Value Based Care Advisory (VBCA) Podcast

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 COVERFinancial 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 TRUTHMost 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.

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 solutionsWhy engagement — not automation — is the real leverage pointThe economics of supplemental benefits and underutilized Star opportunitiesHome-based and remote care as risk containment strategiesThe future vision of standardized specialty care marketplacesThis is a structural conversation about incentives, risk ownership, and where execution truly matters in value-based care.Key TakeawaysIncentive 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.Timestamps00:00 – Introduction01:39 – What Medicare Advantage plans actually want from AI vendors03:27 – Why engagement infrastructure is the real leverage point04:28 – Virtual care, socioeconomic complexity, and risk ownership06:18 – High-acuity members and access-driven cost escalation07:11 – Supplemental benefits and engagement economics08:36 – Stars, utilization, and revenue implications09:55 – Employers paying 2–4x Medicare rates10:27 – Why commercial pricing diverges12:17 – Incentive structure and negotiation power12:47 – Vision for standardized specialty care marketplacesAbout the GuestDr. 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 HealthClover Health

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.

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 monitoringNew behavioral health add-ons to primary careIncentives that reward value-based careExpanded reimbursement for digital therapeutics & telehealthA major shift from inpatient to outpatient proceduresWhether 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.

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.

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-serviceContracting tips for Series A and B stage startupsRisk corridors, capitation, and performance metricsHow to speak the payer language and win trustTarget 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

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 SchoolPrivate equity: health care's vampire | STATHow McKinsey Makes Its Own RulesHow Merck plans to fill the void of Keytruda patent expiration | Fox Business VideoFTC Deepens Inquiry into Prescription Drug MiddlemenRecord-breaking federal lobbying tops $2.2 billion in first half of 2024Big Pharma’s Business Model: Corporate GreedPBM Math: Big Chains Are Paid $23.55 To Fill a Blood Pressure Rx. Small Drugstores? $1.51. - KFF Health News

Welcome to this eye-opening episode of the VBCA Podcast, where we tackle one of the most pressing yet underreported issues in healthcare: hidden fees, surprise bills, and the alleged cartel controlling out-of-network reimbursements.In this episode, host Alex Yarijanian breaks down the allegations against MultiPlan, a third-party repricing company accused of working with major insurers like UnitedHealthcare, Cigna, and Aetna to suppress out-of-network payments. We explore:How MultiPlan's practices impact patients, providers, and employers.The AMA’s antitrust lawsuit accusing MultiPlan of operating a cartel.Real stories, like that of Kelsey Toney, a behavioral therapist forced to turn away patients due to unsustainable payment rates.The staggering $19 billion providers lose annually to these practices.If you’ve ever wondered why your healthcare bills are so high or why your provider suddenly stopped taking your insurance, this is the episode for you.Key Topics Discussed:What are in-network vs. out-of-network providers?How does MultiPlan determine reimbursement rates?The human cost of suppressed reimbursements for providers and patients.Legal implications of the AMA and ISMS lawsuit against MultiPlan.The broader impact on value-based care and healthcare transparency.Takeaways:Hidden fees in healthcare create a sense of unpredictability and financial anxiety for patients. MultiPlan's involvement in processing out-of-network claims often leads to underpayment for healthcare providers. Out-of-network providers typically charge fees that reflect their true cost of delivering services. Patients frequently find themselves responsible for covering the difference in reimbursement rates from insurers. Real-life patient stories underscore the profound human impact of rising healthcare costs and surprise bills. The current healthcare system often prioritizes profit margins over genuine patient care and outcomes. Companies mentioned in this episode: MultiPlan UnitedHealthcare Cigna Aetna Research Links:Legal Complaint (PDF): AMA v. MultiPlan Full Complaint - Filed in the United States District Court for the Northern District of Illinois involves the American Medical Association (AMA) and the Illinois State Medical Society (ISMS) as plaintiffs, suing MultiPlan, Inc. for alleged antitrust violations.Community Health Systems adds another antitrust lawsuit to MultiPlan's collection - Community Health Systems is the latest health system to allege that MultiPlan’s data-driven claims repricing business meets the bar for antitrust violation.AMA lawsuit targets collusion in health care pricingInsurers Reap Hidden Fees by Slashing Payments. You May Get the Bill. - A little-known data firm helps health insurers make more when less of an out-of-network claim gets paid.New York Times Investigation: Health Insurers' Lucrative, Little-Known Alliance - How a private-equity-backed firm called MultiPlan has helped drive down payments to medical providers and drive up patients' bills, while earning billions. AMA Press Release - The American Medical Association’s press release discussing the antitrust lawsuit against MultiPlan.

This podcast episode dives deep into the complexities of mental health parity and the implications of the Mental Health Parity Act. The conversation emphasizes the necessity for behavioral health services to be treated with the same level of care and coverage as physical health services, addressing the ongoing disparities in treatment and reimbursement practices. Alex Yarijanian and Dr. Chris Esguerra discuss the challenges providers face when navigating insurance plans and the barriers to accessing equitable care for patients.Dr. Esguerra is board certified in both Psychiatry and Health Care and Quality Management and is a Fellow of the American Psychiatric Association and the American Board of Quality Assurance and Utilization Review Physicians. Dr. Esguerra’s extensive payer-side executive experience includes:Senior Medical Director, Blue Shield of CaliforniaSenior Medical Director, Magellan HealthDeputy Chief Medical Officer, Health Plan Of San Mateo They highlight the critical role employers play in advocating for better mental health coverage and how they can leverage their purchasing power to ensure compliance with parity laws. Ultimately, the episode aims to empower providers with the knowledge and tools necessary to advocate effectively for their patients and promote a more integrated and equitable healthcare system.A significant focus of the episode is on the role of providers in identifying and addressing parity violations. The speakers guide listeners through the necessary steps for raising concerns regarding unequal treatment, emphasizing the importance of gathering evidence and understanding insurance policies. This segment is particularly valuable for behavioral health providers who may face obstacles in securing appropriate coverage for their patients. The discussion also touches upon the regulatory landscape, explaining how self-insured plans differ from traditional insurance plans and the implications this has for parity enforcement. Additionally, the episode discusses the importance of employers in advocating for better mental health coverage, encouraging providers to leverage their relationships with these entities to push for systemic changes that prioritize mental health equity.Takeaways: The Mental Health Parity Act requires equal coverage for both physical and behavioral health services, ensuring that patients receive the same level of care. Providers should gather evidence of parity violations and present it to state regulators to advocate for fair treatment. Behavioral health is lagging behind primary care in integration and reimbursement models, highlighting the need for systemic reform. Employers play a crucial role in advocating for mental health parity by demanding better coverage from their insurance plans. Effective communication and partnerships between providers and health plans can lead to better patient outcomes and innovative care models. Tracking outcomes and demonstrating quality of care is essential for providers to negotiate better contracts with health plans. Companies mentioned in this episode: Blue Shield of California Magellan Kaiser Permanente Google Apple Anthem Centene United Cigna Aetna Humana CalPERS Pacific Business Group on Health National Business Group on Health Chris Esguerra MD MBA

The system used to pay for health care today does not encourage the integration of health care and social care, nor can it adequately adapt to the trending shift toward value-based payments for care — paying for better quality and better health outcomes. New financing approaches are needed to enable the health care sector to engage in activities that strengthen social care and community resource. This episode is also available as a blog post: https://healthcare-wiki.com/2021/07/21/paying-for-biopsychosocial-care/

During the 2019 legislative session, Florida passed http://laws.flrules.org/2019/137 (Chapter 2019-137, Laws of Florida), which establishes standards of practice for telehealth services, including patient evaluations, record-keeping, and controlled substances prescribing. The law also authorizes out-of-state health care practitioners to perform telehealth services for patients in Florida. Signed by the Governor on June 25, 2019, this law became effective on July 1, 2019. Out-of-state health care practitioners must be registered with the Florida Department of Health to perform telehealth services for patients in Florida. Health care providers must be licensed within their scope of practice by the appropriate licensing body to practice telehealth in Florida. Providers must also use two-way, interactive communication tools, such as live video, instead of email or audio-only communication. If you use Medicaid, your telehealth provider must be registered with the Florida Medicaid program to receive reimbursement for telehealth services. Florida doesn’t require private insurers to cover telehealth, so check with your insurance company to determine if you’re eligible for the service. Some of these regulations may be altered during the COVID-19 pandemic. In Florida, telehealth providers are permitted to prescribe medications if the medications aren’t listed as https://flboardofmedicine.gov/latest-news/board-revises-floridas-telemedicine-practice-rule/ (controlled substances). https://flboardofmedicine.gov/latest-news/board-revises-floridas-telemedicine-practice-rule/ (Telemedicine Rule, Rule 64B8-9.0141, F.A.C.)Controlled substances shall not be prescribed through the use of telemedicine except for the treatment of psychiatric disorders. This provision does not preclude physicians from ordering controlled substances through the use of telemedicine for patients hospitalized in a facility licensed pursuant to Chapter 395, F.S. However, there is one important exception to this rule: If you need a controlled substance to manage a mental health condition, your telehealth provider is allowed to prescribe it. Before prescribing medication, your telehealth provider must conduct an evaluation and explain the risks and benefits of the medication to you. Filling out a questionnaire before your telehealth appointment isn’t enough to satisfy the evaluation requirement, so you should expect the provider to ask multiple questions about your symptoms and health history. This episode is also available as a blog post: https://healthcare-wiki.com/2021/06/22/florida-market-telehealth-rule/ (https://healthcare-wiki.com/2021/06/22/florida-market-telehealth-rule/) A Carenodes Production.