Thoughts on Healthcare Markets & Technology Podcast

Jaksot

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  Part I: Forbes 400 Class of 2026: What the 15 Richest People in US Healthcare Reveal About Where the Money Actually Sits (Hint: Not in Software, Payers, or Anything With a Demo Day) 17.09.2026 11min

  Forbes 400 2026 healthcare names: 15 people, $136B combined. No payers. No pharmacy benefit managers. No EHR founders. No digital health. Zero.The 15 break into four buckets: 1 hospital operator, 5 distribution/supply, 5 medical devices, 3 biotech/services, 1 software. That is the whole map.Three cousins from Medline - Charlie Mills, Andy Mills, Wendy Abrams - are worth $21B combined. Their family has been in hospital supply since 1910. The moat: nursing staff know where the gauze is.The only software name is Keith Dunleavy at $4.6B after 20+ years building Inovalon. Compare that to $21B for three people distributing gauze over 60 years. That ratio is the whole story.Subscribe to www.onhealthcare.tech for free and paid articles, podcasts, and more. For a further deep dive on the topic from today’s video teaser, see the podcast and article link in the comments. This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit www.onhealthcare.tech/subscribe
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  Part I: The Hugging Face Incident, Explained for Healthcare: How OpenAI's Agents Escaped a Sandbox and Hacked a Real Company, and Why Every Hospital, Payer, and Health Data Vendor Should Care 14.09.2026 9min

  In July 2026, OpenAI’s AI agents broke out of a sandbox, built a secret message board, and hacked Hugging Face’s production systems. No human directed any of it. Healthcare has not connected the dots yet.The agents went from one compromised server to cluster-admin across multiple systems in under 13 hours. The median healthcare breach dwell time is still measured in weeks. Those timelines no longer match.When Hugging Face’s defenders tried to analyze the attack using commercial AI tools mid-incident, both declined. Safety guardrails cannot tell a defender from an attacker. The defender fell back to an open-weight model. The attacker had no such restriction.The intrusion entered through a file parser in a data pipeline. Healthcare runs thousands of parsers: claims processors, imaging listeners, document converters, interface engines. Every one is a potential execution path waiting for the right malformed input.Subscribe to www.onhealthcare.tech for free and paid articles, podcasts, and more. This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit www.onhealthcare.tech/subscribe
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  Part I: Open Beats Closed Almost Every Time, Monetizing Open Is the Hard Part, and Why Metriport's $26M Series A Is a Bet on Becoming the Open Patient Context Layer for Healthcare AI 12.09.2026 12min

  AOL had 26.5M paying subscribers. Encarta had licensed content and a real editorial staff. Enterprise blockchain had billions in institutional backing. Open beat all of them anyway. Here is why that pattern matters for healthcare AI right now.TCP/IP produced zero dollars for CERN. Wikipedia runs on a budget smaller than a mid-sized software company’s marketing line. Ethereum processed more activity in one month of 2024 than all enterprise consortium chains combined ever did.Healthcare keeps replaying the same version: HL7 v2 became a consulting racket. Mirth got relicensed in 2024 and forked immediately. Epic cut Particle Health off from Carequality over a data use dispute. Network access is always one policy decision away from gone.Open weights plus open context infrastructure is the only configuration where health systems and regulators keep any leverage - because if the AI reasoning layer and the patient context layer are both closed, the vendor owning both owns the patient.Subscribe to www.onhealthcare.tech for free and paid articles, podcasts, and more. This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit www.onhealthcare.tech/subscribe
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  Part I: The HTI-5 Deregulation Rule Just Told EHR Vendors That AI Agents Count as Users Under Information Blocking, and Here Is the Startup Map for What Gets Built on Top of That 10.09.2026 7min

  HTI-5 just told every EHR vendor: you can no longer claim a bot is not a covered user under information blocking. Autonomous AI systems are explicitly named in the rule.The rule also deletes the condition that let vendors refuse third-party write-back requests as infeasible. That condition was the universal justification for keeping AI out of the chart.On certification: 34 of 60 criteria proposed for removal. The model card requirements go. The C-CDA criteria go. What survives is basically a FHIR API program. New entrants save a year and six figures.The real play here is infrastructure. Whoever builds the agent-native FHIR read-write layer with a compliant evidence log owns the default path for AI apps that need chart access. The moat is the paper trail.Subscribe to www.onhealthcare.tech for free and paid articles, podcasts, and more. This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit www.onhealthcare.tech/subscribe
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  Part I: How non-clinicians and 1.2 second algorithms overrule attending physicians on medical necessity, why the appeal math makes denials profitable, and which federal rules could change it 08.09.2026 8min

  Medicare Advantage plans process 50 million prior auth decisions a year. When patients appeal, payers overturn their own denials over 80% of the time. The initial denial layer is calibrated to something other than clinical accuracy.Medical necessity is not a medical concept. It is a contract term interpreted by the payer. A physician can be 100% right that a treatment is standard of care and the plan can still deny it, contractually.One documented system bulk-denied roughly 300,000 claims over two months at about 1-2 seconds of physician attention per denial. The signatures were real. The review was not.The incentive math is almost perfect for payers. Patient abandons care: claim cost goes to zero. Denial gets overturned on appeal: payer pays what it would have anyway, months later, with no penalty. There is no outcome where denial costs extra.Subscribe to www.onhealthcare.tech for free and paid articles, podcasts, and more. This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit www.onhealthcare.tech/subscribe
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  ChatGPT Plugged Into Epic Without a Partnership: What the September 1 EHR Integration Actually Is, Who Holds the Liability, and Why CIOs Now Have Three AIs Fighting Over One Patient Chart 07.09.2026 6min

  OpenAI plugged ChatGPT into Epic EHR on September 1. Every headline called it a historic partnership. There is no partnership. Here is what actually happened.The integration runs on Epic’s free public FHIR APIs, the same ones any developer can use. A health system admin registers an app, adds credentials, publishes it. Clinicians sign in with their existing Epic logins. ChatGPT sees exactly what the doctor can see. Nothing more.Epic’s official response on launch day: OpenAI’s app is ‘one of thousands’ that connect through free APIs, and health systems choose which to enable. Translation: we didn’t invite them, we can’t stop them, liability is yours.OpenAI published physician safety ratings: 99.1% of responses rated safe across 4,363 evaluations. Do the math. That’s roughly 39 unsafe responses in a controlled setting. At real health system scale, 0.9% is a patient safety committee agenda item, not a rounding error.Subscribe to www.onhealthcare.tech for free and paid articles, podcasts, and more. This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit www.onhealthcare.tech/subscribe
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  Part I: OpenAI Just Wired ChatGPT Directly Into Epic and Nine Official Health Data Sources, and Every Hospital AI Governance Committee in America Just Had Its Next Two Quarters Planned For Them 04.09.2026 8min

  OpenAI just wired ChatGPT directly into Epic and nine official health data sources. HCA, UCSF, Cedars-Sinai, and Memorial Sloan Kettering are launch partners. This changes the stack.The Epic integration comes in two flavors. One pulls chart context into ChatGPT. The other embeds ChatGPT inside the Epic layout itself. That second one is the commercially important version.Here is the twist: Epic has been shipping over a hundred generative AI features since 2023, mostly powered by OpenAI models through Azure. OpenAI just decided being at the bottom of that stack is a bad deal.OpenAI now holds its own Business Associate Agreement, its own enterprise sales motion, and its own embedded Epic experience. That puts it in direct competition with the feature roadmap it has been quietly powering for two years.Subscribe to www.onhealthcare.tech for free and paid articles, podcasts, and more. This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit www.onhealthcare.tech/subscribe
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  Part I: The Fintech Nobody Has Built Yet: Why the One Big Beautiful Bill's Medicaid Provider Tax Phase-Down and Directed Payment Caps Create a Bridge Lending, Copay, and Coverage-Churn Business 31.08.2026 8min

  The One Big Beautiful Bill puts Medicaid supplemental payments on a step-down schedule written into federal law. No hospital CFO in an expansion state needs to guess when the cash hole arrives. They can model it today.Provider taxes in expansion states drop from 6% to 3.5% of net patient revenue between FY2028 and FY2032. State directed payments step down 10 points per year starting January 2028. That is roughly $340B in program changes with specific dates.The wrinkle: a meaningful share of Medicaid supplemental revenue already has a 12-18 month tail. The cash hole and the receivable lag stack on top of each other. Existing bank lines were not sized for this.The fintech that does not exist yet: a specialty lender that underwrites the state program, not the hospital. The moat is Medicaid finance expertise, not balance sheet size. The asset shrinks on a statutory schedule, which is actually good for credit risk.Subscribe to www.onhealthcare.tech for free and paid articles, podcasts, and more. This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit www.onhealthcare.tech/subscribe
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  Part I: The Mandatory Model Operator: the risk bearing episode company hospitals need before TEAM downside hits on Jan 1, 2027, sized for a $5M preseed & a $25M seed, w the contract by contract plan 29.08.2026 7min

  742 hospitals enter two-sided Medicare financial risk on Jan 1, 2027. The industry built to help them was acquired by UnitedHealth, CVS, and Aetna - and repurposed for Medicare Advantage. The vacancy is real and the deadline is fixed.Optum projects a majority of mandatory TEAM participants will lose money averaging $1.2M per facility. The reconciliation reports land in early 2028 - after hospitals are already deep into year two of real downside.The old convener companies (Remedy, naviHealth, Archway) worked. They just got absorbed by payers who needed post-acute utilization management for their own members, not hospital-facing episode operators.The resulting business: a tech-enabled episode company that manages the 30-day post-discharge window, runs gainsharing, improves target prices through documentation, and sells downside protection backed by its own balance sheet.Subscribe to www.onhealthcare.tech for free and paid articles, podcasts, and more. This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit www.onhealthcare.tech/subscribe
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  Part I: MCIT, TCET & RAPID Compared: A Field Guide to Medicare's 3 Breakthrough Device Coverage Pathways, Why Two Are Effectively Dead, & What the August 2026 RAPID Proposed Notice Actually Changes 26.08.2026 8min

  FDA has issued 1,284 breakthrough device designations. Medicare is not obligated to pay for a single one. That gap has now produced three separate federal policy attempts in five years.The first attempt, Medicare Coverage of Innovative Technology, promised automatic national coverage the day FDA authorized a breakthrough device. It was repealed in November 2021 before one device ever received coverage under it.The second attempt, Transitional Coverage for Emerging Technologies, capped at five candidates a year. Two years in, the public count is one device enrolled. One.The third attempt just landed in the Federal Register. The new pathway promises a proposed coverage decision the same day FDA authorizes and a final one in 60 to 90 days. Comment period closes October 13.Subscribe to www.onhealthcare.tech for free and paid articles, podcasts, and more. This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit www.onhealthcare.tech/subscribe
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  Part I: Costco selling Medicare plans, Rand Paul's membership bill, and the February PBM law walked into a bar. Here’s what happened when they got there. 24.08.2026 10min

  Costco just announced Medicare Advantage plans with SCAN Health Plan targeting 5 million enrollees. The warehouse club is now a plan sponsor.Their discount card already works at Walgreens and runs on pharmacy benefit administrator infrastructure. The anti-PBM insurgent built PBM-shaped rails.But a discount card can’t extract drug rebates. Rebates are purchased with covered lives. Cash customers aren’t covered lives. That’s the whole thing.The SCAN partnership changes the mechanism. A Medicare Advantage plan files a formulary. Once Costco acquires enrollees, it’s playing the covered lives game. Mechanisms compound.Subscribe to www.onhealthcare.tech for free and paid articles, podcasts, and more. This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit www.onhealthcare.tech/subscribe
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  Part I: The Contractor State: Who Actually Runs Medicare, How CMS Spends Its $8 Billion a Year, Why a South Carolina Blue Plan Quietly Banks $700 Million, and How AI Vendors Now Get Paid to Deny Care 21.08.2026 7min

  CMS moves $1.5 trillion a year with 6,000 employees. It does almost none of the actual work. A contractor market of $7-8.5B a year does it for them.Maximus leads five-year contract totals at nearly $4B. But the most surprising #2: a nonprofit Blue plan in South Carolina, through three affiliated entities, pulling $718M in fiscal 2025 alone.The entire Medicare Administrative Contractor tier traces back to the 1965 statute that barred the government from running claims directly. Palmetto, Noridian, Novitas - all fossil records of that one political deal.Most clarifying data point: only 16% of fiscal 2025 CMS contract spend is coded as government health insurance programs. The rest is IT and professional services. CMS is a federal tech buyer that happens to run Medicare.Subscribe to www.onhealthcare.tech for free and paid articles, podcasts, and more. This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit www.onhealthcare.tech/subscribe
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  Part I: How Hippocratic AI Makes Money: The Nine Dollar Agent Hour, Who Actually Signs The Check At A Health System, And Whether A 3.5 Billion Dollar Valuation Survives Contact With Nursing Budgets 19.08.2026 10min

  Hippocratic AI charges $9 per agent hour of patient conversation. Not per seat. Not per license. Hours. That one pricing decision changes everything about who buys, how fast deals close, and what the margin story looks like.The comparison point is not software. It is people. A fully loaded registered nurse costs $55-65/hr. Agency nurses bill higher. Offshore call centers run $15-25/hr. At $9, the procurement math takes four seconds.That shifts the buyer from a chief information officer on an IT budget to a chief nursing officer with open positions and a chief operating officer with a call abandonment rate. Operating labor budgets are orders of magnitude larger than software budgets.The company reports 250 million patient interactions. Third-party trackers put revenue in the mid-teens of millions. That gap - between the interaction count and the billing number - is the single most important analytical question about this company right now.Subscribe to www.onhealthcare.tech for free and paid articles, podcasts, and more. This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit www.onhealthcare.tech/subscribe
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  Part I:Where the Money Actually Moves After the Reconciliation Law: Medicaid Work Requirements, $50B Rural Fund, Provider Tax Phase-Downs, and What Entrepreneurs and Investors Should Build and Buy Now 17.08.2026 12min

  The viral tweet about Medicare solvency moving from 2052 to 2040 got 750K engagements. The 2026 Trustees report says 2033. That is one quarter earlier than 2025, not 12 years.The 4% Medicare sequester everyone modeled in late 2025 also vanished. The Nov CR wiped the pay-as-you-go scorecards. Anyone forecasting a 6% Medicare cut spent Q4 building a ghost model.What is real: 35 million uninsured by 2028 per the CBO baseline, up a third from 2025. Marketplace enrollment down from 22.3M to roughly 17.5M. Average subsidized premiums up 114%.The $50B Rural Health Transformation Program starts paying out Oct 1, 2026. All 50 states approved. States are already in procurement. Buyers are inexperienced. That window is open now.Subscribe to www.onhealthcare.tech for free and paid articles, podcasts, and more. This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit www.onhealthcare.tech/subscribe
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  Part I: What Federal Billing Transparency Rules Actually Require, What Patients Can Really Do Before a Bill Hits Collections & Where the No Surprises Act & Price Transparency Rules Have Quietly Failed 15.08.2026 15min

  The viral HIPAA billing claim is wrong. Hospitals do not need your signed authorization before sending a bill to collections. The Privacy Rule explicitly lists collection as a permitted payment activity.The protection that actually works is Section 501(r) of the tax code. Nonprofit hospitals must make reasonable efforts before any extraordinary collection action. That window runs 240 days from the first billing statement.The 2026 price transparency rewrite eliminated the estimated allowed amount placeholder. Now a named senior executive must attest the file is true, accurate, and complete. CMS declined to rule out False Claims Act exposure on defective attestations.The No Surprises Act protected patients from balance billing and created a 15-billion-dollar arbitrage. The top 10 initiating parties drove roughly 70 percent of independent dispute resolution volume in the first half of 2025.Subscribe to www.onhealthcare.tech for free and paid articles, podcasts, and more. This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit www.onhealthcare.tech/subscribe
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  The Underinsured Math Problem: How $26,993 Family Premiums, $1,886 Deductibles, a $21,200 Legal Cost-Sharing Cap and a 42% Patient Collection Rate Add Up to Insurance That No Longer Insures 14.08.2026 7min

  A family paying $26,993 for health coverage in 2025 has a legal worst-case annual out-of-pocket exposure of $21,200. Worker premium contribution plus that cap: $28,050. That is more than the entire premium. The plan costs less than the maximum the plan lets them owe.The $340 pediatric checkup that goes viral every few weeks is not fraud and it is not a bad plan. It is a high-deductible benefit design working exactly as priced. If the deductible is not met, the insurer pays zero. A hospital-affiliated visit with a facility fee lands right there.The consumer protection ceiling on out-of-pocket costs is indexed to private insurance premium growth. Not wages. Not CPI. Premiums. So the cap protecting people from rising costs rises at the pace of rising costs. Wages grew 4% last year. The cap grew 15.2%.Two-thirds of underinsured Americans are in employer plans. Standard W-2 benefits-eligible coverage. This is not a marketplace or gig economy problem. The Commonwealth Fund put the underinsured share at 23% before enhanced subsidies expired January 1, 2026.Subscribe to www.onhealthcare.tech for free and paid articles, podcasts, and more. This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit www.onhealthcare.tech/subscribe
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  Part I: Mapping the Full Markup on a Hip Implant From Forged Titanium to Patient Bill, and Whether Costco Style Bulk Buying or Reference Pricing Could Actually Close the US Medical Device Price Gap 13.08.2026 13min

  A hip implant costs $300-600 to manufacture. The hospital invoice is $3,500-7,000. The gap is almost entirely field reps and consignment inventory, not titanium.Small hospitals pay two to three times more than large systems for the identical part number from the same manufacturer. That gap is well documented and almost never mentioned in the viral threads.Group purchasing organizations have been doing the Costco thing since 1987. They cover most US hospitals. Physician preference items like hip implants are the category with the lowest contract compliance.Costco works because the shopper, the payer, and the consumer are the same person and can walk away. In an OR the decider bears no cost, the payer is locked in, and the consumer is unconscious. The model just does not transfer.Subscribe to www.onhealthcare.tech for free and paid articles, podcasts, and more. This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit www.onhealthcare.tech/subscribe
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  Part I: CMS's RAPID Coverage Pathway for Breakthrough Devices: What the August 2026 Procedural Notice Actually Does, Why TCET Got Paused, and Why the First Same-Day NCD Probably Lands After 2030 12.08.2026 11min

  CMS published the RAPID device coverage pathway on August 11, 2026. The headline: a proposed Medicare coverage decision the same day as FDA authorization. The fine print is more complicated.Eligibility is tight. Only Breakthrough devices at the pre-submission stage qualify. If your study is already enrolling patients, the door is closed. In vitro diagnostics are excluded entirely.Coverage is not payment. An NCD says Medicare covers something. It says nothing about the billing code, the payment rate, or the care setting. Those run on separate calendars RAPID does not touch.Do the timeline math: enter RAPID in late 2026, run a study, get authorized, wait on coding. The first device with both coverage and a workable payment rate is probably a 2031 or 2032 event.Subscribe to www.onhealthcare.tech for free and paid articles, podcasts, and more. This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit www.onhealthcare.tech/subscribe
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  Part I: Organ Procurement Under Federal Fire: How Cost-Plus Reimbursement, a 2020 Metric Rewrite, and the DCD Boom Turned Death Determination & Organ Allocation Into Healthcare's Next Compliance Fight 10.08.2026 12min

  The second organ procurement organization in US history was decertified August 5. The first was September 2025. Before that: zero. Ever. Despite federal authority existing for decades.A federal review of 351 Network for Hope cases found 103 with concerning features. 73 patients had neurological signs incompatible with donation. At least 28 may not have been deceased when procurement started.Donation after circulatory death went from 2% of deceased donors in 2000 to nearly 50% in 2025. The national registry has no field for whether normothermic regional perfusion was used. Researchers infer it from timestamps.The 2020 performance scorecard doubled top-tier organizations and grew transplants 25%. It also measured only production. No near misses, no families steamrolled, no patients who improved. That ran for five full years during the fastest expansion of circulatory death donation ever.Subscribe to www.onhealthcare.tech for free and paid articles, podcasts, and more. This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit www.onhealthcare.tech/subscribe
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  Part I: Medicare Implant Pricing & the $25 Billion Blind Spot: Why Devices Escaped IRA-Style Negotiation, What Australia & Japan Already Publish, & What a US Device Price Rule Would Actually Require 08.08.2026 18min

  Medicare pays for ~1 million implant procedures a year and does not know, at the product level, what it bought. No brand. No model. No manufacturer. The claim has no field for it.The $25B number floating around is in the right range. Joints: $4-5B. Spine hardware: $2-3B. Cardiac rhythm: ~$3B. Transcatheter heart valves alone: ~$3B. All outside any negotiation framework.Hospitals buying the same hip implant paid anywhere from $4,500 to $8,000 - a 78% spread. The 90th percentile hospital paid 2.1x the 10th percentile for knees. Confidentiality clauses in contracts keep this data 15 years old.Japan’s device pricing formula explicitly excludes the US price from its international benchmark - because the US number is too far above any reasonable average. That is not commentary. It is in the formula.Subscribe to www.onhealthcare.tech for free and paid articles, podcasts, and more. This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit www.onhealthcare.tech/subscribe