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The Grand Roundup will be live today at 12p ET/9a PT
It’s Monday, April 27th, and earnings season in health care is very much underway, which means everyone in our respective households is already tired of hearing disclaimers about certain “forward-looking statements” within the meaning of the Private Securities Litigation Reform Act of 1995.
On today’s show, we’ll be recapping Q1 reports from UnitedHealth Group, Molina, Elevance, and HCA; Martin will describe the “tragedy of the commons” shape of $440k breast reduction procedures and the No Surprises Act IDR process; and Kevin will be sharing his controversial yet brave opinion on what you should be willing to give up to make American health care better.
Plus, we’ve got an incredible guest line-up to cover the state of the behavioral health market, AI advocates for Medicaid patients, ACCESS, and the state of the health insurance broker market.
Today’s Guests
12:15 pm ET: Allison Oakes, Chief Research Officer at Trilliant Health, to discuss their latest behavioral health report.
12:35 pm ET: Neil Batlivala, CEO and Founder of Pair Team, on AI-Powered Advocates for Medi-Cal and participation in ACCESS.
1:05 pm ET: Amanda Rees, CEO and Co-Founder of Bold, on their ACCESS participation and the challenges of behavior change.
1:35 pm ET: Patrick Keavy & Rebecca Springer from Bailey & Company, reflecting on Medicarians and their recent report on the Medicare Advantage brokerage space.
Puts & Takes
In one of many memorable scenes from the Great Financial Crisis era classic Margin Call, John Tuld (played by Jeremy Irons), the CEO of an unnamed investment bank, reminds the bank’s senior leadership that there are “three ways to make a living in this business: be first, be smarter, or cheat.”
I’m not sure what that list would look like for a health insurance company, but it hasn’t really mattered all that much, since, for the most part, health insurance companies, big and small, aren’t making much of a living at all lately. The Wall Street Journal’s David Wainer worries they’re becoming “chronically uninvestable,” and HealthScape Advisors paints a bleak picture for regional and non-profit plans in the coming years.
But the three-part playbook for an insurer to make a living (or at least remain solvent) looks something like: make good actuarial projections about your risk pool, design benefits thoughtfully, and/or manage patient utilization so that premium dollars cover all the medical and administrative costs and leave a little something left over for the shareholders. Of these, actuarial projections, like most predictions, especially about the future, are hard, and benefit design is an incredibly complex bit of game theory, so it’s a lot easier, relatively, to manage utilization.
Of the specific plays in the utilization management part of the playbook, prior authorization is among the least loved in Washington, D.C., and in state capitols, as well as among patients and doctors. So much of the recent regulatory scrutiny has been around reducing or eliminating prior authorizations, with major payors announcing significant changes to the way they’re used, and UnitedHealthcare going as far as to eliminate most prior auths for rural hospitals and providers.
This seems like good P.R., given how much people dislike prior authorization, but likely to exacerbate the profitability problems for health insurance companies. In MedCity News, Humata CEO Jeremy Friese published an op-ed titled “‘Prior Authorization’ Has Become a Dirty Word in Healthcare, But it Might Be Medicare’s Smartest Path Forward,” which lines up with my thinking on the subject.
Of course, as Kevin pointed out in Weekly Health Tech Reads yesterday, there’s a fourth way for insurers to make a living: winter snowstorms and a lighter-than-expected respiratory illness season, which led to lower hospital utilization.
Unfortunately for the health insurers, controlling the weather or the acuity of the flu season is probably harder still than predicting the future, so it looks like the utilization management will have to continue.
Rounding Out The Roundup
For a summary of funding announcements, headlines, and jobs, check out Kevin’s Weekly Health Tech Reads here.
Management consulting firm BCG shared an Executive Perspectives deck titled AI-First Providers Win The Future which makes the case that labor productivity improvements from AI are the best lever for health systems to manage structural pressures
Seth Cohen, President at Cedar, noted: “nearly 40% of collectible dollars now come from patients without insurance coverage — up 54% in just three years” which tracks a theme we heard from HCA management on earnings last week about self-pay rates, financial counselors, and the ~$150 million impact in the first quarter from the expiration of the enhanced premium tax credits for the ACA.
In a provocatively titled Substack, John Mandrola writes that “‘Sick’ care is what doctors are for,” making the case that the “primary prevention of disease is best left to society, and of course, luck. Not doctors.”
On LinkedIn, Benjamin Schwartz, MD, MBA, replies to Zeke Emanuel’s Bulwark op-ed, taking issue with the longer wait times for elective surgery proposal, citing a study from the NHS which “found that waiting beyond three months for TJA resulted in excess costs and diminished health-related quality of life.”
Jason Locasale, Joseph Marine, and Ge Bai, writing in Health Affairs Forefront, outline a strategy for “Enhancing The NIH’s Return On Investment for Taxpayers,” apropos as a debate in D.C. over the agency’s funding, pace of grants, and purpose continues.
More from Health Tech Nerds
Weekly Health Tech Reads 4/26/26: Q1 earnings season kicks off, AI pilots running into political issues, a musing on sacrificing for better healthcare, and more. Read here.
Community Brain Trust: Earnings season coverage, FDA begins process of easing peptide restrictions, legal standards for digital patient consent, and more. Read here.
Weekly Health Policy Briefing: A real tragedy of the commons situation in the IDR process and state-level "public options.” Read here.
The Grand Roundup: Digital vs consumer health participation in ACCESS, maternity care unbundling, Abridge and clinical intelligence, Yuzu's pivot to power alternative plans, peptide market, price transparency, AI-driven risk adjustment funding, and more.
Maternity care unbundling: why the global payment bundle is ending and what it means for innovation, costs, and access | Neel Shah (Maven Clinic)
From AI scribing to clinical intelligence: how Abridge is expanding its role across the clinical encounter | Shiv Rao
Why a connected device company is well positioned for CMMI's ACCESS model | Patrick Sheehan (Withings)
From building an alternative health plan to powering them: what Yuzu learned and why they pivoted | Russell Pekala & Will Gillach
Why so few patients access palliative care, and how Empassion is addressing that | Robin Heffernan (Empassion)