuses incentivize Medicare Advantage plans to improve care.
• Hospitals face challenges with payment delays and denials from Medicare Advantage plans.
• The popularity of Medicare Advantage is increasing among seniors.
• Tighter margins for Medicare Advantage plans may lead to reduced benefits.
• Future changes in Medicare Advantage will depend on regulatory adjustments and market dynamics.