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“Your Margin Is My Opportunity”—Jeff Bezos

Jeff Bezos originally used this line in 2012 to describe Amazon’s strategy of attacking industries where incumbents protected their own high margins instead of improving efficiency. At that time, these were the retail, publishing, logistics, and cloud computing sectors.

He also believes all companies need to be “young forever,” and that companies should “work to charge less, not more.”

Fast forward to 2026, and AI turns Bezos’ philosophy into a universal law of disruption.

And no sector of the economy is more vulnerable to disruption by AI than healthcare.

But healthcare organization incumbents of all kinds have been generally okay with the status quo, or at least haven’t felt significant risk of disruption. On top of that, they feel “protected” by rules and regulations, complexity, historical stability, and licenses. Remember the failure of Haven Healthcare? Ironically, that was Amazon’s early attempt to disrupt healthcare with Berkshire Hathaway and JP Morgan Chase!

The past attempts failed for explainable reasons when we look back in hindsight. But I think this time is actually different.

The old moats matter less every day, and policy (particularly via CMS and CMMI) is accelerating that.

Artificial intelligence’s ability to disrupt healthcare is being further enabled and accelerated by policy. Organizations moved and innovated before there were payment pathways in place because they anticipated that was a temporary problem.

CMS is pushing on interoperability, digital-first care, digital front doors, risk-bearing and outcomes-based payment, and quality being measured by outcomes data, not manual reporting.

AI-enabled disruptors are aligning with policy initiatives. Disruptors see margin sitting on the table, and they will take it.

Incumbents didn’t ask for AI.

They were stable. They were compliant. But stability is not a strategy.

In healthcare, the organizations that will be left standing are the ones that adapt faster than their margin disappears.

Because AI is increasingly

• exposing inefficiencies.

• automating administrative tasks.

• slowly shifting value away from traditional clinical labor.

• enabling new entrants to build business models around incumbent friction.

Care Management Is Particularly Vulnerable

There is margin in care coordination and management, and that “manual care management” margin is being absorbed by tech-enabled care navigation companies. AI-enabled outreach platforms can:

• stratify risk

• automate outreach

• escalate only the highest-need cases

• run 24/7

Humans alone can’t compete.

Working in Population Health in the 2010s, clinician case managers and navigators could spend 1-2 hours reviewing various EMRs to get a grasp of a patient’s clinical care journey and social and functional factors to understand where they were now and what they needed. It was actually fun! I felt a bit like a sleuth 🕵️‍♀️ But efficient? 🤣 

This is becoming a thing of the past. Care management platforms integrate information and surface it in just the right way for care teams to use it to engage meaningfully and build trust with patients and care partners. Here’s an example.

It’s Time to Evolve

The question is “What do you do now if you believe that organizations that survive will be those that get out of “denial mode?”

Denial is not just a river in Egypt.—idiom

1. Build an AI Integration Strategy

Groups need to look at their workflows and find where the costs are high and the value is low.

• Audit repetitive tasks like documentation and patient outreach.

• Start small pilots for administrative automation.

• Teach clinicians how to supervise these systems rather than viewing them as rivals.

2. Double Down on Human-Only Skills

The value of a clinician is shifting.

AI can process data, but it cannot build trust or navigate all the emotional nuances of a patient's journey and the complexity of managing the continuum of care. Focus your talent development on the skills that value-based care actually requires. (See the Career Pulse section for more! 👇️ )

3. Create "AI + Human" Hybrid Models

The goal is probably protecting margins while retaining clinical talent and expertise. One example is implementing AI outreach for low to moderate complexity patient engagement and care management, with humans managing clinical escalation at the right time.

4. Anticipate Policy Acceleration

CMS is making it clear that they see the future as digital and outcomes-based. The policy levers are moving toward more risk, more accountability, and enabled by better interoperability.

• Invest in data infrastructure that actually talks to other systems.

• Join pilots and communicate through public comment letters to help shape future regulations.

• Stay ahead of the shift instead of reacting to it once it becomes a mandate.

(See this May 11, 2026 JAMA Network article by Abe Sutton and Jacob Schiff on tech-enabled care and ACCESS. Note there is a paywall.)

5. Treat AI as a Strategic Asset

The antidotes to denial?

Experiments. Pilots. Persistence.

Find internal champions and measure ROI early.

Champion a mindset of early adoption, and communicate that value clearly to the clinical team.

Remember the uselessness of denial? 🙃 

So if disruptors come in and re-imagine healthcare, and the healthcare industry evolves out of necessity, where does that leave the clinicians whose careers have been built on the way we’ve done things for decades?

After all, it’s all they know.

Hone The Skills AI Can’t Replace

Combine clinical and health tech knowledge with these “soft” skills:

Sales/Persuasion

Ever heard the saying “everything is sales?” It’s true. So lean in, because you need this skill in any role. This is more true now than ever.

“Remember that ”sales” means the ability to communicate value, successfully influence decisions, and help people take action.

Storytelling

Practice making the complex simple for others. Help others understand why something matters.

Rejection Tolerance

Resilience is always important, but never more than now. As roles morph, needs change, and expectations evolve, having this skill will help you roll with the punches and persevere. It may be a rocky few years.

Of coures, emotional durability will help you in all parts of your life.

Pair human skills with emerging tools and tech

All indicators are that this time really IS different.

Healthcare professionals are accustomed to relative stability, and that can make it hard to see the present for what’s actually happening.

Regardless of what changes, adaptability is the superstar trait employers, customers, and clients will look for in employees.

I’m a fan of Justin Welsh. I’ve taken other courses of his and am currently taking his Creator MBA course. So I’m passing along this Linked In post (adapted from a Tweet) for you, because he says it best 👇️ 

100% of successful people are lucky. The catch is they created the luck themselves. Luck shows up for people who keep putting themselves in better situations, around better people, and holding more… | Justin Welsh | 961 comments

100% of successful people are lucky. The catch is they created the luck themselves. Luck shows up for people who keep putting themselves in better situations, around better people, and holding more interesting ideas. You can't guarantee it. But you can engineer way better odds. Every successful person I know runs some version of this: - Read. The cheapest way to collect ideas worth using. - Write. The clearest way to find out what you actually think. - Build. The fastest way to learn what's real and what isn't. - Network. The simplest way to be in the room when something happens. - Introduce. The most generous way to become someone people remember. If you want a system you can run on autopilot, try this: Monday: Read for 30 minutes. Tuesday: Write about something you learned. Wednesday: Code with Claude for 30 minutes. Thursday: Send 5 thoughtful DMs on LinkedIn. Friday: Connect two cool people (double opt-in.) That's 2 hours a week. About one quarter of a workday. In 12 months, your life will look unrecognizable. Job offers, partnerships, ideas, and friendships you didn't see coming will start showing up. People will tell you how lucky you are! And they'll mean it. Or don't run the system. Watch other people pull it off, and chalk it up to good fortune. If you're trying to engineer more luck into your career and your life, I write one short essay every Saturday on exactly how to do that. 5 minutes. No spam. Read by 180,000+ people. Get Saturday's essay: https://buff.ly/fmdmQ8T | 961 comments on LinkedIn

LinkedIn

*Disclaimer: All opinions and ideas expressed in this article are solely mine and none represent a recommendation or should be viewed as advisement of any kind to anyone to do anything.*

Beyond the Walls, in Brief

Download your free copy of the report 👇️ 

What this report will tell you (and why you should care)

If you work anywhere near care delivery, payment policy, or health operations, or you are a leader in healthcare or health tech, 2026 is not a typical year for hospitals. Four structural forces (regulatory, statutory, commercial, and capital) are moving in the same direction for the first time in two decades. The result: billions in hospital‑based revenue are being redirected toward offices, ASCs, and the home.

This report breaks down what changed, why it’s happening now, and what it means for clinicians, operators, and policy pros who need to stay ahead of the slope.

Executive Summary | The 2026 Site‑of‑Service Reset

1. Hospital spending is the biggest and fastest‑growing line in U.S. healthcare.

Hospitals captured $1.6T in 2024 and drove 40% of national spending growth. Prices have outpaced inflation for two straight years.

2. Inpatient volume keeps shrinking while outpatient keeps rising.

Between 2000 and 2023, inpatient admissions dropped by nearly 19%, while outpatient visits surged by 31%.

3. Four forces are converging in 2026

• Regulatory: IPO list elimination, ASC list expansion, OPPS site‑neutral expansion, PFS indirect‑PE redistribution.

• Statutory: Unique NPI requirement for off‑campus HOPDs, Hospital‑at‑Home extension to 2030.

• Commercial: Employers and MA plans steering aggressively to lower‑cost sites.

• Capital: Nearly $40B in PE investment into ASCs across 2024–2025.
  Together, these forces are structural, not cyclical.

4. CMS moved more in one rulemaking cycle than in the last decade.

• 285 procedures removed from the IPO list in 2026.

• 547 procedures added to the ASC list.

• Grandfathered HOPDs now paid 40% of OPPS for drug administration.

• Facility‑based cardiology projected to see –7% revenue change from PFS redistribution.

5. Home is now a (nearly) permanent, reimbursed site of care.

Hospital‑at‑Home is extended through 2030, with outcomes showing 38% lower cost and 44% lower readmissions. Virtual supervision is permanent. RPM is standard. The home is now part of hospitals’ infrastructure.

6. By 2030, the slope, not the direction, is what’s uncertain.

The optimistic scenario? Maybe it shifts $200B+ in outpatient spend to ASCs, offices, and home. The pessimistic scenario slows federal savings but doesn’t stop commercial migration. The baseline: steady erosion of hospital pricing power and a consolidation wave.

So here’s what you now know

The shift away from hospital‑based care is at least partially the result of a structural realignment of incentives, capital, and clinical capability. That means:

• Clinicians should position around outpatient leverage: ASC partnerships, portable case mix, or APM‑aligned work.

• Healthcare leaders should track the boring‑but‑foundational infrastructure changes (unique NPIs, site‑neutral scoring, state facility‑fee bans) that set up the next round of reform.

• Operators and health tech should build for distributed care—ASC‑grade systems, home‑based diagnostics, and coordination across fragmented sites.

The takeaway:
Care delivery finally moving to the settings where patients prefer to be, and where the system can afford to send them.

Use this report as your briefing for the next phase of the shift. The levers are already pulled. The question now is how you position yourself and how it might impact you and your work.

Two Incentive Layers, And Why You May Feel Stuck

It’s easy to think this as a clinician: If you do good work, the system will reward you.

But healthcare isn’t one system. It’s two incentive layers running on top of each other:

• Personal incentives (you): patient outcomes, professional reputation, work-life balance, clinical craft, doing the right thing.

• Organizational incentives (your employer): revenue, efficiency metrics, market share, payer leverage, throughput, risk, and optics.

If you don’t separate these two layers, you end up in constant confusion:

“Why is leadership pushing this?” “Why doesn’t this change?” “Why do I feel like I’m compromising?”

The cause of confusion? An incentive mismatch.

Stop trying to “find a better job” before you learn to read the incentive layer you’re standing on.

Because incentives shape what gets measured, funded, staffed, and rewarded—and that shapes your options.

Why this matters in any setting

When you can name the incentive conflict clearly:

• You stop internalizing it as personal failure (“I’m not doing enough”)

• You reduce moral injury (“I’m trapped in a system that rewards the wrong thing”)

• You gain leverage (“I know what language decision-makers respond to”)

Or said differently:

You stop asking “why don’t they just do the right thing?” and start asking:

“What would make the right thing the easy thing?”

The real career unlock: learn which lever you’re holding

Here are a few examples of how incentives quietly steer your day-to-day—and your career ceiling:

• Hospital-based practice

  If the system earns more from facility-based billing, there can be subtle pressure to keep services in-house. Understanding this helps you advocate for the safest, most appropriate site of care and avoid getting pulled into “keep the volume” politics.

• Primary care

  If compensation is panel size and RVUs, prevention and coordination get squeezed. Clinicians who understand this often build a niche: complex care management, value-based programs, team-based workflows, quality leadership.

• Anywhere you’re asked to do “more” with no resources

  “We want better outcomes and happier staff” paired with no staffing change is an incentive mismatch. Naming it is how you ask for the missing input: time, training, tools, staffing.

A simple framework to save and reference later 👇️ 

Ask these 3 questions about any role you’re in or considering:

1. What gets paid for?

2. What gets measured and reported?

3. Who benefits if we do more of X and less of Y? 

If you can answer those, you can predict your future stress points and your future opportunities.

Write 2 short lists:

A) Personal Incentives (Top 5)

What you actually optimize for (even if you haven’t been allowed to say it out loud): outcomes, autonomy, schedule, mastery, relationships, energy, learning, leadership, etc.

B) Organizational Incentives (Top 5)

What your employer optimizes for: volume, RVUs, payer mix, downstream capture, length of stay, star ratings, HEDIS, readmissions, margin, referrals, etc.

Then answer:

Where do these overlap? Where do they clash?

That clash is your burnout risk.

That overlap is your career leverage.

How this helps your career (and makes you feel less powerless)

When you learn incentives, you can:

Make better career decisions: Evaluate jobs by the real drivers, not the brochure.

Negotiate smarter: Ask for what changes outcomes/workload: support staff, visit length, protected time, caseload caps, documentation support, training budget.

Influence more effectively: Frame proposals in access, retention, quality, cost avoidance, risk reduction, patient experience.

This is the difference between being “right” and being effective.

*Disclaimer: All opinions and ideas expressed in this article are solely mine and none represent a recommendation or should be viewed as advisement of any kind to anyone to do anything.*

Fear of Falls Causes Falls: The One Exercise That Changes the Trajectory

Most falls prevention conversations start with the environment.

Yes, remove the throw rugs.

Yes, raise the bed, add grab bars, and help someone order a lift chair.

Those things matter.

But in home health, I kept seeing the same pattern: the real risk often lived inside the person, not just inside the house.

When someone is afraid of falling, they move less.

When they move less, they get weaker, stiffer, and less steady.

And then the fear becomes reality.

This is the loop I want to interrupt.

The invisible driver of falls: fear + immobility

In practice, “fall risk” rarely has a single cause. It is usually a pile-up of factors that make a person feel unsteady, exhausted, and unsafe.

Here are some of the common contributors I saw again and again:

• Impaired sensation

• Depression

• Fear of falls

• Not feeling well

• Obesity

• Very limited endurance

• Arthritis

• Edema

Many of these are chronic.

Some are hard to change quickly.

And when someone has longstanding ways of doing things?

Building new habits can feel almost impossible.

They need to feel progress.

Because one setback, like an illness or a short hospital stay with immobility, can drop someone right back to “square one.” Weakness is both a side effect and a cause of exacerbations. It can be insidious.

It can even be why patients get labeled “non-compliant,” when what is really happening is that movement has become scary and exhausting!

The one thing I tried to make (almost) everyone do

Over time, I stopped looking for the perfect plan and started looking for the most repeatable plan.

What could someone remember on their hardest day?

What could someone do safely at home without special equipment?

What would actually build strength, balance, and confidence at the same time?

The answer was surprisingly simple:

Sit-to-stand repeats

Stand up from a chair.

Sit back down.

Repeat.

That is it.

And it is powerful.

Why habits matter more than heroics

The biggest challenge was never explaining the exercise. The challenge was adherence.

Most people won’t actually follow another complex program. They will abandon it the moment they have a flare-up, a bad night of sleep, or a week of feeling low.

They need reassurance. They need practice. They need a habit that survives real life.

That is why “success” in falls prevention is less about a single perfect intervention and more about building feedback mechanisms that keep someone going.

Progress has to be noticeable, barriers have to be removed, and support cannot depend on one clinician being a superhero.

The bigger opportunity: prevention embedded in care episodes

Don’t think of falls prevention as a “clinical issue.” It is a system opportunity.

If we take episodes like Resilience and Independence in a Safe Environment (RISE) to Age in Place Episodes seriously, we can build embedded prevention into the moments when risk is highest.

Pull the falls-prevention lever before the next crisis.

Use prevention to avoid another episode, another hospitalization, another stretch of immobility.

Because when we reduce immobility, we reduce weakness.

And when we reduce weakness, we reduce falls.

From CMS-Administered Risk Arrangements (CARA) Factsheet

(Note that CMMI made an update to explicitly include physical therapists in the RISE care team.)

Getting started: the simplest version

If you want to test this approach with yourself, a family member, or a patient, start small.

• Pick a stable chair.

• Make sure the setup is safe.

• Do a number that feels easy.

• Repeat it daily.

Then scale up gradually.

The goal is not to “crush a workout.”

The goal is to build a behavior that still happens on the day someone feels tired, stiff, or scared.

The Policy Bottom Line

We can view “sit-to-stand” as a clinical micro-habit, but we can also view it as a risk-mitigation strategy.

Because whether you care about the TEAM Model, an MSSP ACO, the new CJR-X, or even in the Home Health Quality Reporting Program (QRP), Skilled Nursing Facility QRP or Value-Based Purchasing Program, immobility is a liability.

By embedding simple, repeatable habits into care episodes, we can reinforce the financial success of the entire value-based care framework.

Closing thought

Fear of falls causes falls.

But confidence is trainable.

And sometimes the most effective tool is the one a person can do, remember, and repeat day after day until it becomes normal.

Next step: If you are building a falls-prevention program, ask one question: What is the habit we want people to do when life gets hard?

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I saw this post last week and it stuck with me.

Here’s a snip from the post:

He was referring to eating well and exercise. But this applies to career growth, too.

You may be doing things on your own time to grow your non-clinical skills and think “Am I wasting my time?” or “How is this going to really help me?” Because when you start out, we are taking a leap of faith. We must believe that this work on our free time will pay off. We may be sacrificing our time with our families and friends, or free time to just relax. The bottom line is we may not know HOW the investments in ourselves will pay off.

Know that they will, in one way or another.

You will have the fresh idea to solve an old problem, or a perspective your peers don’t see.

I have a few friends who are physical therapists in an outpatient PT department of a hospital. They have spent time on their own learning about value-based care and what physicians in ACOs are trying to accomplish. They started taking small steps to contribute to the efforts.

In one example, the rehab manager reached out to a primary care nurse practitioner in the ACO. The NP was receptive to a collaboration on a standardized pathway where therapists helped manage patients with musculoskeletal pain, balance impairments, and movement issues.

But it started with self-educating on how ACOs work and what the levers are success are. Managing patients with musculoskeletal pain, balance impairments, movement impairments and more via physical therapy is a great alternative to higher cost and avoidable interventions. PCPs should know what the PTs’ capabilities are at the top of their scope of practice and feel confident that the therapists can offer prompt access to care.

The takeaway:

If you find a spark of interest in something related to healthcare, learn more, even if you don’t know how you will apply it. The non-clinical self-education we do on our own time will pay dividends, even if you don’t know what that looks like yet.

Here are three pieces of recent content that stuck with me:

From KFF: Affordability is the Issue Now, But Look for the Uninsured to Make a Comeback. Find it here.

Drew Altman emphasizes affordability’s political salience but warns the uninsured, especially the sick, represent a glaring system failure and calls for policy attention to protect vulnerable families and workers.

From McDermott+: Food for thought: Automatic enrollment into Medicare Advantage. Find it here.

CMS recently signaled it’s studying models to automatically enroll newly eligible beneficiaries into Medicare Advantage or into accountable care arrangement in fee-for-service, while allowing opt-outs. Authors Jeffrey Davis, Parashar Patel, Lynn Nonnemaker, and Olivia Gomez examine possible implications. The piece explains current enrollment pathways via Social Security Administration (SSA) and Medicare.gov/plan-compare, considers default assignment mechanics (including impact on access to Special Needs Plans and on future Medigap guaranteed issues), and outlines alternatives such as affirmative choice or expanded seamless enrollment. They explore effects on beneficiaries, providers, MA plans, and federal agencies, noting potential shift in market concentration, administrative burdens, legal risks around assignment criteria, and the need for stronger interagency coordination and funding to implement any change.

From Health Affairs: Levels, Growth, and Semantics: The Role of Prices in Driving Health Care Spending. Find it here.

Michael Chernew examines how price definitions and semantics shape interpretation of recent health spending data, arguing that price growth did not drive the roughly 4 percent inflation-adjusted increase in National Health Expenditures between 2023 and 2024, according to analyses by CMS. He contrasts explanations for spending levels, where high US prices (relative to other countries) are central, with drivers of spending growth, which CMS attributes mainly to volume and mix. He urges policymakers to pursue both price-focused reforms (like caps on high prices and site neutral payments) and measures addressing utilization, mix, and innovation. he notes that fixing persistently high prices remain important even if they aren’t currently the primary source of year-to-year growth.

*Disclaimer: All opinions and ideas expressed in this article are solely mine and none represent a recommendation or should be viewed as advisement of any kind to anyone to do anything.*

Silos are Strategic Liabilities

Most people pick a side in value‑based care.
Episodes of care or total cost of care.
As if they’re rival ideologies instead of complementary levers.

That false divide is slowing progress.

Models like BPCI‑Advanced, which overlapped with ACOs (patients can be attributed to an ACO and “fall into” a BPCI-A episode based on their hospital stay final DRG), make the connection impossible to ignore. When a patient sits in both programs, incentives stack. Suddenly, the ROI of devoting resources to managing an acute episode starts to look different.

And that’s where the real leverage is.

Acute episodes create accountability for the post‑discharge trajectory and post-acute throughput of often complex, vulnerable patients.
ACO infrastructure creates accountability for the long‑term trajectory of all attributed patients. Together, they form a feedback loop that improves quality and reduces avoidable spend.

Policy is moving in this direction.
The LEAD model and the IPPS proposal to expand CJR nationwide signal a future where episodic and population‑based models overlap by design.

Clinicians should take note.

Hospitals should take note.

Advanced primary care teams accountability for cost and quality of care should take note.

Then layer on chronic episodes of care, which the LEAD model plans to add in the near future.

Here’s the thing—

Chronic disease management, typically the work of advanced primary care teams, can reduce ED visits and inpatient admissions. But care for some conditions is often driven by clinicians outside the advanced primary care team’s walls. This is the basis of long-term episode types. They create a framework for partnering with providers managing specific conditions that are the drivers of high spend.

Chronic episodes of care payment arrangements, such as those for diabetes, depression, low back pain, and chronic kidney disease, can help reduce the likelihood of a patient presenting to the ER or being admitted to the hospital by aligning incentives between the at-risk providers and/or organization and others in the clinical care ecosystem.

And when a patient in a chronic episode IS admitted to a hospital, the acute episode program structure can function as a part of the continuum of coordinated care.

This is where trust is built with patient.
This is also where goals‑of‑care conversations finally happen. And speaking of goals of care—

Advanced Care Planning Emerges in the 2027 IPPS Proposed Rule 

The latest IPPS proposal includes an eCQM advanced care planning measure. CMS understands that patients need to be engaged in conversations that help them understand their options and make informed choices. Yes, advanced care planning must happen regularly in outpatient physician practices. But they belong in the hospital, too. More on that shortly.

The bottom line: 

Episodes of care and total cost of care aren’t separate domains.
They’re interlocking gears.
Acute episodes, chronic care management, and population‑level accountability work best when they work together.

That’s how you improve outcomes.
That’s how you reduce avoidable spending.
And that’s how you build a system that finally makes sense for patients.

Why the Overlap Matters Now

• Episodes address the “discharge fast, hope for the best” problem. 
  Hospitals have historically been incentivized to move patients out quickly, not ensure what happens next is in the best interests of the patient given the totality of their needs.

• ACOs address the “nobody owns the long‑term outcome” problem. 
  Primary care teams have a long-term perspective and often focus on population-based levers like preventive testing, annual wellness visits, and patient engagement.

• Together, they create shared accountability for the full patient journey and the reality of navigating the health care ecosystem. 
  Acute → post‑acute → chronic → preventive.
  One continuous arc instead of disconnected events.

• Policy is aligning the incentives. 
  More overlap between episodic and population models is growing because we’ve learned how powerful it can be based on model tests.

                ┌──────────────────────────┐
                │      GEAR 1: ACUTE       │
                │        EPISODES          │
                ├──────────────────────────┤
                │ • Manage hospitalization │
                │ • Own post‑discharge     │
                │   trajectory             │
                │ • Reduce complications   │
                │   + readmissions         │
                └─────────────▲────────────┘
                              │
                              │ feeds into
                              │
┌──────────────────────────┐  │   ┌──────────────────────────┐
│   GEAR 3: TOTAL COST     │◄─┘   │     GEAR 2: CHRONIC       │
│        OF CARE           │       │        EPISODES          │
├──────────────────────────┤       ├──────────────────────────┤
│ • Close preventive gaps  │       │ • Stabilize complex pts  │
│ • Manage long‑term risk  │       │ • Engage caregivers       │
│ • Reinforce episode      │       │ • Enable goals‑of‑care    │
│   success                │       │   conversations           │
└─────────────▲────────────┘       └─────────────▲────────────┘
              │                                    │
              └────────────── interconnected ──────┘

What Policymakers Are Signaling

We are entering the phase where learnings from the past 12+ years of value-based care model testing are paying off. Policymakers know more about what works, and they are doubling down on that.

Model overlap is more intentional.

There is an incremental benefit to the patient and there’s a greater chance of improving cost and quality outcomes when patients fall into both program types. The TEAM Model and CJR-X are overlapping with MSSP and LEAD by design. What this means is hospitals must think about their role differently. Their engagement in helping to drive down medical cost trend is non-negotiable.

There’s a greater emphasis on advanced care planning. 

It was tested as a quality measure in prior models. In the 2027 IPPS Proposed Rule, we see it emerge as a quality measure for the hospital itself. It’s time to move beyond the acute care excuses of “that’s not my job,” and of physicians in the hospital saying “that’s for their primary care doctor to deal with.”

No.

Primary care must do its part. They must have regular discussions with their patients with chronic and serious illness and make sure they understand their disease trajectory, their goals, and their options. No argument here from me.

But hospital-based clinicians don’t just get to wash their hands of it because of where they interact with patients. It’s easier (and necessary) to access the information needed to have a meaningful conversation about a patient’s advanced care plan while a patient is in the hospital.

And it’s not something that can be punted to a nurse or a social worker—a frustrating push-back I heard for years. Physicians must own this as part of their responsibility. Hospitals will need to put systems in place to ensure this happens. That being said, it’s harder than most think.

But this is the beauty of CMS’ statutory authority to drive care transformation. It’s a requirement for everyone, so everyone will have to figure it out.

CMS is ratcheting up expectations of cross-setting coordination of patient care, and caring for patients with their whole care plan in mind. Not just the plan to discharge them.

A lack of meaningful incentives has yielded fragmented silos of care. Hospitals, primary care, specialty care, post-acute sites—they can’t operate in their own bubbles anymore. Or at least they shouldn’t.

Accountability expectations are changing.

It used to be perfectly acceptable to only be accountable for the actual work you do when in front of a patient or when they are in your building. Soon, we will all see that those were the “bad old days.” Policy changes, including payment incentives, changes to conditions of participation, interoperability requirements, and health tech advancements are accelerating the pace of change.

For hospitals themselves, length of stay is no longer the only metric that counts.

Stop Asking AI for Answers

Most people are using AI incorrectly.

They treat it like a vending machine:
Type a question, get a fact.

But facts aren’t what move your career forward.
Frames do.

The people who win in non‑clinical roles aren’t the ones who know the most.
They’re the ones who can interpret the most.

So here’s my take:

Stop asking AI for information.
Start asking it for orientation.

Ask it to show you:

• How experts think

• What beginners miss

• Where the leverage points are

• Which questions matter and which don’t

Because once you understand the shape of a problem, you can generate insights that no one else is thinking about.

And insights are what make you valuable in the modern healthcare economy.

Not credentials, not job titles, not years of experience.

Insights.

AI won’t replace you.
But if you keep using it like Google with better manners, someone who uses it to think will.

Here’s an example prompt and response about the 2027 Inpatient Payment System Proposed Rule that was published Friday late afternoon:

Here’s how you can use this information:

This kind of prompt and response can help you build a strategic lens to consider “What is CMS really trying to make hospitals become?”

It can also give you an automatic upgrade in conversations with leadership. The response may be what they perhaps should be considering, but that doesn’t mean they are. If a Director has those points in hand, they can bring to executive leadership meetings:

“How are we planning for CJR-X beyond just finance modeling?”

“Which eCQMs are we treating as enterprise priorities, not just quality projects?”

Armed with this AI-assisted analysis, the Director can create a one-pager or a slide or talking points, positioning themselves as someone who can translate policy into operations and strategy promptly.

And that’s the real advantage. AI can help you understand policy. Without a doubt, that’s valuable on its own. But it also helps you show up as the person who can turn policy into action.

Because anyone can read a rule. But few think to translate it into strategy. With AI as your amplifier, you become one of the few.

So much to consume, so little time. But healthcare and health policy content fluency can give you a career edge, so give it a try.

Here are three pieces of content that stuck with me this week:

From KFF: Affordability is the Issue Now, But Look for the Uninsured to Make a Comeback. Find it here.

Drew Altman emphasizes affordability’s political salience but warns the uninsured, especially the sick, represent a glaring system failure and calls for policy attention to protect vulnerable families and workers.

From McDermott+: Food for thought: Automatic enrollment into Medicare Advantage. Find it here.

CMS recently signaled it’s studying models to automatically enroll newly eligible beneficiaries into Medicare Advantage or into accountable care arrangement in fee-for-service, while allowing opt-outs. Authors Jeffrey Davis, Parashar Patel, Lynn Nonnemaker, and Olivia Gomez examine possible implications. The piece explains current enrollment pathways via Social Security Administration (SSA) and Medicare.gov/plan-compare, considers default assignment mechanics (including impact on access to Special Needs Plans and on future Medigap guaranteed issues), and outlines alternatives such as affirmative choice or expanded seamless enrollment. They explore effects on beneficiaries, providers, MA plans, and federal agencies, noting potential shift in market concentration, administrative burdens, legal risks around assignment criteria, and the need for stronger interagency coordination and funding to implement any change.

From Health Affairs: Levels, Growth, and Semantics: The Role of Prices in Driving Health Care Spending. Find it here.

Michael Chernew examines how price definitions and semantics shape interpretation of recent health spending data, arguing that price growth did not drive the roughly 4 percent inflation-adjusted increase in National Health Expenditures between 2023 and 2024, according to analyses by CMS. He contrasts explanations for spending levels, where high US prices (relative to other countries) are central, with drivers of spending growth, which CMS attributes mainly to volume and mix. He urges policymakers to pursue both price-focused reforms (like caps on high prices and site neutral payments) and measures addressing utilization, mix, and innovation. he notes that fixing persistently high prices remain important even if they aren’t currently the primary source of year-to-year growth.

*Disclaimer: All opinions and ideas expressed in this article are solely mine and none represent a recommendation or should be viewed as advisement of any kind to anyone to do anything.*

The Long-Term Enhanced ACO Design (LEAD) Model’s long-awaited Request for Applications is out. Applications are due May 17th, and CMMI graciously made the application abbreviated for ACOs already participating in ACO REACH!

My initial thoughts when the basics of LEAD were announced in December of 2025 can be found here.

Since I’m not doing a deep dive summary of LEAD today, here’s a super comprehensive and awesome landing page with organized details about the model made by Brad Heywood. Check out the cards that link out to all the relevant areas! 👏 👇️ 

From Brad Heywood’s LEAD Model Overview | LEAD Model Knowledge Center

Here are two components of LEAD that I’m particularly interested in:

1. CMS Administered Risk Arrangements

2. Testing of “AI Inferred Risk”

Let’s dive in:

CMS Administered Risk Arrangements (CARAs)

This model is the first time CMS is testing CARAs. They are a voluntary option for ACOs in Global Risk Arrangements only.

The idea is this:

Some ACOs whose patients overlapped with other CMMI episodic models’ inclusion criteria, like the Bundled Payment for Care Improvement Advanced (BPCI-A) Model, would receive what I called “bundle data” at the time.

From that data, they could (and we did) build longitudinal views of patient journeys. Combine that with access to EMRs along that journey and we were able to identify root causes of avoidable spend and poor patient outcomes and address them. For those patients who overlapped with our ACO patients, the value was actually exponential.

Called out by Premier, Inc. and others, CMMI saw the value in this data and began providing it to ACOs for their attributed patients. So let’s say my patient Mrs. Smith is in my ACO and had a hip fracture with ORIF. If that patient “fell into” a BPCI-A program, that would trigger a “surgical hip and femur fracture treatment” DRG and that would trigger a BPCI-A episode. So CMMI started sharing the same information on that episode with the ACO as if they were also participating in BPCI-A and the patient “fell into” that episode.

Some ACOs have used that data like we did back in the late 20-teens, mapping patient journeys and addressing root causes of potentially avoidable high cost and lower quality care that led to poor outcomes. That information and those insights could be shared with providers in the community along the continuum that provided care to the patient for some portion of time during the episode. It’s a powerful way to help incentivize care transformation!

From the Notioly Collection

Enter the LEAD Model, and CARAs are an embedded part of the model. CMS is offering two options:

1. Default. ACOs can choose CMS-constructed Episode-Based Cost Measures (EBCMs). They may not be customized for which codes are included or the episode lengths (acute + 30 vs. 90, for example) but can be customized for certain quality measures and discounts. Great starting point.

2. “Max Flex.” Here’s where it really gets interesting. ACOs can now customize existing EBCMs and can even work with vendors for alternate episode construction! Requires more advanced analytics and experience with episodes. Prior overlap with BPCI-A or the Comprehensive Care for Joint Replacement (CJR) model? Ideal.

It gets even more exciting! 😂 

Not only will there be acute medical, surgical and procedural episodes, but CMS will phase in chronic condition episodes! I’m sure I’m not the only one thinking about how beautifully, and likely intentionally, this overlaps with the ACCESS Model.

And enter the Resilience and Independence in a Safe Environment (RISE) to Age in Place falls prevention episode! 🥳 🙌 

I spent years working in and then with home health and can’t say enough about how big the opportunity is to improve quality of life, the ability to age in place, and to reduce total cost of care if we can prevent a percentage of falls via addressing balance impairments and home modifications.

CMS establishes Level II HCPCS G-codes for RN and OT services that will be zeroed out. My only beef here is PT should be included. PT at home can be provided under Medicare Part B for medically necessary balance training and other interventions. For my PT friends, it’s a great opportunity to collaborate with your local ACOs on this!

For all the details, find the LEAD RFA here. The resource linked above by Brad Heywood is another great starting point.

Why I Love CARAs:

The overlap of ACOs and Episodes of Care is a powerful one. My past experience taught me the value of managing both total cost of care and embedded episodes of care. Episodes of care, especially the acute care episodes, are often triggered by the most vulnerable of our population.

And it’s a jungle out there!

Transitions of care, competing incentives of post-acute providers, data-sharing challenges, medication reconciliation issues and much more are inherent risks for anyone, but especially our most vulnerable. The outcomes of an episode can influence someone’s life literally forever. There is still so much opportunity to do better. Embedded episodes create an incentive for ACOs to invest in care continuum navigation, post-acute partnerships, strengthening home-based care opportunities, and more.

My biggest fear? ACOs don’t volunteer.

Preferred Providers

I don’t have the data, but ACO REACH entities largely haven’t jumped on the bandwagon to enter into downstream contractual relationships with specialists and other providers like post-acute providers and rehab therapy clinics. Yet we know a high percentage of spend lives right there!

My wish for LEAD: Much greater adoption of Preferred Provider relationships and widespread participation in CARAs.

Testing AI Inferred Risk Adjustment

Risk adjustment in Medicare Advantage and Fee-for-Service value-based care models is the topic of book chapters and out of scope for this article.

Here’s an article by the Commonwealth Fund covering the basic and a visual snippet from the article 👇️ 

Risk adjustment in Medicare was developed to prevent adverse selection by plans so that CMS pays plans more for beneficiaries with a higher risk of medical spend based on certain diagnoses and demographic information. Diagnoses must be identified by physicians (and advanced practice providers) to determine this component of the risk adjustment factor. ACOs use the same methodology but calculate expected spend a bit differently, and it varies based on the model.

In LEAD, CMMI is actually doing two things with risk adjustment for the first time.

First, they are embedding three different models based on beneficiary category.

• Aged and Disabled

• End Stage Renal Disease

• High Needs (which had its own Track in ACO REACH whose participants were all at-home medical providers like Harmony Cares).

Three different risk adjustment models is exciting in and of itself.

But then, they added a twist.

CMS will test a transition away from provider-identified diagnoses to construct an individual’s risk adjustment factor annually to an artificial intelligence “inferred” risk.

This is not the first time “inferred risk” has come up. Abe Sutton, now Director of the CMS Innovation Center (CMMI), and Gabe Drapos, the COO of Pearl Health, wrote what is now an infamous Health Affairs article in 2024 called “Inferred Risk: Reforming Medicare Risk Scores to Create a Fairer System.”

From Health Affairs Forefront April 24, 2024

Here’s how this will work in LEAD:

In 2027 and 2028, CMMI will calculate benchmarks and reconciliation in LEAD using the standard risk adjustment methodology and the LEAD Model specifics.

In 2028, they will “shadow test” AI-Inferred Risk.

In 2029, the AI weight of risk adjustment will be 33%.

In 2030, the AI weight of risk adjustment will be 67%.

And in 2031, risk adjustment in LEAD will be 100% captured by AI inferred risk.

Here’s my take:

CMMI tests new models and methodologies to incentivizing and paying for care in Medicare and Medicaid.

They are testing inferred risk adjustment in the fifth generation of the advanced ACO model at CMMI (Pioneer ACO → Next Gen ACO → Direct Contracting → ACO REACH → LEAD).

They have been refining and adapting the advanced ACO model with each generation. And for the skeptics out there—it’s incredibly hard to change how care is paid for, incentivized, and especially, delivered. Healthcare is unique in many ways. It makes total sense that research and development through model tests have been needed to get us this far.

If inferred risk is successful, keep this in mind next: CMS has always used the same HCC Model for Medicare Advantage and the ACO Models. We saw that most recently in the move from V24 to V28 of HCC, when CMS finalized a three-year phase in of the new model. They created the same phase-in for MSSP and ACO REACH.

So if successful model tests lead to successful permanent models or model components being adapted in Medicare, and if CMS has always used the same risk adjustment model in MA and FFS ACOs, there’s a more than minimal possibility that inferred risk becomes the model used in MA in the future, too.

No doubt there will be refining of the model over the next few years. CMS as the payer in a CMMI model is more able to manage these refinements than plans are. So it makes sense to test first in LEAD.

More to come on the details of the new AI Inferred Risk Model in the future.

Note: Martin Cech also covered this nicely and in more detail in his “Weekly Health Policy Briefing 04/02/2026” post for Health Tech Nerds. 

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The Hidden Advantage Clinicians Often Don’t Realize They Have

Every non-clinical role I’ve earned was the result of a combination of two main things:

• What I learned from years of direct patient care, such as what drives outcomes, what people really need, what gets in the way of that

• What I observed happening at the system level. I connected dots most people weren’t looking at.

That was my competitive advantage. Unintentional, maybe. But looking back, it’s clear.

Here’s what you already know

• You’ve seen where care breaks down, and these are quality, operations, and product insights

• You understand what motivates people vs. what derails them, and these are behavior change and user experience insights

• You know what actually improves outcomes vs. what the system assumes improves outcomes

What you’ve learned by paying attention (and if you haven’t been, start today!)

• patterns in workflows, documentation, communication gaps, and patient journeys

• how policy changes, staffing models, and reimbursement rules played out and impacted care

• understood the downstream impacts of decisions made above your pay grade

• recognize opportunities before leadership because you were actually closer to the truth

Know this, my clinician friends: the system often trains clinicians to stay in their own lane. And because few clinicians have had education in payment policy or the business of healthcare, they sometimes doubt their own insights. Don’t be one of those clinicians. You can learn most of what you need to on your own time to help make sense of what you observe in the clinic and in the system around you!

You see, leaders in healthcare delivery organizations are often too far removed from the front line to see emerging problems early.

And very few people have actively worked to translate clinical reality into business strategy.

That is your differentiator.

You understand the human side of care and the system side of care and can bridge the two.

You have lived the friction points that product, policy, operations, and other teams are trying to solve.

You can spot risks, opportunities, and unintended consequences before they hit the business’ dashboards.

You bring insight that only comes from being close to patients and close to the system in which they are cared for.

So take this inspiration this week and articulate what you already see. You don’t need another degree for that. Embrace your competitive advantage as a clinician. And do NOT take for granted the skills you think are “just part of the job” because they are the things non-clinical teams struggle with.

Here’s what used to ring in my head on the regular—”Why does no one else notice this?” “This” is the insight you have when you notice how systems awareness intersects with clinical experience in ways that can be improved upon. It can be a pattern, a breakdown, an unintended consequence, and often it’s hiding in plain sight.

That’s your signal.

Here’s an example:

A patient was discharged after a CHF exacerbation with a stack of papers, a rushed medication list, and no real teach‑back. Everyone assumed the discharge was “complete.” But you noticed the pattern: every readmission in that unit involved the same three issues:

• inaccurate med rec

• no care partner involvement

• no confirmation that the patient understood the plan

Here’s what was actually happening:

• Medication Chaos: Patients were going home with outdated lists or duplicate meds because no one cross-checked the EMR against the bottles they actually had at home.

• The Communication Void: Care partners were left out of the loop, and "teach-back" was skipped, leaving patients nodding along without truly understanding red flags like fluid overload.

• The Bridge to Nowhere: Follow-up appointments weren’t booked until the patient was already home, leading to late visits and inevitable ED returns within 10 days.

The solution you came up with:

• Verified Med Rec: A two-step process to verify EMR lists against actual home bottles.

• Care Partner Bridge: A mandatory phone script for families and a simplified teach-back checklist.

• Confirmed Follow-up: A new workflow to ensure the first appointment and transportation were locked in before discharge.

Readmissions for heart failure dropped.

Extra work outside your role? Very likely!

An indirect investment in your career? Absolutely!

So the next time you find yourself asking “Why does no one else see this?” don’t dismiss the thought. It’s gold. That question is the beginning of a strategy. You don’t need a seat at the executive table to connect the dots. Trust that what you see from the front lines is the valuable data the system has but only treating clinicians can see.

Start circulating those insights with something like a “field insight” email to the director or to a team huddle: “I noticed a pattern with our last three CHF discharges. There’s a consistent gap in med rec that seems to be driving the readmission rate. I’ve put together a 3-point checklist that might plug this hole. Who should I send this to for a quick look?”

When you translate what you see at the ground level into a suggestion for the business, you are actually auditioning for your non-clinical role.

This week, I’m listening to and reading a book by my friend Gary Jacobs’ called The Zen Lobbyist.

The book follows Gary’s journey from entrepreneur to lobbyist and offers a framework for transforming the healthcare system through prevention, primary care, and thoughtful policy engagement. He also teaches readers how to stay centered and effective in high-pressure environments, which is an added bonus.

Here’s why I recommend reading it:

It shows how to advocate with compassion and pragmatism, which are skills every “clinician-turned-strategist” needs in their toolkit.

*Disclaimer: All opinions and ideas expressed in this article are solely mine and none represent a recommendation or should be viewed as advisement of any kind to anyone to do anything.*

**Disclaimer: All opinions and ideas expressed in this article are solely mine and none represent a recommendation or should be viewed as advisement of any kind to anyone to do anything.*

Policy Pulse

Your Hospital Isn't Designed to Heal You

Why the shift to care at home is the most important transformation in modern medicine

If you want to know where the biggest dent in American healthcare spending will come from, look no further than the hospital. Specifically, the significant amount of care we provide within its walls that simply doesn't belong there.

The Hospital Was Built to Stabilize You. Not to Heal You.

The case against the hospital as a default care setting starts with a fact most patients would find shocking: the hospital is one of the more dangerous places you can spend time. On any given day, about 1 in 31 hospital patients has at least one healthcare-associated infection. The CDC estimates roughly 687,000 healthcare-associated infections occur in U.S. acute care hospitals annually, with approximately 72,000 patients dying during hospitalizations linked to those infections.

A summary of peer-reviewed research published in the BMJ puts the total at an estimated 250,000 deaths per year from preventable errors and infections in American hospitals. The WHO's 2024 Global Patient Safety Report confirmed that more than one in ten patients globally experience harm in medical care settings — and roughly half of that harm is preventable.

Beyond infection risk, there's the immobility trap. Patients confined to beds for days experience deconditioning. That muscle atrophy, those falls, that functional decline–they have nothing to do with the underlying illness.

In many cases, we are paying premium 'hospital prices' for care that doesn't actually require a hospital's infrastructure. This fiscal waste stems from a deeper misunderstanding of what these buildings are designed to do. While patients come through the doors in some ways expecting a journey toward long-term health optimization, they are entering a high-velocity stabilization hub. The entire institution is engineered around managing crises and clearing beds, a setup that fundamentally prioritizes short-term stability over the slow, intentional work of human flourishing and a return to a state of wellness. 

To fix the math of American medicine, we have to move care into environments that are actually capable of prioritizing a patient's quality of life, rather than just their most recent data points.

What We Are — and Aren't — Going to Disrupt

Here is what we are not going to disrupt in the hospital setting: childbirth, the ER, surgery, and the ICU. These belong in hospitals. Acute, emergent, high-acuity situations that require sterile operating environments, immediate life-support technology, and surgical teams on standby — that's exactly what hospitals were built for, and they remain essential for it. In the future, hospitals will function to support what only they can do. 

A massive portion of our national healthcare spend is essentially a real estate tax—we are paying premium 'hospital prices' for care that doesn't actually require a hospital's infrastructure. This fiscal waste stems from a deeper misunderstanding of what these buildings are designed to do. While patients walk through the doors expecting a journey toward long-term health optimization, they are entering a high-velocity stabilization hub. The entire institution is engineered around managing crises and clearing beds, a setup that fundamentally prioritizes short-term stability over the slow, intentional work of human flourishing. 

The federal government has clearly recognized this mismatch; as of 2026, CMS has expanded the Acute Hospital Care at Home initiative to include over 320 hospitals across 37 states, recently extending the necessary waivers through September 2030. This shift marks the first time Medicare has fundamentally decoupled high-acuity payment from the physical hospital ward, proving that the 'hospital' is increasingly becoming a set of services rather than a specific zip code

The Care-at-Home Continuum Is Already Operational

The vehicle for this shift is "hospital at home.” It includes full inpatient-level care, including IV medications, daily physician visits (hybrid), lab draws, remote monitoring, and more, delivered inside a patient's home. Johns Hopkins, which pioneered the model, reports cost savings of 30% compared to traditional inpatient care, with lower average length of stay and fewer unnecessary diagnostic tests. 

Patient use of hospital-at-home programs grew tenfold from 2020 to 2024. By April 2024, CMS had authorized more than 320 hospitals across 133 health systems in 37 states to offer this model. And Massachusetts data shows hospital-at-home patients are more than 14 times less likely to be discharged to a skilled nursing facility than matched inpatient counterparts — which is its own quiet revolution, because SNF stays are miserable, expensive, and often functionally damaging.

The care-at-home spectrum is broader than most people realize. 

This shift moves beyond standard primary care into high-acuity medical intervention. Through consolidated platforms like DispatchHealth, which recently merged with Medically Home to form a unified acute-to-transitional continuum, patients now access emergency-level care and inpatient-style monitoring in their own living rooms. This integrated model is already diverting complex cases from overcrowded emergency departments and is projected to free up more than 62,000 hospital bed days annually. From wound care and IV antibiotics to full-scale 'hospital at home' programs, the shift has fundamentally redefined the site of care.

Tech, AI, and Robots Are Making It Possible

Technology is the backbone. Over 68% of Medicare-certified home health agencies now use some form of telemonitoring or virtual care. AI-driven predictive tools in home care are demonstrating the ability to reduce hospitalizations by up to 27%. Remote monitoring devices, AI-generated clinical alerts, tele-rehabilitation, and robotics-assisted care have crossed the line from pilot program to production tool. The infrastructure that didn't exist ten years ago is here, and the question is no longer whether it works. It's how fast the system reorganizes around it.

The financial signals are unambiguous. Home healthcare spending is projected to grow at 7.1% annually — the leading category among all healthcare sectors, outpacing hospitals at 4.7% and nursing homes at 4.8%. The U.S. home healthcare services market, valued at over $100 billion in 2024, is projected to reach $176 billion by 2032. The American Hospital Association's own Sg2 forecasting model projects home health will grow 22% in the coming decade, enabled by virtual care capabilities. The FDA launched its "Home as a Health Care Hub" initiative in April 2024, reimagining the home as a central, integrated health environment.

Payers and Outpatient Providers Want the Same Thing

This truly doesn't get enough attention: there’s so much alignment that can happen between payers and outpatient providers.

In the hospital setting, payers and providers have often been seen as adversaries. Hospitals want to fill beds and bill for services. Insurers want to be sure patients who don’t need hospital-level care are treated in less restrictive and high cost settings. The incentives are structurally opposed. 

But in the outpatient and home-based care world, something different is possible and is beginning to happen. Payers and outpatient providers can find common ground, because both benefit from keeping patients out of the hospital. Remember, it’s the hospital and the sequelae of utilization after the hospital that drives the bulk of avoidable and/or preventable healthcare spending. 

A primary care practice that proactively manages a diabetic patient's blood sugar (and teaches them to self-manage and provides access when they need help), a home health agency that catches a heart failure exacerbation before it becomes an admission, an AI-powered monitoring platform that flags a medication interaction before it sends someone to the ER…these interventions reduce cost for the insurer and create value for the provider (especially in value-based care payment structures) and for the patient. That's an alignment in American healthcare, and it shouldn't be underestimated.

As value-based care contracts expand, Medicare Advantage plans are increasingly acting as the primary financiers of the home-based shift. While KFF reports that the total share of plans offering in-home support services dipped slightly to 6% in 2025 as insurers recalibrate their margins, the demand for these services continues to act as a flywheel. For outpatient providers, getting paid to keep patients healthy rather than simply treating them when sick makes every successful home-management case a catalyst for further investment.

However, this alignment only works if it directly tackles the primary drivers of hospital over-utilization: affordability and access. KFF reports that more than one-third of U.S. adults (36%) skipped or postponed needed care in 2025 specifically because of the cost. When patients defer care, manageable chronic conditions inevitably spiral into acute crises, forcing them into the very high-cost inpatient settings we are trying to disrupt. By removing the logistical and financial friction of the traditional office visit (where 1 in 6 adults now report cost-related delays) home-based models transform patient behavior from reactive to proactive. They eliminate the price-driven barriers that currently make the emergency room the only 'affordable' option for millions

The Patient Mandate: Preference vs. Infrastructure

Nearly 9 out of 10 seniors say they want to age in place rather than move into institutional settings. The demand isn't just a preference; it’s a demographic inevitability. Yet, there is a stark physical mismatch: while the desire is nearly universal, only 10% of U.S. homes are actually 'aging ready' with the modifications needed to make that stay safe

The hospital isn't going away and never will. It's going to become what it should have always been: a place of last resort, not first instinct. The disruption of healthcare spending — the thing that has eluded three decades of policy ambition — will come from moving care to where it belongs. The data is there. The infrastructure is building. And the business case has never been clearer.

Sources: CDC HAI Data · WHO Global Patient Safety Report 2024 · Leapfrog Group Hospital Safety Grades · Massachusetts HPC Report · Vizient/Sg2 Impact of Change 2024 · CMS Acute Hospital Care at Home Data · DispatchHealth/Medically Home Merger · FDA Home as a Health Care Hub · AARP Home Preferences · KFF Medicare Advantage Benefits Spotlight · McKinsey & Company Healthcare Shift

Career Moves

The Command Center Era: From the Unit-Bound Clinician to the Clinical Architect

The decoupling of medicine from the hospital zip code will fundamentally redefine the "office" for the modern professional. We are entering the era of the Clinical Air Traffic Controller.

For stakeholders like the physician, physical therapist, and health tech innovator, this is a massive invitation to move from a reactive, facility-bound existence to a proactive, environment-agnostic career. Instead of waiting for a patient to arrive at a clinic or a ward, the next generation of leaders will operate from "clinical cockpits," using streams of real-time biometric data to orchestrate high-acuity care across hundreds of living rooms simultaneously.

This evolution is fueled by a projected 23% growth in virtual consultative services and the emergence of nationwide clinical command centers that require a new kind of "virtualist" expertise. The opportunity here is to transition from being a "cog in the facility" to an "architect of the outcome":

For the Physician: The path leads toward the Acute Virtualist. This role trades the "floor walk" for high-level data synthesis, overseeing complex hospital-at-home clusters where you are the invisible hand ensuring stability in a decentralized ward.

For the PT: This is the shift from reactive rehab to Predictive Movement Management. Using remote biometric streams, you become the primary defense against the 'immobility trap,' identifying functional decline in real-time and intervening in the living room—not the clinic

For the Health Tech Innovator: Your "customer" is moving from the hospital IT department to the human environment. The mission is building the "invisible infrastructure.” This includes the sensors, AI-triage layers, and logistics engines that make a living room feel as safe and precise as an ICU.

This is going to make the bedside more scalable. If you are willing to trade the “safety” of the hospital walls for the autonomy of the “clinical cockpit,” the next decade of healthcare can be a professional rebirth.

This Week, Try This

Read about the Kidney Care Choices Model Year Two Results and Celebrate What Good Looks Like

If you care about kidney disease, Medicare payment reform, or simply what it looks like when healthcare policy gets something right, this week's assignment is to read the newly released Kidney Care Choices (KCC) Model Performance Year 2023 Evaluation — and to sit with what it actually means.

First, some context: why this model exists at all.

End-stage renal disease (ESRD) is one of the most expensive, complex, and devastating conditions in the Medicare program. More than 430,000 Medicare fee-for-service beneficiaries with ESRD spend an average of 12 hours a week receiving in-center hemodialysis. It’s a grueling, life-altering regimen that is also, critically, the default. The current Medicare payment system encourages in-center hemodialysis as the default treatment for patients beginning dialysis.

In traditional Medicare fee-for-service, providers get paid per service rendered. A dialysis facility receives a bundled payment every time a patient comes in for in-center hemodialysis which is three times a week, week after week, for hours at a time. It creates a stable, predictable revenue stream built around the patient showing up at the center. Nobody is being villainous. Providers are simply responding rationally to the incentives in front of them.

Home dialysis disrupts that model. If a patient switches to peritoneal dialysis at home, they stop coming to the center. The facility's revenue drops. There's no financial reward built into the traditional system for the care coordination and training work it takes to get a patient successfully doing dialysis at home, even if that patient will have a dramatically better quality of life. Transplants are even more complicated: a successful kidney transplant means the patient no longer needs dialysis at all. From a pure revenue standpoint, a dialysis center loses a patient when a transplant succeeds.

So when we say in-center hemodialysis became the default, what we mean is: the payment system made it the path of least resistance — for providers and for patients who were never given real information about their alternatives. Patients with chronic kidney disease may experience fragmented care and high-cost treatments that do little to slow disease progression. They also receive limited if any education about their disease and treatment options.

Patients are often receiving some of the most intense medical treatment in all of Medicare without being properly educated about what other choices exist. And those choices like home dialysis, preemptive transplant waitlisting, and living donor transplants, can be life-changing.

Meanwhile, in-center hemodialysis patients suffer from poorer health outcomes, such as higher hospitalization and mortality rates, often the result of underlying disease complications and multiple co-morbidities.

This is precisely why CMMI launched the KCC Model — and why you should care.

The CMS Innovation Center (CMMI) is the federal body charged with testing new ways to pay for and deliver care. Congress created it because it recognized that fee-for-service rewards volume over value, and that someone needs to systematically test whether better care designs can produce better outcomes before being scaled nationally.

CMMI is, in essence, the laboratory, the research and development arm, of American healthcare.

The KCC Model's approach is this: rewrite the financial logic so that doing right by the patient is also financially rational for the provider. The KCC Model brings nephrologists and other kidney care providers and practices together to take accountability for patients who have late-stage chronic kidney disease, ESRD, or a kidney transplant, offering coordinated and seamless treatment and care, along with patient education.

Practices receive payments for care coordination, bonuses for successful transplants, and shared savings opportunities when they keep costs down and quality up. Home dialysis stops being a revenue threat and starts being a goal.

The model's three core goals are clear and ambitious: slow the progression of CKD, increase home dialysis, and increase kidney transplantation.

This evaluation is only for year two of the model. The longer models run, the more positive the results.

The results just released cover Performance Year 2023, which is only the second year the model has been running. The first cohort of participants didn't even begin until January 2022. We are watching a new care delivery model find its footing in real time, across 44 states and the District of Columbia, serving patients who represent 51% of Medicare fee-for-service patients with advanced kidney disease. That context matters enormously when you read the findings.

So what did Year 2 actually show? Four things worth celebrating. 🥂 

1. More patients on home dialysis. Home dialysis rates increased by 10%, translating to 800 more patients receiving care at home rather than in a center, driven primarily by increased use of peritoneal dialysis. This matters because home dialysis is associated with better quality of life, greater flexibility, and for many patients, better clinical outcomes. Remember: the old payment system gave providers no reason to make this happen. The KCC Model changed that calculus — and 800 more patients are living it.

2. More patients starting dialysis the right way. Optimal ESRD Starts — meaning new dialysis patients who began renal replacement therapy in a planned, coordinated way rather than urgently or in crisis — increased by 31%, reaching 700 more patients. An unplanned start to dialysis is a medical emergency and a signal of care failure. A planned start means the patient was educated, prepared, and supported before the moment of crisis arrived. That's 700 patients who didn't have to experience the chaos and trauma of landing in dialysis without warning.

3. More living donor transplants and earlier waitlisting. While overall transplant rates didn't move yet, living donor transplant rates rose by 22% — 75 more patients. Even more encouraging, preemptive waitlisting (being placed on the transplant list before needing to start dialysis at all) increased by 37%, reaching 128 more patients. These are patients whose care teams are thinking ahead, planning proactively, and giving them the best possible shot at a transplant before dialysis becomes their reality. Under the old model, a successful transplant meant lost revenue. Under KCC, it means a bonus payment. Same providers, different incentives, better outcomes.

4. Better-informed, more activated patients. The KCC Model was associated with more CKD patients receiving information about their treatment options, and KCC patients showed improved patient activation scores. This is a validated measure of a person's ability to understand and manage their own health. This is the foundation everything else is built on. Educated patients ask better questions, make more informed decisions, and are more likely to pursue options like home dialysis or transplant listing. You cannot fix a system that kept patients in the dark without first turning the lights on.

Net Medicare spending increased — and here's how to think about that.

The evaluation found a net increase in Medicare spending of $304.8 million in Year 2, primarily from incentive payments made to participating practices. This is the number that will generate headlines, and it deserves an honest reading. The model did not increase Parts A & B payments, and it did not increase acute care utilization — hospitalizations, readmissions, and emergency department visits were all unchanged. The spending increase came from the model's own payment design: the investments made to reward better behavior.

CMMI models are explicitly designed to test whether upfront investments in better care coordination generate downstream savings and quality improvements. Two years in, the quality signal is real and pointing in the right direction. The financial story is still being written, and it will take time for improved starts, more home dialysis, and more transplants to translate into avoided hospitalizations and reduced total cost of care over a patient's lifetime. Kidney disease is a long game. So is payment reform.

Why does this matter to you?

Because every value-based model, every shared savings arrangement, every effort to move beyond fee-for-service starts here — with real patients and real dollars and real evidence. When a model like KCC shows genuine quality improvement in just its second year of operation, that's not a small thing. It's proof that when you align incentives, coordinate care, and actually tell patients what their options are, better things happen.

The CKCC model option has been extended through December 31, 2027. There is more to learn, more to refine, and more patients to reach. In the meantime, Year 2 gave us something rare in healthcare policy: measurable, meaningful, patient-centered progress — achieved by changing not what providers are capable of, but what the system rewards them for doing.

Full evaluation materials are available here.

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Strategic healthcare trailblazer and systems thinker turning clinical expertise, policy insights, and market intelligence into actionable frameworks..

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*Disclaimer: All opinions and ideas expressed in this article are solely mine and none represent a recommendation or should be viewed as advisement of any kind to anyone to do anything.*

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**Disclaimer: All opinions and ideas expressed in this article are solely mine and none represent a recommendation or should be viewed as advisement of any kind to anyone to do anything.*

Policy Pulse

The Moment Has Arrived

The average clinician is going to start feeling it. Not just hearing about it in a conference or reading about it on Linked In, but actually experiencing it in how they care plan, how they interact with patients, and what’s expected of them.

And for healthcare practice owners, this is no longer a future consideration. The pivot is now. Those who don’t transform how they deliver care will not survive the decade.

So what changed? Why now?

Four forces have converged:

• More data — more usable, more comprehensive, and more actionable

• Data insights built for the end user, not the analyst

• Greater interoperability across systems and settings of care

• Digital health tools that put real power in the hands of the healthcare consumer

The Only Lever That Bends the Cost Curve

Let’s be honest about where we stand.

CMS drives healthcare policy in this country, particularly since the Affordable Care Act created the CMS Innovation Center and enabled rigorous testing of what actually improves outcomes and lowers cost.

And the headwinds are real: high-cost medications, heavy use of acute care, expensive new treatments, and inflated reimbursement rates for non-time-based procedural services. None of that is going away on its own.

The Innovation Center needs time to test and find solutions that scale. Those who aren’t being realistic about the time this takes are taking the wrong approach to appreciating how enormous the task is.

There are really only two meaningful levers:

• Value-based care payment models and care delivery structures

• Biosimilar drugs

Biosimilars are relatively straightforward. Value-based care, on the other hand, is all-encompassing. It also often triggers eye-rolls and sighs. I understand the skepticism. But nothing else is capable of bending the cost curve.

What Happens When the Rules Change: A Real Example

The best way to understand value-based care is through how it changes traditional incentives inherent in fee-for-service. When incentives shift, behavior follows.

Take the Transforming Episode Accountability Model (TEAM). Hospitals are held accountable for every healthcare dollar spent in the 30 days after a patient is discharged. When the norm is responsibility for the stay itself (and a readmission hit for certain diagnoses captured in the Hospital Readmission Reduction Program) and essentially nothing starting the day of patient discharge, this is a big deal.

What should a hospital do when their wallet is on the line the moment a patient walks out the door? Here are some big levers if they want to at least prevent owing CMS money.

1. They assess actual, accurate patient function and safety before hospital admission and identify real support systems from day one.

2. They mobilize patients aggressively. Mobility reduces inpatient post-acute stays, the single biggest driver of episode cost overruns. The loss of physical power that happens in acute care stays without a medical necessity for bedrest is almost unforgivable. (It’s one of the hills I’ll die on.)

3. They partner with home health agencies and outpatient PT/OT providers (including OP providers that make home visits) that can begin treatment within 24 hours of discharge.

4. They invest in discharge planning teams who can train patients, communicate across settings, and set expectations with post-acute providers.

5. They scrutinize IRF placements. The cost of inpatient rehab often exceeds the cost of the hospital stay itself. No meaningful functional change? The patient shouldn’t be there.

6. They manage SNF throughput tightly. Many patients can move through a skilled nursing facility in 5–10 days when the episode is closely managed, realistic and appr.

7. They hire care navigators with deep expertise in Medicare payment policy to be the connective tissue across the entire care journey.

My team and I were doing all of this in 2017 and blowing away expectations. We were improving patients’ lives and helping them achieve a long-term successful care journey. We focused on the big picture and insisted everyone who touched our patients did the same.

We were rare then. The difference now is that the tools, the data, and the policy architecture are catching up to make this the standard.

What We Learned Building This in 2017

When my team supported BPCI-A, CJR, and MSSP patients through acute and post-acute episodes, we had something most health systems didn’t: good data, near real-time. ADT feeds. A risk-stratified dashboard. A vendor who integrated multiple data sources into a proprietary risk score that kicked in the moment we identified a patient through concurrent coding. A team of skilled and trained clinicians inside the hospital and embedded in post-acute sites of care working to help successful navigate patients through successful, safe care journeys and help them get back home and remain there.

We stratified. We shared. We did deep dives into patient journeys with stakeholders across the continuum. We saved money for CMS by improving quality, reducing unnecessary post-acute utilization, and setting patients and families up for long-term success. We earned shared savings by reducing avoidable and unnecessary spending. We improved the patient experience and their outcomes.

When I left that health system after 20 years and multiple roles, I realized this:

We were way ahead of the game. 

Not because of luck. Because we made major investments in people, data, interoperability, and analytics, and because we had the C-suite buy-in to see it through.

A movement has been building. If you haven’t experienced it yet, that’s likely because of your employer or, if you’re an owner, because you’ve chosen to remain entrenched in fee-for-service. And you yourself may not have made the deliberate decision to learn how the pieces all fit together and how VBC works. It’s not too late!

Straddling fee-for-service and value-based care is genuinely hard. So just expect it. For most, it’s a multi-year transition. But the direction is set. Invest in change or be disrupted.

Digital Health: The Accelerant Few Saw Coming

Digital health tools have mostly existed as employer-sponsored add-ons and parallel to healthcare, not integrated within it. Your employer offers free access to a digital health point solution. A small percentage of employees opt in. Those who need real clinical care hit a wall: the digital tool doesn’t talk to the PT clinic. The PT doesn’t have access to the platform. The consumer experience is fractured.

That’s about to change fundamentally.

Enter the ACCESS Model

For the first time, a digital health vendor will be able to submit to become a Medicare provider and bill under Medicare Part B. CMS is betting that integrating digital health into mainstream medical care (rather than keeping it as an employer add-on) is a game-changer.

CMS isn’t writing blank checks for billing for digital health, however. ACCESS Model participants must demonstrate avoided duplicate care management spending and improved outcomes using well-established measures. Underperform? Receive as little as half the payment.

They’re also requiring data sharing between digital health providers and the patient’s primary medical provider managing their chronic condition, and requiring those providers to ingest and share data back. In return, providers can bill a co-management code for collaborating with the digital health provider and data sharing. It also opens up the option for reducing their own investment in patient engagement tools and care management staff, depending on their partnerships with ACCESS Model participants and clinicians like physical and occupational therapy practices and behavioral health practices.

And here’s the detail that might seem minor but isn’t: CMMI is allowing ACCESS participants to waive the co-pay. For a repeated service like care management, the friction of getting verbal consent for cost-sharing is of a common dealbreaker. Many practices already provide care management without billing for it because of this friction alone.

The End of Healthcare’s Information Monopoly

For decades, healthcare operated on information asymmetry. Providers knew things patients didn’t.

The system was built around that imbalance, and, in many ways, depended on it.

That era is ending.

Patients are done tolerating what they once accepted:

• Months-long waits for an appointment

• Phone-only, 9–5 scheduling

• Urgent care as the default option for everything

• Repeating their medical history at every visit

• Paper forms and faxed records

• Weeks of waiting for test results

• Cookie-cutter advice and treatment plans

• No follow-up, no proactive outreach, no real continuity

The bar is no longer set by healthcare. It’s set by the best consumer and AI experiences people have everywhere else, such as in banking, in travel, in retail. Patients now expect the same in their healthcare.

Data availability, digital health, single-touch data sharing, and easy identification of low-value providers are creating a monumental shift. Good data and value-based care agreements are the tools that allow forward-thinking providers and organizations to get ahead of it.

The Call is Clear

This isn’t doom and gloom. It’s a wake-up call, and there’s still time to answer it on your own terms.

For Clinicians

Understand what value-based care actually requires of you. It’s not just a billing change — it’s a different relationship with your patients, their data, and their care journey. Learn the incentive structures. Know what programs your organization participates in. Understand what metrics matter and why. Your patients will be more engaged, better informed, and less forgiving of experiences that don’t meet modern expectations. That’s not a threat. It’s an opportunity to practice at the top of your capability.

For Owners

The window to lead this transformation is open. Straddling fee-for-service and value-based is the reality for a while. But don’t let that stop you from building toward a future that isn’t entirely dependent on volume. Invest in data infrastructure. Invest in care navigators. Partner with digital health vendors who are entering the Medicare ecosystem. Build the care teams and processes that make your organization indispensable in a value-based world.

The iceberg is visible. The tools to change course exist. The only question is whether you’ll act before or after the collision.

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This Week, Try This

Check out this article by my friend Alex Bendersky! 👇️ 

The Memes Running Physical Therapy

And the Five We Need to Rewrite Before the Profession Falls Behind

medium.com/@sashadpt/the-memes-running-physical-therapy-6c08dfc573e6

*Disclaimer: All opinions and ideas expressed in this article are solely mine and none represent a recommendation or should be viewed as advisement of any kind to anyone to do anything.*

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**Disclaimer: All opinions and ideas expressed in this article are solely mine and none represent a recommendation or should be viewed as advisement of any kind to anyone to do anything.*

Policy Pulse

Spinning Its Wheels: How Medicine Keeps Getting Vertigo Wrong

You roll over in bed at 2 a.m. The room lurches. You’re convinced something’s very wrong—like a stroke or something else that feels catastrophic. You head to the ER. Hours and tens of thousands of dollars later, you go home with a diagnosis of "dizziness" or “vertigo” and a prescription for a drug that does absolutely nothing to fix what's wrong (meclizine/Antivert).

I watched this or something similar play out dozens of times as a physical therapist. A patient has a general diagnosis of “dizziness” or “vertigo” after a rule out of something neurological and they are given an oral medication and sent home.

The condition is called Benign Paroxysmal Positional Vertigo (BPPV) and it is almost absurdly treatable. Tiny calcium crystals called otoliths (also known as “otoconia”) drift out of position in the inner ear and trick the brain into thinking the body is spinning. The fix?

A clinician guides your head through a specific repositioning sequence called the Epley maneuver (in the most common presentation of BPPV with a slightly different “maneuver” for the others) and the crystals migrate back where they belong. One visit. Sometimes one treatment. Symptoms gone.

No MRI required. No CT. No overnight admission. No neurologist. No ENT.

I treated BPPV regular in outpatient rehabilitation and even in home health rehabilitation. I’ve since treated multiple family members and friends.

And yet.

It’s the most expensive dizzy spell in medicine.

From Cleveland Clinic’s Page on BPPV

Healthcare costs associated with diagnosing BPPV alone approach $2 billion per year in the United States, with more than 65% of patients undergoing potentially unnecessary diagnostic testing or interventions (and that’s from a 2017 article, so let’s assume it’s a low estimate of dollars spent). Unnecessary diagnostic procedures have been reported in more than 65% of BPPV patients even in advanced countries, including rates of 70% for MRI and 45% for CT.

Why? Some hypotheses:

Because vertigo can feel terrifying, and terror in medicine often defaults to imaging.

Because stroke and BPPV can look similar to an undertrained eye.

Because medical education gives vestibular disorders roughly the attention of a footnote.

And because fee-for-service payment systems reimburse the scan, not the skillful bedside maneuver. That maneuver is commonly perfected by trained physical therapists.

The drug most commonly prescribed for BPPV, meclizine (Antivert), is a particular frustration. It suppresses vestibular signals. It sedates the complaint. It does not and cannot move the otoconia. Patients taking it aren't getting better. Sometimes the crystals drift back to where they belong on their own. Sometimes the crystals remain exactly where they don't belong, and the clock runs out on days the patient could have been functional, working, and not terrified.

Delayed diagnosis and treatment of BPPV is associated with increased rates of anxiety and depression, lost workdays, inappropriate use of emergency resources, and reduced quality of care. These are the kind of outcomes that show up in utilization data, readmission rates, and disability claims.

What we’re not teaching

Ask most ER physicians (or primary care providers in urgent care and primary care) to perform a Dix-Hallpike (the bedside test that can diagnose BPPV in under two minutes) and many will hesitate. It's not complicated. It requires tilting the patient's head at a specific angle and watching for characteristic eye movement. But it takes practice and pattern recognition that a brief residency mention doesn't build.

Physical therapists, by contrast, evaluate and treat BPPV regularly. It is one of the rare conditions in PT where full resolution in a single session is not just possible but common. The irony is that patients often reach us only after exhausting every expensive wrong turn the system sent them on first. Another great reason for PTs to work as the norm in primary care, urgent care, and emergency rooms.

What AI can do right now to help

Here's where it gets interesting. Researchers have developed machine learning models to classify vestibular disorders using patient-reported symptoms alone, achieving 88% accuracy. Why? Because conditions like BPPV can often be diagnosed primarily through what patients describe.

The symptom profile is specific: brief spinning triggered by lying down or turning the head, no hearing loss, no neurological symptoms, no spontaneous vertigo. A dizzy patient describing those features to an ambient listening tool in a busy ER is practically flagging their own diagnosis. A patient saying "the room spins when I roll over, just for a few seconds" is practically self-diagnosing.

Tools that provide ambient AI infrastructure already suggest ICD-10 codes in real time based on what a clinician says aloud. They can hear a patient describe positional vertigo. The technology to flag that pattern and prompt "consider Dix-Hallpike before ordering imaging" is a configuration decision that someone needs to prioritize.

This one is solvable

Value-based care models have an opening here. Treat BPPV as a sentinel condition: high-frequency, low-complexity, wildly over-imaged. Track inappropriate imaging rates. Reimburse the bedside maneuver. Build BPPV recognition into clinical decision support as a default, not an afterthought. Require a Dix-Hallpike before a vertigo-related CT and/or MRI order in low-risk presentations.

Sidenote: The inspiration for this piece was my mother’s visit to the ER this week. They added an MRA to the above-mentioned diagnostic tools employed before someone finally said “we noticed your eye flickering and that’s from BPPV. Here’s meclizine to take.” (That “flickering” is nystagmus.)

That was the treatment provided. No referral to PT for the Hallpike-Dix to evaluate and the Epley maneuver to treat. Just meds after throwing the kitchen sink of imaging at her. I did tell her when she texted me from the hospital that her texted symptoms sounded like BPPV…. 🙃 

There are more than four million U.S. ED visits annually for dizziness or vertigo, costing over $4 billion in yearly workup costs. A meaningful percentage of those patients have BPPV. They're not sick. They're otoliths are out of their normal position. But we keep charging them (and the system) a fortune in imaging, overnight stays, and specialist consults, while a frightened patient waits days for an answer a ten-minute bedside test could have given them in the ER.

The otoliths just need repositioning. So does the medical approach to evaluating and treating them.

Career Moves

What are you doing between now and your next career after direct patient care?

For the clinicians who have a gut feeling or even know they will transition away from the bedside “at some point,” take heart! You can start preparing today. Preparing before you want to leave or are ready to leave direct patient care can make it so much easier when it’s time to plan your transition.

Here are a few things you can do right now as a starting point.

1. Build your professional reputation. Your reputation is one of the most portable assets you have. It travels with you outside the clinic or organization’s walls. Start by showing up consistently and being known for something beyond your clinical role. That might mean volunteering to precept students, joining a committee, presenting at a staff meeting, or contributing to a policy update.

   In my case, I was first known for being an expert in managing the throughput of fragile patients from hospital through post-acute settings to home safely. That led to me as the obvious choice to help lead the development and implementation of a transitions of care program and team.

   Outside your workplace, think about LinkedIn. If you don't have a profile, create one. If you have one, dust it off. Don't announce anything. Just start connecting with colleagues, sharing the occasional insight from your clinical experience, and engaging with content in spaces you're curious about. Add value to others. Set a cadence for interacting on Linked In. Three times per week is a good starting point.

   The goal right now isn't to job hunt. It's to make sure that when opportunities come up, people already know who you are

2. Unsure what’s valuable to learn about? Start by reading industry journal and blogs. One of the biggest barriers clinicians face when exploring non-bedside roles is not knowing what skills or experience actually translate. The good news is you can start closing that gap just by reading.

   Pick one or two journals, newsletters, or blogs in an area that interests you, whether that's health tech, care management, informatics, policy, or something else entirely. Start consuming content. You're getting familiar with the language, the problems people are trying to solve, and the conversations happening in that space.

   As you read, you'll start to notice things. You'll recognize gaps that your clinical perspective could speak to. You'll see job titles you've never heard of. You'll come across skills that keep coming up. Start a running list.

   This is low-stakes intel gathering that costs nothing but a little time. It’s a great investment.

   Here are a bunch of suggestions for journals, publications, and news sources to check out. Check them out and pick a few. If I were choosing three to call mandatory, they would be a., e., and k.:

   1. Health Affairs (especially Forefront)

   2. NEJM Catalyst

   3. JAMA Network, especially health policy and informatics pieces

   4. The Commonwealth Fund

   5. KFF Health News

   6. Stat News

   7. Techy Surgeon

   8. Andreesen Horowitz (Bio and Health)

   9. Advisory Board Daily Briefing

   10. Fierce Healthcare

   11. CMMI newsletters: sign up for email updates at this link

   12. Newsletters I recommended at the top of this article

3. Start managing what you learn. Reading is only half the equation. What you do with what you read is where the real value builds.

   This is where personal knowledge management comes in. In simple terms, it's a system for capturing, organizing, and revisiting what you're learning — so it doesn't just disappear after you close the tab.

   Start small: when something you read resonates, write a few sentences about it in your own words and save it somewhere intentional. A notes app, a doc, a dedicated notebook—whatever you'll actually use.

   Here's why this matters more than it might seem at first:

   When you take notes in your own words, you're not just saving information. In fact, the point is to not just save information. The valuable part is that you're processing it.

   You start connecting ideas across different articles. You begin forming opinions. And over time, you develop a point of view that is uniquely yours and shaped by both your clinical experience and your growing knowledge of the industry you want to move into.

   That point of view is what makes you valuable outside the clinic. It's what gives you something to say in an interview, something to write about, something to share with a colleague.

   It also helps you stand out. When you start the job search for your first non-clinical role, this may be the most important tool in your toolbox. It 100% was for me.

   I wrote about personal knowledge management here.

This Week, Try This

I co-host a relatively niche podcast on the “future of physical therapy,” aptly named Future Proof PT. The most recent episode, Episode 27, is about AI in Healthcare. It’s for any clinical or clinically-adjacent audience. My cohost Alex Bendersky and I have a chat with Sergei Polevikov.

Check it out the episode here:

Here’s a “short” from the episode that’s under 60 seconds:

*Disclaimer: All opinions and ideas expressed in this article are solely mine and none represent a recommendation or should be viewed as advisement of any kind to anyone to do anything.*

**Disclaimer: All opinions and ideas expressed in this article are solely mine and none represent a recommendation or should be viewed as advisement of any kind to anyone to do anything.*

Policy Pulse

The Cognitive Comeback | Reimbursing Brain Power

I was thinking about various policy changes and models rolled out by CMS and the Innovation Center over the past decade.

They’ve created additional codes for cognitive work and coordination of care, such as chronic care management, principal illness navigation, caregiver training, advance care planning, and much more. We have needed to pay for these types of activities for forever. Not paying for them, plus fee-for-service incentives, have led to little longitudinal care and failures of population health in America.

While adoption of advanced primary care is variable, it’s working!

But there’s this other dynamic happening in parallel. 

CMS is creating codes like the Advanced Primary Care Management (APCM) codes, which essentially allow practices to simplify care management tracking and bill one monthly code that includes a number of these “cognitive codes.”

APCM Services and Codes on CMS.gov

It can lead to higher overall primary care practice reimbursement and encourage these activities to be performed, especially for practices who aren’t participating in value-based care arrangements.

For practices who have operationalized the various codes and services, it can potentially yield lower revenue by the nature of bundling of the codes.

Of course, those at full financial risk are typically not concerned about code volumes. They are concerned about engaging their attributed population and preventing unnecessary and avoidable healthcare utilization. Their reimbursement isn’t determined by billable units. The administrative time it takes to track and comply with the rules around use of these codes is often determined to be “the juice is not worth the squeeze.”

The “So What”

Policymakers began reimbursing for services that are now seen as valuable and worth paying for. 👏 

At the same time, I see them trying to address two other dynamics.

The first is making adoption more widespread by simplifying and bundling related “cognitive” services.

The second is proactively mitigating the risk of the overutilization of the same services by simplifying and bundling related “cognitive” services.

Let’s look at how this applies to two models—one active, one beginning this year.

The GUIDE Model: A Condition-Specific Longitudinal Care Model

Let’s look at the Guiding an Improved Dementia Experience, or GUIDE Model, for dementia and its code for the Dementia Care Management Payment (DCMP). It’s meant to replace all these services below. 👇️ 

Medicare Physician Fee Schedule Services covered under the Dementia Care Management Payment in the GUIDE Model

Note: this doesn’t stop another provider from billing the above codes for a patient in GUIDE (assuming the other provider is not a GUIDE “Partner Organization”), and the GUIDE Participant isn’t penalized for “substitute spend” if that does happen. (Like in ACCESS, which we’ll talk about next.)

GUIDE is structured in a way that’s not necessarily meant to save money, although CMMI hopes it does. Dementia patients are thought to be under-utilizing upstream services significantly, leading to high downstream costs and high risk of institutionalization.

The Guide Model is meant to improve quality of care and life for patients living with dementia and their unpaid caregivers. It’s a Biden-era model that the Trump Administration’s CMMI Director Abe Sutton retained.

GUIDE aligns patients voluntarily, and patients with ICD.10 coded diagnoses for dementia can be referred ongoing by anyone at any time (think discharge planners, home health agencies, PCPs, therapists, etc). These patients are often not getting the care management and coordination of care they need in fee-for-service. They and their caregivers often end up in ERs and eventually skilled nursing facilities because they don’t know what else to do. The GUIDE Model is meant to address this.

Participants in the model can only “lose” a small amount of their payment based on poor quality performance, so there’s no true, significant risk. CMMI even provides a helpful data dashboard to each Participant so they identify actionable insights and can track their performance, perhaps without needing to secure additional outside analytics solutions .

The ACCESS Model | A Model testing Recurring, Outcome-Aligned Payments for Managing a Patient’s Qualifying Condition

Now let’s look at the Advancing Chronic Care Through Effective, Scalable Solutions (ACCESS) Model. ACCESS participants bill the g-codes to provide monthly support for a bucket of conditions. The same Medicare Part B provider can’t bill any FFS codes for a patient if they are billing the ACCESS code.

ACCESS is the first model to withhold significant reimbursement per patient from the Participant. 50% of reimbursement will be paid retrospectively based on outcomes and the presence or absence of “substitute spend.”

Then CMMI is paying the ACCESS orgs a low annual fee meant to encourage innovation. This will limit the types of organizations who can successfully implement the model, and that’s by design.

Visual from https://www.theaccessmodel.com

Notable Differences

GUIDE and ACCESS both feature monthly payments for managing a condition.

Unlike the approach taken in GUIDE, CMMI is paying the referring and coordinating provider about $100 per patient per year that’s enrolled in ACCESS. The combined payments to the ACCESS org and the referring/coordinating provider are now about on par with the GUIDE payment. There’s nothing like that in GUIDE, but CMMI surely knows it’s hard for primary care practices to effectively manage many patients with dementia and other parts of the healthcare continuum are already looking for places to refer them.

(Note: GUIDE also includes up to $2500 per year reimbursement for respite services for qualifying beneficiaries, but that’s out of scope for this post.)

The coordination payment in ACCESS also addresses something else. 

If a provider is billing the coordination fee, they are not permitted to bill the “substitute spend” codes. So this could reduce monthly care management, RPM, and additional code utilization. It also includes PT and OT evaluations in substitute spend codes for the MSK track, and has a similar structure for the Behavioral Health track.

Side note from a PT and VBC expert: Thank you to CMMI for changing the policy and allowing therapists to be the referring providers and bill the co-management fee for the MSK track. It was announced this past week on a webinar. This is a gamechanger for therapists. I Just hope they realize the layers of opportunity here—this is a meaningful inroad into ACO partnerships!

In ACCESS, note CMMI is incentivizing the referring provider to receive and incorporate information from the ACCESS org into the patient’s overall care plan. I see this as an investment so ACCESS orgs have enough patient volume to create a margin with CMMI’s “disciplined” reimbursement rates for what effectively will be digital health access for Medicare beneficiaries.

ACO Primary Care Flex Model | Prospective Primary Care Payments for Certain MSSP ACO Participants

While out of scope for this post, The ACO Primary Care Flex Model is another model that bundles primary care services into a payment for Participants. This is relatively similar to how ACO REACH determines prospective payments for primary care.

This is somewhat different from the APCM, GUIDE, and ACCESS examples because this payment is made as part of participation in the model. Codes billed that overlap are “zeroed out” and not reimbursed. I’m oversimplifying here to give a 30,000 foot view only. There’s lots of information available if you want to dig in.

Here are the codes used to determine the base rate, from the ACO Primary Care Flex RFA:

ACO Primary Care Flex RFA

I wrote about ACO Primary Care Flex in 2024 if you want to check it out👇️ 

Should you Consider Primary Care Flex?

CMMI's Hybrid Payment Primary Care Model for PCPs in Certain MSSP ACOs

www.timelessautonomy.com/p/primarycareflex

Here’s My Point

CMS post-Affordable Care Act changed direction and began to reimburse for the “cognitive work” of primary care teams.

They have added to the list of available services and codes.

They are also building a primary care “bundle” code, which they may add to further.

Then CMMI creates models that “bundle” codes for cognitive services.

But here’s the thing:

Cognitive services, prevention activities, proactive outreach—these are not services we should be trying to limit, right? They aren’t causing runaway spending.

You know what is? High cost biologics, avoidable and preventable hospitalizations, avoidable surgeries, avoidable imaging….

CMS wants to prevent overuse of codes, but we are focused heavily on the low cost and high-value codes.

Sometimes I wonder—why don’t we just pay primary care more and differently across the board? Yes, it will require reducing reimbursement for other Medicare Part B services. I suppose CMS may think that will just lead to more volume of those services if their reimbursement drops?

They may also be afraid of the backlash after finalizing G2211, which Congress required CMS to hold on implementing for several years because it was going to reduce reimbursement to specialists (it also reduced reimbursement to PT and OT, which is crazy—they are already underpaid 😠 ).

On that note, I’ll leave you with this tidbit I read somewhere this week. If I find the link, I’ll add it to the online post version later. 👇️ 😁 

There was so much noise around the add-on complexity code for longitudinal care, G2211.

The predictions of primary care provider utilization of this code were very high. Turns out? Specialists (those who can bill E and M codes) are using the codes more than PCPs. I’m being a cynic and generalizing here, but I don’t know a lot of specialty physicians who own longitudinal care like primary care providers do.

The Future of Primary Care: Team-Based, Higher-Paid, Prospectively-Paid, with Longitudinal Accountability

I’ll venture to say we are realistically 5-10 years away from the widespread norm of paying at least our primary care provider teams prospectively, not just in CMS Innovation Center models. We might see the same for certain specialty care, like for those treating dementia and ESRD patients, also.

The work is heavily overweight on care that requires communication, connection, patient engagement, patient outreach. Figuring out how to price and bill for those services individually seems like an intractable problem.

The X-factor will be what role technology plays outside of human interaction. This is really what ACCESS is testing in my opinion. Put technology in the extended care team and give it wide freedom to innovate. Where it will fit and how it will be reimbursed in the future will surely be informed by the results of ACCESS.

This Week, Try This

Please consider attending the webinar I’m on with Dr. Marc Gruner, Dr. Christian Penn, and Dr. Ben Schwartz on the ACCESS Model on Thursday, March 12th.

Check out Dr. Penn’s Substack article here.

Check out some classics from the Timeless Autonomy archives! 👇️ 

Should you participate in the Innovation Center's GUIDE Model?

The GUIDE Model (Guiding and Improved Dementia Experience) broken down

www.timelessautonomy.com/p/guide

Beneath the Surface of ACCESS

Plus, the predictor of career success that you can improve on today

www.timelessautonomy.com/p/beneath-the-surface-of-access

OT Potential Blog and VBC Resources

Plus: Intro to Medical Cost Trend

www.timelessautonomy.com/p/ot-potential-blog-and-vbc-resources

Check out my Medbridge webinar on the Transforming Episode Accountability Model (TEAM) for clinicians! 👇️ It’s free with a Medbridge subscription or can be purchased as an individual course from Medbridge.

Not a subscriber? Using my link gives you $106 off your subscription for unlimited CEUs with code DanaStrauss. They have a host of different types of CEUs for various clinicians. The subscription is a must for me since N.J. requires live CEUs and Medbridge adds live webinars monthly.

Medbridge’s CEU platform, where you can find my TEAM webinar

**Disclaimer: All opinions and ideas expressed in this article are solely mine and none represent a recommendation or should be viewed as advisement of any kind to anyone to do anything.*

Check out my Medbridge webinar on the Transforming Episode Accountability Model (TEAM) for clinicians! 👇️ It’s free with a Medbridge subscription or can be purchased as an individual course from Medbridge.

Not a subscriber? Using my link gives you $106 off your subscription for unlimited CEUs with code DanaStrauss. They have a host of different types of CEUs for various clinicians. The subscription is a must for me since N.J. requires live CEUs and Medbridge adds live webinars monthly.

Medbridge’s CEU platform, where you can find my TEAM webinar

**Disclaimer: All opinions and ideas expressed in this article are solely mine and none represent a recommendation or should be viewed as advisement of any kind to anyone to do anything.*

Policy Pulse

What the Accountable Health Communities Model Tested

From 2017 to 2023, the Centers for Medicare & Medicaid Services ran the Accountable Health Communities (AHC) model across 28 communities nationwide. The question was this: if we screen Medicare and Medicaid patients for social needs in healthcare settings and connect them to community resources, can we improve health outcomes and reduce costs?

The model screened over 1 million patients. Thirty-seven percent had at least one unmet social need. The most common barriers to health were housing instability, food insecurity, transportation problems, utility needs, and interpersonal safety concerns.

The results shouldn’t be surprising. Patients with navigation support had 3-7% lower total healthcare costs, driven by fewer ED visits and hospital admissions. The intervention worked because having someone help navigate resources made a measurable difference in whether patients could show up for care and follow through on treatment plans.

How It Actually Worked: The Camden Coalition Example

To understand how this plays out in practice, look at the Camden Coalition in South Jersey. They're a community-based nonprofit that served as one of the AHC "bridge organizations." Think of that as the connective tissue between healthcare systems and community services.

The structure: The Camden Coalition is funded through a mix of federal demonstration grants (they received CMS funding for AHC), state Medicaid dollars (New Jersey allocated funding to support their Regional Health Hub designation), and shared savings arrangements with managed care organizations.

They partnered with five health systems across Camden, Burlington, and Gloucester counties: Cooper University Health Care, Jefferson Health, Virtua Health, CAMcare, and Oaks Integrated Care.

The model: Unlike traditional CBOs that provide a single service (like a food bank or housing program), the Camden Coalition coordinates the entire ecosystem. They train hospital and clinic staff, manage the screening process, run a referral platform, employ community health workers (CHWs) who navigate patients to services, and maintain relationships with dozens of CBOs that deliver actual assistance.

Over the course of their AHC implementation, they screened over 30,000 patients and demonstrated significantly lower ED utilization rates in the intervention group compared to the control group.

The Workflow: From Screening to Better Outcomes

Here's how it worked:

1. The screening happens A patient comes to Cooper Hospital's emergency department or one of the partner clinics. A staff member (sometimes a medical assistant, sometimes a care coordinator, sometimes a CHW stationed at the site) administers the AHC screening tool. It's a standardized questionnaire with 10 core questions covering five domains: housing, food, transportation, utilities, and safety.

The questions are direct. "Do you have a steady place to live?" "In the past 12 months, have you worried your food would run out before you got money to buy more?" "Has lack of transportation kept you from medical appointments, meetings, work, or from getting things needed for daily living?"

The screening takes about 5-10 minutes. If the patient screens positive for any need, they're offered a tailored referral list through the Camden Coalition's platform called My Resource Pal (powered by Findhelp). Everyone who screens positive gets this list.

2. Navigation kicks in for high-risk patients But not everyone gets navigation support. The model focused resources on patients most likely to benefit. If a patient screened positive for at least one social need AND reported two or more ED visits in the past 12 months AND lived in the community (not in a nursing facility), they were eligible for navigation services.

About 18% of all screened patients met these criteria. Of those eligible, 79% opted in to navigation. An important takeaway is that most people wanted the help when it was offered.

3. The community health worker makes contact A CHW from the Camden Coalition reaches out, often by phone. They don't just confirm the screening results. They dig deeper.

Take Frank, one of the patients the Camden Coalition team described. He screened positive for housing and transportation needs. But when his CHW talked with him, the real issue emerged: employment instability due to a felony record, which meant he couldn't get stable work, which meant he couldn't afford reliable transportation, which affected his housing.

The CHW connected Frank with a job coaching program at Hispanic Family Center—a resource Frank, a Black man, didn't even know would be available to him. The program helped him find employment that included transportation as part of the position. That job stability helped him save for a car and work toward stable housing.

4. The navigation process The CHW uses what the Camden Coalition calls their COACH framework—particularly "observing the normal routine" and "connecting tasks with vision and priorities." This isn't about handing someone a phone number and moving on. It's about understanding what's actually preventing someone from accessing help and troubleshooting those barriers.

Maybe the food pantry has hours when the patient is at work. Maybe the housing assistance application requires documents the patient doesn't have. Maybe the patient tried calling a service before and got lost in voicemail. The CHW helps solve these practical problems.

The Camden Coalition Health Information Exchange plays a role here too. With patient consent, it allows real-time data sharing between hospitals and community providers, so the CHW can see if someone had an ED visit, and the hospital can see if the patient successfully connected with services.

5. The closed-loop referral When the CHW refers a patient to a CBO—say, a food bank or a transportation program—they track whether the patient actually got served. This is the "closed loop" part. They follow up with both the patient and the CBO to confirm the connection happened and the need was addressed.

This is also where the system often breaks down. CBOs are frequently at capacity. They have waitlists. The Camden Coalition has to maintain relationships with multiple providers for each type of need, know which ones have availability, and sometimes get creative when standard resources aren't accessible.

6. The impact on health outcomes Here's how it connects back to healthcare: when Frank got stable employment with transportation, he could make medical appointments. When Jeanette (another patient who screened positive for food insecurity around the holidays and was stressed about caring for her grandkids) got connected to resources, she had fewer crises that might have sent her to the ED.

The model didn't necessarily resolve every social need completely—the evaluation showed mixed results on whether needs were fully met. But navigation demonstrably reduced healthcare utilization and costs. Why? Because having someone actively helping you navigate the system makes it more likely you'll access primary care instead of the emergency department, follow up on referrals, and stay connected to care.

Find more information about case studies of post-model scaling and spreading of innovations from the AHC Model here. Additional examples and resources are in the newsletter’s “Sources and Additional Links” page here.

Why This Model Matters

The AHC model proved several important things:

Screening at scale is possible. A million patients were screened. It can be integrated into clinical workflows in emergency departments, primary care clinics, and specialty settings. Staff can be trained to do it. Patients are generally receptive.

Social needs are prevalent and consequential. Over a third of Medicare and Medicaid patients have at least one unmet social need affecting their health.

Navigation is the critical piece. Just identifying needs and giving people a list doesn't move the needle. Having someone like a CHW, a navigator, a care coordinator who stays with the patient and helps them actually connect to resources is what makes the difference.

Infrastructure requires investment. The Camden Coalition exists because of deliberate funding choices: federal grants, state Medicaid dollars, and payment arrangements that recognize the value of care coordination. Organizations like this don't emerge spontaneously. They need sustained financial support.

CBOs are the rate-limiting factor. The biggest barrier isn't screening. It's not even navigation. It's that community-based organizations providing housing assistance, food support, and transportation programs are chronically underfunded and at capacity. You can't refer people to services that don't exist or can't take more clients.

What Clinicians and Innovators Should Know

For clinicians: Screen. Even if you're worried you can't solve every problem, the data matters. Document the barriers you identify. When you can't address a transportation need or housing instability, write it down. That documentation builds the case for system change.

Know what's available in your community. Build relationships with local CBOs or organizations like the Camden Coalition if they exist in your area. A warm handoff to a specific navigator or program is far more effective than generic information.

For innovators: If you're building tools or solutions for social needs, understand that the workflow requires people. Technology can facilitate screening, referrals, and tracking, but it can't replace navigation. The Camden Coalition used a platform (Findhelp/My Resource Pal) to manage referrals and track outcomes, but that platform worked because CHWs used it to do their jobs better. It was not used as a replacement for human connection.

Focus on interoperability. If your tool doesn't integrate with EHRs and CBO case management systems, you're creating more work, not less. The Camden Coalition's Health Information Exchange enabled data sharing across providers precisely because they invested in making systems talk to each other.

The Funding Reality

Here's what sustaining a model like Accountable Health Communities requires:

Someone has to pay for bridge organizations like the Camden Coalition. That means Medicaid reimbursement for navigation services, state funding for regional health infrastructure, or value-based payment arrangements that recognize preventing an ED visit is worth something.

CBOs need dedicated, stable funding to build capacity. Grants help build infrastructure and are often an important step, but they usually aren’t enough. If we want them to absorb referrals from healthcare systems, they need resources to hire staff and expand services.

Navigation itself needs to be recognized as a reimbursable service. Several states have been moving in this direction through Section 1115 waivers and Medicaid state plan amendments, partly because of what the AHC model demonstrated. However, federal legislation enacted in 2025 imposes stricter budget neutrality requirements on 1115 waivers starting January 1, 2027, which may make it harder for states to get approval for innovative payment approaches that require upfront investment.

Why You Should Believe in This

The AHC model worked because it acknowledged reality: patients live in the world, not in clinical pathways. Meeting clinical needs is necessary but not sufficient. Whether someone can actually get healthier depends on whether they can get to appointments, afford food, and live in stable housing.

Frank didn't need a better diabetes medication. He needed a job that came with transportation so he could get to his medical appointments and work toward stable housing.

Jeanette didn't need a lecture about nutrition. She needed help getting food for her grandkids so she wasn't overwhelmed with stress that kept her from taking care of herself.

The model proved that when we identify these barriers, connect people to someone who can help navigate resources, and invest in the infrastructure to make that happen, patients have better outcomes and use healthcare more appropriately.

This structure is documented, measured, and replicable.

The question now is whether we can actually fund and scale it.

Find all sources and additional context here.

Are you an OT or a PT? Check out my podcast for OT Potential on “How PTs and OTs Get Paid” here:

How OTs and PTs Get Paid • OT Potential

Learn about the 2026 reimbursement landscape with policy expert Dana Strauss. Shift the needle with 3 concrete advocacy efforts and a roadmap for action.

otpotential.com/ceu-podcast-courses/how-ots-and-pts-get-paid

Career Moves and This Week, Try This

Keep it simple. The Timeless Autonomy Resources page has great resources for this week’s newsletter. Learn more about 1115 waivers, CBOs, and the AHC Model by checking out the links I shared there.

New knowledge acquisition is critical to career growth, particularly for those interested in non-clinical career paths.

Career growth is built one educational block after another. If you want non-clinical options, be someone “knowledge rich.” Think of learning non-clinical/clinically-adjacent topics as part of your career growth and development. Each piece of knowledge you acquire is an opportunity to find what “lights you up.” Follow the flickers.

You can become someone whose knowledge and “second brain” has access to solutions when problems come up that you can solve.

You can liken it to investing broadly when you are young in things like total stock market index funds and international index funds, knowing that the compounding of those investments over time will pay you dividends. If you want to be financially independent, you must have invested broadly and diversely over time.

Careers are no different. Gather knowledge and experience. Dig into topics that interest you. Explore different avenues. Make notes about what you learn and store in your personal knowledge management tool.

This is really great news. It means there isn’t a specific “formula” to worry about first. Start learning and exploring. Find what resonates for you. Find what can combine with your clinical knowledge to give you a superpower!

You WILL find ways to apply that knowledge. You WILL find topics that resonate. You WILL find ways to share that. You WILL open doors to opportunities by combining knowledge areas to solve problems, stand out, or become indispensable.

I’m convinced that the willingness to learn about healthcare innovation outside the clinic is the “X” factor that predicts the potential for career growth.

*Disclaimer: All opinions and ideas expressed in this article are solely mine and none represent a recommendation or should be viewed as advisement of any kind to anyone to do anything.*

Check out my Medbridge webinar on the Transforming Episode Accountability Model (TEAM) for clinicians! 👇️ It’s free with a Medbridge subscription or can be purchased as an individual course from Medbridge.

Not a subscriber? Using my link gives you $106 off your subscription for unlimited CEUs with code DanaStrauss. They have a host of different types of CEUs for various clinicians. The subscription is a must for me since N.J. requires live CEUs and Medbridge adds live webinars monthly.

Medbridge’s CEU platform, where you can find my TEAM webinar

**Disclaimer: All opinions and ideas expressed in this article are solely mine and none represent a recommendation or should be viewed as advisement of any kind to anyone to do anything.*

Volume of Services per Beneficiary vs. Costs of Service Units

There’s a lot of finger-pointing in healthcare. That leads to a lot of confusion. And that leads to people thinking they know the problem, or what will solve it, or who’s at fault. It leads to feeling helpless and frustrated.

I am a value-based care expert and advocate. VBC principles are undeniably better for providers and patients. Reward upstream, team-based care that’s structured so long-term patient outcomes improve. That is the nuts and bolts of it. Change incentives, transform how care is delivered.

When done well, which I’ve seen happen in advanced, team-based primary care, managing acute episodes of care, and much more, you get great results for everyone. You reduce the utilization of high-cost settings like inpatient hospital stays and reduce risk of readmissions after a stay, care is coordinated between providers, patient pro-active outreach is prioritized, preventive screenings are done on more patients so high-morbidity and mortality diseases are caught earlier, patients are more directly engaged in their care, they have better access to care, chronic disease progression slows…and the list goes on.

What value-based care can excel at, when structured and executed well, is reducing the volume of high-cost medical interventions.

What it can’t do well is lower unit costs of care outside the primary care setting. There are exceptions, of course. In advanced VBC arrangements, primary care practices can establish downstream relationships with specialists and others, like post-acute providers, to better align incentives and partner with high-value practices and organizations who agree to support the goals of the arrangement.

Spending per enrollee that’s driven by high cost specialty drugs, high hospital prices, new high-cost procedures, device and supply prices, and more is the major force that negatively impacts benefit compression, higher premiums, plan market exits, higher deductibles, co-pays, and co-insurance, and more.

I think sometimes we say value-based care isn’t working because we don’t fully appreciate all the drivers of cost and what can and can’t be controlled by whom. Besides that, transitioning away from transactional, volume-awarded reimbursement is very, very hard. There’s been major progress in the ten years since it became a concept many physicians understand.

As a physical therapist by training, I can say that most non-physician healthcare professionals have little to no understanding of VBC. They have largely been left out and are often struggling to stay afloat even harder than physicians have. It’s hard for them to take the time to learn about it, even if they were exposed to it more. And their buy-in is crucial. For PTs alone, there are several hundred thousand employed in the United States.

Unit Cost and Mix are Difficult to Address

While these are dominant drivers of spending spikes, they are hard to fix.

Here are some concentrated areas of high costs:

• Specialty drugs and drug mix make up a high share of Part D spending. Use of new, high-cost agents for oncology, biologics, GLP-1s, cellular therapies, and more and shifts in the mix contribute a lot to the growth. Milliman does a great job covering this here. Here’s a nice visual from their site 👇️ 

  

  From Milliman’s White Paper “Early 2025 Medicare Part D claims show continued increase in non-low income specialty drugs.”

• Hospital prices and intensity remain the largest slice of Medicare goods and services. Per-enrollee spending is increasing as a result of price growth, labor costs, and service intensity. Also, consolidation and market power can amplify negotiated prices. This article in Health Affairs dives deeper into this 👇️ 

• High-cost procedures and supplies—rapid growth in spending for items like skin substitutes (addressed in the 2026 Physician Fee Schedule final rule) has produced dramatic year-over-year jumps.

• Higher-priced and high site-of-care imaging modalities—this article published in Radiology in 2021 (FDA Commissioner Dr. Marty Makary is a co-author) looks at commercial negotiated prices for CMS-specific shoppable radiology services. This 2025 article in Health Affairs Scholar. This is directly from the “Results” section, no surprise: “Key findings include greater variation in facility fees compared to professional fees, with facility coefficients of variation often 3 to 6 times higher than professional components.”

Why All Stakeholders Should Understand

• Value based care can and should be expanded. It will help blunt future volume growth and improve outcomes. But utilization reductions from VBC can’t offset line items like single drugs or devices or interventions that cost tens to hundreds of thousands of dollars.

• Market mechanics amplify the pain. Health system consolidation, transparency limitations, and more allow dominant providers to command higher prices and widen regional price gaps. This makes it harder for payers and policymakers to control spending and for consumers to understand the true costs of their healthcare.

Some Practical Levers to Pull

• Double down on VBC to address volume and quality. This includes things like investing in care navigation, chronic care models, addressing social and functional drivers of health, ED diversion, and more. Keep working to scale VBC and reduce avoidable utilization while improving patient experience.

• Attack unit costs through formulary design, negotiation biosimilar uptake (besides VBC, this is the major lever to drive lower medical trend), utilization management for specialty drugs that includes patient engagement efforts, and more.

• Align payment to evidence. For poorly evidenced, high-cost supplies (like skin substitutes), tighten coverage rules and prior authorization.

• Fix healthcare market distortions through hospital price transparency and benchmarking methodology that limits the ability of providers to achieve outsized prices.

• Keep fighting fraud, waste, and abuse in the extreme areas. Address unexplained spikes in utilization immediately. Let’s not forget that ACOs blew the foghorn when their claims data started showing urinary catheter spend when patients weren’t receiving it and it wasn’t being ordered!

Here’s the Takeaway

There are many inter-connected factors driving our healthcare affordability problems. When it comes to volume and costs, two truths can coexist. VBC is essential to reduce avoidable volume and improve quality of care, outcomes, and the patient experience. But unit costs and the changing mix of care are a real fiscal problem driving spending per beneficiary in Medicare.

We can make progress with VBC. That being said, expectations for overall results in VBC should take into account the time it takes to get everyone rowing the same direction (we have a long way to go) and the culture and practical changes that have their own associated costs.

But the runaway train is the unit cost and mix of services being used. There are levers to pull to address them, but they are also heavy lifts. Keeping in mind the factors involved in taking action that include: what changes would be needed, who can make the changes, who doesn’t want the changes, and more.

One final thought. Something simple often gets lost when clinicians talk about things like the shrinking conversion factor and reimbursement pressures and when we all rightly lament about the cost of care. I often hear the blame pointed at payers, from CMS to health plans to self-insured employers.

But this is a factor that often gets lost:

There’s a fixed amount of money in a budget every year to cover all expenses that a payer’s population will incur. When unit costs and mix are so high, like we covered here, and the spending trend is up close to double digits in a single year, what are the options to stay in the budget?

They can pay for fewer units of care, increase responsibility on patients, reduce reimbursement levels to clinicians and other providers, raise maximum out of pocket costs, and other cost-control mechanisms. The pie can only be cut so many ways.

Good solutions can only be developed when we recognize there’s no one individual or entity or part of the system to “blame.”

Become An AI Expert In Just 5 Minutes

If you’re a decision maker at your company, you need to be on the bleeding edge of, well, everything. But before you go signing up for seminars, conferences, lunch ‘n learns, and all that jazz, just know there’s a far better (and simpler) way: Subscribing to The Deep View.

This daily newsletter condenses everything you need to know about the latest and greatest AI developments into a 5-minute read. Squeeze it into your morning coffee break and before you know it, you’ll be an expert too.

Subscribe right here. It’s totally free, wildly informative, and trusted by 600,000+ readers at Google, Meta, Microsoft, and beyond.

*Disclaimer: All opinions and ideas expressed in this article are solely mine and none represent a recommendation or should be viewed as advisement of any kind to anyone to do anything.*

Check out my Medbridge webinar on the Transforming Episode Accountability Model (TEAM) for clinicians! 👇️ It’s free with a Medbridge subscription or can be purchased as an individual course from Medbridge.

Not a subscriber? Using my link gives you $106 off your subscription for unlimited CEUs with code DanaStrauss. They have a host of different types of CEUs for various clinicians. The subscription is a must for me since N.J. requires live CEUs and Medbridge adds live webinars monthly.

Medbridge’s CEU platform, where you can find my TEAM webinar

**Disclaimer: All opinions and ideas expressed in this article are solely mine and none represent a recommendation or should be viewed as advisement of any kind to anyone to do anything.*

Policy Pulse

ACCESS Model Updates are Out.

If you are a treating clinician or provide team-based clinical support in primary care, physical therapy, or behavioral health, here’s what you should read between the lines before the model even starts. You have preparing to do!

There so much content online about how ACCESS works and opinions about the model. Before coming to any conclusions, consider doing these two things:

1. Read CMS’ own documents. Pay special attention to:

   1. Who can be an ACCESS organization (NOT providers billing FFS for the same patients)

   2. Who can own an ACCESS org (NOT an organization who is at least 5% owned by an organization billing FFS for the same patients)

   3. What codes are considered “substitute spend” in each category

   4. What outcomes measures will determine the Outcome Aligned Payments.

2. Read my assessment of what clinicians should be prepared for. I haven’t read this elsewhere yet. I hope it helps. 👇️ 

As you may have read, clinicians billing the physician fee schedule for a patient population can’t be ACCESS organizations unless they want to stop billing fee-for-service codes. Given the very low reimbursement ($180-$420 per year maximum, depending on outcomes, substitute spend, and ACCESS Track), that is highly unlikely.

CMS established codes for which they consider ACCESS codes to be a substitute. For Tracks 1 and 2, these are a host of care management codes and remote monitoring. The full lists per Track are in the CMS documents.

For the sake of example, let’s look at Track 3, Musculoskeletal Care. The ACCESS code substitutes for PT Evaluation, OT Evaluation, and Remote Therapeutic Monitoring Set Up. These are three non-time-based codes, and all therapy episodes begin with the evaluations, of course.

If a patient is receiving care from an ACCESS organization and seeks a PT or OT evaluation for the same condition, the ACCESS organization will earn less than their full reimbursement because of the “substitute spend” rule. We can only speculate whether patients will be less likely to seek therapy while receiving the digital health care of the ACCESS organization.

For patients who do not receive both the ACCESS services and a PT or OT evaluation, CMS will be able to compare the costs over any longitudinal period between the ACCESS organization and the PT or OT services. They can look for any differences in spend across a longitudinal time period to observe differences in care trajectories.

Does one path or the other, for a similar patient, correlate with lower ED utilization? Lower use of advanced imaging? Lower use of specialty medical visits? Lower use of injections or surgical procedures? CMS will be able to answer these questions as the model progresses.

Are you prepared for CMS to compare the ACCESS org patient trajectory to the traditional care trajectory and the results?

Then let’s look at the outcomes measures CMS is using to determine whether the ACCESS organization providing care for Musculoskeletal conditions has earned their full reimbursement. They focus on patient reported outcomes measures in the MSK Track.

From the ACCESS Model Payment Amounts and Performance Targets

From the ACCESS Model Payment Amounts and Performance Targets

With this information, CMS can analyze spend and the outcomes achieved subsequent to that spend. CMS doesn’t presently have all of this information from OT or PT episodes of care.

I would argue this makes the Outcome Aligned Payment measures the new gold standard for demonstrating value in rehabilitation episodes starting in 2026.

Interestingly, these are not the same measures as are offered in the MIPS Value Pathway (MVP) “Rehabilitation Support for Musculoskeletal Care.”

However, if I was a clinical owner or operator, or an owner or operator in behavioral health or primary care related to the other ACCESS Model Tracks, I would be collecting the OAP measures for your patients starting in July. Even if CMS doesn’t require them, it’s valuable information. Know in real time if you are meeting the targets set for ACCESS organizations.

Find all sources and additional context here.

Career Moves

Success is Predictable.

And it has a name.

The good news and the punchline? It’s plastic. You can improve on it.

It can be grown by aligning your daily actions with a north star goal that excites you.

So what is this crucial ingredient to the recipe of success?

Grit.

Watch Angela Duckworth’s famous, brief, Ted Talk on Grit that has 17 million You Tube videos 👇️ 

What does it look like to be gritty in the game of career growth?

Clinicians who successfully transition into non-clinical roles and/or leadership positions keep trying when others give up.

They aren’t necessarily the ones who start with good networks, perfect resumes, or have the clearest plan.

Because transitions of any kind are hard. They don’t have a perfect roadmap. Many people quit.

The good news? Grit is a skill. It’s not a personality trait like you might think.

Career grit is just a longitudinal differential diagnosis of your own life

It’s staying the course towards a new life because you want to.

Think about it.

If a patient doesn’t respond to the first treatment, you don’t quit caring for them. You iterate, research, and try the next thing.

Career grit is similar. It’s about getting out of your comfort zone, practicing, and developing rituals that will keep you on track regardless of how you feel on a given day. Consistency is key.

If you’re thinking “but I’m not a gritty person,” STOP. You made it through advanced education that has a built-in attrition rate. You have worked in some of the most physically and emotionally demanding professional roles. You often have incomplete information when you are evaluating a patient and yet you make it work.

We are often conditioned to believe having perseverance in clinical settings as “just doing our jobs,” while viewing the same behavior in career transitions as some special trait that others have.

You objectively can sustain effort towards difficult goals. Give yourself permission to apply that same persistence to your own ambitions instead of towards achieving your license or helping patients achieve their goals.

The perseverance you have been using was already there! In clinical training and roles, you directed it where you needed to because that’s what your training demanded and what felt legitimate.

Grit in career transitions and growth is about mental permission.

You justify endless persistence for clinical work but perhaps feel that dreaded “imposter syndrome” in applying the same tenacity to your own ambitions.

“Success” in this journey is about redirecting the grit you already have. You are strategically building your future.

A “grit framework” for clinician career transitions

Inspired by Angela Duckworth, here’s a framework to apply to your career transitions and growth strategy:

Establish Your “North Star,” or Top-Level Goal

Write down your ultimate concern. Do you want more autonomy? Systemic Impact? Financial Freedom? “Better hours” won’t keep you going in the face of rejection, but something like “changing how one million people access primary care” will.

Seek “Low-Stakes” Failure

Clinician often fear mistakes. Fear of law suits, patient harm, reputational harm, etc. However, in the corporate world, mistakes = data.

“Practice” your transition. Send the cold Linked In message (but not with an “ask,” of course 😃 ). Apply for a job you aren’t too excited about just for the chance to experience the interview.

Build grit by being immune to the sting of being told “no.”

Build a Grit Scaffold

It’s easier to become more gritty when you automate the practice.

Create a non-clinical hour two or three days a week.

Maybe it’s after the kids are in bed, 8-9 PM Tuesdays and Thursdays, or before the house is awake, 6-7 AM. Maybe you skip happy hour on Fridays with the clinical team.

During these hours, you are a career architect. You research, learn, comment on Linked In posts to expand your reach, read a book chapter, or upskill.

(Whatever you do during your career architect hours, make sure you make notes in your personal knowledge management tool, of course!)

The Career Grit Scorecard

I created this to help you audit your transition. It’s purpose? Help you stop guessing and start measuring the three pillars of a successful move: The North Star, Low Stakes Failure, and The Boring Habit.

Here’s how to use it:

1. Open the Scorecard: Click here to access the Google Doc.

2. Make a Copy: Go to File > Make a copy to create your own private version.

3. Audit Your Week: Be brutally honest. Are you actually practicing the skills you're "bad" at, or just reading more articles?

4. Pick One Metric: Don't try to fix all five pillars at once. Pick the one with the lowest score and commit to one "boring habit" to improve it this week.

This Week, Try This

1. Read about the ACCESS Model. Start with the facts. Read the RFA, Model Payment Amounts and Performance Targets, and the Technical FAQs

2. Take this test by Angela Duckworth. It’ her Grit Scale. If you score lower than you like, realize this is NOT diagnostic failure. In fact, for high achievers, it usually indicates “situational fatigue” rather than lack of character. It’s definitely not a “fixed” score! Get a baseline. Read more about what the score means and how to improve your grittiness based on her research in her book, GRIT | The Power of Passion and Perseverance.

Angela Duckworth’s GRIT in paperback on Amazon

*Disclaimer: All opinions and ideas expressed in this article are solely mine and none represent a recommendation or should be viewed as advisement of any kind to anyone to do anything.*

This post sponsored by Saatva, the official mattress and restorative sleep provider of Team USA! 👇️ 🛏️ 

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**Disclaimer: All opinions and ideas expressed in this article are solely mine and none represent a recommendation or should be viewed as advisement of any kind to anyone to do anything.*

Policy Pulse

Follow the Money: How Health Savings Accounts Are Becoming one of Healthcare’s Quiet Market Makers

Health Savings Accounts (HSAs) now hold about $159 billion in assets by mid-2025 (16% higher than in 2024). If you’re not thinking about how this shifts patient behavior and impacts where healthcare innovation is happening, you’re missing a major market force.

HSAs are a financial asset that provides funding for about 17-18% of the population’s healthcare costs as of 2025. That’s over 59.3 million Americans and about 40 million HSA accounts.

Few individuals use the HSA as a financial asset by investing it in the stock market (about 4 million people do this). The HSA is the only triple tax advantaged account. It’s never taxed if used for healthcare expenses.

The other >95% of those with HSAs either don’t know they can do this or intentionally keep them liquid to pay for immediate medical costs. That seems to track with who holds HSAs. About 64% of HSA holders live in zip codes with median household incomes below $100,000.

Interestingly, Millennials hold about 30% of HSA accounts.

Republicans Have Been Vocal Proponents of HSAs

Republicans generally like the idea of putting spending decisions about healthcare in the hands of individuals themselves. They support consumer-driven healthcare, and this fits. Why?

They largely believe skin in the game changes behavior and that market competition is accelerated by price transparency. They believe in personal ownership/responsibility, and the HSA combines tax policy with healthcare policy.

HSAs are available when your insurance coverage is a high deductible health plan (HDHP). As the name implies, there’s a high deductible. There’s also often higher copays.

As part of the One Big Beautiful Bill, or the Working Families Tax Cuts Act of 2025, all Bronze and Catastrophic plans on the ACA marketplace are HSA-compatible, and annual contribution limits have increased. They are now $4400 for individual contributions and $8750 for families.

Broadly speaking, Democrats prefer the approach of comprehensive coverage and lower costs at the point of care, like low co-pays and deductibles, which they believe encourages individuals to seek healthcare sooner and more upstream. That doesn’t mean Democrats don’t support or use HSAs. As you’ll see, there’s a lot of nuance around them.

The Great Healthcare Plan

The below framework was shared by the White House in January of 2026. Notably, the Consolidated Appropriations Act of 2026 does not address these asks. Some wonder about a second Budget Reconciliation package this year. We’ll have to wait and see.

The Great Healthcare Plan Fact Sheet

You may agree with one side or the other, or you may be like me and see the positives in each.

My personal take: I love the HSA as an investment vehicle but do believe it can have the unintended consequence of discouraging upstream care. I also have concerns that it is often confused by consumers as something that could replace or pay for insurance, which it cannot (except in the case of future Medicare premiums).

Wherever you stand on HDHPs and HSAs, they are creating a market shift worth understanding if you work in healthcare.

What HSAs Mean for the Market

The widespread and growing adoption of High-Deductible Health Plans (HDHPs) and Health Savings Accounts (HSAs) is fundamentally impacting the business of healthcare. Note that idividual behavior often changes when they have higher deductibles.

Some Impacts of the Proliferation of HDHPs and HSAs

1. Cost-conscious shopping: Because they are either spending from their own HSA dollars or their own cash accounts, people are more likely to compare prices for things like prescriptions, lab tests, and imaging.

2. Risk of deferred care rises: Patients with HDHPs often skip or delay not only “low value” care (which is what proponents hope will happen but is somewhat flawed as a concept, because consumers don’t usually know what is low and high value in a given circumstance), but also necessary and preventive services and treatments for chronic conditions. The immediate out-of-pocket cost can be a deterrent.

3. Preference for virtual-first solutions. Many patients now prefer lower-cost, pre-deductible options like telehealth.

The growth of HSAs has also created opportunities and challenges for health tech and for healthcare providers.

Some businesses have been born and thrived because of the HDHP/HSA structure. Price transparency platforms are a good example of this, as are Direct Primary Care models, which are now HSA eligible.

There’s also a growing number of businesses with some version of curating products that are HSA eligible. There are even companies that facilitate the letter of medical necessity completion. They simplify the spending process and let consumers easily put that HSA debit card to work.

AI-driven navigation is also growing, as payers and employers are using AI more and more to help employees predict their healthcare spending, choose the right plan, and automate the process of managing medical receipts needed to use the HSA dollars, either now or in the future (HSAs can be kept indefinitely in investment accounts and spent years in the future. Those receipts from 2025 can be used to withdraw money in retirement, for example.

Some Business Types enabled by HSAs:

• Price transparency and cash pay like GoodRx and MDsave

• Lower-cost care delivery like virtual care companies, direct primary care companies, and direct to consumer testing

• New insurance models like Sidecar Health and Cake, which are designed around consumer engagement and bundled payment navigation programs like Carrum Health

• Consumer products stores like HSA stores and pharmacy models like Cabinet Health

In some cases, HSAs changed what kinds of healthcare businesses can succeed.

More on the Mechanics of HSAs

• You must have health insurance that’s labeled a high-deductible health plan. Just because you have a “high deductible” doesn’t automatically mean you have a HDHP.

• They can pay for qualified medical expenses.

• They can also grow tax-free and roll over forever.

• They do NOT have the “use it or lose it” rules of FSAs.

• They CANNOT replace insurance.

• They CAN be used for covering deductibles.

The Triple Tax Advantage and Financial Independence, AKA “FI” Movement

On one hand, HDHPs and their corresponding HSAs are chosen by those who don’t have another choice. They typically have the lowest premiums in exchange for requiring more cost-sharing with beneficiaries.

On the other hand, they are also chosen intentionally by those who are either planning for early retirement or who consider themselves part of the “FI” Community.

The HSA is a very generous savings vehicle. Why?

The money is put in tax-free, not deferred.

Once you own it, you always own it.

It grows tax free.

If and when you withdraw it, you withdraw it tax-free for healthcare expenses. Forever.

If you use it to pay Medicare or Medicare Advantage premiums, that’s also tax-free, even though it can’t be used under 65 to pay insurance premiums unless you are on Medicare.

Oh, and if you withdraw from it after 65, you pay only income tax on it. You might need to do that if you hadn’t been diligently saving your receipts, but even that is a pretty darn good deal.

If you must withdraw it before 65 and don’t have receipts to use so it’s tax-free, you will pay a 20% penalty. In the “FI” community, this is not so common. But even if you do, that means it effectively becomes an addition to your traditional 401k or traditional rollover IRAs.

As noted, it’s investible. Employers often offer similar mutual funds for HSA investing as they do for 401k investing.

Employers usually match at least a small portion of the money you contribute per paycheck. That money you choose to invest in the HSA can be thought of as “in lieu of” the higher payroll deductions of a PPO or other traditional plan. Except in the case of PPO payroll deductions, HSA deductions are yours as long as you want or need.

You can choose to pay cash for your healthcare expenses as you spend. An important point that I find many folks don’t realize: if you save your receipts (I save mine as a jpeg picture in Notion), you can submit those receipts anytime in the future to withdraw money from your HSA if you need it with no penalty.

Here’s an example of how I, and many others, use their HSA 👇️ 

I max out my contribution every year and max out the employer match.

I have a bi-annual specialist appointment. I use a provider in-network with my plan (but my HDHP has out-of-network benefits just like the PPO option, which is as non-negotiable for me) for those check-ins.

I pay the negotiated rate my insurance carrier has with the practice, which is very reasonable—and of course I pay on a credit card where I get 2 points for every dollar! 😀 

I save the receipt in Notion.

I leave my HSA invested in several mutual funds and have liquid assets to cover my in-network and out-of-network deductibles and “out of pocket maximums” for my health plan in the unlikely but always possible event I have an unforeseen major medical event.

How early retirees think about HDHPs and the HSAs 👇️ 

Retirement before Medicare age is common, either by choice or otherwise. About 50% Americans retire before age 65, and 11% retire between 55 and 59. The average age is 62.

Here’s where the Affordable Care Act (ACA) Premium Tax Credit comes in.

The Affordable Care Act Premium Tax Credit is alive and well, even though the Enhanced Advanced Premium Tax Credit has expired.

To qualify for the Premium Tax Credit, your household income must generally fall between 100% and 400% of the Federal Poverty Level (FPL). But if your income exceeds 400% FPL by even $1, you are ineligible for any federal premium subsidies.

(Table generated by Gemini)

I’m simplifying to keep this post from becoming a novella 😁. There are specifics for Medicaid expansion states, additional cost-sharing reductions, and regional differences. There are also state-specific subsidies. In my home state of New Jersey, for example, they have state-level Health Plan Savings for households with incomes up to 600% FPL.

For someone planning to retire early (before age 65), or for someone who is retired early and needs health insurance, the Premium Tax Credits can be used strategically. If an individual has little or low W2 or 1099 income and is funding their life on investments and cash where their tax burden is low, they can often access at least part of the Premium Tax Credit when they enroll in a qualifying ACA Marketplace plan.

If they choose, their HSA investments can be used to reimburse themselves for health-related expenses tax-free during these years while limiting investment withdrawals that will trigger taxable events.

Some in the “FI” community plan so strategically about their sources of “under 65 income” that they have to be sure their “income” is high enough so they don’t accidentally end up qualifying for Medicaid!

The Takeaways

HDHP/HSA Supporters

Some love the HSA because it fits their political leanings.

Some love it because it’s an additional, powerful investment vehicle.

Some love it because it’s part of their “Financial Independence Retire Early”/”FIRE” plan.

Some love it because it is part of the ACA Marketplace plan options, giving low income Americans access to health insurance.

You can love it and also have concerns that it’s sometimes presented as an alternative to health insurance. It is firmly NOT an alternative to health insurance. But perception is powerful, and misinformation is hard to distinguish from fact.

Career and Personal Finance Considerations

1. Understand your total compensation as you consider career transitions, and review your options for health insurance carefully. Compare HDHP + HSA vs. PPO benefits, especially if the deductibles and out of pocket maximums (MOOP) are similar.

   1. If you’re healthy and can cover the deductible and out of pocket maximum from your emergency funds, consider running the comparison numbers.

   2. Remember that the HSA can be used as a retirement and early retirement tool (early retirement is under 65 for these purposes). It’s not just for medical expenses in the present.

   3. Important Note: I certainly don’t cover everything in this post! HDHPs are not for everyone and individual and family circumstances very widely. Coverage options vary wildly between employers. Do your own research and consult with your tax and/or financial advisor. I am not a tax or accounting professional and this is not advice!

2. Understand patient decisions better. HDHPs can contribute to patient behavior changing and patients may want more information if they are paying more out of pocket.

3. Be on the lookout for opportunities. Understanding this next layer about HDHPs and HSAs can help when considering health tech ideas and where innovation is heading and why. It is a part of the puzzle to know about.

Some Things to Watch 👇️ 

• The Trump Administration and Congress’ possible actions on HSAs.

• Notice which health tech companies may be building options for HSA holders as part of their addressable market

• Pay attention to how price transparency requirements may interact with HDHP growth

Whether HSAs expand dramatically or plateau, they’ve already reshaped healthcare markets in ways most clinicians and health tech professionals don’t fully appreciate. Understanding them is part personal finance education and part understanding how healthcare actually works for millions of patients and where the next wave of innovation is headed.

More resources on HDHPs and HSAs can be found on many podcasts. I link a few in my Timeless Autonomy Resources site. Below are two excellent books I own by approachable financial independence enthusiasts who talk about HDHPs and HSAs from the personal finance lens, among many other personal finance topics, if that interests you!

Find all sources and additional context here.

Career Moves

Be the Hardest Working Person in the Room

If you are aspiring to transition into a non-clinical role or your goal is a promotion in a clinical or non-clinical role, don’t underestimate this deceptively simple and powerful strategy 👇️ 

Standout from Everyone Else

Don’t overthink this.

Here are a bunch of suggestions you can implement immediately.

But first, what NOT to do! Don’t participate in negative conversations or complaining. This needs no explanation. This is the last way you want to standout!

Come to work 15 minutes early to do a task that helps someone. Make someone’s day a little better.

Find problems that need solutions and deliver the solution when you surface the problem. Don’t wait for permission. If you see a gap in how your organization addresses a business challenge, write a brief memo with recommendations. Consistently show that you think beyond your job description.

Build relationships across other departments. Invest in relationships continuously. Note: this doesn’t mean asking people for things! Have coffee with people in departments like finance, IT, operations, and strategy. The goal? Understand their challenges. Look for ways your unique combination of knowledge, skills, and expertise could help them.

Read what healthcare and health policy leaders read rather than just clinical journals. Health Affairs and KFF are great places to start. Remember, everything in healthcare starts with health policy. Nothing and no one influences the business of healthcare more.

Translate jargon in both directions. If you want to be exceptional and be known for it, don’t just flex to understand the business of healthcare. Actively translate it for others. You are indispensable if you can objectively explain what the CFO means for frontline staff and what clinicians need in ways executives appreciate and are incentivized to care about. Along those lines:

Know the annual goals of your manager, their manager, the head of your part of the organization, and the CEO. That will help you understand what they care about. Often for manager or directors and above, annual goals are tied to compensation. The higher up you get, the more is tied to bonus and/or equity. That has a major impact on what they care about.

Ask for feedback, and then implement the suggestions. Demonstrate that visible improvement and you also demonstrate self-awareness and an orientation towards growth. You will also be seen as someone leaders want to work with.

Be the person who everyone knows can bridge silos. Connect people, share information across departments, and facilitate collaboration. Leaders notice who makes an organization work better.

Develop competency in skills that complement clinical expertise. Most of this you can get in free online education. Health economics, data analytics, project management, strategic planning, health policy, and more. Competency, not certifications, are what matter in non-clinical work. The indispensable employee is the one who can do many things well and work with a high level of agency.

Pick two or three of the above actions that align with your strengths and interests. Execute them consistently. Within 6-12 months, you'll be noticeably different from your peers. You will create infectious positivity. Leaders will notice. Serendipity can do its thing!

And if your work environment doesn’t support the ability to stand out, you may want to consider whether or not remaining with your employer aligns with your career and financial goals.

This Week, Try This

Check out my free resources page!

Read this post by Cody Lee, PT, DPT about creating value beyond patient care and systems thinking for clinicians who are interested in non-clinical career growth 👇️ 

Read my article for OT Potential on how clinicians get paid 👇️ 

By Dana Strauss, PT, DPT

Listen to this 5-minute YouTube clip on HSAs by The Money Guy Show 👇️ 

*Disclaimer: All opinions and ideas expressed in this article are solely mine and none represent a recommendation or should be viewed as advisement of any kind to anyone to do anything.*

Additional reading by Cody Lee, PT, DPT 👇️ 

By Cody Lee, PT, DPT

**Disclaimer: All opinions and ideas expressed in this article are solely mine and none represent a recommendation or should be viewed as advisement of any kind to anyone to do anything.*

Policy Pulse

Problem/Solution = 20%

We’ve long known that about 80-90% of clinical outcomes are not the result of clinical care. Clinical care is defined here as treating clinical conditions.

Yes, the below are a sampling of factors that have more of an effect on you, your patients, your members, your clients’ clinical outcomes than anything.

• Where you live

• Health literacy

• Income and wealth

• Social status

• Employment and working conditions

• Nutrition and diet

• Physical activity, strength, and power

• Access to care and social supports

• Food environment

• Safety

• Housing stability

• Preventive health behaviors

Made with Canva Pro

Let’s step back and think of the role policymakers can and are playing as they consider this reality. The term CMS has been using lately is “evidence-based prevention.”

Talking Out of Two Sides of Their Mouths?

There’s a paradox worth noting here.

On one hand, leadership at CMS and CMMI, like Dr. Mehmet Oz and Abe Sutton, have been talking about and creating programs that fund substitutions in spending to tackle high downstream utilization costs. Models like ELEVATE, ACCESS, and the Rural Health Transformation Program are testing the ability of innovation to address the non-clinical drivers of health outcomes and high spending.

In these and other programs, CMMI is allocating resources to nutrition counseling, partnerships with community-based organizations, funding technology, transportation, etc.

They also want to control what spending is considered “prevention” and which is considered “wasteful social spending.”

On the other hand, CMS has taken three major actions to phase out state-led social determinants of health programs that are trying to accomplish much of the same—address the issues that drive long-term poor outcomes and high costs.

(Note that the below doesn’t even touch on the $1 trillion in Medicaid cuts that begin to be implemented in 2027.)

In March of 2025,CMS rescinded Biden-era guidance that allowed states to use Medicaid to cover housing supports, nutrition interventions, and infrastructure for community health workers. They allow existing state programs to continue until their waivers expire but no new ones will be approved.

In April of 2025, CMS announced it won’t renew Designated State Health Programs (DSHP)/Designated State Investment Programs (DSIP) funding, which is how CMS gave states federal matching dollars for health-related social programs. There are eight states using that funding of about $2.7 billion for programs like California’s housing navigation services, North Carolina’s food-as-medicine pilots, and New York’s nutrition supports.

In July of 2025, CMS blocked the extensions of “continuous eligibility” waivers (keeping people enrolled in Medicaid for 12-24 months regardless of income changes) and workforce development programs training community health workers and primary care providers in underserved areas.

Here are two real-world examples:

• North Carolina’s “Healthy Opportunities” program showed $85/month in savings per person through rental assistance and medically-tailored meals. It can’t be renewed.

• Massachusetts’ nutrition programs for pregnant women and children was just launched when guidance was rescinded.

How CMMI Funding vs. State Medicaid Waiver Funding Differ

The funding mechanisms for CMMI and the State Medicaid 1115 Waivers are completely different. CMMI spending is capped, and Medicaid waivers are uncapped. However, the policy rationale for their funding is the same. Both are based on a recognition that:

• clinical care can only influence outcomes a small percentage

• addressing food, housing, transportation, and other factors improves health

• “upstream” interventions save money downstream

The other thing to keep in mind is the influence of the executive orders that drove the Medicaid actions, such as rescinding executive orders of President Biden like Executive Order 14009 “Strengthening Medicaid and the Affordable Care Act.”

However, Dr. Oz has said that reasons for changes to Medicaid waivers was budget-related. From the transcript of his swearing-in summary, this was number one of his four priorities as Administrator of CMS:

Eight days before his swearing-in, his agency had announced it would phase out DSHP/DSIP funding (the mechanism that gave states federal matching dollars for programs that address SDOH). The agency stated that these programs were “overly creative financing mechanisms to skirt state budget responsibilities.”

Center for Medicare and Medicaid Innovation (CMMI)

• Funded by the Affordable Care Act at the level of $10 billion every ten years. These are not funds that are subject to annual appropriations.

• The funding is part of mandatory spending, which has already been authorized by Congress. The executive branch controls how to spend it. In this case, it’s HHS/CMS/CMMI.

• There’s no state match required. These are all federal dollars.

• There’s no budget neutrality requirement. Models can cost money if they’re projected to eventually save money.

• The HHS Secretary and the CMMI Directors decide which models to test

• There’s limited judicial review

• The Secretary of HHS can expand models nationwide without Congressional approval if the Chief Actuary certifies savings

State Medicaid 1115 Waivers

• These are funded through the Federal Medical Assistance Program (FMAP). The federal government matches state Medicaid spending (50-75% match, depending on the state).

• The state must match 25-50% of the cost.

• They are state driven, so states design, propose, and implement them and CMS approves or denies.

• Discretionary approval is required. The waivers are granted at the discretion of the HHS Secretary.

• Require renewal every 3-5 years.

What Does This Mean for Private Industry?

The market for “substitute spend” products is still around, but who holds the purse-strings is a consideration.

Keep in mind that if an administration change comes in 2029, “health equity” and state Medicaid SDOH waivers could come back. At the same time, the $1 trillion in Medicaid cuts starting in 2027 are part of a mandatory spending package and will not be easy to rollback. They may also have an impact on these initiatives.

Also, the long-term trend is toward a value-based payment regardless of political administration. What’s nearly unavoidable is that companies that can prove they can reduce total cost of care through non-clinical interventions will thrive under any payment model or whomever is funding the product solutions.

That being said, the market may evolve and bifurcate, where risk-averse organizations adopt lower cost point solutions and “wait and see” approaches, while sophisticated health systems and providers taking full delegated risk from payers may still invest in full-stack platforms. However, they will need to justify them based on diversified value propositions rather than just Medicaid reimbursement.

What is a “full stack” platform for addressing non-medical needs? It’s a company that does screening, intervention, fulfillment, and outcomes measurement.

What is a “point solution” platform? It’s software or a tool that is designed to solve a specific, narrowly-defined problem rather than addressing multiple needs across an entire workflow. They require integration with other systems to support a complete process.

An example of a full-stack platform is Unite Us.

An example of a point solution platform is Aunt Bertha (now called Findhelp). 

Integrated Solution or Greater Flexibility and Customization

Regardless of who is funding a product solution, they should be considering this:

• Do we want the “elegant” simplicity of one vendor, one platform, one data model? We will have to accept their workflow assumptions, network limitations, and pricing power.

• Do we want the flexibility to choose best-in-class tools for each function? We have to accept the integration burden, coordination overhead, and potential data fragmentation.

Might the desire for simplicity, the need to do care coordination, and needing to succeed in value-based payment models push organizations towards integrated social determinant of health platforms?

Might the rapid acceleration in interoperability make it more appealing to choose point solutions?

The Future-Proof Professional

The “substitute spend” trend is becoming an industry norm. It seems like it happened overnight, but it’s here. This is the firewall between health and healthcare cracking. Funding is moving upstream to address what is considered to be the driver of outcomes. As noted above, federal resources via the Innovation Center are pivoting this way while state Medicaid flexibilities are scaled back.

It’s important to recognize this shift and look for opportunities and risks. More on this in Career Moves 👇️ 

Find all sources and additional context here.

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Career Moves

Using the Policy Pulse section as a reference, here are three ideas to bridge the gap between policy and your career:

1. Become a “value navigator.” Clinical and social determinant silos are coming down, and organizations need translators, even if they don’t know it. Learn the language of “total cost of care” and “substitute spend.” If you can frame a non-clinical intervention as a way to prevent downstream utilization and spend, it may strengthen being perceived as a strategic thinker and an asset in a new way.

2. Bridge the federal-local gap. With state-led waivers facing hurdles, the future may lie in federal innovation models. Position yourself as the person who can identify these federal funding programs and identify potential opportunities.

3. Master the concept of “full-stack” vs. “point solution.” As organizations choose tools, be able to evaluate them based on value. What solutions may fit better where you work? The “elegant simplicity” of an integrated platform or the flexibility of best-in-class point solutions? Consider what you might recommend based on how these tools solve short-an- long term sustainability vs. solely short-term reimbursement or other solutions.

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This Week, Try This

Last week, I talked about my weekly process for managing knowledge and notes that I capture during the week. I shared that I capture to-dos and notes in Apple Reminders and mymind, respectively.

Once or twice per week, I pull up both apps. I decide what belongs in my knowledge management app, Notion.

While I use Notion for many things, one thing I use it for is to collect ideas and content for this newsletter. There is nothing worse than staring at blank page. My capture system helps me hold onto an idea or inspiration or a reference at the moment it hits me, because otherwise, there’s little chance I’ll remember it.

But Notion is where I turn each “capture into something useful.

Here’s a screenshot of a blank version of the database I use 👇️ 

If you want to copy my database template and use it yourself, use this link and then when the site open, click the duplicate button in the top right hand corner.

Click this and the template will duplicate into your own workspace.

If you don’t yet use Notion and still want this database, Notion’s free version has a lot of functionality. When you click the duplicate button, it will take you to this:

A screenshot of the login page that opens when you duplicate a template. If you are using the desktop version already or are already logged in on the web version, it will open immediately when you duplicate it.

Click a “Continue” option and it will set you up automatically and duplicate this template for you.

Let me know what you think! If you like Notion, you can also send any content directly to Notion instead of the Capture step into another app. There’s a chrome extension and a phone app that enable this.

If you try it, let me know what you think!

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Thank you for being part of this community. If you enjoyed the newsletter, please share it with a friend!

All the best,

Dana Prommel Strauss, PT, DPT

*Disclaimer: All opinions and ideas expressed in this article are solely mine and none represent a recommendation or should be viewed as advisement of any kind to anyone to do anything.*

The Future of Tech. One Daily News Briefing.

AI is moving faster than any other technology cycle in history. New models. New tools. New claims. New noise.

Most people feel like they’re behind. But the people that don’t, aren’t smarter. They’re just better informed.

Forward Future is a daily news briefing for people who want clarity, not hype. In one concise newsletter each day, you’ll get the most important AI and tech developments, learn why they matter, and what they signal about what’s coming next.

We cover real product launches, model updates, policy shifts, and industry moves shaping how AI actually gets built, adopted, and regulated. Written for operators, builders, leaders, and anyone who wants to sound sharp when AI comes up in the meeting.

It takes about five minutes to read, but the edge lasts all day.

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**Disclaimer: All opinions and ideas expressed in this article are solely mine and none represent a recommendation or should be viewed as advisement of any kind to anyone to do anything.*

Policy Pulse

The House of Representatives Passed the Consolidated Appropriations Act of 2026, HR 7148

Background

Congress must pass funding, or appropriations bills, to pay for discretionary spending of the federal government. The last time they attempted to do this, they could not get it done in time via bipartisan support before the deadline of funding expiring, so the government had a “shutdown.”

It was the longest in American history. They eventually passed a Continuing Resolution, or “CR,” to extend funding at the same levels as the prior CR, which was passed because they failed to pass the last funding package at the end of 2024. If you recall, the bill was ready to be passed, but then Elon Musk’s tweet put the kibosh on it.

Let’s see if the appropriations bills make it to a vote by the president by January 30th and we avoid another government shutdown.

Topline Summary of HHS Provisions

• Appropriates $116.8 billion of discretionary funding to HHS, which is $210 million more than fiscal year 2025

• Medicare Telehealth Extensions through December 31, 2027 (for services on the Medicare Telehealth List for 2026), with waivers that include the following:

  • Removal of originating site requirements

  • Audio-only telehealth covered for patients who can’t or won’t use audiovisual telehealth

  • Expanded provider eligibility (PTs, OTs, STs, audiologists)

  • Waiver of the intermittent in-person requirements for behavioral health services

• Extension of the Acute Hospital Care at Home Program through September 30, 2030

• One-year extension of the Medicare-Dependent Hospital Program

• One-year extension of the Low Volume Hospital Payment Adjustment Program

• $515 million for rural health programs

• Eliminate the Medicaid Disproportionate Share Hospital (DSH) cuts for 2026 and 2027

• Site neutral national provider identification (NPI) policy: requires separate NPIs for off-campus hospital outpatient departments (HOPDs)

  • This requirement for separate NPIs is considered a precursor to site neutral payments, and a nod of approval to CMS’ site-neutral payment policy actions this year in the Physician Fee Schedule

• $1.85 billion to Community Health Centers

• $1.36 billion for health workforce development

• $48.7 billion for the National Institutes of Health ($415 million increase)

• Multi-Cancer Early Detection Act (with language pulled from HR 842)

• Permanent extension of the World Trade Center Health Program

• $100 million for Make America Healthy Again initiatives including rural prevention, chronic care, and nutrition services

• One year extension of the advanced alternative payment model bonus of 3.1% for providers who achieve APM Qualifying Participant (QP) Status

  • Signals major bipartisan commitment to downside risk APMs. This bonus was brought back after one year lapse when the December 2024 funding package failed to pass.

• $5 million minimum for interoperability and information sharing efforts related to FHIR (Fast Healthcare Interoperability Resources) standards

Notably Missing

• An extension of the Enhanced Advanced Premium Tax Credits

• The White House | President Trump’s The Great Healthcare Plan, January 2026

Differences Between What Congress Adopted in the CAA of 2026 and What President Trump Requested in the Budget in Brief

Find all sources and additional context here.

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Career Moves

Personal Positioning and Your Career Narrative

Your clinical experience means less than the story you can tell about it.

And you can tell the story well if you know what non-clinical hiring managers are looking for. You must tell them what you are prepared to do successfully. They don’t want to guess, and you don’t want them to have to guess.

It doesn’t matter if you are the best clinician you know. That’s not relevant.

But don’t worry, you can do this! It’s all about preparation.

Which Healthcare Superpowers Sound Like You?

Clinicians have superpowers they bring to non-clinical roles that non-clinicians just don’t have and will never have.

Here are some examples:

You understand healthcare from the inside.

You influence behavior change every day.

You make the complex simple, reading your audience to align communication with their level of health literacy.

You identify system inefficiencies and create solutions that improve efficiency and workflows

You navigate difficult conversations daily, including giving unwelcome news.

You partner with clients on achievable and stretch goals and manage expectations.

You see problems that need fixing but fixing them means fundamentally changing the business model.

You identify risks and then think in terms of root causes, variation, and system reliability to improve outcomes and reduce risks to safety.

You can know how decisions made by leadership impact patient and clinician satisfaction, and how incentives drive behavior. This perspective will help organizations make smarter, more human‑centered strategic decisions.

The Career Narrative ROI

Remember: You must invest in the superpower you identified above (and others you identify!). Tell a great story by remembering the plot points.

Next step: Use the “capture system” I describe in the next section to start a list of “business wins.” Every time you influence a behavior change or fix an inefficiency, log it. Do it right away while you have momentum going. By the time you are ready for your career move, your narrative will already be written.

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This Week, Try This

Set up a simple “capture” system that works on your phone. What you capture is your proverbial inbox, much of it on its way to becoming part of your “second brain.”

Capture what?

Ideas, notes, to-dos, reminders, due dates, and anything that resonates along with a way to jot down “why.”

Here’s what’s working for me lately:

 

1. iPhone “Reminders” | I use this for time-sensitive tasks. For example, I need to renew my passport for a May trip because it expires in October. I set a reminder for mid-March and toggled on “urgent” to ensure I get an audible alarm.

   

   Screenshot of iPhone “Reminders” app

2. mymind | While I use Notion for deep organization and project management, publishing simple landing pages, as well as planning and self-producing the passion project podcast, Future Proof PT, I use mymind for effortless capturing. It’s highly visual, which works very well for me.

   I recently dropped the PDF of the CAA of 2026 into it, and the AI automatically summarized and tagged it. No manual filing required. And it looks clean and beautiful 👇️ 

When I click the above card in mymind, here’s what I see, including an AI summary, auto-tags, and the quick note I attached when I saved it using the iPhone “share to” app function. You can even scroll the entire pdf right inside the card itself! There’s also a chrome extension to save anything while working on your desktop.

Note: these are NOT mymind affiliate links. They are just for reference if you want to check the app out.

3. The Weekly Review | every few days, or at a minimum, weekly, I review my captures and move the "keepers" into Notion. Look for more on that process in next week’s newsletter!

Here’s a quick video from mymind showing some of their filtering magic with time-based search, which simplifies my review process:

Read my prior posts on “personal knowledge management,” starting here

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Thank you for being part of this community. If you enjoyed the newsletter, please share it with a friend!

All the best,

Dana Prommel Strauss, PT, DPT

*Disclaimer: All opinions and ideas expressed in this article are solely mine and none represent a recommendation or should be viewed as advisement of any kind to anyone to do anything.*

**Disclaimer: All opinions and ideas expressed in this article are solely mine and none represent a recommendation or should be viewed as advisement of any kind to anyone to do anything.*

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Policy Pulse

We Aren’t Getting a Good ROI From Our Ballooning Healthcare Spending in the U.S.

Find all sources and additional context here.

The 2026 National Healthcare Expenditure data reports are out, and it is another sobering reflection of our current system. Personal healthcare spending has surged by over 8%, and our healthcare spend as a share of the GDP has followed that same aggressive trajectory.

For years, we’ve found comfort in blaming "the boogeyman"—pointing at payers and their perceived runaway profits. But the data tells a different story. As Michael Chernew, PhD, Chair of MedPAC, highlights in his recent Health Affairs Forefront piece and Health Affairs This Week podcast appearances (see this post’s references here), payer margins aren’t the engine behind this spike.

The engine is us. The driver is utilization volume and intensity. I see this as a reflection of the continued blurred lines between what a patient (and a clinician) wants and what a patient needs.

Metric	2026 Report Finding
Total US Health Spend	$5.3 Trillion
Growth in Spending	7.2% to 8.2% (Sector-dependent)
Healthcare % of GDP	~18.0%
Primary Driver	Utilization Volume & Intensity
Secondary Driver	Aging Population (Demographics)
Payer Profits	Stabilized/Flat (Not a primary driver of the 2026 spike)

*Table created with Google Gemini Pro using Health Affairs’ January 2026 article (see references)

Sponsor Type	2024 Spending	Share of Total Spend
Federal Government	$1.7 trillion	31%
Households	$1.5 trillion	28%
Private Businesses	$967.4 billion	18%
State and Local Government	$859.7 billion	16%

*Made with Google Gemini Pro using National Health Expenditures data (see references)

What is a “sponsor?”

A sponsor is who is putting the money into the payer’s account in the first place. The federal government puts money in CMS’ accounts to pay healthcare bills, households pay copays, premiums, and also payroll taxes to fund the federal and state governments (states contribute at least half of Medicaid funding), and employers directly pay a portion of their employees’ premiums. Even that, ultimately, is on the employee also. Employees are contributing more to their employer-sponsored plans and employers will often have to reduce other total compensation to offer health benefits.

Reminder that Our Nation is an Outlier in the Worst Way

We spend more and have the worst outcomes 🥴of all wealthy nations. Read my guest post, an educational blog I did for OT Potential, and learn more about this!

 

From OT Potential, January 1, 2025

The ROI Crisis: Paying More for Less

The most troubling takeaway from the 2026 report is the lack of a "health dividend." Despite an 8% increase in spending, we aren’t seeing a corresponding 8% increase in longevity, wellness, or chronic disease management. People aren't getting significantly healthier; they are just getting more "care." And that “care” isn’t always good care, or the right care, or care by the right type of clinician, at the right time, in the right setting.

The ROI for every dollar spent is essentially plummeting. We are stuck in a cycle of high-intensity utilization. While we as clinicians (and often our employers) often complain about declining reimbursements, the quiet but systemic response by the healthcare community on the “providing care” side has been to "make it up on volume." But not all volume is created equal, and that is actually just making the problem worse. The more volume of services, the less the payer can pay for each unit if they want to stay inside the budget of dollars they receive from the plan sponsor.

The Volume Trap: Time-Based vs. Procedure-Based Care

In a Fee-For-Service (FFS) world, the incentive structure is skewed. Cognitive, time-based services like the difficult conversations about lifestyle and chronic disease management, having dialogues about options for care, the complex coordination of care, are hard to scale and are either not valued or valued at low reimbursement levels in terms of reimbursement. They are also services that are based on time spent on the service, so there’s a limited amount a clinician can “add more volume.” There are only so many hours in a day.

The fact is, it’s often “easier” to order an MRI, a specialized lab panel, or refer for or perform a minor procedure than it is to spend thirty minutes navigating the nuances of a patient’s chronic pain. This has led to a common normalization of "intensity" that doesn't always correlate with "necessity."

The “Wants vs. Needs” Framework

In 2016, I presented a simplified framework for value-based care to health system leadership. I argued that the most practical way for a physician to understand this value-based approach to care plans and patient management is to master the distinction between wants and needs.

This actually applies to both sides of the proverbial stethoscope 🩺 👇️ 

• The Patient Want: May be driven by fear, direct-to-consumer marketing, or a desire for a "quick fix" (e.g., "I need an MRI for my back today").

• The Clinician Want: May be driven by FFS incentives, the path of least resistance, or the fear of a negative patient satisfaction score or Google review.

• The Actual Need: What the evidence actually supports as medically necessary and likely to improve the outcome.

The Cost of Clinical Compliance

We sometimes unconsciously justify unnecessary care by saying we are "advocating for the patient." But when we order that MRI for acute low back pain without red flags, for example, we aren't helping. We are often triggering a cascade of "normal abnormals,” (I think I made that term up 😁 ) or incidental findings that lead to unnecessary interventions.

We see this same pattern in advanced illness. When we pursue aggressive treatments for life-limiting conditions without a transparent discussion with patients and their care partners about the likelihood of success of a given treatment or care plan, we aren't providing care; we are providing intensity of billable services. If we fail to share the various options and the potential results of those choices, we effectively make the decision for the patient by omission.

When we accept third-party reimbursement, we also commit to a set of rules regarding medical necessity. Yet, we frequently bypass these rules, justifying "non-medically necessary" care through creative charting or by simply not saying "no."

Looking Inward for the Solution

The 2026 data proves that we are paying for some care that is unnecessary, uninformed, and often avoidable. If we don’t look inside ourselves to understand the role we play in this continued utilization and spending growth, we can never contribute to the solution.

Real value-based care means:

1. Communicating and Connecting: Having the hard conversation about why a "want" isn't a "need."

2. Empathetic Honesty: Letting patients know when care isn't medically necessary and that it won't be covered by their insurance based on payer requirements for covered services.

3. Informed Agency: Giving patients with serious illnesses the full picture—the "grey areas"—and allowing them to decide what a "good" result looks like for them.

The $5 trillion we spend is partly a reflection of our collective clinical choices. It’s time we start choosing differently if we ever want to slow the growth of spending.

Find all sources and additional context here.

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Career Moves

The Power of Project and Process Skills

In last week’s post, I talked about the "clinical stagnation" trap. We often think that to move into a non-clinical role, we need a new degree or a complete identity overhaul. But the truth is, the bridge to your next career isn't built with more credentials—it’s built with foundational non-clinical skills that you can start honing right where you are today.

This week, we’re looking at one of the most vital “languages” of the non-clinical world: Project and Process Skills.

The Translation Gap

Clinicians are used to saying we "manage a caseload" and "coordinate a discharge." But in the corporate and tech worlds, for example, those activities are viewed through the lens of processes (how the work flows) and projects (how a specific goal is achieved within a timeline).

If you want to move into a non-clinical trajectory, you must stop merely "doing the work" and start "observing the system."

Grow Your Pre-Move Superpowers

Most clinicians are masters of "workarounds." If a piece of equipment is missing or a referral form is confusing, we find a way to get it done anyway. In a non-clinical role, that "workaround" mindset can sometimes be a liability. Companies value process improvement by identifying the friction point and building a system so the workaround is no longer necessary.

That being said, it is sometimes different in a start-up where you have to find solutions to get things done without the bandwidth or tools to structure a formal process upon which you can improve. You have to be scrappy and resourceful. Clinicians have that covered! You may need that skill even more in a start-up.

By developing these skills while you are still in your clinical role, you are training your brain to see healthcare as a series of interconnected systems rather than a series of individual patient encounters.

How to Practice "In the Sandbox" (Before You Leave Your Clinical Role)

Don't wait until you have a new job title to act like a Project Manager. Use your current clinical environment as a low-stakes sandbox:

Map a Workflow: Pick one routine task in your clinic that feels "clunky" (e.g., patient intake, prior authorizations, or room turnover). Literally draw out every step. Where is the "waste"? Where does information get lost?

Standardize One Thing: Create a "Standard Operating Procedure" (SOP) for a task you do every day. If you were to leave tomorrow, could someone else follow your document and do the job perfectly?

Adopt a Digital Tool: Move your personal task list or a small committee project into a tool like Notion, Trello, or Asana (I’m particularly fond of Notion. It can serve as a life hub, too, not just something for a work project.). Getting comfortable with the "logic" of these platforms is essential, and you only need YouTube videos to learn enough to become a pro over time. Learn to be comfortable in project management and knowledge management tools. And have FUN with it! Here’s an intro tutorial if you want to check it out! 👇️ 

Lead a "Mini-Project": Volunteer to lead a small initiative—like updating the clinic’s patient education materials or organizing a staff training. Treat it like a formal project: set a goal, a timeline, and a way to measure success.

The Bottom Line

The goal of this preparation phase isn't to add a line to your LinkedIn—it’s to change your professional lens. When you eventually sit down for a non-clinical interview, you won't just say, "I'm a great clinician." You’ll say, "I identified a 20% inefficiency in our intake process and implemented a standardized workflow that reduced clinician burden and improved productivity."

Learn to speak the language of autonomy.

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This Week, Try This

Check out PainScience.com The site owner and author, Paul Ingraham, is dedicated to the science of pain and examining what works and what doesn’t from studying and disseminating the scientific evidence. He covers topics in great depth. Some of his recent articles.

From his “About” Page:

Paul is also the Assistant Editor Emeritus at Science-Based Medicine.

Why This Resonates With Me

We should have a healthy sense of skepticism of what any clinician tells us is the right treatment path for pain and be willing to question them. Evidence-based practice of particularly musculoskeletal care is hard for the public to distinguish from pseudoscientific medicine.

But there’s a distinction I want to point out. A treatment may be evidence-based but not be the right treatment for a specific patient. That’s different from pseudoscience but may be just as useless when it comes to helping facilitate outcomes the patient believes they will receive from a care plan.

For example, a patient may have a torn rotator cuff that could be repaired, but it may not be an intervention that would lead to better outcomes for that patient vs. a strengthening program with a PT for a wide variety of reasons.

Or a patient may be given Vicodin after dental surgery, and that medication has real risks associated with it. An alternative option with fewer risks could have been provided if clinically appropriate and the patient may have preferred it if the options were discussed.

Pseudoscience of Pain Management and the Patient

Patients rarely know when treatment being offered to them is not evidence-based, and it isn’t uncommon for clinicians not to share with a patient when something they suggest as part of the treatment plan is not evidence-based or when there’s scant or poor evidence.

Even worse? Clinicians commonly:

• don’t know something isn’t evidence-based

• know but don’t know what else to do

• know what else to do but think it won’t be enough

• are comfortable providing pseudoscientific care for pain and choose comfort

Artificial Intelligence and Hope

As clinical decision support tools become standard features within EHRs, the bar for clinical excellence is being raised. I expect all clinicians committed to mainstream medicine to leverage these tools to move away from pseudoscientific practices.

For my fellow PTs and OTs, this evolution includes us. While our specialized platforms might trail behind major medical EHRs, and full interoperability may not be fully realized today, it is rapidly approaching.

CMS is aggressively advancing data-sharing standards, meaning total transparency is no longer a distant goal. Ask yourself: when other clinicians, patients, and payers eventually have seamless access to your records, what story will your documentation tell about the quality and evidence-based nature of your care?

*Disclaimer: All opinions and ideas expressed in this article are solely mine and none represent a recommendation or should be viewed as advisement of any kind to anyone to do anything.*

**Disclaimer: All opinions and ideas expressed in this article are solely mine and none represent a recommendation or should be viewed as advisement of any kind to anyone to do anything.**

This post is sponsored by:

Link for 15% off all mattresses and other products (for in-store discount, let them know I sent you: Dr. Dana Strauss)—affordable luxury mattresses ideal for superior support

Saatva Mattresses (my link gives you 15% off all purchases, a discount that stacks on any discount Saatva is running at the time!) If you are purchasing in a showroom and not online, let them know Dr. Dana Strauss sent you and you will receive the same 15% discount.

Policy Pulse

I normally cover a policy issue related to the Center for Medicare and Medicaid Services, the CMS Innovation Center (CMMI), or Congressional activity related to healthcare delivery. But this week, I want to share what happened at the Centers for Disease Control and Prevention (CDC).

The Centers for Disease Control and Prevention Acting Director Jim O’Neill has updated the U.S. childhood immunization schedule. The change follows a Presidential Memo for the Secretary of Health and Human Services instructing Secretary Kennedy in “Aligning United States Core Childhood Vaccine Recommendations with Best Practices from Peer, Developed Countries.”

You may read “updated” and think “tweaked.” The changes are unprecedented. In researching updates in the past, there has been no comparably significant change in the decades leading up to the 2020s.

There have been incremental additions, like:

• HPV added in 2005

• Rotavirus added in 2006

• Meningococcal B added in 2015

• COVID-19 added in 2023

Key Changes Made in January 2026:

CDC’s universal recommendations no longer include vaccines against flu, COVID-19, rotavirus, hepatitis A, hepatitis B, or meningococcal meningitis, and only one dose of HPV is now universally recommended instead of two. This drops the recommended vaccines from 17 to 11.

Moving forward, these shots will still be available through a process of “shared clinical decision-making” between physicians and parents.

Table Created with Microsoft 365 Copilot

If you are asking “So what’s the problem? The vaccines are still available, so isn’t this just a technical issue?” 👇️ That may be a dangerous simplification of something thought by most experts to be a serious concern.

Physicians and public health experts are warning that the change will create confusion and preventable illnesses will spread as vaccination rates fall. The American Academy of Pediatrics is not changing its recommendations to align with the CDC.

Many Experts are Worried About Confusion, Misinterpretation, and Erosion of Trust Will Lead to Negative Consequences for Public Health

(Note: all references can be found here.)

• Parents may interpret the downgrade of certain vaccines as meaning they are “not important or necessary.”

• The changes to the recommendations warn that they are likely to “undermine confidence in long-standing immunization guidance.”

• Some states are rejecting the new CDC recommendations and will follow the recommendations of the American Academy of Pediatrics. The dueling scheduling can create more confusion.

• Fewer parents may choose vaccines now labeled “shared decision-making,” which can lead to lower uptake of vaccines that can prevent serious illness in children like flu, rotavirus, hepatitis A/B, and meningococcal disease

• Confusion may cause parents to delay decision, especially for infants, leaving infants exposed to life-threatening but preventable illnesses

• There’s likely to be more variability in how strongly clinicians recommend the “shared decision-making” vaccines or how much time they take or have the time to take with parents who are hesitant

• Lower uptake of vaccines will lead to more hospitalizations and deaths

• Healthcare systems will have to meet the higher capacity needs of sick children in ERs and admitted to hospitals, and there will be more loss of school and of work for parents

• Families with limited access to care and in rural and underserved communities may be disproportionately affected

The bottom line:

A major change to the vaccine schedule, especially one made without widespread consensus, can increase risks to public health and cause a rise in preventable diseases. There are many prominent scientific and medical experts concerned about public interpretation, behavioral changes, and negative impacts on population health because of these changes.

Additional listening 👇️ 

Here, the Johns Hopkins Bloomberg School of Public Health speaks to Dr. Josh Sharfstein, MD, when this announcement came out.

2025_01_06-PHOC-EPBonus-JoshVaccines

Find all sources and additional context here.

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Read online

Career Moves

Most clinicians who are hoping or planning to exit full-time patient care are planning it because they have outgrown the box they were trained to stay inside. If you are feeling that pull, or the sense that you’re meant to contribute in a different way, take heart!

You don’t need another degree or a five-year plan. Instead, do this:

• Develop a few foundational skills to function in non-clinical roles

• Learn how the healthcare ecosystem works, where the incentives are, and why the healthcare economy is so complicated and unlike any other

• Be willing to see yourself as someone whose value extends far beyond a treatment table or exam room

Embrace and capitalize on this universal truth: everything is sales, and sales isn’t a dirty word.

Even what you do every day as a treating clinician involves sales.

And every significant career move you make involves sales.

Sales should be very human.

When you build rapport with a patient, explain and align on a plan of care, or help someone believe they can get better and help them find ways to activate motivation in the toughest moments, you are “selling.”

Transitioning out of clinical care means learning to sell yourself with the same clarity, confidence, and compassion you’ve always used to advocate for your patients. Once you understand that, the whole landscape opens up.

Here are a handful of other foundation skills to develop. You will notice you have many of these skills already and can consider how you can develop them further.

Each week, I’ll dive into a foundation skill:

• Personal positioning and a career narrative (building further on the “sales” skill)

• Translating clinical expertise into business language

• Problem framing and critical thinking

• Communication and storytelling

• Project and process skills

• Basic data literacy

• Systems thinking

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This Week, Try This

Read this quick article in Med City News by Victoria Adinkra on January 4, 2026, entitled “Housing is the Next Frontier in Proactive Care. Here’s How Health Plans Can Help.” Clinicians frequently don’t have time to think about or ask about non-medical drivers of health. Part of the reason is often attributed to not knowing how to help someone if they DO identify a problem. But these drivers have real consequence on health and on the healthcare system, and more can be done by a variety of stakeholders.

Here’s the TL/DR 👇️ 

Non-medical drivers of health like housing instability can be a trigger for a clinical crisis, which the health system is blind to what’s happening until an emergency happens. Housing insecurity can be a linchpin social determinant of health because it creates a ripple effect across almost every other aspect of health.

The article suggest payers incorporate routine screening for housing insecurity and that supportive housing tied to Medicaid reduces ER visits, inpatient stays, and total costs. The author frames housing as a core social determinant of health and recommends integrating housing risk into assessments and benefit design to prevent worse health outcomes and higher system costs.

Want a little more depth of knowledge on the topic? Here’s a good article from April 2025 from the Milbank Quarterly entitled “Without Affordable, Accessible, and Adequate Housing, Health Has No Foundation.” Even the article’s references are a rich information source.

As a clinician, do you routinely screen for non-medical drivers of health such as housing instability, food insecurity, transportation access, and education access and quality? If so, what do you do when you identify one or more?

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*Disclaimer: All opinions and ideas expressed in this article are solely mine and none represent a recommendation or should be viewed as advisement of any kind to anyone to do anything.*

**Disclaimer: All opinions and ideas expressed in this article are solely mine and none represent a recommendation or should be viewed as advisement of any kind to anyone to do anything.**

The Question

A subscriber shared that they have limited exposure to value-based care and asked:

“How do we get value in a world evaluated by billable units, and with little to no multidisciplinary conversation?”

This question surfaces two foundational tensions in U.S. healthcare delivery:

1. The dominance of fee-for-service reimbursement

2. The structural barriers to meaningful interdisciplinary collaboration

Both are central to why value-based care exists in the first place.

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Fee-for-Service and the Absence of Incentives for Health

Under fee-for-service, providers are not reimbursed for improving long-term health or preventing illness unless a billable service exists. Historically, those services did not exist.

While the Affordable Care Act introduced several preventive and care management codes—Annual Wellness Visits, Advance Care Planning, Chronic Care Management—these remain transactional constructs layered onto a fundamentally reactive payment system.

Even these newer codes introduce operational friction:

• Copays apply to most services

• Ongoing patient consent is required

• Practices must track time, outreach, and documentation meticulously

The result is incremental progress within a structure that still prioritizes volume over outcomes.

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Why Billable Units Are Transactional by Design

Understanding this requires historical context.

Fee-for-service reimbursement traces back to early Blue Cross and Blue Shield models, which were designed to mitigate utilization risk. Insurance coverage focused on discrete, verifiable events—hospitalizations, procedures, physician encounters—where costs could be predicted and controlled.

Preventive and cognitive services were deprioritized not because they lacked value, but because they were harder to quantify and considered easier to overutilize. Their inherent value was not appreciated at the time.

The unintended consequence was a system that systematically undervalued prevention and coordination while incentivizing reactive care. This imbalance was later codified through the RVU framework adopted by CMS in the 1980s, which continues to weight procedural services more heavily than cognitive or longitudinal care.

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CPT, Professional Self-Governance, and Structural Bias

Following the creation of Medicare, the AMA developed CPT codes to standardize physician billing. Physicians themselves determined which services warranted codes and how those services were valued.

Early CPT development focused on procedures and surgeries. Comprehensive preventive care billing emerged decades later. For example, Medicare did not cover Annual Wellness Visits until 2011 after passage of the Affordable Care Act.

The result is a structural legacy in which reimbursement remains misaligned with population health goals, despite incremental policy corrections.

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Showing Value Before Taking Risk

One assumption that persists in healthcare is that value-based care requires downside financial risk to be legitimate.

That assumption deserves some scrutiny.

In practice, many effective care models improve outcomes without immediate risk transfer. They focus on access, clinical execution, care continuity, and follow-through. Value is demonstrated operationally before it is formalized contractually.

Risk can and usually does accelerate alignment, but when introduced prematurely, it often exposes infrastructure gaps rather than driving improvement. There needs to be a stepwise approach to adopting risk.

The sequence matters:

1. Build the care model

2. Demonstrate outcomes

3. Align payment mechanisms

Not the reverse.

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Multidisciplinary Communication: From Checkbox to Signal

My experience in home health illustrates this clearly.

Medicare-required verbal plan-of-care reviews with physicians were largely perfunctory. Unless a specific clinical issue required intervention, these calls added little value and consumed time on both sides.

When communication was clinically meaningful, such as for medication reconciliation issues and specific safety concerns, it was necessary and appropriate. But those moments were the exception, not the rule.

Doctorally prepared clinicians like PTs operating within their scope do not require (clinically speaking) redundant physician sign-off for clinical validity. They require signal-based communication, not checkbox compliance.

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What Value-Based Care Enables Operationally

In value-based environments, interdisciplinary communication is expected to be:

• Asynchronous when appropriate

• Routed through the most effective channel

• Actionable for downstream care teams

A physical therapist’s functional assessment can inform transitional care management outreach. A nurse care manager can reinforce follow-up, coordinate home-based services, and close gaps without unnecessary physician interruption.

This is all operationally achievable when care teams are resourced and empowered.

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Why This Is Not the Default

Because it requires investment.

Care coordination, nurse-led outreach, and technology-enabled communication are cost centers under fee-for-service. They become assets only when outcomes matter financially.

Value-based arrangements, often through ACO participation, create the economic conditions for this work. Preventing avoidable admissions and readmissions generates shared savings that can be reinvested into care teams.

Historically, practices have been expected to front these investments themselves, sometimes through loans or advance investment payments tied to future performance.

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A Note on CMMI and Infrastructure Support

CMMI exists to test alternative payment and delivery models, including what services can be reimbursed.

Newer models, such as LEAD, acknowledge a critical reality: sustainable care transformation requires upfront, predictable funding. Providing non-reconciled infrastructure payments allows practices to build care models without assuming immediate financial risk.

This represents a meaningful evolution in CMS policy thinking.

CMMI is still young, but its role in shaping future payment structures should not be underestimated.

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Final Thoughts

The question posed in my survey was not how to bill differently. It was how to deliver value in a system optimized for transactions.

The answer is not to wait for perfect payment alignment.

It is to design care as if outcomes matter, demonstrate value operationally, and allow reimbursement models to evolve in response.

That work can, and should, begin now.

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Appendix

Here is the present list of covered preventive services in Medicare.

CMS’ quick reference chart of preventive services

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**Disclaimer: All opinions and ideas expressed in this article are solely mine and none represent a recommendation or should be viewed as advisement of any kind to anyone to do anything.**

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Top of Mind

The Advancing Chronic Care with Effective, Scalable Solutions (ACCESS) Model Request for Applications (RFA) is Here

The Centers for Medicare and Medicaid Innovation CMMI released the ACCESS RFA this week. It provides many more details about participation requirements but does not yet share the funding levels for the monthly Outcome Aligned Payments (OAPs) that will be billed for care provided by ACCESS organizations.

My Take

One thing I’m thinking about now as I review this RFA is how a traditional practice who wants to offer services available through the ACCESS Model mechanisms (such asynchronous care and digital health tools’ support) can participate directly rather than avoid what could easily become fragmented care between the ACCESS organization and the providers caring for those patients. This is particularly top of mind for me for two of the ACCESS Tracks for Musculoskeletal (MSK) and behavioral health.

The care provided for these conditions is typically via rehabilitation therapists and behavioral health providers, respectively. While many don’t consider these providers primary care, they are often providing the frontline primary care for MSK and behavioral health conditions, not the primary care practice.

Here’s an example of a scenario I’m thinking through:

Let’s say I’m a PT treating a patient for mechanical low back pain. PTs have direct access in every state under licensure and may evaluate and treat patients with Medicare with a physician signature on the plan of care. (Most other payers don’t require a physician referral or prescription for physical therapist care.)

Let’s say I’m seeing them twice per week and they are simultaneously participating in a robust self-management program to achieve the goals based on their rehab prognosis. I’m billing for the in-person and/or telehealth visits during this episode, and I would like to add on asynchronous communication with my patient and a digital health education support tool for additional patient engagement, which I assess will improve the likelihood of the patient achieving long term symptom resolution and help prevent a subsequent disc derangement.

I’d also like to collaborate with the patient’s PCP and share the comprehensive care plan and results of the interventions, including those achieved through the OAP-reimbursed solutions. I’ll track the outcomes and cost of both the episode and the longer-term healthcare utilization related to this condition and be integrated into the longitudinal care plan for the patient as part of the team.

If I’m billing FFS for treating the patient, I’m looking for clarification about how I can provide the ACCESS treatment simultaneously (if I’m approved to be an ACCESS org as a Med B provider) rather than choosing between traditional treatment per statute and the ACCESS treatments or referring the patient to a different organization to manage this carved-out service in my patient’s care plan.

If I would have to refer the patient to the ACCESS org for the additional services that I’ve assessed would improve the chance of meeting long term goals, the ACCESS org’s obligation is to the PCP, who may not be actively involved in medical management of the patient, not the physical therapist. Also, if I have access to the ACCESS org services and I’m the treating PT, I could strategically and efficiently deploy services in my patient’s comprehensive treatment plan. That could mean a reduced number of FFS PT visits in total and lower contribution to total cost of care.

I’ll have to give this more thought as I fully digest the RFA.

ACCESS Model RFA.pdf

936.31 KB • PDF File

Download

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Drug Price Negotiations and Two CMMI Drug Models Announced on Friday

President Trump announced Friday afternoon that the White House secured agreements with nine additional pharmaceutical companies (bringing the total to 14) for “Most Favored Nation” pricing on Trump Rx. The companies agreed to reduce the prices on some of their drugs to the prices paid by other wealthy countries. Three other pharmaceutical companies have not yet made an agreement with the White House for the MFN pricing deals. Here are the 14 companies. The first nine are new:

• Novartis

• Amgen

• Bristol Meyers Squibb

• Boehringer Ingelheim

• GSK

• Merck

• Sanofi

• Gilead Sciences

• Genentech

• Pfizer

• Eli Lilly

• Astra Zeneca

• Novo Nordisk

• EMD Serono

The following three companies haven’t finalized commitments

• Regeneron

• Johnson and Johnson

• Abbvie

Here’s an opinion piece sharing concerns about MFN if you are interested in checking it out.

Also Announced 📣 

CMMI Has Released Notice of Proposed Rulemaking (NPRM) for Two Medicare Drug Models

One is for Medicare Part B drugs, the other is for Medicare Part D drugs.

Global Benchmark for Efficient Drug Pricing (GLOBE) Model

This model focuses on drugs administered in a clinical setting, like chemotherapy and autoimmune medications. GLOBE is a mandatory, 5-year program aimed at reducing Medicare Part B drug costs by tying prices to what economically comparable countries pay. If finalized, it will launch on October 1, 2026.

What it does 👇️ 

GLOBE would require manufacturers to pay rebates when their Medicare Part B drug prices exceed an international benchmark based on pricing in similar developed countries. Americans currently pay three times what other developed nations pay for the same medications.

Guarding U.S. Medicare Against Rising Drug Costs (GUARD) Model

This model focuses on drugs obtained via pharmacies. GUARD is a mandatory 5-year program aimed at reducing Medicare Part D prescription drug costs by benchmarking prices to economically comparable countries. If finalized, it will launch January 1, 2027.

What is does 👇️ 

GUARD would require manufacturers to pay rebates when their Medicare Part D drug prices exceed an international benchmark based on pricing in similar developed nations.

Don’t forget the Inflation Reduction Act Negotiations

The IRA, a Biden-era law passed through Budget Reconciliation when the Democrats held the Executive branch and both Houses of Congress, included the Medicare Drug Price Negotiation Program.

Here are the drugs selected for 2027 negotiation 👇️ 

Fact Sheet

Here are the drugs previously selected for 2026 negotiation, going into effect in January 👇️ 

Fact Sheet

For additional reading on this, here’s KFF’s FAQs:

FAQs about the Inflation Reduction Act’s Medicare Drug Price Negotiation Program | KFF

The Centers for Medicare & Medicaid Services (CMS) recently announced the drugs selected for the second round of negotiation for the Medicare Drug Price Negotiation Program, which was established by the Inflation Reduction Act. These FAQs address several questions related to Medicare’s drug price negotiation program and CMS's implementation of the program, with a focus on the details that apply for 2027, the second year that negotiated prices will be available under the program.

www.kff.org/medicare/faqs-about-the-inflation-reduction-acts-medicare-drug-price-negotiation-program

My Take:

This is the second Administration in a row to create vehicles to address rising drug costs. Medical cost trend is influenced by a number of factors, which I’ve talked about in the past. Drug costs are both an access and affordability issue, top Healthcare challenges for Americans. Both parties are attempting to make their mark on the issue of drug prices.

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The ACO REACH Successor Is Here!

The ACO REACH Model is a seven-year Innovation Center model ending December 31, 2026. It is testing prospective, capitated payments up to full financial risk in Traditional Medicare. For especially advanced primary care providers who have transformed their practices in team-based care delivery, this model enables advanced primary care, team-based practices to create the same clinical care structure for their TM beneficiaries as many have with their Medicare Advantage plan contracts.

Quick recap on ACOs—payers, providers, and patients all benefit when providers are incentives to deliver the right care (including prevention, early detection, and care management) at the right time in the right place. Improved health outcomes are the direct result of paying providers for different things. In full-risk VBC programs, providers own the responsibility of spending the payer’s budgeted dollars well. Most invest in deploying more resources at the primary care level. Providers can be very successful in these arrangements by building teams, workflows, and patient engagement structures so the use of and need for emergent care, hospitalizations, and low value and avoidable care is reduced.

It’s no small feat. But the benefit to these providers is they share in the savings from the avoided high-cost spend. And the benefit to patients? They have better access to more upstream care, wrap-around care, and a team of experts who want nothing more than for them to be healthy and home in the community.

When an Innovation Center model ends, a few things can happen. It can be successful enough to be made permanent, like the Home Health Value-Based Purchasing program and the Medicare Diabetes Prevention Program. Parts of it can be made permanent inside the traditional Medicare program, like waivers in the Medicare Shared Savings Program. Or the next generation of the model can be implemented, sometimes via a mandatory program. An example here are the Bundled Payments for Care Improvement and the Advanced version, now becoming the mandatory Transforming Episode Accountability Model (TEAM), starting January 1, 2026.

There’s been angst about the end of ACO REACH. This model was born from the very similar Direct Contracting Model and prior to that, the Next Generation ACO Model and before that, the Pioneer ACO Model. One might assume that this next model, after a ten-year test, will become a statutory component of the Medicare program after testing iterations for many years. In the below video, Abe Sutton explains this intent.

Enter the Long-Term Enhanced ACO Design (LEAD) Model 🎆 

First, a caveat. The Center for Medicare and Medicaid Innovation (CMMI) has released just enough information so far to calm our panic about how these practices will participate in a full-risk model for TM patients twelve months from now. They have implied some things while others are a bit more clear. So please do your own due diligence in interpretation by clicking on the model link and reading other thought leaders in this space who are opining on this announcement. I’m sharing what I know and how I’m reading the tea leaves of partial information in the context of themes and references made publicly by CMS over the last few months.

What we Know:

LEAD is a voluntary, 10-year ACO model for TM beneficiaries. It is managed and funded by CMMI. It will launch on January 1, 2027, the day after the end of the ACO REACH model. This will be the longest ACO model to date, which is designed to foster long-term stability and innovation. This is different from ACO REACH, which was a shorter-term model. In LEAD, there are fixed benchmarks for the full 10 years of the model, which removes the rebasing issues from benchmark resets.

Like ACO REACH, LEAD offers two tracks:

1. Global Risk—100% of savings or losses

2. Professional Risk—50% of savings or losses

LEAD also provides enhanced and flexible upfront payments, including capitated, population-based cash flow support to ease administrative burden and sustain proactive care.

LEAD will also expands eligibility to smaller, rural, and independent practices, including FQHCs, RHCs, and Medicare FFS providers not previously in ACOs. It also intensifies focus on homebound and dually eligible Medicare-Medicaid patients, offering strategies and tools for better coordination of care.

LEAD Incorporates the Complex, Homebound, and Home Limited Population

Read my earlier post on supporting the high needs population here

ACO REACH has a specific, separate track for “High Needs” beneficiaries. Those ACO participants have provided in-home advanced primary care to some of the most complex, often seriously ill beneficiaries with significant mobility impairments. By embedding these beneficiaries into LEAD rather than forcing providers to choose between only managing this population and the standard Medicare population, providers can include their full patient panel while (apparently) benefitting from the more generous benchmarking structure of the ACO REACH High Needs Track. We need more information on this, but it is implied here 👇️ 

From the LEAD Model landing page

Specialty Care Integration

LEAD includes the new CMS-administered risk arrangements (CARA) to enable episode-based contracting with specialists and downstream providers. While ACO REACH offered ACOs the option of creating formal alternative payment agreements with specialists via the “Preferred Provider” mechanism, adoption was poor. The feedback CMMI received from participants was that they didn’t have the expertise to administer these on their own without a more structured framework. This makes sense. When a practice enters into risk arrangements with Medicare Advantage plans, the plans collaborate with the providers and bring needed expertise to developing those arrangements. In CARA, CMS will do the heavy-lifting, incentivizing providers with the tools and resources to successfully implement arrangements with high-value providers.

Falls Prevention! 👏🙌 🥳 

From Deposit Photos Royalty-Free Photos

I couldn’t be more excited to read this, and I hope my fellow physical rehabilitation providers are equally as excited and motivated to participate! From what CMS shares on the landing page and Abe Sutton and Gary Bacher of CMMI share in the below video from an interview with AMA President Dr. John Whyte, among the first CARA efforts is the launch of a falls prevention program featuring evidence-based intervention services curated for use by ACOs.

It will allow ACOs to quickly connect patients to proven falls-prevention services such as balance assessments, home safety evaluations, and exercise without having to build these programs from scratch themselves. It allows ACOs and their providers to leverage a CMS-endorsed prevention pathway integrated into care delivery under an advanced value-based model.

Additional Incentives and Support

LEAD will offer an add-on payment for rural providers to support infrastructure investments, which is a big shift! They also introduce new beneficiary enhancements and engagement incentives including the option of a cost-sharing buy-down for Part D premiums by 2029, which is a first.

Here are Abe Sutton and Gary Bacher discussing LEAD with Dr. John Whyte of the AMA. 👇️ 

More information will be available in early 2026 with applications opening this spring.

My Take

Unlike ACO REACH, which had participants from both health systems and provider practices, this model is more deliberately aimed at advanced primary care practices and similar organizations. I suspect when we see the benchmarking structure, it will be more favorable for those participants. By including the complex patients whose risk was not fully captured (medical, social, functional, etc) in ACO REACH unless your ACO’s sole focus was the complex, homebound, or home-limited population, funding levels for ACOs to care for those beneficiaries should be particularly favorable. In other words, if your ACO has a significant percentage of complex beneficiaries, you may have higher funding levels for those beneficiaries on a PMPM basis than you did in the Standard Track of ACO REACH.

I also think we will see more advanced primary care providers exit MSSP and apply for LEAD instead. I’ll be better able to predict this once CMMI shares details about the benchmarking and financial structures of the model.

And as a doctor of physical therapy who spent many years addressing the impacts of non-medical (functional and social) drivers of health in the home that led to loss of mobility and independence and frequent medical care events, I’m thrilled to see a falls prevention program noted and look forward to reading more. 😁 

Resources, Research, and Reading

What is Fast Healthcare Interoperability Resources (FHIR)?

You may hear this acronym throw around, and it’s important to know what it means. Pronounced “fire,” FHIR is a standard for exchanging healthcare information electronically developed by the Health Level Seven International (HL7). It’s purpose is the enable different healthcare systems and organizations like EHRs, apps, hospitals, payers, etc. to share data in a way that’s secure, consistent, and interoperable.

It uses web technologies like RESTful APIs and JSON to make it easier for developers to integrate healthcare data into applications. The core concept to understand in FHIR is the “resource,” which represents a piece of healthcare data such as patient, medication, appointment, etc.

Since CMS and the CMS Innovation Center are deeply committed to advancing interoperability, it’s important to understand the basic concepts of FHIR and what they mean for you.

Here’s a resource from a Substack I found that I had saved to my “second brain” months ago that breaks the concepts down nicely:

FHIR 101: Basic Fundamentals

Resources, APIs and Terminology

open.substack.com/pub/digihealbydrarpita/p/fhir-101-basic-fundamentals?utm_campaign=post-expanded-share&utm_medium=web

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Low Value Care in Medicare

I don’t know providers who like dealing with prior authorization and denials. But if you understand denial patterns, you can anticipate the direction of regulatory changes. Denials can be seen as a signal in the shift towards value-based care, where the potential outcomes are considered when determining whether something should be covered. They do create internal administrative inefficiencies in practices, but they serve as a way to curb low-value care by discouraging unnecessary and/or duplicative services.

In this December 16, 2025 Health Affairs article, Michael Chernew and A. Mark Fendrick discuss clinical “grey areas” where evidence is limited or outcomes are uncertain.

Addressing Low-Value Care In Traditional Medicare | Health Affairs Forefront

Targeted approaches to cost containment (for example, focusing on low-value services or inappropriately high-price services) avoid the potential deleterious consequences of broad, poorly targeted cost containment strategies.

www.healthaffairs.org/content/forefront/addressing-low-value-care-traditional-medicare

They talk about how they are unavoidable and must be acknowledged, and that Medicare must address them. Depending on the program, Medicare uses strategies like utilization management, including the Wasteful and Inappropriate Spending Reduction (WISeR) Model and prior authorization, and value-based care incentives (like the Medicare Shared Savings Program) to prevent spending on low value care.

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Bedbound in the Final Year of Life | Dementia Drives Caregiver Strain and Highlights Policy Gaps

Insights gleaned from this JAMA Open Network article published online December 19, 2025 entitled “Bedbound Status During the Last Year of Life Among Community-Dwelling Older Adults,” by Katherine A. Ornstein, PhD, MPH, Mary Louise Pomeroy, PhD, MPH, and Hanna Charankevich, PhD.

Highlights and Takeaways

One out of every six older adults spend at least one month bedbound before death. For those with dementia it’s 77%.

This is a cross-sectional analysis of community-dwelling decedents using data from the National Health and Aging Trends Study to estimate bedbound prevalence and associated characteristics during the last year of life. The authors classified bedbound status by frequency of leaving the bed/bedroom, requiring assistance, and having difficulty transferring. They also examined dementia status, frailty, sociodemographics, and the care they received.

In their study, they found 16.6% of decedents were bedbound in the year before death, or about 2.5 million people, and those with dementia had a fivefold higher odds of being bedbound. With bed boundedness comes inevitably higher need for caregiving hours and they did receive almost three times as many hours. They were also more likely to require paid care.

The study surfaces what we who have worked in the home-based site of care know well. There are not enough supports for caregivers and not enough home-based care resources available for those who cannot live without support for activities of daily living and instrumental activities of daily living.

The price of private pay caregivers is out of reach for many Americans and their families, adding to the burden on friends and family if they are even available. Proactive clinical planning should be initiated well in advance of significant functional decline. For those with dementia, who may not regularly be able to visit their provider regularly because of social and functional limitations, it’s critical to have access to a home-based primary care provider and their team who can help with this process. Here’s an example of the type of provider I’m talking about.

Expanded home and community-based services are needed to make a dent in the needs of the homebound and then often bedbound population of seriously ill and those with complex care needs. Policy will need to enable much of this at both the state and federal level.

From A Place for Mom’s Website

*Disclaimer: All opinions and ideas expressed in this article are solely mine and none represent a recommendation or should be viewed as advisement of any kind to anyone to do anything.*