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The VBCA Podcast is a solution-focused platform dedicated to advancing the transformation of healthcare through value-based care (VBC) models. Our mission is to break down complex healthcare topics into accessible, actionable insights for leaders, entrepreneurs, engaged consumers, and anyone passionate about meaningful change in healthcare. By challenging the healthcare industrial complex, we provide tools, strategies, and expert perspectives that empower our listeners to navigate and accelerate the shift toward better outcomes, lower costs, and improved patient experiences. Each episode delivers thought-provoking discussions and practical advice from industry experts, spotlighting innovative approaches to healthcare reform and highlighting voices that are often overlooked in traditional dialogues. Whether you're a healthcare executive, provider, payer, policy influencer, entrepreneur, or informed patient, we aim to inspire new ideas and support you in driving transformation in the healthcare space. Powered by Carenodes.
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Youth Loneliness & Chronic Conditions: The Shared Strength Project Guest: Esha Mittal, Founder, The Shared Strength Project Expert Words: Todd May, MD, Vice President & Medical Director, Health Net Host: Alex Yarijanian Episode Summary One in three young people in the U.S. live with a chronic condition, according to the National Library of Medicine — yet almost none of the funding, research, or attention going toward senior loneliness has followed youth loneliness into the room. Esha Mittal knows the gap firsthand. Diagnosed with a chronic condition in the fall of her freshman year of high school, she found that the diagnosis-based support groups meant to help her instead became what she calls "a pity party" — rooms where the illness was the only thing anyone had in common. In November 2025, Esha launched The Shared Strength Project, a mentorship program that pairs youth and young adults living with chronic conditions with mentors matched by shared interest, not shared diagnosis. The model grew directly out of her own experience at UCSF's Wellness Center for Youth and Young Adults with Chronic Conditions, where a nurse practitioner and social worker treated her as a whole person before they ever discussed her symptoms — and where she met the mentor whose own story became the blueprint for the project. In this episode, Esha walks through what that first isolating year actually felt like, why interest-based pairing works where diagnosis-based support groups didn't, and how a trauma-informed curriculum — built with a licensed social worker — structures every mentor meeting. We also hear from Todd May, MD, Vice President and Medical Director at Health Net, on why "youth loneliness" as a term hasn't yet made it into payer boardroom conversations — even as youth mental health broadly has. Esha will be speaking at Behavioral Health Tech 2026 in Nashville (September 22–24, Gaylord Opryland Resort and Convention Center) on a panel about designing tools youth and young adults will actually use. Timestamps 00:00 — Cold open: the funding gap between senior and youth loneliness 01:39 — Esha's diagnosis, freshman year of high school 03:24 — "They did not get it" — the friend-group disconnect 04:56 — Why the first (diagnosis-matched) support group made things worse, not better 07:20 — Launching The Shared Strength Project (November 2025) and the interest-based pairing model 09:19 — Todd May, MD (Health Net) on why youth loneliness hasn't reached payer conversations yet 10:33 — The UCSF Wellness Center partnership and the mentor whose story inspired the project 13:20 — Where to find Esha and what she's looking for next 13:54 — BHT2026 — Esha's panel on designing tools for youth and young adults Key Quotes Esha Mittal , on the diagnosis-matched support group: "Once we started talking about our chronic condition, it felt like that was all we could talk about. And it just became like a pity party." Esha Mittal , on the design principle behind The Shared Strength Project: "I chose to pair people up based on shared interest because... it would have been so valuable for me to understand myself again outside of my illness." Todd May, MD , on payer awareness of youth loneliness: "That term hasn't actually come up... The loneliness piece is just not getting a lot of airplay." Guest-cited statistics (attributed to source) Per the National Library of Medicine, as cited by Esha Mittal: one in three young people in the U.S. live with a chronic condition, and 20 million American children with serious or chronic conditions face a higher risk of isolation, bullying, and mood disorders. Where to find Esha Esha is currently reachable via LinkedIn and is building out a project website. She's looking for opportunities to scale The Shared Strength Project beyond California. Upcoming Catch Esha Mittal at Behavioral Health Tech 2026 — September 22–24, 2026, Gaylord Opryland Resort and Convention Center, Nashville, TN. Value-Based Care Advisory Podcast | vbcapodcast.com Companies mentioned in this episode: Shared Strengths Project UCSF Wellness Center for Youth and Young Adults with Chronic Conditions Behavioral Health Tech Conference National Library of Medicine Health Net LinkedIn Gaylord Opryland Resort & Convention Center Value Based Care Advisory podcast Esha Mittal Esha Mittal is a junior at Design Tech High School living with multiple chronic conditions. She founded the Shared Strength Project in 2025, aiming to reduce isolation among youth/young adults through meaningful mentorship. Todd May MD FAAFP Dr. Todd May serves as Vice President Medical Director at Health Net where he provides clinical expertise for the Commercial Team. He is deeply engaged in quality improvement, population health management, health equity, advanced primary care, and implementation of innovative member engagement programs. He also provides key leadership in an innovative multi-payer initiative that promotes Advanced Primary Care in California, and another focused on improving hospital quality. Immediately prior to joining Health Net, Dr. May was a Professor at UCSF for over 20 years. During this tenure, he served as Chief of the Medical Staff and then as Chief Medical Officer at the San Francisco General Hospital campus. He has been practicing family medicine for over 30 years and continues to see patients at a community clinic in Half Moon Bay.
This bonus episode is the full recording of Alex Yarijanian's HBMA continuing-education webinar. It runs longer than a standard VBCA episode — treat it as a resource, not a highlight reel. Most revenue cycle teams treat denials and underpayments as billing problems. A meaningful share of them are actually contract problems wearing a billing costume — and you can't fix a contract problem at the claims desk. This session walks through the five payer-contract provisions that generate the most downstream billing failures, a three-phase audit framework for finding them before they cost you, and a denial-routing model that keeps contract-based underpayments from getting silently written off in a clinical appeals queue. What you'll learn: Why contract language — not coding errors — is where most systematic underpayment actually starts The five provisions to check first: fee schedule effective dates, carve-outs/exclusions, coordination of benefits, authorization & notification, and timely filing Why "rates effective upon execution by both parties" can quietly cost you weeks of underpaid claims Why vague terms like "experimental" or "time to time" in a contract are a red flag, not boilerplate Why state law — not the payer's internal policy — governs coordination-of-benefits primacy Why retroactive denial of an already-issued authorization is not just bad practice — it's against federal law for government-funded products A three-phase contract audit framework: highest-leakage provisions → highest-volume services → highest-friction appeal/recoupment timelines A three-bucket denial-routing model (clinical / administrative / contract-based) so contract-based underpayments get escalated instead of written off Session outline: Introduction — Alex's background: clinic operations, Cardinal Health/HCA, head negotiator for Humana's West Territories, then founding Carenodes to close the payer/provider information asymmetry. The framing stat — a striking share of providers don't actually know what they're supposed to be paid, and contract language is where the error is born. Provision 1 — Fee schedule effective dates & updates. Provision 2 — Carve-outs & exclusions. Provision 3 — Coordination of benefits. Provision 4 — Authorization & notification. Provision 5 — Timely filing. The three-phase audit framework. Denial routing: clinical vs. administrative vs. contract-based. Close — pick your top two payers, run the checklist, renegotiate. Resources: Contract audit checklist referenced in this session — request it at vbcapodcast.com About the host: Alex Yarijanian is CEO & Founder of Carenodes. He spent seven years managing payer contracting operations for 600+ provider organizations across 48 states, including a prior role as leadership and negotiator for Humana's West Territories contracting and network management team.
17 minutes. That's how long Lindsay Clancy's last psychiatric visit lasted — the day before her three children died. Nine prescribers. Two hospitals. A suicide hotline called twice. And allegedly, not one person connecting the dots. Before you listen: This episode discusses allegations from a civil complaint and public criminal-trial testimony only. We do not cover the criminal case, describe what happened to the children, or speculate on Lindsay Clancy's state of mind. None of the allegations below have been proven, and no defendant has been found liable. One named defendant has petitioned for a Massachusetts medical malpractice tribunal — a screening step, not a liability ruling. South Shore Health and the Women & Infants Health Hospitals operator have said they cannot comment on pending litigation; Astor Mental Health has not responded to requests for comment. This is the care coordination failure hiding inside the Lindsay Clancy civil complaint (Norfolk Superior Court, filed January 2026) — postpartum psychiatric care, telehealth psychiatry's blind spots, and the reimbursement incentives nobody wants to talk about. Alex and Jasmine break down what the complaint alleges went wrong in the system, not the person. In this episode: Why access without coordination isn't the same as coordinated care The alleged medication cascade — nine to ten prescriptions, no single clinician alleged to own the regimen A courtroom cross-examination over one comma in a clinical note, and what it says about documentation standards Two crisis hotline contacts that reportedly didn't meet the "emergency" threshold, and why postpartum psychiatric crises fall outside standard screening calibration 14 consecutive telehealth visits during an acute stabilization period — and testimony on what an in-person exam might have caught Where AI can actually help operationally, and where it can't Why reimbursement incentives, not individual clinicians, are the root of this gap Hosted by Alex Yarijanian and Jasmine Singh. #ValueBasedCare #CareCoordination #BehavioralHealth #PostpartumCare #HealthcarePolicy Links referenced in this episode: risewestconference.com lindseyclancycase.com newbedfordsuicidehotline.com Companies mentioned in this episode: South Shore Health McLean New Bedford
Episode Summary A pediatric patient in a New Jersey hospital is medically ready for discharge — equipment arranged, family ready, nursing hours authorized by the health plan. The only missing piece: an actual nurse. This episode uses that scenario to examine the structural gap between authorized private duty nursing (PDN) hours and filled hours in Medicaid managed care, why standard provider directories overstate real pediatric home health capacity, and what CMS's 2024 Medicaid managed care access rule signals for how plans will need to prove — not just claim — network adequacy going forward. "When the network looks broad on paper, but families still cannot get care, the question is not, do we have enough providers listed? The question is, can a child actually get home?" Chapters The Discharge That Doesn't Happen — A clinically ready child, an authorized care plan, and no nurse to staff it. The Directory Problem — Why a state can show hundreds of home health agencies while only a handful actually serve pediatric high-acuity cases. Authorized vs. Filled Hours — The distinction that matters most for families, and the 20–40% unfulfilled-hours range documented by MACPAC. What Makes a Network a "Ghost Network" — Six reasons a directory listing doesn't equal real access. Why Pediatric Home Health Is a Different Labor Market — Ventilators, trachs, feeding tubes, and why acuity narrows the real provider pool. The CMS Rule — Secret shopper surveys, wait-time standards, and the shift from "is the directory complete" to "can members get care." The Pediatric PDN Access Audit — A 7-step framework for MCOs to move beyond static network adequacy reporting. What Providers and Advocates Should Document — Turning anecdote into evidence health plans and regulators can act on. Companies mentioned in this episode: Affirmed Home Care Pediatrics and Adolescent Therapy Associates Active Pediatrics Therapy Services Growing Hope Pediatric Care for Kid Care Family Care Agency New Jersey Children's Hospital New Jersey Hospital Association Carenodes Sources cited in this episode: Baxley, J. "Will increased pay solve North Carolina's home nursing shortage?" North Carolina Health News, via CityView NC. Brown, J. "Nurses for medically fragile kids are underpaid and hard to find. Parents want the state to step in." The Colorado Sun. AHA News. "OIG says MA, Medicaid managed care plans have limited, inaccurate behavioral health provider networks." American Hospital Association. "Ghost Network Busters." Managed Healthcare Executive. Fierce Healthcare. "OIG report raises red flags about maternal health 'ghost networks' in Medicaid managed care." Key Data Points Referenced MACPAC has documented that a meaningful share of authorized private duty nursing hours nationally go unfulfilled — often cited in the 20%–40% range. CMS's 2024 Medicaid Managed Care Access, Finance, and Quality final rule introduces secret shopper survey requirements, moving oversight from directory completeness toward actual service access.
Most revenue cycle teams are chasing the wrong fire. Persistent underpayment, denials that don't respond to appeals, patterns nobody can explain — these are often contract problems wearing a billing problem's disguise. In this episode, Alex breaks down the structural gap between contracting and RCM that costs providers real money every day, and delivers three things you can take to your next denial review right now. WHAT YOU'LL HEAR The real story behind a multi-specialty group underpaid for 12 months — and why their billing team did nothing wrong Why contracting and RCM live in separate worlds — and why that gap is your biggest revenue risk Fee schedule effective date clauses: the most dangerous amendment language in managed care contracts Carve-out clauses and why behavioral health denials keep looking like coding errors Contract dispute timelines vs. your denial management cycle — what happens when they don't match The one question to add to every denial review THREE THINGS TO APPLY NOW Check your fee schedule effective dates. Know the execution date on every amendment. Confirm your billing system actually flipped to the new rates. 73% of providers don't know what they're contracted to receive. Map your carve-out clauses. Know which services are excluded from the base agreement and where those claims need to route — behavioral health is the most common gap. Find the contract dispute window in every active agreement. If it's shorter than your internal denial cycle, that's a configuration problem costing you money today. THE DIAGNOSTIC QUESTION When a denial pattern doesn't respond to standard appeals, ask: Is this a billing problem or a contract problem? They need entirely different escalation paths. If your team is routing both into the same queue, contract-based underpayments are being written off — silently. GO DEEPER: HBMA WEBINAR — AUGUST 12 Alex presents the full framework — denial categorization methodology and a contract audit checklist — live through the Healthcare Business Management Association ( HBMA ). 1 CEU credit available. Your Billing Problem Started in the Contract: What Revenue Cycle Leaders Need to Know Before a Claim Is Ever Filed. Presented by Alex Yarijanian Register: https://www.hbma.org/meeting_calendar/details.php?event=3148 Checklist directly: vbcapodcast.com
You've built the operation — clinicians credentialed, tech stack running, compliance buttoned up. Then a regional Medicaid managed care plan wants to talk about contracting. Your first instinct: great, let's do it. Then someone pulls up the 40-page contract with a 43-code prior authorization matrix and a data-sharing provision you're not sure sits cleanly with your other obligations. The fee schedule is fine. Not great — fine. And now the question isn't can we do this. It's should we, and on what terms? In this episode, Alex breaks down the payer contracting decision as what it actually is: a market entry and operational alignment commitment that happens to include a rate negotiation inside it. He walks through the six-dimension evaluation framework every health operator should run before signing anything. On the Out-of-Network Alternative Staying out of network intentionally can be a viable model — particularly in specialty markets where a practice can command premium rates on a self-pay or direct-pay basis. But it requires an honest accounting of trade-offs: Payment at UCR (usual and customary rates) — not your billed charges, not in-network contracted rates Limits on what patients can recover from their own plans, affecting your ability to attract and retain members Collection burden shifts to the practice, along with associated staff time and friction The No Surprises Act materially changed the out-of-network landscape for behavioral health providers in certain care settings — understand your exposure before assuming OON is a clean alternative Key Takeaways Treat payer contracting as a market entry and operational alignment decision — not just a rate negotiation In high-concentration markets, staying out of network often means locking out of the majority of the addressable population Your value proposition — especially HEDIS gap closure and measurement-based care data — is a negotiating asset most practices leave on the table Operational alignment costs don't show up in the fee schedule. Map them before you sign The intersection of payer data sharing requirements and 42 CFR Part 2 is not hypothetical risk — it's real compliance exposure For contracts involving risk-sharing, value-based payment terms, or complex data provisions, involve experienced healthcare counsel before execution Chapter Markers 00:00: Opening scenario — the 40-page contract lands in your inbox 01:30: Reframing the network decision — it's not a rate negotiation 02:40: Dimension 1 — Market access and concentration reality 04:00: Dimension 2 — Knowing and articulating your value proposition 05:10: Dimension 3 — Operational alignment and hidden administrative costs 06:20: Dimension 4 — Payer's past performance and claims adjudication reality 07:30: Dimension 5 — Physician profiling and measurement programs 09:00: Dimension 6 — Data sharing, 42 CFR Part 2, and compliance exposure 10:15: The out-of-network alternative — honest trade-offs 11:20: Practical takeaways and when to involve healthcare counsel
CMS has posted the LEAD (Long-Term Enhanced ACO Design) model application materials. Preliminary scoring is due April 27, 2026. Full applications are due May 17, 2026. LEAD replaces ACO REACH in 2027 and runs as a 10-year demonstration with enhanced payments and care coordination flexibility. Most ACO applications fail before they're submitted — not because organizations are ineligible, but because they were never really built for risk. This episode breaks down the six scoring domains, in order of importance, that CMS will use to evaluate your application. WHAT WE COVER Financial Risk Readiness Define your risk corridor tolerance and downside exposure thresholds before anything else. Build a three-year proforma with utilization and trend assumptions. The CFO gut check: if trend runs 2% worse than expected, do you still survive? Secure financial guarantees and a reinsurance strategy before you submit. Data and Interoperability It is not enough to collect data. CMS wants to see integrated clinical, claims, and SDOH data feeds with real-time or near real-time performance tracking. Demonstrate evidence of data-driven interventions — not just reporting. The core question CMS is asking: can you act on data, or just collect it? Care Model Differentiation Define your care coordination infrastructure. Are you using RNs, community health workers, behavioral health integration? Do you have programs targeting high-cost, high-need (HCHN) populations? Are you integrating non-traditional services like doula care or CHWs? Reviewers want to see biopsychosocial care — not just medical management. Medical management alone is a red flag. Network and Contracting Strategy CMS wants to see documented value-based contracts downstream — not just your arrangement with CMS. Can you push risk one step further? Do you have a specialist and post-acute alignment strategy? Note: roughly 80% of costs occur in the 90 days post-hospital discharge. Weak alignment equals leakage equals missed savings equals poor financial performance. Operational Execution Plan Submit named executives and clinical leadership. Define your care workflows and escalation pathways. Provide a clear go-live and scale timeline. CMS reviewers are specifically watching for the "nice idea, no operator" red flag. They want robust operators behind every submittal. Equity and Access Strategy Health disparities planning is no longer a narrative — it is a scoring mechanism. Whether or not you call it equity, operationalizing access will directly impact your financial outcomes. Integration with community-based organizations signals this. If you cannot operationalize access, you cannot succeed in this program. THE BRUTAL TRUTH Most organizations won't fail LEAD because they're ineligible. They'll fail because they realize too late they were never built for risk. LEAD isn't the program — it's a mirror. Start with your assumptions, not your application.
Rate sheets don't tell the whole story. In this episode, Alex Yarijanian breaks down the 8-indicator playbook he uses to evaluate any tele-behavioral health market before committing capital — and names the specific states he'd enter today and why. Most operators default to the biggest states: California, Texas, Florida, New York. But population size alone is one of the weakest predictors of a winning market. The real levers live in parity law enforcement, workforce economics, MCO concentration, and infrastructure readiness. WHAT YOU'LL LEARN Why the biggest states are rarely the best markets for tele-behavioral health The 8 indicators that separate win-win markets from cheap-rate mirages How to build a weighted scoring model before entering a new market What associate-level billing eligibility does to your workforce margins How MCO concentration affects contracting speed and rate-cut risk Which states Alex rates as best all-around, high-risk, and growth-stage bets THE 8 MARKET INDICATORS Medicaid market size: Total addressable population and realistic capture potential Payment parity: State-level mental health parity laws and strength of enforcement Cost of living index: The single best proxy for labor margin on clinical staff Associate-level billing: Whether licensed associates can bill independently HRSA HPSA demand mapping: Documented unmet need in mental health shortage areas Broadband & 5G coverage: Infrastructure required for reliable telehealth delivery MCO landscape: Plan count, behavioral carve-outs, any-willing-provider law exposure Tax & corporate climate: State-level business environment and regulatory posture MARKET ARCHETYPES Best all-around: Arizona, Nebraska, Delaware, Oregon Volume, thin margins: Arkansas, North Dakota High rate, high cost niche: Alaska Growth stage bets: New Mexico, Montana 4 ACTION STEPS Build a scroll scoring model — layer all 8 indicators into a weighted scorecard Validate demand on the ground — overlay HRSA HPSA maps + FCC broadband gap data Check your plan mix — count Medicaid MCOs and behavioral carve-outs Run a payroll stress test — model cost of living vs. your target clinician pay band RESOURCES MENTIONED HRSA Mental Health HPSA maps: data.hrsa.gov FCC broadband coverage maps: broadbandmap.fcc.gov NCSL mental health parity law tracker Licensure compact maps: PSYPACT, ASWB Compact, Nurse Licensure Compact State Medicaid rate databases
In this episode of the VBCA Podcast, Alex Yarijanian sits down with Dr. Kumar Dharmarajan — co-founder and Chief Medical Officer of World Class Health and former Chief Scientific and Medical Officer at Clover Health — to unpack one of the most important structural differences in U.S. healthcare: incentive alignment. Why are employers often paying two to four times Medicare rates for identical procedures performed in the same hospital by the same physician? The answer isn’t clinical complexity. It’s incentive design. Dr. Kumar breaks down how Medicare Advantage plans negotiate as owners of financial risk — and why that matters. In contrast, much of the commercial self-insured market relies on administrators who negotiate without full downside exposure, creating a structural pricing gap. The conversation also explores: What Medicare Advantage plans are actually looking for when contracting with digital health and AI solutions Why engagement — not automation — is the real leverage point The economics of supplemental benefits and underutilized Star opportunities Home-based and remote care as risk containment strategies The future vision of standardized specialty care marketplaces This is a structural conversation about incentives, risk ownership, and where execution truly matters in value-based care. Key Takeaways Incentive alignment drives pricing discipline. Medicare Advantage plans negotiate differently because they own the full medical loss ratio. Commercial self-insured markets often lack that same alignment, contributing to higher negotiated rates. AI in Medicare Advantage is less about backend efficiency and more about member activation and physician-level quality improvement. Underutilized supplemental benefits represent unrealized revenue and quality movement. Home-based and remote care models are fundamentally about managing high-acuity risk, not convenience. Timestamps 00:00 – Introduction 01:39 – What Medicare Advantage plans actually want from AI vendors 03:27 – Why engagement infrastructure is the real leverage point 04:28 – Virtual care, socioeconomic complexity, and risk ownership 06:18 – High-acuity members and access-driven cost escalation 07:11 – Supplemental benefits and engagement economics 08:36 – Stars, utilization, and revenue implications 09:55 – Employers paying 2–4x Medicare rates 10:27 – Why commercial pricing diverges 12:17 – Incentive structure and negotiation power 12:47 – Vision for standardized specialty care marketplaces About the Guest Dr. Kumar Dharmarajan is a practicing cardiologist and geriatrician and the co-founder and Chief Medical Officer of World Class Health. He previously served as Chief Scientific and Medical Officer at Clover Health and was on faculty at Yale School of Medicine, where his research helped shape national post-acute care quality measures. He has published in the New England Journal of Medicine, JAMA, and Health Affairs. Companies mentioned in this episode: World Class Health Clover Health
CMS is moving tens of billions of dollars into every state to stabilize rural healthcare heading into 2026—not through across-the-board rate increases, but through targeted investments in workforce, technology, care coordination, and alternative payment models. In this episode, Alex Yarijanian breaks down what the Rural Health Transformation Program / Rural Health Fund (RHTF) actually is, what state strategies reveal about the future of rural access, and why this matters far beyond rural hospitals—impacting payer strategy, provider contracting, network adequacy, and healthcare economics. You’ll hear key highlights from state plans including California, Texas, Florida, New York, and Illinois, plus the cross-state themes showing up everywhere: hub-and-spoke models, shared services, EMS reform, telehealth hubs, and AI-driven admin reduction (including automated fax processing). What You’ll Learn What the Rural Health Transformation Program actually is Why this funding wave is different (state plans are concrete and approved) What state strategies reveal about access risk + reimbursement limits How payers should interpret this as a network adequacy / access signal Why providers should see this as both opportunity + accountability shift State Highlights Covered California Hub-and-spoke maternal + specialty access models Example of rate + infrastructure working together (Health Plan of San Mateo specialty rate increases) Texas Technology as a force multiplier AI-enabled specialty access, telehealth coordination, clinically integrated networks Tech becomes a parallel lever to reimbursement in high-dispute markets Florida Remote patient monitoring (RPM) + community paramedicine Utilization management upstream in MA-heavy environments New York Patient-centered medical homes + workforce pipelines Care coordination over unit cost expansion in concentrated payer markets Illinois Integrated primary + behavioral health infrastructure EMS treat-not-transport models Alternative models as a response to inflation vs lagging rates Key Cross-State Themes Hub-and-spoke models are returning at scale Shared services (centralized EHR, billing, analytics) to reduce admin burden AI as infrastructure (clinical decision support + operational efficiency) Specific AI use cases being funded: Automated fax processing AI scribes AI-enabled care coordination Key Takeaway Rural health stabilization strategy is not uniform across states — but the goal is consistent: protect access where reimbursement alone hasn’t been enough. Mentioned in this episode: Health plan of San Mateo California Texas Florida New York Illinois Oklahoma Washington Utah Vermont
While most providers are waiting on CMS, payers are already narrowing networks and rewriting delegation terms. Payers are quietly narrowing networks and rewriting delegation expectations. This playbook explains how to do business with MA business for 2026. If you’re waiting, you’re already reacting—not positioning. In this episode, Alex Yarijanian breaks down what’s actually showing up in payer conversations right now , long before final CMS rules are published. Drawing from real contracting, network, and delegation discussions, Alex explains why waiting for regulatory clarity is already costing providers and health tech companies leverage. You’ll hear how payer priorities have shifted from enrollment growth to margin durability, why network narrowing is accelerating quietly, how delegation has become a stress test, and what “value-based care” really means in Medicare Advantage today. This episode also outlines who is most at risk heading into 2026, the three types of organizations positioned to win, and what provider and health tech leaders should do in the next 90 days to stay relevant. Who should listen: Provider executives, payer leaders, value-based care operators, and health tech founders navigating Medicare Advantage.
A federal jury has convicted the founders of Done, one of the fastest-growing telehealth companies in the stimulant-prescribing space, for orchestrating one of the largest Adderall distribution and fraud schemes in U.S. history. More than 40 million stimulant pills, over $100 million in revenue, and a business model engineered around speed, volume, and automated prescribing — all built with no real clinical guardrails. In this episode, host Alex Yarijanian breaks down not only what happened, but what this case means for the entire digital health ecosystem, especially behavioral health and companies prescribing controlled substances. When a company like Done collapses — and its founders now face up to 20 years in federal prison — it doesn’t just take itself down. It drags trust, access, and payer willingness down with it. Alex outlines how this case will reshape: Payer contracting and credentialing Prescribing oversight and compliance expectations Trust in telehealth platforms The future of value-based behavioral health Why incentives — good or bad — always scale And most importantly, he explains why value-based care is the antidote to the shortcuts and misaligned incentives that fueled this scandal. If you’re building, funding, regulating, or partnering with telehealth organizations, this is a must-listen. Takeaways: The case of the telehealth startup highlights the critical importance of clinical oversight in health services. Payers are likely to impose stricter regulations on telehealth providers following recent fraudulent activities. Building a sustainable healthcare model requires prioritizing patient interests over profit maximization strategies. The future of digital health will hinge on trust, necessitating alignment between clinical and business models.
Medicare’s 2026 physician fee schedule is packed with change — but change means opportunity. In this episode of the VBCA Podcast, Alex Yarijanian breaks down the five biggest updates every provider and startup should know : Shorter, billable windows for remote monitoring New behavioral health add-ons to primary care Incentives that reward value-based care Expanded reimbursement for digital therapeutics & telehealth A major shift from inpatient to outpatient procedures Whether you’re running a clinic or building the next health tech solution, this playbook will help you turn policy into profit and thrive in the future of care.
Welcome back to the Value-Based Care Advisory podcast! In this episode, host Alex Yarijanian delves into the significant updates and strategies for 2026 in the Medicare Advantage space. He covers essential news and policy changes, including a 5% increase in Medicare payment rates, the scaling back of supplemental benefits, and the permanence of telehealth for behavioral health. Alex also discusses updates to the Medicare physician fee schedule, redesigned enrollment forms, new health risk assessment requirements, and the transition to a new risk adjustment model. Learn how these changes will impact care delivery, compliance, and strategy, and discover what it takes to thrive in this evolving landscape. Tune in and prepare for the Medicare Advantage showdown of 2026! 00:00 Welcome to the Value-Based Care Advisory Podcast 00:15 2026 Medicare Advantage Showdown Overview 01:24 Key Policy Updates for 2026 03:11 Telehealth and Virtual Care Innovations 04:39 Enrollment and Form Updates 06:12 Risk Adjustment and Star Ratings 08:52 Strategic Focus Areas for 2026 14:44 Final Thoughts and Conclusion Takeaways: The 2026 Medicare Advantage payments are set to increase by approximately 5%, contributing an excess of $25 billion to the plans. Significant changes have been initiated regarding supplemental benefits, particularly affecting non-medical services like transportation and meals. Telehealth services for behavioral health will become a permanent fixture, with no geographic restrictions imposed from 2026 onward. New billing codes will be introduced for digital therapeutics and remote monitoring, enhancing the infrastructure for virtual care delivery. The upcoming risk adjustment model will utilize the full 2024 CMS HCC risk model, significantly impacting financial strategies for Medicare Advantage organizations. Plans must prioritize compliance and operational integrity to navigate the complexities of changing regulations and maintain their competitive edge.
In this episode of the VBCA podcast, host Alex Yarijanian delves into the often overlooked yet crucial aspect of leadership: emotional labor. Discover how managing emotions plays a pivotal role in negotiations and leadership effectiveness. Alex shares personal experiences and insights on how emotional labor can be both a powerful tool and a silent tax on leaders, especially for those challenging dominant norms. Tune in to learn how to harness emotional intelligence to build trust and lead with empathy and strength. Takeaways: In the realm of healthcare leadership, emotional labor serves as an essential yet often unacknowledged component that significantly influences negotiation outcomes. Effective leadership necessitates an acute awareness of emotional dynamics, as managing feelings is integral to fostering productive dialogue among stakeholders. The notion of emotional labor encompasses not just personal emotional management, but also the responsibility to create a supportive environment for others. A leader's capacity to engage in emotional labor can lead to profound transformations, underscoring the importance of empathy and understanding in professional interactions.
This podcast episode delves into the intricate relationship between mindfulness meditation and its profound implications for healthcare leadership. We explore how mindfulness practices not only enhance emotional well-being but also significantly improve the quality and effectiveness of leadership within healthcare settings. Through a rigorous examination of scientific evidence, we elucidate the neurological benefits of mindfulness, demonstrating its capacity to modulate stress and foster cognitive flexibility, thereby enabling leaders to navigate the complexities of their roles with greater composure and efficacy. Furthermore, we provide practical mindfulness training techniques that can be seamlessly integrated into the daily routines of healthcare professionals, offering a pathway to both personal and organizational transformation. Ultimately, this discourse underscores the necessity of cultivating a mindful approach in healthcare leadership to enhance overall performance and well-being. Mindfulness meditation and its application within the healthcare sector represent a profound intersection of neurological research, emotional intelligence, and leadership efficacy. The discussion begins with a thorough exploration of mindfulness, defined as a state of present-oriented consciousness, which fosters a non-judgmental awareness of one's moment-to-moment experiences. This foundational understanding serves as a springboard to investigate the transformative potential of mindfulness practices for healthcare leaders, who are often beleaguered by high levels of stress and burnout. The episode highlights compelling evidence demonstrating that mindfulness can mitigate stress, enhance cognitive flexibility, and improve emotional regulation—qualities that are indispensable for effective leadership in the ever-evolving landscape of healthcare. By integrating mindfulness into their daily routines, healthcare leaders can cultivate a more resilient mindset, ultimately translating into better organizational outcomes and improved patient care. Through the lens of empirical studies, the podcast delves into how mindfulness training yields significant neurological benefits, such as increased white matter density and enhanced executive function. One landmark study cited illustrates that patients undergoing mindfulness-based interventions reported a greater awareness of their symptoms and a reduced identification with negative cognitive patterns—a finding that underscores the therapeutic potential of mindfulness in both clinical and leadership contexts. In practical terms, the episode outlines actionable strategies for implementing mindfulness practices within healthcare organizations, emphasizing that even modest initiatives can catalyze meaningful improvements in workplace culture and employee wellbeing. As the conversation unfolds, listeners are encouraged to reflect on their own practices and consider how mindfulness could serve as a catalyst for personal and organizational growth. Takeaways: Mindfulness training serves as a pivotal mechanism for enhancing the performance of healthcare leaders by fostering emotional resilience and cognitive flexibility. The practice of mindfulness has been scientifically corroborated to mitigate stress levels significantly, enabling leaders to navigate high-pressure environments more effectively. Utilizing mindfulness techniques within healthcare organizations can yield substantial improvements in employee productivity, as evidenced by a notable increase in productive hours per week. Healthcare leaders must cultivate a non-judgmental awareness of their experiences to effectively integrate their internal and external realities, thereby enhancing overall leadership efficacy. Implementing mindfulness practices in healthcare settings has demonstrated substantial positive outcomes, such as reduced burnout among healthcare professionals and improved organizational performance. The neurological benefits of mindfulness training, including increased gray matter density, underscore its importance in developing a sharp, focused mind essential for effective healthcare leadership. Companies mentioned in this episode: Aetna Boston Medical Center
How Health Tech Startups Can Win at Managed Care Contracting: Insider Strategies for Scalable Payer Partnerships. This episode dives deep into the essentials of navigating managed care contracts as a health tech startup. Whether you're a founder, operator, or policy strategist, you'll walk away with a clear understanding of how to position your company for payer partnerships, structure risk-based contracts, and avoid common pitfalls in the healthcare financing space. We explore real-world examples and discuss how to align your innovation with payer priorities, compliance standards, and long-term sustainability. Perfect for early-stage startups, digital health innovators, and anyone looking to scale within the complex world of managed care. Key Themes: Understanding managed care mechanics (HMOs, PPOs, ACOs) Value-based care vs. fee-for-service Contracting tips for Series A and B stage startups Risk corridors, capitation, and performance metrics How to speak the payer language and win trust Target Audience: Health tech entrepreneurs, product and ops leads, VCs in digital health, provider networks, and healthcare consultants. Takeaways: Understanding managed care contracting is essential for health tech startups to succeed. Health tech entrepreneurs must align their innovations with payer priorities and compliance standards. Effective negotiation strategies are crucial for securing favorable managed care contracts. Startups should utilize data transparency to build credibility and foster trust with payers. Establishing a structured contracting process is vital to avoid unfavorable agreements and ensure sustainability. Learning from real-world case studies can provide invaluable insights into successful managed care strategies. Companies mentioned in this episode: Innovate Health MedTech Solutions Health Wave United Humana Aetna
This conversation explores the historical context of childbirth, the current state of maternal mortality in the U.S., and the emerging role of doulas in modern maternity care. It highlights the paradox of high maternal mortality rates despite advanced medical technology and discusses how doulas can improve outcomes and reduce costs in the healthcare system. Tips are provided to strategically leveraging the doula opportunity in risk-based contracting. Takeaways: The integration of doulas into maternity care significantly reduces unnecessary interventions and enhances outcomes. Evidence demonstrates that doulas can lower postpartum depression rates, benefiting both mothers and healthcare systems. Doulas are increasingly recognized as a strategic component in modern maternity care, facilitating cost savings. Companies mentioned in this episode: Blue Shield Blue Cross
The podcast delves into the complexities and challenges of the American healthcare system, arguing that it often prioritizes profit over patient care. Through the lens of investigative journalism from More Perfect Union, the hosts explore how companies like CVS Caremark and pharmaceutical giants manipulate the system to maximize their profits, often at the expense of those they are supposed to serve. They highlight the troubling trend of Medicare Advantage plans cherry-picking healthier patients to boost their bottom line, leaving those with greater needs reliant on traditional Medicare. The discussion also uncovers the hidden influence of consulting firms like McKinsey, which contribute to a system that seems rigged against everyday citizens. Ultimately, the episode emphasizes the importance of staying informed and advocating for healthcare reform to ensure that the interests of patients are prioritized over corporate greed. The podcast delves into the intricacies and issues surrounding the American healthcare system, raising critical questions about its efficacy and accessibility. The hosts, with the help of investigative journalism from More Perfect Union, examine whether the healthcare landscape is fundamentally designed to benefit corporations rather than patients. They highlight the confusion and frustration many face when navigating healthcare options, particularly Medicare Advantage plans, which are heavily marketed as cost-effective choices but may prioritize profit over patient care. Through examples like CVS Caremark and the impact of the Biden administration's actions against fraud, the discussion reveals how healthcare companies often prioritize their bottom line, leading to detrimental effects on both employees and consumers. With a focus on the systemic issues, the episode emphasizes the need for transparency and accountability in a system that often feels rigged against the average person. The narrative also explores the alarming consequences of corporate control in healthcare, illustrated by the shortage of critical medical supplies, such as IV bags, following Hurricane Helene. The podcast underscores the dangers of having a single company dominate a vital resource, highlighting how such monopolistic practices can endanger lives. Furthermore, the hosts discuss the role of pharmacy benefit managers (PBMs) in escalating drug prices, portraying them as hidden players in a convoluted system that drives up costs for consumers. The episode challenges listeners to consider the broader implications of these practices, urging them to recognize the interconnectedness of corporate greed and public health. Towards the conclusion, the podcast shifts towards empowerment, encouraging listeners to become advocates for change. It stresses the importance of staying informed, engaging with elected officials, and participating in local organizations dedicated to healthcare justice. The episode serves as a call to action, emphasizing that collective efforts can lead to meaningful reforms in a healthcare system that often feels overwhelming and unfair. By fostering awareness and community engagement, the hosts aim to inspire listeners to take ownership of their health care experiences and push for a system that genuinely serves the needs of all individuals, rather than just corporate interests. Takeaways: The American healthcare system is structured to prioritize profits over patient care, leading to widespread issues. Pharmaceutical companies often set exorbitant prices for medications, making them inaccessible to many. Medicare Advantage plans are designed to attract healthier patients, leaving vulnerable individuals behind. The influence of consulting firms like McKinsey perpetuates a culture of profit-driven healthcare. Pharmacy benefit managers operate as middlemen, contributing to rising drug prices and complicating the system. The case of Keytruda (Pembrolizumab) highlights how taxpayer-funded drugs can be sold at outrageous prices. Companies mentioned in this episode: More Perfect Union CVS Caremark Baxter International Merck What Happens When Private Equity Takes Over a Hospital | Harvard Medical School Private equity: health care's vampire | STAT How McKinsey Makes Its Own Rules How Merck plans to fill the void of Keytruda patent expiration | Fox Business Video FTC Deepens Inquiry into Prescription Drug Middlemen Record-breaking federal lobbying tops $2.2 billion in first half of 2024 Big Pharma’s Business Model: Corporate Greed PBM Math: Big Chains Are Paid $23.55 To Fill a Blood Pressure Rx. Small Drugstores? $1.51. - KFF Health News
What Every Provider and Innovator Must Know Going into 2025: The health insurance industry is facing a perfect storm characterized by rising healthcare costs, increased patient demand, and intense scrutiny from lawmakers. As we move into 2025, the challenges confronting Medicare Advantage plans, once considered the crown jewel of insurer profitability, are becoming increasingly apparent. Industry giants like Humana and UnitedHealth are grappling with significant pressures that could redefine managed care. However, amidst this turmoil, there are opportunities for healthcare providers and entrepreneurs to innovate and adapt. By focusing on high-cost patient areas and exploring innovative contracts, stakeholders can position themselves to thrive in this evolving landscape. This episode delves into the tumultuous state of the health insurance industry as it faces unprecedented challenges heading into 2025. Rising healthcare costs, increased patient demand, and government scrutiny are converging to create a 'perfect storm' for insurers, particularly in the Medicare Advantage sector. This segment highlights how traditional revenue models are being tested as utilization rates rebound post-COVID, with many patients returning for procedures they deferred during the pandemic. Insurers are grappling with higher medical loss ratios (MLR), which are squeezing their profit margins and forcing a reevaluation of their operational strategies. Industry giants like Humana and UnitedHealth Group are highlighted as they navigate this challenging landscape, revealing how their dependence on Medicare Advantage has made them particularly vulnerable amidst shifting policies and scrutiny from lawmakers. The discussion emphasizes the urgent need for healthcare providers and entrepreneurs to identify innovative solutions that can not only alleviate cost pressures but also enhance patient care, suggesting that these turbulent times may present new opportunities for growth and transformation within the industry. Takeaways: The health insurance industry is facing significant challenges due to rising costs and increased scrutiny. Medicare Advantage plans are experiencing financial strain from surging patient demand and utilization rates. As healthcare providers, understanding your patient population is crucial for identifying high-cost areas. The medical loss ratio is a key metric that impacts insurers' profitability and operational strategies. Entrepreneurs should focus on innovative solutions that reduce waste and improve healthcare delivery efficiency. The evolving healthcare landscape presents opportunities for proactive adaptation and strategic partnerships. Companies mentioned in this episode: Humana UnitedHealth CVS Aetna Morgan Stanley Research Links: There's uncertainty ahead for the health insurance industry in 2025 Hearing: Hacking America’s Health Care: Assessing the Change Healthcare Cyber Attack and What’s Next | The United States Senate Committee on Finance Potential Health Policy Administrative Actions in the Second Trump Administration | KFF UnitedHealthcare Profits Less About Denials, More About The Pandemic Higher and Faster Growing Spending Per Medicare Advantage Enrollee Adds to Medicare's Solvency and Affordability Challenges | KFF Humana stock declines on Medicare Advantage star rating struggle | STAT
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Observed October 22, 2026. Cached outside the daily freshness window; the positions keep the date they were taken on.
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