Value Based Care Advisory (VBCA) Podcast

In this episode of the VBCA Podcast, Alex Yarijanian sits down with Dr. Kumar Dharmarajan — co-founder and Chief Medical Officer of World Class Health and former Chief Scientific and Medical Officer at Clover Health — to unpack one of the most important structural differences in U.S. healthcare: incentive alignment.Why are employers often paying two to four times Medicare rates for identical procedures performed in the same hospital by the same physician?The answer isn’t clinical complexity. It’s incentive design.Dr. Kumar breaks down how Medicare Advantage plans negotiate as owners of financial risk — and why that matters. In contrast, much of the commercial self-insured market relies on administrators who negotiate without full downside exposure, creating a structural pricing gap.The conversation also explores:What Medicare Advantage plans are actually looking for when contracting with digital health and AI solutionsWhy engagement — not automation — is the real leverage pointThe economics of supplemental benefits and underutilized Star opportunitiesHome-based and remote care as risk containment strategiesThe future vision of standardized specialty care marketplacesThis is a structural conversation about incentives, risk ownership, and where execution truly matters in value-based care.Key TakeawaysIncentive alignment drives pricing discipline. Medicare Advantage plans negotiate differently because they own the full medical loss ratio.Commercial self-insured markets often lack that same alignment, contributing to higher negotiated rates.AI in Medicare Advantage is less about backend efficiency and more about member activation and physician-level quality improvement.Underutilized supplemental benefits represent unrealized revenue and quality movement.Home-based and remote care models are fundamentally about managing high-acuity risk, not convenience.Timestamps00:00 – Introduction01:39 – What Medicare Advantage plans actually want from AI vendors03:27 – Why engagement infrastructure is the real leverage point04:28 – Virtual care, socioeconomic complexity, and risk ownership06:18 – High-acuity members and access-driven cost escalation07:11 – Supplemental benefits and engagement economics08:36 – Stars, utilization, and revenue implications09:55 – Employers paying 2–4x Medicare rates10:27 – Why commercial pricing diverges12:17 – Incentive structure and negotiation power12:47 – Vision for standardized specialty care marketplacesAbout the GuestDr. Kumar Dharmarajan is a practicing cardiologist and geriatrician and the co-founder and Chief Medical Officer of World Class Health. He previously served as Chief Scientific and Medical Officer at Clover Health and was on faculty at Yale School of Medicine, where his research helped shape national post-acute care quality measures. He has published in the New England Journal of Medicine, JAMA, and Health Affairs.Companies mentioned in this episode:World Class HealthClover Health

CMS is moving tens of billions of dollars into every state to stabilize rural healthcare heading into 2026—not through across-the-board rate increases, but through targeted investments in workforce, technology, care coordination, and alternative payment models.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 LearnWhat the Rural Health Transformation Program actually isWhy this funding wave is different (state plans are concrete and approved)What state strategies reveal about access risk + reimbursement limitsHow payers should interpret this as a network adequacy / access signalWhy providers should see this as both opportunity + accountability shiftState Highlights CoveredCaliforniaHub-and-spoke maternal + specialty access modelsExample of rate + infrastructure working together (Health Plan of San Mateo specialty rate increases)TexasTechnology as a force multiplierAI-enabled specialty access, telehealth coordination, clinically integrated networksTech becomes a parallel lever to reimbursement in high-dispute marketsFloridaRemote patient monitoring (RPM) + community paramedicineUtilization management upstream in MA-heavy environmentsNew YorkPatient-centered medical homes + workforce pipelinesCare coordination over unit cost expansion in concentrated payer marketsIllinoisIntegrated primary + behavioral health infrastructureEMS treat-not-transport modelsAlternative models as a response to inflation vs lagging ratesKey Cross-State ThemesHub-and-spoke models are returning at scaleShared services (centralized EHR, billing, analytics) to reduce admin burdenAI as infrastructure (clinical decision support + operational efficiency)Specific AI use cases being funded:Automated fax processingAI scribesAI-enabled care coordinationKey TakeawayRural 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:Health plan of San MateoCaliforniaTexasFloridaNew YorkIllinoisOklahomaWashingtonUtahVermont

While most providers are waiting on CMS, payers are already narrowing networks and rewriting delegation terms.Payers are quietly narrowing networks and rewriting delegation expectations. This playbook explains how to do business with MA business for 2026.If you’re waiting, you’re already reacting—not positioning.In this episode, Alex Yarijanian breaks down what’s actually showing up in payer conversations right now, long before final CMS rules are published. Drawing from real contracting, network, and delegation discussions, Alex explains why waiting for regulatory clarity is already costing providers and health tech companies leverage.You’ll hear how payer priorities have shifted from enrollment growth to margin durability, why network narrowing is accelerating quietly, how delegation has become a stress test, and what “value-based care” really means in Medicare Advantage today.This episode also outlines who is most at risk heading into 2026, the three types of organizations positioned to win, and what provider and health tech leaders should do in the next 90 days to stay relevant.Who should listen: Provider executives, payer leaders, value-based care operators, and health tech founders navigating Medicare Advantage.

A federal jury has convicted the founders of Done, one of the fastest-growing telehealth companies in the stimulant-prescribing space, for orchestrating one of the largest Adderall distribution and fraud schemes in U.S. history. More than 40 million stimulant pills, over $100 million in revenue, and a business model engineered around speed, volume, and automated prescribing — all built with no real clinical guardrails.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 credentialingPrescribing oversight and compliance expectationsTrust in telehealth platformsThe future of value-based behavioral healthWhy incentives — good or bad — always scaleAnd 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.

Medicare’s 2026 physician fee schedule is packed with change — but change means opportunity. In this episode of the VBCA Podcast, Alex Yarijanian breaks down the five biggest updates every provider and startup should know:Shorter, billable windows for remote monitoringNew behavioral health add-ons to primary careIncentives that reward value-based careExpanded reimbursement for digital therapeutics & telehealthA major shift from inpatient to outpatient proceduresWhether you’re running a clinic or building the next health tech solution, this playbook will help you turn policy into profit and thrive in the future of care.