In this episode, Alex Yarijanian breaks down the 8-indicator playbook he uses to evaluate any tele-behavioral health market before committing capital — and names the specific states he'd enter today and why.

Most operators default to the biggest states: California, Texas, Florida, New York. But population size alone is one of the weakest predictors of a winning market. The real levers live in parity law enforcement, workforce economics, MCO concentration, and infrastructure readiness.

WHAT YOU'LL LEARN

• Why the biggest states are rarely the best markets for tele-behavioral health
• The 8 indicators that separate win-win markets from cheap-rate mirages
• How to build a weighted scoring model before entering a new market
• What associate-level billing eligibility does to your workforce margins
• How MCO concentration affects contracting speed and rate-cut risk
• Which states Alex rates as best all-around, high-risk, and growth-stage bets

THE 8 MARKET INDICATORS

1. Medicaid market size: Total addressable population and realistic capture potential
2. Payment parity: State-level mental health parity laws and strength of enforcement
3. Cost of living index: The single best proxy for labor margin on clinical staff
4. Associate-level billing: Whether licensed associates can bill independently
5. HRSA HPSA demand mapping: Documented unmet need in mental health shortage areas
6. Broadband & 5G coverage: Infrastructure required for reliable telehealth delivery
7. MCO landscape: Plan count, behavioral carve-outs, any-willing-provider law exposure
8. Tax & corporate climate: State-level business environment and regulatory posture

MARKET ARCHETYPES

• Best all-around: Arizona, Nebraska, Delaware, Oregon
• Volume, thin margins: Arkansas, North Dakota
• High rate, high cost niche: Alaska
• Growth stage bets: New Mexico, Montana

4 ACTION STEPS

1. Build a scroll scoring model — layer all 8 indicators into a weighted scorecard
2. Validate demand on the ground — overlay HRSA HPSA maps + FCC broadband gap data
3. Check your plan mix — count Medicaid MCOs and behavioral carve-outs
4. Run a payroll stress test — model cost of living vs. your target clinician pay band

RESOURCES MENTIONED

• HRSA Mental Health HPSA maps: data.hrsa.gov
• FCC broadband coverage maps: broadbandmap.fcc.gov
• NCSL mental health parity law tracker
• Licensure compact maps: PSYPACT, ASWB Compact, Nurse Licensure Compact State Medicaid rate databases

Why are employers often paying two to four times Medicare rates for identical procedures performed in the same hospital by the same physician?

The answer isn’t clinical complexity. It’s incentive design.

Dr. Kumar breaks down how Medicare Advantage plans negotiate as owners of financial risk — and why that matters. In contrast, much of the commercial self-insured market relies on administrators who negotiate without full downside exposure, creating a structural pricing gap.

The conversation also explores:

1. What Medicare Advantage plans are actually looking for when contracting with digital health and AI solutions
2. Why engagement — not automation — is the real leverage point
3. The economics of supplemental benefits and underutilized Star opportunities
4. Home-based and remote care as risk containment strategies
5. The future vision of standardized specialty care marketplaces

This is a structural conversation about incentives, risk ownership, and where execution truly matters in value-based care.

Key Takeaways

1. Incentive alignment drives pricing discipline. Medicare Advantage plans negotiate differently because they own the full medical loss ratio.
2. Commercial self-insured markets often lack that same alignment, contributing to higher negotiated rates.
3. AI in Medicare Advantage is less about backend efficiency and more about member activation and physician-level quality improvement.
4. Underutilized supplemental benefits represent unrealized revenue and quality movement.
5. Home-based and remote care models are fundamentally about managing high-acuity risk, not convenience.

Timestamps

00:00 – Introduction

01:39 – What Medicare Advantage plans actually want from AI vendors

03:27 – Why engagement infrastructure is the real leverage point

04:28 – Virtual care, socioeconomic complexity, and risk ownership

06:18 – High-acuity members and access-driven cost escalation

07:11 – Supplemental benefits and engagement economics

08:36 – Stars, utilization, and revenue implications

09:55 – Employers paying 2–4x Medicare rates

10:27 – Why commercial pricing diverges

12:17 – Incentive structure and negotiation power

12:47 – Vision for standardized specialty care marketplaces

About the Guest

Dr. Kumar Dharmarajan is a practicing cardiologist and geriatrician and the co-founder and Chief Medical Officer of World Class Health. He previously served as Chief Scientific and Medical Officer at Clover Health and was on faculty at Yale School of Medicine, where his research helped shape national post-acute care quality measures. He has published in the New England Journal of Medicine, JAMA, and Health Affairs.

Companies mentioned in this episode:

1. World Class Health
2. Clover Health

In this episode, Alex Yarijanian breaks down what the Rural Health Transformation Program / Rural Health Fund (RHTF) actually is, what state strategies reveal about the future of rural access, and why this matters far beyond rural hospitals—impacting payer strategy, provider contracting, network adequacy, and healthcare economics.

You’ll hear key highlights from state plans including California, Texas, Florida, New York, and Illinois, plus the cross-state themes showing up everywhere: hub-and-spoke models, shared services, EMS reform, telehealth hubs, and AI-driven admin reduction (including automated fax processing).

What You’ll Learn

1. What the Rural Health Transformation Program actually is
2. Why this funding wave is different (state plans are concrete and approved)
3. What state strategies reveal about access risk + reimbursement limits
4. How payers should interpret this as a network adequacy / access signal
5. Why providers should see this as both opportunity + accountability shift

State Highlights Covered

California

1. Hub-and-spoke maternal + specialty access models
2. Example of rate + infrastructure working together (Health Plan of San Mateo specialty rate increases)

Texas

1. Technology as a force multiplier
2. AI-enabled specialty access, telehealth coordination, clinically integrated networks
3. Tech becomes a parallel lever to reimbursement in high-dispute markets

Florida

1. Remote patient monitoring (RPM) + community paramedicine
2. Utilization management upstream in MA-heavy environments

New York

1. Patient-centered medical homes + workforce pipelines
2. Care coordination over unit cost expansion in concentrated payer markets

Illinois

1. Integrated primary + behavioral health infrastructure
2. EMS treat-not-transport models
3. Alternative models as a response to inflation vs lagging rates

Key Cross-State Themes

1. Hub-and-spoke models are returning at scale
2. Shared services (centralized EHR, billing, analytics) to reduce admin burden
3. AI as infrastructure (clinical decision support + operational efficiency)
4. Specific AI use cases being funded:
5. Automated fax processing
6. AI scribes
7. AI-enabled care coordination

Key Takeaway

Rural health stabilization strategy is not uniform across states — but the goal is consistent: protect access where reimbursement alone hasn’t been enough.

Mentioned in this episode:

1. Health plan of San Mateo
2. California
3. Texas
4. Florida
5. New York
6. Illinois
7. Oklahoma
8. Washington
9. Utah
10. Vermont

Payers are quietly narrowing networks and rewriting delegation expectations. This playbook explains how to do business with MA business for 2026.

If you’re waiting, you’re already reacting—not positioning.

In this episode, Alex Yarijanian breaks down what’s actually showing up in payer conversations right now, long before final CMS rules are published. Drawing from real contracting, network, and delegation discussions, Alex explains why waiting for regulatory clarity is already costing providers and health tech companies leverage.

You’ll hear how payer priorities have shifted from enrollment growth to margin durability, why network narrowing is accelerating quietly, how delegation has become a stress test, and what “value-based care” really means in Medicare Advantage today.

This episode also outlines who is most at risk heading into 2026, the three types of organizations positioned to win, and what provider and health tech leaders should do in the next 90 days to stay relevant.

Who should listen: Provider executives, payer leaders, value-based care operators, and health tech founders navigating Medicare Advantage.

In this episode, host Alex Yarijanian breaks down not only what happened, but what this case means for the entire digital health ecosystem, especially behavioral health and companies prescribing controlled substances. When a company like Done collapses — and its founders now face up to 20 years in federal prison — it doesn’t just take itself down. It drags trust, access, and payer willingness down with it.

Alex outlines how this case will reshape:

• Payer contracting and credentialing
• Prescribing oversight and compliance expectations
• Trust in telehealth platforms
• The future of value-based behavioral health
• Why incentives — good or bad — always scale

And most importantly, he explains why value-based care is the antidote to the shortcuts and misaligned incentives that fueled this scandal.

If you’re building, funding, regulating, or partnering with telehealth organizations, this is a must-listen.

Takeaways:

• The case of the telehealth startup highlights the critical importance of clinical oversight in health services.
• Payers are likely to impose stricter regulations on telehealth providers following recent fraudulent activities.
• Building a sustainable healthcare model requires prioritizing patient interests over profit maximization strategies.
• The future of digital health will hinge on trust, necessitating alignment between clinical and business models.

1. Shorter, billable windows for remote monitoring
2. New behavioral health add-ons to primary care
3. Incentives that reward value-based care
4. Expanded reimbursement for digital therapeutics & telehealth
5. A major shift from inpatient to outpatient procedures

Whether you’re running a clinic or building the next health tech solution, this playbook will help you turn policy into profit and thrive in the future of care.

00:00 Welcome to the Value-Based Care Advisory Podcast

00:15 2026 Medicare Advantage Showdown Overview

01:24 Key Policy Updates for 2026

03:11 Telehealth and Virtual Care Innovations

04:39 Enrollment and Form Updates

06:12 Risk Adjustment and Star Ratings

08:52 Strategic Focus Areas for 2026

14:44 Final Thoughts and Conclusion

Takeaways:

• The 2026 Medicare Advantage payments are set to increase by approximately 5%, contributing an excess of $25 billion to the plans.
• Significant changes have been initiated regarding supplemental benefits, particularly affecting non-medical services like transportation and meals.
• Telehealth services for behavioral health will become a permanent fixture, with no geographic restrictions imposed from 2026 onward.
• New billing codes will be introduced for digital therapeutics and remote monitoring, enhancing the infrastructure for virtual care delivery.
• The upcoming risk adjustment model will utilize the full 2024 CMS HCC risk model, significantly impacting financial strategies for Medicare Advantage organizations.
• Plans must prioritize compliance and operational integrity to navigate the complexities of changing regulations and maintain their competitive edge.

Takeaways:

• In the realm of healthcare leadership, emotional labor serves as an essential yet often unacknowledged component that significantly influences negotiation outcomes.
• Effective leadership necessitates an acute awareness of emotional dynamics, as managing feelings is integral to fostering productive dialogue among stakeholders.
• The notion of emotional labor encompasses not just personal emotional management, but also the responsibility to create a supportive environment for others.
• A leader's capacity to engage in emotional labor can lead to profound transformations, underscoring the importance of empathy and understanding in professional interactions.

Mindfulness meditation and its application within the healthcare sector represent a profound intersection of neurological research, emotional intelligence, and leadership efficacy. The discussion begins with a thorough exploration of mindfulness, defined as a state of present-oriented consciousness, which fosters a non-judgmental awareness of one's moment-to-moment experiences. This foundational understanding serves as a springboard to investigate the transformative potential of mindfulness practices for healthcare leaders, who are often beleaguered by high levels of stress and burnout. The episode highlights compelling evidence demonstrating that mindfulness can mitigate stress, enhance cognitive flexibility, and improve emotional regulation—qualities that are indispensable for effective leadership in the ever-evolving landscape of healthcare. By integrating mindfulness into their daily routines, healthcare leaders can cultivate a more resilient mindset, ultimately translating into better organizational outcomes and improved patient care.

Through the lens of empirical studies, the podcast delves into how mindfulness training yields significant neurological benefits, such as increased white matter density and enhanced executive function. One landmark study cited illustrates that patients undergoing mindfulness-based interventions reported a greater awareness of their symptoms and a reduced identification with negative cognitive patterns—a finding that underscores the therapeutic potential of mindfulness in both clinical and leadership contexts. In practical terms, the episode outlines actionable strategies for implementing mindfulness practices within healthcare organizations, emphasizing that even modest initiatives can catalyze meaningful improvements in workplace culture and employee wellbeing. As the conversation unfolds, listeners are encouraged to reflect on their own practices and consider how mindfulness could serve as a catalyst for personal and organizational growth.

Takeaways:

• Mindfulness training serves as a pivotal mechanism for enhancing the performance of healthcare leaders by fostering emotional resilience and cognitive flexibility.
• The practice of mindfulness has been scientifically corroborated to mitigate stress levels significantly, enabling leaders to navigate high-pressure environments more effectively.
• Utilizing mindfulness techniques within healthcare organizations can yield substantial improvements in employee productivity, as evidenced by a notable increase in productive hours per week.
• Healthcare leaders must cultivate a non-judgmental awareness of their experiences to effectively integrate their internal and external realities, thereby enhancing overall leadership efficacy.
• Implementing mindfulness practices in healthcare settings has demonstrated substantial positive outcomes, such as reduced burnout among healthcare professionals and improved organizational performance.
• The neurological benefits of mindfulness training, including increased gray matter density, underscore its importance in developing a sharp, focused mind essential for effective healthcare leadership.

Companies mentioned in this episode:

• Aetna
• Boston Medical Center

This episode dives deep into the essentials of navigating managed care contracts as a health tech startup.

Whether you're a founder, operator, or policy strategist, you'll walk away with a clear understanding of how to position your company for payer partnerships, structure risk-based contracts, and avoid common pitfalls in the healthcare financing space. We explore real-world examples and discuss how to align your innovation with payer priorities, compliance standards, and long-term sustainability.

Perfect for early-stage startups, digital health innovators, and anyone looking to scale within the complex world of managed care.

Key Themes:

• Understanding managed care mechanics (HMOs, PPOs, ACOs)
• Value-based care vs. fee-for-service
• Contracting tips for Series A and B stage startups
• Risk corridors, capitation, and performance metrics
• How to speak the payer language and win trust

Target Audience:

Health tech entrepreneurs, product and ops leads, VCs in digital health, provider networks, and healthcare consultants.

Takeaways:

• Understanding managed care contracting is essential for health tech startups to succeed.
• Health tech entrepreneurs must align their innovations with payer priorities and compliance standards.
• Effective negotiation strategies are crucial for securing favorable managed care contracts.
• Startups should utilize data transparency to build credibility and foster trust with payers.
• Establishing a structured contracting process is vital to avoid unfavorable agreements and ensure sustainability.
• Learning from real-world case studies can provide invaluable insights into successful managed care strategies.

Companies mentioned in this episode:

• Innovate Health
• MedTech Solutions
• Health Wave
• United
• Humana
• Aetna

Tips are provided to strategically leveraging the doula opportunity in risk-based contracting.

Takeaways:

• The integration of doulas into maternity care significantly reduces unnecessary interventions and enhances outcomes.
• Evidence demonstrates that doulas can lower postpartum depression rates, benefiting both mothers and healthcare systems.
• Doulas are increasingly recognized as a strategic component in modern maternity care, facilitating cost savings.

Companies mentioned in this episode:

• Blue Shield Blue Cross

The podcast delves into the intricacies and issues surrounding the American healthcare system, raising critical questions about its efficacy and accessibility. The hosts, with the help of investigative journalism from More Perfect Union, examine whether the healthcare landscape is fundamentally designed to benefit corporations rather than patients. They highlight the confusion and frustration many face when navigating healthcare options, particularly Medicare Advantage plans, which are heavily marketed as cost-effective choices but may prioritize profit over patient care. Through examples like CVS Caremark and the impact of the Biden administration's actions against fraud, the discussion reveals how healthcare companies often prioritize their bottom line, leading to detrimental effects on both employees and consumers. With a focus on the systemic issues, the episode emphasizes the need for transparency and accountability in a system that often feels rigged against the average person.

The narrative also explores the alarming consequences of corporate control in healthcare, illustrated by the shortage of critical medical supplies, such as IV bags, following Hurricane Helene. The podcast underscores the dangers of having a single company dominate a vital resource, highlighting how such monopolistic practices can endanger lives. Furthermore, the hosts discuss the role of pharmacy benefit managers (PBMs) in escalating drug prices, portraying them as hidden players in a convoluted system that drives up costs for consumers. The episode challenges listeners to consider the broader implications of these practices, urging them to recognize the interconnectedness of corporate greed and public health.

Towards the conclusion, the podcast shifts towards empowerment, encouraging listeners to become advocates for change. It stresses the importance of staying informed, engaging with elected officials, and participating in local organizations dedicated to healthcare justice. The episode serves as a call to action, emphasizing that collective efforts can lead to meaningful reforms in a healthcare system that often feels overwhelming and unfair. By fostering awareness and community engagement, the hosts aim to inspire listeners to take ownership of their health care experiences and push for a system that genuinely serves the needs of all individuals, rather than just corporate interests.

Takeaways:

• The American healthcare system is structured to prioritize profits over patient care, leading to widespread issues.
• Pharmaceutical companies often set exorbitant prices for medications, making them inaccessible to many.
• Medicare Advantage plans are designed to attract healthier patients, leaving vulnerable individuals behind.
• The influence of consulting firms like McKinsey perpetuates a culture of profit-driven healthcare.
• Pharmacy benefit managers operate as middlemen, contributing to rising drug prices and complicating the system.
• The case of Keytruda (Pembrolizumab)  highlights how taxpayer-funded drugs can be sold at outrageous prices.

Companies mentioned in this episode:

• More Perfect Union
• CVS Caremark
• Baxter International
• Merck

• What Happens When Private Equity Takes Over a Hospital | Harvard Medical School
• Private equity: health care's vampire | STAT
• How McKinsey Makes Its Own Rules
• How Merck plans to fill the void of Keytruda patent expiration | Fox Business Video
• FTC Deepens Inquiry into Prescription Drug Middlemen
• Record-breaking federal lobbying tops $2.2 billion in first half of 2024
• Big Pharma’s Business Model: Corporate Greed
• PBM Math: Big Chains Are Paid $23.55 To Fill a Blood Pressure Rx. Small Drugstores? $1.51. - KFF Health News

The health insurance industry is facing a perfect storm characterized by rising healthcare costs, increased patient demand, and intense scrutiny from lawmakers. As we move into 2025, the challenges confronting Medicare Advantage plans, once considered the crown jewel of insurer profitability, are becoming increasingly apparent.

Industry giants like Humana and UnitedHealth are grappling with significant pressures that could redefine managed care. However, amidst this turmoil, there are opportunities for healthcare providers and entrepreneurs to innovate and adapt. By focusing on high-cost patient areas and exploring innovative contracts, stakeholders can position themselves to thrive in this evolving landscape.

This episode delves into the tumultuous state of the health insurance industry as it faces unprecedented challenges heading into 2025. Rising healthcare costs, increased patient demand, and government scrutiny are converging to create a 'perfect storm' for insurers, particularly in the Medicare Advantage sector. This segment highlights how traditional revenue models are being tested as utilization rates rebound post-COVID, with many patients returning for procedures they deferred during the pandemic.

Insurers are grappling with higher medical loss ratios (MLR), which are squeezing their profit margins and forcing a reevaluation of their operational strategies. Industry giants like Humana and UnitedHealth Group are highlighted as they navigate this challenging landscape, revealing how their dependence on Medicare Advantage has made them particularly vulnerable amidst shifting policies and scrutiny from lawmakers.

The discussion emphasizes the urgent need for healthcare providers and entrepreneurs to identify innovative solutions that can not only alleviate cost pressures but also enhance patient care, suggesting that these turbulent times may present new opportunities for growth and transformation within the industry.

Takeaways:

• The health insurance industry is facing significant challenges due to rising costs and increased scrutiny.
• Medicare Advantage plans are experiencing financial strain from surging patient demand and utilization rates.
• As healthcare providers, understanding your patient population is crucial for identifying high-cost areas.
• The medical loss ratio is a key metric that impacts insurers' profitability and operational strategies.
• Entrepreneurs should focus on innovative solutions that reduce waste and improve healthcare delivery efficiency.
• The evolving healthcare landscape presents opportunities for proactive adaptation and strategic partnerships.

Companies mentioned in this episode:

• Humana
• UnitedHealth
• CVS
• Aetna
• Morgan Stanley

Research Links:

• There's uncertainty ahead for the health insurance industry in 2025
• Hearing: Hacking America’s Health Care: Assessing the Change Healthcare Cyber Attack and What’s Next | The United States Senate Committee on Finance
• Potential Health Policy Administrative Actions in the Second Trump Administration | KFF
• UnitedHealthcare Profits Less About Denials, More About The Pandemic
• Higher and Faster Growing Spending Per Medicare Advantage Enrollee Adds to Medicare's Solvency and Affordability Challenges | KFF
• Humana stock declines on Medicare Advantage star rating struggle | STAT

In this episode, host Alex Yarijanian breaks down the allegations against MultiPlan, a third-party repricing company accused of working with major insurers like UnitedHealthcare, Cigna, and Aetna to suppress out-of-network payments. We explore:

• How MultiPlan's practices impact patients, providers, and employers.
• The AMA’s antitrust lawsuit accusing MultiPlan of operating a cartel.
• Real stories, like that of Kelsey Toney, a behavioral therapist forced to turn away patients due to unsustainable payment rates.
• The staggering $19 billion providers lose annually to these practices.

If you’ve ever wondered why your healthcare bills are so high or why your provider suddenly stopped taking your insurance, this is the episode for you.

Key Topics Discussed:

• What are in-network vs. out-of-network providers?
• How does MultiPlan determine reimbursement rates?
• The human cost of suppressed reimbursements for providers and patients.
• Legal implications of the AMA and ISMS lawsuit against MultiPlan.
• The broader impact on value-based care and healthcare transparency.

Takeaways:

• Hidden fees in healthcare create a sense of unpredictability and financial anxiety for patients.
• MultiPlan's involvement in processing out-of-network claims often leads to underpayment for healthcare providers.
• Out-of-network providers typically charge fees that reflect their true cost of delivering services.
• Patients frequently find themselves responsible for covering the difference in reimbursement rates from insurers.
• Real-life patient stories underscore the profound human impact of rising healthcare costs and surprise bills.
• The current healthcare system often prioritizes profit margins over genuine patient care and outcomes.

Companies mentioned in this episode:

• MultiPlan
• UnitedHealthcare
• Cigna
• Aetna

Research Links:

• Legal Complaint (PDF): AMA v. MultiPlan Full Complaint - Filed in the United States District Court for the Northern District of Illinois involves the American Medical Association (AMA) and the Illinois State Medical Society (ISMS) as plaintiffs, suing MultiPlan, Inc. for alleged antitrust violations.
• Community Health Systems adds another antitrust lawsuit to MultiPlan's collection - Community Health Systems is the latest health system to allege that MultiPlan’s data-driven claims repricing business meets the bar for antitrust violation.
• AMA lawsuit targets collusion in health care pricing
• Insurers Reap Hidden Fees by Slashing Payments. You May Get the Bill. - A little-known data firm helps health insurers make more when less of an out-of-network claim gets paid.
• New York Times Investigation: Health Insurers' Lucrative, Little-Known Alliance - How a private-equity-backed firm called MultiPlan has helped drive down payments to medical providers and drive up patients' bills, while earning billions.
• AMA Press Release - The American Medical Association’s press release discussing the antitrust lawsuit against MultiPlan.

Segment Highlights

Startup Realities in Value-Based Care

• Analogy to Streaming Service Overload: Alex compares the influx of VBC startups to the crowded streaming industry, highlighting how many of these startups lack a practical strategy, assuming that contracts with big payers alone will drive patient volume.
• Importance of Patient Acquisition: Building meaningful connections and community engagement is critical for driving patient volume—something often overlooked by startup founders. Alex discusses tactics like forming referral networks and partnering with local organizations to build a sustainable patient base.

Key Strategies for Healthcare Startups

• Understanding Payer Volume Thresholds: Alex underscores the need for startups to grasp the minimum patient volumes required by payers to maintain contracts.
• Patient Engagement & Marketing: Effective marketing and visibility are as essential as clinical quality. Engaging patients through tailored messaging and demonstrating value within local communities can solidify a startup's presence and relevance in the healthcare landscape.

New Segment: 'Tough Calls in Healthcare'

• This episode introduces a new segment, where Alex addresses real-world negotiation dilemmas faced by healthcare professionals. In this installment, he discusses:
• Negotiating Reimbursement Rates: Tips on understanding local market rates and using data to strengthen negotiation positions with payers.
• Handling Contract Amendments: Strategies for managing unilateral changes imposed by payers and knowing when to push back or walk away.

Key Takeaways

• Beyond Business Models: For startups, having a robust business model isn’t enough—securing patient volume is essential.
• Value-Based Contracts: These can be highly advantageous, but they require a substantial patient base to fulfill the value equation.
• Community Connection: Building credibility and visibility within the local healthcare ecosystem is crucial.
• Balancing Act: Startups must balance patient volume and care quality to sustain payer relationships.
• Negotiation Essentials: Effective contract negotiation includes knowing market benchmarks and maintaining flexibility.

Companies Discussed:

• UnitedHealthcare
• Cigna

Listeners can expect a blend of in-depth analysis, actionable advice, and fresh perspectives on how to navigate the complexities of launching and sustaining a healthcare startup focused on value-based care.

• Hospital ER fees: They’ve been secret. We’re uncovering them. | Vox
• ER bills: A baby was treated with a nap. His parents got an $18,000 bill. | Vox
• Cigna hit with class action alleging it used an algorithm to reject claims

Alex Yarijanian and Dr. Chris Esguerra discuss the challenges providers face when navigating insurance plans and the barriers to accessing equitable care for patients.

Dr. Esguerra is board certified in both Psychiatry and Health Care and Quality Management and is a Fellow of the American Psychiatric Association and the American Board of Quality Assurance and Utilization Review Physicians.

Dr. Esguerra’s extensive payer-side executive experience includes:

• Senior Medical Director, Blue Shield of California
• Senior Medical Director, Magellan Health
• Deputy Chief Medical Officer, Health Plan Of San Mateo

They highlight the critical role employers play in advocating for better mental health coverage and how they can leverage their purchasing power to ensure compliance with parity laws. Ultimately, the episode aims to empower providers with the knowledge and tools necessary to advocate effectively for their patients and promote a more integrated and equitable healthcare system.

A significant focus of the episode is on the role of providers in identifying and addressing parity violations. The speakers guide listeners through the necessary steps for raising concerns regarding unequal treatment, emphasizing the importance of gathering evidence and understanding insurance policies.

This segment is particularly valuable for behavioral health providers who may face obstacles in securing appropriate coverage for their patients. The discussion also touches upon the regulatory landscape, explaining how self-insured plans differ from traditional insurance plans and the implications this has for parity enforcement.

Additionally, the episode discusses the importance of employers in advocating for better mental health coverage, encouraging providers to leverage their relationships with these entities to push for systemic changes that prioritize mental health equity.

Takeaways:

• The Mental Health Parity Act requires equal coverage for both physical and behavioral health services, ensuring that patients receive the same level of care.
• Providers should gather evidence of parity violations and present it to state regulators to advocate for fair treatment.
• Behavioral health is lagging behind primary care in integration and reimbursement models, highlighting the need for systemic reform.
• Employers play a crucial role in advocating for mental health parity by demanding better coverage from their insurance plans.
• Effective communication and partnerships between providers and health plans can lead to better patient outcomes and innovative care models.
• Tracking outcomes and demonstrating quality of care is essential for providers to negotiate better contracts with health plans.

Companies mentioned in this episode:

• Blue Shield of California
• Magellan
• Kaiser Permanente
• Google
• Apple
• Anthem
• Centene
• United
• Cigna
• Aetna
• Humana
• CalPERS
• Pacific Business Group on Health
• National Business Group on Health

Chris Esguerra MD MBA

This episode is also available as a blog post: https://healthcare-wiki.com/2021/07/21/paying-for-biopsychosocial-care/

These differences are to be expected, given that each state defines its Medicaid policy parameters, but it also creates a confusing environment for telehealth participants to navigate, particularly when a health system or practitioner provides health care services in multiple states. In most cases, states have moved away from duplicating Medicare’s restrictive telehealth policy, with some reimbursing a wide range of practitioners and services, with little to no restrictions.

One of the most common trends with live video reimbursement was the addition of eligible services to the list of telehealth eligible services, with applied behavioral analysis being the most common service addition mentioned in Medicaid manuals.

Additionally, in the wake of the COVID-19 pandemic, some states do seem to be adopting the Center for Medicare and Medicaid Services (CMS) communication technology-based services (CTBS) codes, including the virtual check-in and remote evaluation of prerecorded information, audio-only service codes and remote physiologic monitoring.

All fifty states and the District of Columbia have a definition in law, regulation, or their Medicaid program for telehealth, telemedicine, or both. Additionally, because of the allowance in most states to utilize telephone as a form of telehealth during COVID-19, some states are taking steps to broaden its permanent definitions of telehealth or telemedicine by removing the explicit exclusion of telephone or including audio-only services within the definition itself.

One of the states with the most significant changes to their telehealth policy was Massachusetts which passed a comprehensive telehealth law to require reimbursement for both Medicaid and private payers if the services are covered in-person and it is appropriately delivered through telehealth. The law contained some unique elements including specifying that the rate of payment for telehealth services provided via interactive audio-video technology and audio-only telephone may be greater than the rate of payment for the same services delivered by other telehealth modalities. It also provided payment parity for in-network providers of behavioral health services delivered via interactive audio-video technology or audio-only telephone only.

Read: https://healthcare-wiki.com/2021/08/01/telehealth-landscape-overview-50-states-dc/

Out-of-state health care practitioners must be registered with the Florida Department of Health to perform telehealth services for patients in Florida.

Health care providers must be licensed within their scope of practice by the appropriate licensing body to practice telehealth in Florida.

Providers must also use two-way, interactive communication tools, such as live video, instead of email or audio-only communication. If you use Medicaid, your telehealth provider must be registered with the Florida Medicaid program to receive reimbursement for telehealth services. Florida doesn’t require private insurers to cover telehealth, so check with your insurance company to determine if you’re eligible for the service. Some of these regulations may be altered during the COVID-19 pandemic.

In Florida, telehealth providers are permitted to prescribe medications if the medications aren’t listed as controlled substances.

Telemedicine Rule, Rule 64B8-9.0141, F.A.C.Controlled substances shall not be prescribed through the use of telemedicine except for the treatment of psychiatric disorders. This provision does not preclude physicians from ordering controlled substances through the use of telemedicine for patients hospitalized in a facility licensed pursuant to Chapter 395, F.S.

However, there is one important exception to this rule: If you need a controlled substance to manage a mental health condition, your telehealth provider is allowed to prescribe it.

Before prescribing medication, your telehealth provider must conduct an evaluation and explain the risks and benefits of the medication to you.

Filling out a questionnaire before your telehealth appointment isn’t enough to satisfy the evaluation requirement, so you should expect the provider to ask multiple questions about your symptoms and health history.

This episode is also available as a blog post: https://healthcare-wiki.com/2021/06/22/florida-market-telehealth-rule/

A Carenodes Production.