Health Tech Nerds Radio

Kevin and Martin dig into a busy week of Q2 earnings, starting with Doximity's whiplash quarter. From there they run through then payer calls: Oscar and Clover both grew close to 50% while improving MLR. They discuss Oscar's Oswell radiology agent and Clover's Counterpart licensing play, Hinge Health's investor day excitement and Cylinder acquisition, and Bank of America's $250 million GLP-1 spend.They close on Minneapolis' HCMC bailout, a Denver hospital antitrust standoff, and the current "value-based care is back" moment powered by Vytalize, Agilon, and a wave of new AI-enabled ACO enablers — before previewing Hims' earnings as a bellwether for consumer healthcare affordability.Brought to you byGarner uses industry-leading analytics to identify the best-performing doctors and reimburse employees when they see them, helping over 2.5 million people find better care at lower cost. Explore careers with Garner. GarnerHealth.com/careersLinks referencedBank of America CEO on GLP-1s: https://fortune.com/2026/08/07/bank-of-america-splashing-out-250-million-a-year-on-weight-loss-drugs-for-staff-great-impact-ceo-says/Challenges for HCMC: https://www.startribune.com/minneapolis-hospital-burned-through-cash-reserves-amid-behind-the-scenes-turmoil/601841297For more from Health Tech Nerds, subscribe to our weekly newsletters: https://www.healthtechnerds.com/subscribe

Kevin and Martin chat about a packed earnings week: Teladoc's BetterHelp cash pay business fell off a cliff in mid-May, Humana passed its 2026 MA stress test but is still terming 600,000 members from low-star plans to hit its 2028 margin target, Centene raised ACA guidance a week after Molina's "death spiral" quarter, and Centene’s Sarah London's blunt AI cost-management comments drew comparisons to Palantir's Alex Karp. Cigna, Waystar, and Alignment round out the earnings discussion.They then move into private markets: Function raised $450 million in revenue-based financing from General Catalyst's Consumer Growth Fund, Included Health acquired Firefly Health, pairing navigation with an advanced primary care model, and Helia Health raised $14 million on a plan-optimization pitch that Martin calls a short-term arbitrage window rather than a durable business.They close on Iowa's governor's race, where Medicaid managed care itself is on the ballot, and a broader debate about whether the country is drifting back toward fee-for-service.Brought to you byGarner uses industry-leading analytics to identify the best-performing doctors and reimburse employees when they see them, helping over 2.5 million people find better care at lower cost. Explore careers with Garner. GarnerHealth.com/careersFor more from Health Tech Nerds, subscribe to our weekly newsletters: https://www.healthtechnerds.com/subscribe

Kevin and Martin kick off with Q2 payer earnings. Elevance's stock fell 11% despite beating estimates because the company signaled Medicaid market exits without giving Wall Street any sizing to work with, while United warned that the No Surprises Act is driving commercial trend higher than expected.They then discuss the OpenEvidence-Doximity documentation fight, with both citing the same study as proof that they’re winning, as well as reports that OpenEvidence turned down a $20B valuation while fielding acquisition interest from a "large tech player.”They close on the physician fee schedule — clearing up the misleading "CMS cuts pay" coverage and walking through the notice-and-comment process — before a rapid walkthrough of recent private deals: Corner Health's staff-free NP clinic model, Bunkerhill Health's $25M raise and the point-solution-versus-platform debate, and Neko Health's eyebrow-raising $7B valuation on eight clinics.Links referencedThe Information on OpenEvidence: https://www.theinformation.com/articles/chatgpt-doctors-mulls-new-financing-20-billion-valuationFortune on Bunkerhill Health: https://fortune.com/2026/07/16/bunkerhill-health-raises-55-million-ai-agents-work-inside-hospitals/For more from Health Tech Nerds, subscribe to our weekly newsletters: https://www.healthtechnerds.com/subscribe

Bryan Sivak and Sean Glass closed a $24 million first fund for Evidenced. They invest in healthcare companies benefiting from a regulatory or policy tailwind that pushes buyers to act sooner or spend more.Both are repeat entrepreneurs — Sivak sold his company, Glass took his public — and they walk through the portfolio bets that prove the thesis out, from a community health worker platform spun out of UPenn to a cardiometabolic care company navigating GLP-1 coverage. They're candid about the difficulty of fundraising as first-time managers competing against multi-stage giants for LP dollars, and they lay out which policy trends they think are durable versus which ones won’t last through the next administration.Links referencedSean and Bryan (Evidenced): [email protected], [email protected] more from Health Tech Nerds, subscribe to our weekly newsletters: https://www.healthtechnerds.com/subscribe

Sam Melamed spent 20 years building Insurance Forums into the largest online community for insurance agents and brokers before becoming CEO of NCD, a top-rated dental, vision, and supplemental benefits administrator, five years ago. He argues fears of an ACA "death spiral" are overstated, and pushes back on claims that fraud alone explains recent enrollment declines. He also breaks down how CMS's new Bridge program for GLP-1s is likely to play out, and previews the pullback in Medicare Advantage supplemental benefits expected heading into the next open enrollment period.Links referencedSam Melamed (NCD): [email protected] more from Health Tech Nerds, subscribe to our weekly newsletters: https://www.healthtechnerds.com/subscribe

Kevin and Martin open by discussing a question that recently surfaced in the Health Tech Nerds Slack community: is employer-sponsored insurance actually crumbling, or just showing its age? They then move into a conversation about Midi's CEO calling out a $40K/year concierge menopause practice on LinkedIn and a run of quick hits: Elevance and SCAN joining Clover in suing over Stars ratings, a Wall Street Journal piece flirting with "death spiral" language for the ACA, Alignment Health's accounting troubles, and Pearl Health's $110M raise stacked half on credit.Then Bryan Sivak and Sean Glass join to break down Evidenced, the venture fund they just launched with a $24 million raise. They explain the fund's core thesis — backing early-stage health tech and tech-enabled services companies where a specific regulatory or policy tailwind accelerates buying — and walk through portfolio examples like IMPaCT Care, the community health worker infrastructure company spun out of UPenn.Sam Melamed, CEO of NCD and self-described "Chief Insurance Nerd," closes things out. He walks through NCD's supplemental benefits business, then dives into forecasting enrollment in CMS's new Bridge program, discussing what full-page Eli Lilly ads in the New York Times signal about the money already flowing into that market, and lays out why he thinks standalone dental and vision plans keep gaining ground alongside Medicare Advantage.Links referencedOut of Pocket, Out of Reach: https://www.statnews.com/health-insurance-costs-out-of-pocket-out-of-reach-series/The Billionaires’ Vagina Club: https://www.newyorker.com/magazine/2026/07/06/the-billionaires-vagina-clubACA rate increases: https://www.wsj.com/health/healthcare/obamacare-insurers-seek-big-rate-hikes-again-8a4bf9e4Sean and Bryan (Evidenced): [email protected], [email protected] Melamed (NCD): [email protected] more from Health Tech Nerds, subscribe to our weekly newsletters: https://www.healthtechnerds.com/subscribe

Jeremy Friese spent a decade as a physician at Mayo Clinic navigating prior auth from the provider side. Now he runs Humata Health, which helps large health systems submit better prior auths to every plan in the country. Humata is a participant in CMMI's WISeR program, handling Oklahoma's fee-for-service Medicare prior auth, and six months in, providers are submitting almost exclusively through Humata's portal. Jeremy's view on fixing prior auth: use AI only to say yes, build real transparency into the rules, and let humans sort out the small fraction that actually requires a fight.Links referencedCBS article on WISeR rollout in Oklahoma: https://www.cbsnews.com/news/medicare-ai-program-wiser-prior-authorization-errors-delays/Substack on AI usage in prior auth: https://spinalcolumn.substack.com/p/the-algorithm-is-denying-your-authHumata Health: humatahealth.comJeremy Friese: [email protected] more from Health Tech Nerds, subscribe to our weekly newsletters: https://www.healthtechnerds.com/subscribe

Kevin and Martin start with a discussion about a crowded week in healthcare AI funding. Prosper AI and Assort Health’s fundraising announcements were released on back-to-back days, with nearly identical customer quotes claiming each was "the only true platform." Kevin and Martin work through what that signals about the agentic voice AI space. They also cover Alan's €480M raise at a $6.3B valuation, Trase's $107M seed round, Cadence's RPM-to-chronic-care-management pivot, Hera's CCM play, Upside's Medicaid housing engagement numbers, the Cityblock-Homeward acquisition, and UpDoc's FDA 510K clearance. They close by explaining stop-loss lasering and what it means for insurability when the bag keeps getting passed.Then Jeremy Fries, CEO and founder of Humata Health, joins to talk through WISeR — the CMMI prior auth program now live in Oklahoma. Jeremy walks through how the program works (AI says yes instantly; humans adjudicate everything else), what the rollout has actually looked like on the ground, why provider adoption numbers are better than the headlines suggest, and why he thinks prior auth, done right, is one of the few places in healthcare where payers and providers can actually find common ground.Links referencedBloomberg article on MyConnections: https://www.bloomberg.com/news/features/2019-11-05/unitedhealth-s-myconnections-houses-the-homeless-through-medicaidWSJ article on UpDoc: https://www.wsj.com/pro/venture-capital/updocs-ai-gets-fda-nod-to-act-as-concierge-doctor-between-visits-2b7fa41bMarsh McLennan report on lasering: https://view.ceros.com/marsh-mma-mid-atlantic/success-stories/p/19CBS article on WISeR rollout in Oklahoma: https://www.cbsnews.com/news/medicare-ai-program-wiser-prior-authorization-errors-delays/Substack on AI usage in prior auth: https://spinalcolumn.substack.com/p/the-algorithm-is-denying-your-authHumata Health: humatahealth.comJeremy Friese: [email protected] more from Health Tech Nerds, subscribe to our weekly newsletters: https://www.healthtechnerds.com/subscribe

JD Friedland is the executive director for ventures at Cleveland Clinic, where he evaluates and deploys emerging health technology across one of the country's largest and most research-intensive health systems. He walks through what Cleveland Clinic has actually built — some examples include: sepsis detection with Bayesian, clinical trial recruitment via Dyania, and surgical note generation through Theator's ambient video platform. He gets into why Cleveland Clinic's data is worth more today than it will be once the window to be an early contributor has closed, why OpenEvidence's pharma-advertising model gives him pause, and why the liability question, not the technology, determines the speed of clinical AI deployment.Brought to you byUrsa Health: Join HTN, Atlas Oncology Partners, and Ursa Health this Wednesdsay, June 24 at 12pm ET to dive into specialty value-based care. Register to attend and receive the recording: luma.com/htn-ursa-atlasFor more from Health Tech Nerds, subscribe to our weekly newsletters: https://www.healthtechnerds.com/subscribe

Kevin and Martin by discussing the OhioHealth DOJ settlement and what banning anti-tiering, anti-steering clauses in hospital contracts could mean for employer plan design, narrow networks, and upstart insurance models. They talk about the $12B Ensemble Health Partners deal: what it says about the RCM market's appetite for holistic versus point-solution approaches, and where it might fit into Matt Holt's broader Thoreau acquisition agenda. The Clover-Stars recalculation gets a full breakdown: what the judge sided with, what CMS did next, who won, and the uncertainty now rippling through payer teams, provider comp models, and the whole vendor ecosystem built around Star scores. Martin digs into the 340B program via Minnesota's annual state report, explaining Eli Lilly's decision to freeze discounts for non-compliant hospitals, the FQHC access problem at the center of it, and whether a rebate model actually helps or just punishes the safety net players the program was designed for. And Kevin walks through OpenLoop's Shopify-for-telehealth launch, what it would actually mean if anyone with an audience could create a D2C GLP-1 brand in hours, and why the economics of that model are an interesting question.Then JD Friedland, Executive Director for Ventures at Cleveland Clinic, joins to walk through how one of the country's flagship health systems is thinking about AI deployment. JD talks about what Cleveland Clinic has actually built with ambient listening, clinical trial enrollment via Dyania, and surgical documentation through Theator. He gets into the data consortium question—why your institution's data is most valuable when you’re an early contributor—and the liability and brand risk that makes health systems cautious about deploying forward-facing AI solutions they don't fully control.Brought to you byUrsa Health: Join HTN, Atlas Oncology Partners, and Ursa Health this Wednesdsay, June 24 at 12pm ET to dive into specialty value-based care. Register to attend and receive the recording: luma.com/htn-ursa-atlasLinks referencedOhioHealth / DOJ Settlement: https://www.justice.gov/opa/pr/justice-department-requires-ohiohealth-stop-using-anticompetitive-healthcare-contract-termsMinnesota 340B Report: https://www.health.state.mn.us/data/340b/docs/2025report.pdfFor more from Health Tech Nerds, subscribe to our weekly newsletters: https://www.healthtechnerds.com/subscribe

Hashem Zikry is a practicing emergency physician at UCLA, a researcher focused on unnecessary ED utilization, and the medical director for clinical research and policy at Counsel Health — which, this week, began integrating Oura biometric data into clinical decision-making for the first time. That combination of roles gives him an unusual perspective on the question everyone is asking: what should AI actually be allowed to do in clinical care?He also speaks about regulation — the current state-by-state landscape ranges from Utah's live AI sandbox to New York and Colorado bills that would sharply limit patient-facing AI — and Zikry argues a federal floor would accelerate innovation rather than constrain it. On the Oura partnership, he pushes back on the concern that wearables drive unnecessary utilization, contending that access to a clinician at the point of data — not just the data itself — is what changes the demand curve.Brought to you byUrsa Health: Join HTN, Atlas Oncology Partners, and Ursa Health on June 24 at 12pm ET to dive into specialty value-based care. Register to attend and receive the recording: luma.com/htn-ursa-atlasLinks referencedHashem’s LA Times story: https://www.latimes.com/opinion/story/2026-04-25/ai-democratize-medicine-regulationFollow Hashem on LinkedIn: https://www.linkedin.com/in/hashem-e-z-87243529a/For more from Health Tech Nerds, subscribe to our weekly newsletters: https://www.healthtechnerds.com/subscribe

Thirty-five years into Medicare Advantage, John Kao sees the V28 correction as a pricing reset, not a structural rupture. Plans that invested in clinical care delivery are emerging from it better positioned than those that leaned on coding and prior auth. He expects MA to capture 65–70% of the senior market within the next decade — and argues the current administration's push on program integrity is accelerating, not threatening, that trajectory.The second half of the conversation turns to health systems. Hospitals that are over capacity are coming to Alignment Health not out of ideological alignment on value-based care, but because reducing senior admissions frees up beds for commercial patients who reimburse at higher rates. Alignment's pitch is that it can deliver on that operationally — 142 acute admissions per thousand versus original Medicare's roughly 250 — while also moving market share into the system. The business case, he argues, makes the ideological one unnecessary.Brought to you byUrsa Health: Join HTN, Atlas Oncology Partners, and Ursa Health on June 24 at 12pm ET to dive into specialty value-based care. Register to attend and receive the recording: luma.com/htn-ursa-atlasLinks referencedFollow John on LinkedIn: https://www.linkedin.com/in/johnkao1/For more from Health Tech Nerds, subscribe to our weekly newsletters: https://www.healthtechnerds.com/subscribe

Kevin and Martin chat about Matt Holt's return with a reported $12 billion bid for Ensemble Healthcare Partners. They unpack what it means that Thoreau, Holt’s AI-forward play, is interested in a business whose CEO explicitly pitched a more human-centric approach to RCM. From there, they do a deep dive into what’s going on in Hawaii: HMSA's decade-long VBC experiment is unraveling, providers have done a complete 180 on whether they want it, and the state is now pushing a payvider merger that makes even less sense given the backdrop. Kevin traces it all back to the same payer-provider adversarial dynamic playing out across the country. Then they take a look at PwC's 2027 commercial trend report, which projects a 9% increase in medical costs, the highest in 18 years, with AI-driven billing optimization leading the charge, followed by behavioral health volume, GLP-1s, No Surprises Act fallout, and hospital services inflation. The politics aren't subtle: AI that helps providers bill more is innovation, while AI that helps payers deny more is bad. They also touch on recent stock moves for Clover and Alignment as signs that managed care is trending upward again.John Kao, chairman and CEO of Alignment Health, joins to explain why he always says not to bet against Medicare Advantage. He walks through what's made Alignment's California model work, why expanding outside the state is harder than it looks, and how health systems are increasingly coming to them — not the other way around — because keeping MA patients out of beds is good for all parties.Hashem Zikry from Counsel Health closes the show with a discussion on clinical AI regulation. He frames the current U.S. landscape as a laboratories-of-democracy experiment — Utah running a live sandbox, New York and Colorado pulling back — and argues the federal government should set a floor, not a ceiling. He also breaks down Counsel's new partnership with Oura, which this week begins integrating biometric data into clinical decision-making for the first time, and pushes back on the concern that wearables just generate more utilization.Brought to you byUrsa Health: Join HTN, Atlas Oncology Partners, and Ursa Health on June 24 at 12pm ET to dive into specialty value-based care. Register to attend and receive the recording: luma.com/htn-ursa-atlasLinks referencedPwC report: https://www.pwc.com/us/en/industries/health-industries/library/behind-the-numbers.htmlFollow John on LinkedIn: https://www.linkedin.com/in/johnkao1/Hashem’s LA Times story: https://www.latimes.com/opinion/story/2026-04-25/ai-democratize-medicine-regulationFollow Hashem on LinkedIn: https://www.linkedin.com/in/hashem-e-z-87243529a/For more from Health Tech Nerds, subscribe to our weekly newsletters: https://www.healthtechnerds.com/subscribe

Seth Cohen runs Cedar, which sits inside the bill-pay workflow for health systems across the country, meaning he sees the patient collections reality that most hospitals are still processing. Most providers still sort patients into commercial, government, and self-pay, a taxonomy that made sense 15 years ago and doesn't anymore. ACA premium churn is quietly flipping commercial AR to self-pay retroactively, Medicaid redeterminations hit January 1st, and the average hospital is already collecting about 40 cents on every patient dollar owed. For a $5B system, that's $250M in net income lost annually. Seth argues that the billing problem has quietly become an affordability problem, and that the fix isn't better statements or more outreach—it's meeting people where they actually are.Brought to you byUrsa Health: Join HTN, Atlas Oncology Partners, and Ursa Health on June 24 at 12pm ET to learn what it takes to scale specialty value-based care. Register: luma.com/htn-ursa-atlasLinks referencedSeth’s LinkedIn post on ACA premiums: https://www.linkedin.com/feed/update/urn:li:activity:7453134273911455744/How to contact Seth: [email protected] more from Health Tech Nerds, subscribe to our weekly newsletters: https://www.healthtechnerds.com/subscribe

Ezekiel Emanuel helped write the ACA, and now he's thinking about what comes next. To those saying America needs to spend more on healthcare, he points to countries like Germany, Switzerland, Norway—all have universal coverage, their systems provide comparable care quality to the U.S., yet they spend considerably less. The issue isn't money—it's how the system is organized. On the reform timeline, he expects policy change to happen in the 2032 election cycle, when the Medicare trust fund starts coming into view. As for AI, he believes it will be a fully integrated piece of the clinical landscape by 2030, but should be part of value-based payment, not fee-for-service. He also shares his thoughts on the longevity craze... and mentions a standing bet with Bryan Johnson.Brought to you byUrsa Health: Join HTN, Atlas Oncology Partners, and Ursa Health on June 24 at 12pm ET to learn what it takes to scale specialty value-based care. Register: luma.com/htn-ursa-atlasLinks referencedZeke’s article in The Bulwark: https://www.thebulwark.com/p/democrats-must-fix-medicaid-not-just-undo-trump-bbb-damage-universal-coverage-seven-principles-reform-health-careFor more from Health Tech Nerds, subscribe to our weekly newsletters: https://www.healthtechnerds.com/subscribe

Kevin and Martin open with an unusual question: how much fraud should we actually tolerate in healthcare? News from Minnesota prompted the question, where the state just disenrolled 3,400 Medicaid providers, most not for fraud, but for incomplete paperwork. Kevin's argument is that zero-tolerance consolidates the market around whoever's best at compliance, not care. Martin mentions that we're underfunding the people who catch sophisticated fraudsters, and prior auth does actually work. They also discuss the ABA therapy workforce explosion (5X growth in behavioral techs since 2019), which the Wall Street Journal frames as a fraud story and Martin pushes back on. Then they pivot to a very different kind of story: wealthy New Yorkers are buying $5M apartments to be used as "med-à-terres" for just a few specialist visits a year, and some luxury condos now feature Atria longevity clinics.Ezekiel Emanuel—ACA architect, UPenn Vice Provost, author of Eat Your Ice Cream—comes on to talk about whether a real healthcare policy reform moment is coming. He shares the basics of the proposal he is working on drafting, and discusses about when he thinks it will be the right time for this transformative reform. He also talks about how much of U.S. GDP should go toward healthcare costs, and how the industry should use (and bill for) AI in a way that makes sense.Seth Cohen, president of Cedar, closes with a view on provider finance. Hospitals still sort patients into commercial, government, and self-pay, a taxonomy that made sense 15 years ago. Driven by that, plus numerous additional challenges, the system is not working for patients. Seth argues that the billing problem has become an affordability problem, and the fix isn't better statements—it's meeting people where they are.For more from Health Tech Nerds, subscribe to our weekly newsletters: https://www.healthtechnerds.com/subscribeBrought to you byUrsa Health: Join HTN, Atlas Oncology Partners, and Ursa Health on June 24 at 12pm ET to learn what it takes to scale specialty value-based care. Register: luma.com/htn-ursa-atlasLinks referencedWSJ on ABA fraud: https://www.wsj.com/health/healthcare/autism-therapy-insurance-bills-880b9dba?mod=mhp&_bhlid=14a8b4ad00b8b90f14f4e33aeb944007aa658e91WSJ on “med-à-terres”: https://www.wsj.com/real-estate/luxury-homes/wealthy-retirees-are-buying-med-a-terres-to-be-near-their-new-york-doctors-f411c9db?mod=series_housingmarketWSJ on longevity as an amenity: https://www.wsj.com/real-estate/luxury-homes/the-new-amenity-in-luxury-living-longevity-services-91369ca8?mod=WTRN_pos1Zeke’s article in The Bulwark: https://www.thebulwark.com/p/democrats-must-fix-medicaid-not-just-undo-trump-bbb-damage-universal-coverage-seven-principles-reform-health-careSeth’s LinkedIn post on ACA premiums: https://www.linkedin.com/feed/update/urn:li:activity:7453134273911455744/How to contact Seth: [email protected]

Prior to the wave of GLP-1s, Amit Shah has spent a decade working on reversing metabolic disease through nutrition. As a leader at Virta Health, he's experienced the impact that changing what people eat can have on type 2 diabetes, cardiovascular events, and outcomes across a surprising range of conditions.In this episode, he talks about the reality that 93% of American adults have some form of metabolic dysfunction, addresses patient preferences for medication or lifestyle changes through diet, and shares how Virta is showing that a nutrition-first approach, paired thoughtfully with GLP-1s, delivers better outcomes and lower costs for the employers and health plans.For more from Health Tech Nerds, subscribe to our weekly newsletters: https://www.healthtechnerds.com/subscribeBrought to you by:Ursa Health: Join HTN, Atlas Oncology Partners, and Ursa Health on June 24 at 12pm ET to learn what it takes to scale specialty value-based care. Register: luma.com/htn-ursa-atlasAbridge: Join Abridge's first-ever Keynote on June 11, where CEO Dr. Shiv Rao will share their biggest step yet toward saving time, money, and lives. NYC and streaming globally. Register: events.abridge.com/keynote

Michelle Turner spent years as a foster parent watching the healthcare system fail the kids in her home because the existing system wasn't built for them. She founded Here Now Health to fix that, creating a virtual mental health platform purpose-built for foster-connected youth, controlling for the many barriers they face in seeking care. She walks through the little-known world of foster specialty Medicaid plans, why this high-acuity population has attracted almost no innovation, and how Here Now Health is proving that early, consistent care is both better for kids and far cheaper than the crisis cycle states are currently funding.For more from Health Tech Nerds, subscribe to our weekly newsletters: https://www.healthtechnerds.com/subscribeBrought to you by:Ursa Health: Join HTN, Atlas Oncology Partners, and Ursa Health on June 24 at 12pm ET to learn what it takes to scale specialty value-based care. Register: luma.com/htn-ursa-atlasAbridge: Join Abridge's first-ever Keynote on June 11, where CEO Dr. Shiv Rao will share their biggest step yet toward saving time, money, and lives. NYC and streaming globally. Register: events.abridge.com/keynoteReferenced:Here Now Health: herenow.health / [email protected]

News & Analysis from Health Tech NerdsKevin and Martin open with Elevance's "thumb drive gate" CMS update, a $935 million accrual, and questions about what they ultimately owed. They debate how many $100 billion healthcare AI companies the market can support, using Commure's $7B valuation and Rockefeller-esque platform ambitions as a case study. In health law: the Clover Stars ruling and post-Chevron MA bid uncertainty, the Massachusetts AG's D-SNP upcoding lawsuit against UnitedHealthcare, No Surprises Act IDR enforcement chaos in Texas, and CVS suing Tennessee over PBM-pharmacy separation. They close by talking about Providence Health Plan and PacificSource exiting markets and the persistent struggles of regional non-profit health plans.Amit Shah, President of Virta Health, makes the case that the GLP-1 era is actually Virta's moment, with ten years of clinical data on reversing metabolic disease through nutrition showing that Virta is uniquely positioned to serve patients before, alongside, and after drug-based treatment.Michelle Turner, founder of Here Now Health, introduces the niche but consequential world of foster specialty Medicaid plans and the high-acuity, high-transiency population they serve. She explains how Here Now was built from the ground up to get kids into care fast, keep them there through instability, and give health plans a far cheaper alternative to crisis care.For more from Health Tech Nerds, subscribe to our weekly newsletters: https://www.healthtechnerds.com/subscribeBrought to you by:Ursa Health: Join HTN, Atlas Oncology Partners, and Ursa Health on June 24 at 12pm ET to learn what it takes to scale specialty value-based care. Register: luma.com/htn-ursa-atlasAbridge: Join Abridge's first-ever Keynote on June 11, where CEO Dr. Shiv Rao will share their biggest step yet toward saving time, money, and lives. NYC and streaming globally. Register: events.abridge.com/keynoteReferenced:Commure CEO on the Sourcery podcast: https://www.youtube.com/watch?v=Vd4HHQ1l9mMWillamette Week: Inside the Collapse of Providence Health Plan: https://www.wweek.com/news/2026/05/27/inside-the-collapse-of-providence-health-plan/Tennessee Lookout: CVS sues Tennessee: https://tennesseelookout.com/2026/05/26/cvs-sues-tennessee-over-pharmacy-benefit-manager-monopoly-law/JAMA article on growth of provider-sponsored health plans, 2018–2023: https://jamanetwork.com/journals/jama/fullarticle/2849517?guestAccessKey=1784f8b9-4583-4e15-a622-2d458bce7e11Virta peer-reviewed papers: https://www.virtahealth.com/researchHere Now Health: herenow.health / [email protected]

Will Johnson, CEO and Co-Founder of Gyde, joins on the day Gyde announces the acquisition of We Know Medicare to discuss the MA brokerage market and where it's headed.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.For more from Health Tech Nerds, subscribe to our weekly newsletters: https://www.healthtechnerds.com/subscribeBrought 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-medicareGyde Health: https://www.gydehealth.ai/Will Johnson: [email protected]

Loren Adler, Fellow and Associate Director at the Brookings Institution, joins to assess the No Surprises Act four years in after recent coverage in NYT sparked discussion.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.For more from Health Tech Nerds, subscribe to our weekly newsletters: https://www.healthtechnerds.com/subscribeBrought 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

News & Analysis from Health Tech NerdsMass General Brigham faced pushback from two directions in two weeks — the state flagging the MinuteClinic partnership for increasing costs, and its own primary care docs criticizing the K Health AI partnership. Kevin's take: MGB has the highest primary care rates in Massachusetts with PCPs talking about unionizing, raising the question of whether an academic medical center should be in the primary care business at all.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.For more from Health Tech Nerds, subscribe to our weekly newsletters: https://www.healthtechnerds.com/subscribeBrought 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/LorenAdlerPhRMA report: https://cdn.aglty.io/phrma/Attachments/NewItems/PhRMA_OnePager_AccessToNewMedicinesReport_8.5x11_v3.2_Print%20(2)_20260512113247.pdfGyde Health acquisition: https://www.gydehealth.ai/resources/gyde-acquires-we-know-medicareGyde Health: https://www.gydehealth.ai/Will Johnson: [email protected] adoption: https://www.nbcnews.com/tech/tech-news/openevidence-ai-doctor-medical-physician-login-app-what-npi-uptodate-rcna341064Homeward Health: https://www.homewardhealth.com/Jenny Schneider: [email protected]

Otto Sipe, founder and CEO of Photon Health, joins following the company’s $16M Series A to discuss why prescribing infrastructure remains surprisingly antiquated, and why Photon believes the real opportunity is not transmitting prescriptions, but helping patients obtain them. Otto explains how Photon evolved from an e-prescribing network into a consumer-oriented prescribing marketplace focused on transparency, fulfillment, and patient navigation.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.For more from Health Tech Nerds, subscribe to our weekly newsletters: https://www.healthtechnerds.com/subscribe

Sean Doolan and Emre Karatas from Virtue VC join to discuss their thesis that a new actuarial infrastructure layer is emerging in healthcare and why they're investing behind it.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.For more from Health Tech Nerds, subscribe to our weekly newsletters: https://www.healthtechnerds.com/subscribe

Patrick Foley, CEO of Belong Health, joins to discuss the growing opportunity in Medicare Advantage special needs plans and how Belong is helping community health plans compete in a market increasingly dominated by nationals.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.For more from Health Tech Nerds, subscribe to our weekly newsletters: https://www.healthtechnerds.com/subscribe

Dan Ferris, Chief Growth Officer at LifeStance Health, joins following the company's Q1 earnings to discuss how the largest outpatient mental health provider in the country is thinking about growth, operations, and the road ahead.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.For more from Health Tech Nerds, subscribe to our weekly newsletters: https://www.healthtechnerds.com/subscribe

News & Analysis from Health Tech NerdsQ1 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.For more from Health Tech Nerds, subscribe to our weekly newsletters: https://www.healthtechnerds.com/subscribeReferenced:Zack Cooper NYT op-ed: https://www.nytimes.com/2026/05/04/opinion/health-care-hospitals-insurance.htmlAHA response to op-ed: https://www.aha.org/news/blog/2026-05-06-setting-record-straight-three-ways-hospital-blame-narrative-gets-it-wrongVirtue VC thesis: https://www.virtuevc.com/writings/hypothesis---a-new-actuarial-infrastructure-layer-is-emergingCVS <> Mass General Brigham CMIR: https://masshpc.gov/publications/market-oversight-report/cmir-report-mass-general-brigham-and-cvs-minuteclinic-primaryPhoton's funding announcement: https://photonhealth.com/blog/series-a-growth-in-darkness

The North Carolina State Health Plan turnaround offers a compelling case study for what happens when a state leverages the full set of managed care and benefit design tools available to them. Vice Chairman Brian Miller joins to share his perspective on the philosophy behind the plan's member-first approach and what it suggests for healthcare affordability more broadly.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.For more from Health Tech Nerds, subscribe to our weekly newsletters: https://www.healthtechnerds.com/subscribe

Natalie Davis, CEO of United States of Care joins to discuss the organization’s latest polling on healthcare affordability and what it reveals about voter sentiment heading into the next election cycle. 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.For more from Health Tech Nerds, subscribe to our weekly newsletters: https://www.healthtechnerds.com/subscribe

Bryan Roberts from Venrock joins to discuss Eli Lilly's acquisition of Kelonia, a gene therapy company Venrock seeded in 2020, for up to $7 billion.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.For more from Health Tech Nerds, subscribe to our weekly newsletters: https://www.healthtechnerds.com/subscribe

Eliana Berger, CEO and co-founder of Joyful Health, joins Kevin and Martin following the company's recent $17M Series A. Eliana walks through what she observed spending two years inside provider practices as a fractional CFO, the data fragmentation that sits underneath revenue cycle, and how she thinks about the distinction between AI services and AI agents in denials work.Topics discussed:What Eliana found working inside practices as a fractional CFO, and why finance kept surfacing as the hair-on-fire problemAddressing revenue cycle's root problem: the lack of a financial source of truth across EHRs, billing systems, clearinghouses, payer portals, and bank accountsWhy Joyful shifted from selling software to owning the outcome end-to-endThe distinction between AI services and AI agents, and where rules-based automation works versus where expertise is requiredThe mechanics of working a denial, including ERAs, vague denial codes like CO-16, and the cross-system "detective work" involvedThe payer-provider dynamic and how AI is showing up on both sidesJoyful's system-agnostic go-to-market and four-to-eight week implementation timelineThe longer-term vision of integrating from payer contracts through to the bank accountFor more from Health Tech Nerds, subscribe to our weekly newsletters: https://www.healthtechnerds.com/subscribe

News & Analysis from Health Tech Nerds - Anthropic partnered with Blackstone, Goldman Sachs, and a roster of the world's largest asset managers to launch an enterprise AI services firm, a straightforward move to speed adoption of the technology by addressing the implementation bottleneck.- Devoted Health CEO Ed Park made a bold statement at the Medicarians conference, "Please pay MA plans less," which seems counterintuitive for an MA plan growing 120% year-over-year. Kevin's hypothesis: Devoted is building toward a fully integrated payer-provider model that uses MA as the entry point to capture the full healthcare dollar, with ambitions closer to UnitedHealth Group than a traditional MA plan.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.For more from Health Tech Nerds, subscribe to our weekly newsletters: https://www.healthtechnerds.com/subscribeReferenced: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-callJoyful Health: https://www.joyfulhealath.com/post/joyful-health-raises-22m-to-build-denial-intelligence-recovery-infrastructureMass 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-5-3-26Public trust poll: https://unitedstatesofcare.org/wp-content/uploads/2026/04/Affordability-Poll-Polling-Memo.pdfMedicaid work requirements: https://www.kff.org/medicaid/a-closer-look-at-the-work-requirement-provisions-in-the-2025-federal-budget-reconciliation-law/

Amanda Rees, CEO and Co-Founder of Bold, joins to discuss Bold's AI-powered healthy aging platform and how CMMI ACCESS fits into a model the company has already been building in Medicare Advantage.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.For more from Health Tech Nerds, subscribe to our weekly newsletters: https://www.healthtechnerds.com/subscribe

Patrick Keavy and Rebecca Springer from Bailey & Company join following the Medicarians conference and the release of their MA brokerage market report.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/For more from Health Tech Nerds, subscribe to our weekly newsletters: https://www.healthtechnerds.com/subscribe

Neil Batlivala, CEO and Founder of Pair Team, joins to discuss how Pair Team provides AI-powered care management for safety net populations, addressing social needs alongside clinical care through a virtual medical group model and partnerships with social care providers.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.For more from Health Tech Nerds, subscribe to our weekly newsletters: https://www.healthtechnerds.com/subscribe

Alli Oakes, Chief Research Officer at Trilliant Health, walks through Trilliant's behavioral health report across demand, supply, and emerging treatments.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-reportFor more from Health Tech Nerds, subscribe to our weekly newsletters: https://www.healthtechnerds.com/subscribe

Kevin and Martin open on a busy first week of healthcare earnings, where a January snowstorm and collapsing respiratory volumes turned out to be a bigger driver of HCA's quarter than ACA expiration or state directed payments combined. They cover Elevance's nearly billion-dollar accrual on the flash drive saga, Molina's marketplace MLR optics, and the rising patient-pay dynamic Cedar flagged on LinkedIn. They also revisit Zeke Emanuel's Bulwark piece on healthcare cost-cutting and reframe the question around whether 18% of GDP on healthcare is really the problem worth solving.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.For more from Health Tech Nerds, subscribe to our weekly newsletters: https://www.healthtechnerds.com/subscribe

Hospice and palliative care remain widely misunderstood and underused, leading many seriously ill patients in their final year of life to endure unmanaged symptoms, little advance care planning, and avoidable ER visits and hospitalizations. 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.For more from Health Tech Nerds, subscribe to our weekly newsletters: https://www.healthtechnerds.com/subscribe

Russell co-founded Yuzu as a health plan before pivoting to become the infrastructure layer powering alternative health plans.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.For more from Health Tech Nerds, subscribe to our weekly newsletters: https://www.healthtechnerds.com/subscribe

Patrick Sheehan, VP of Value-Based Care at Withings, walks through why a connected device company sees the CMMI ACCESS opportunity differently than pure digital health players. For Withings, the device is the core cost structure, which changes the rate math entirely. Plus, their existing relationships with ACOs and health systems give them a coordination foundation that most ACCESS applicants are still figuring out.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.For more from Health Tech Nerds, subscribe to our weekly newsletters: https://www.healthtechnerds.com/subscribe

Shiv Rao, CEO and Co-Founder of Abridge, walks through how the company is expanding beyond AI scribing following new partnerships with JAMA and NEJM. He frames the expansion around a pre-visit, during-visit, and post-visit product framework, using the context captured across the full clinical encounter to surface relevant evidence and close workflow gaps at the right moment.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.For more from Health Tech Nerds, subscribe to our weekly newsletters: https://www.healthtechnerds.com/subscribe

Neel Shah, Chief Medical Officer at Maven Clinic, breaks down one of the most consequential and underreported changes in healthcare payment: the end of the global maternity care bundle. For roughly 40 years, pregnancy and childbirth were paid for as a single bundled payment. Starting January 2027, care will be paid for through individual CPT codes.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.For more from Health Tech Nerds, subscribe to our weekly newsletters: https://www.healthtechnerds.com/subscribe

Kevin and Martin open with the CMMI ACCESS participant list. Roughly 150 applicants, but many original interested parties opted out presumably over rates, raising real questions about whether digital health can build a sustainable model at current payment levels. They also cover the FDA's peptide deregulation signals, and a price transparency study showing providers raised prices post-implementation, proving transparency alone doesn't fix the problem.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.For more from Health Tech Nerds, subscribe to our weekly newsletters: https://www.healthtechnerds.com/subscribe

Sidecar Health's approach is different from traditional health plans: set a fair price for every service and drug, give members that budget upfront, and let them keep a portion of the savings if they come in under it or pay the difference if they go over.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.For more from Health Tech Nerds, subscribe to our weekly newsletters: https://www.healthtechnerds.com/subscribe

Will Gordon, senior advisor at Manatt Health and former CMMI Chief Informatics Officer, explains CARA (a voluntary component of the ACO REACH/LEAD model starting in 2027) and why it matters for value-based care in specialties. 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.For more from Health Tech Nerds, subscribe to our weekly newsletters: https://www.healthtechnerds.com/subscribe

Conor Green of Truehelm (formerly TT Capital Partners) joins to discuss the firm’s rebrand, its healthcare-only growth equity/growth buyout strategy, and current market dynamics. He outlines Truehelm's focus on founder-owned, tech-enabled services businesses selling to hospitals, health plans, employers, and life sciences, often bootstrapped and “skipping venture." 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.For more from Health Tech Nerds, subscribe to our weekly newsletters: https://www.healthtechnerds.com/subscribe

Andrea Ippolito joins Health Tech NErds to discuss SimpliFed’s $10.8M Series A and how the company is expanding from virtual breastfeeding and baby-feeding support into a broader virtual OB model. 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.For more from Health Tech Nerds, subscribe to our weekly newsletters: https://www.healthtechnerds.com/subscribe

Gabe Drapos, Pearl Health COO and coauthor of the paper informing the LEAD Model, broke down LEAD, the successor to ACO REACH launching in 2027, framing it as a hybrid of REACH and MSSP. Three key changes: bringing specialists formally into total cost of care models for the first time; collapsing the standard and high-needs tracks so ACOs don't have to choose; and piloting AI-inferred risk adjustment, which would derive risk scores from utilization patterns rather than requiring providers to document HCC codes. 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).For more from Health Tech Nerds, subscribe to our weekly newsletters: https://www.healthtechnerds.com/subscribe

The Grand Roundup | April 13, 2026Kevin 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 membershipsPearl Health on ACO LEAD, AI-inferred risk, and what changes from REACHManatt Health on CARA: how specialist bundles work inside LEADTeladoc, BetterHelp, and the activist investor case for a PE buyoutTrueHelm's Conor Green on health tech private markets and AI creating the most confusing environment in a decadeChapter's $100M raise, Blues consolidation, Function Health's Getlabs acquisition, Luminai raise + Cleveland Clinic partnershipSimpliFed 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 birthsFor more from Health Tech Nerds, subscribe to our weekly newsletters: https://www.healthtechnerds.com/subscribe

This week, Martin takes a step back and look at the early GLP-1 era—where the drama is coming from, how costs are reshaping coverage, and why the care model around these drugs matters as much as the molecule itself. 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.For more from Health Tech Nerds, subscribe to our weekly newsletters: https://www.healthtechnerds.com/subscribe