Value Based Care Advisory (VBCA) Podcast

You've built the operation — clinicians credentialed, tech stack running, compliance buttoned up. Then a regional Medicaid managed care plan wants to talk about contracting. Your first instinct: great, let's do it. Then someone pulls up the 40-page contract with a 43-code prior authorization matrix and a data-sharing provision you're not sure sits cleanly with your other obligations.

The fee schedule is fine. Not great — fine. And now the question isn't can we do this. It's should we, and on what terms?

In this episode, Alex breaks down the payer contracting decision as what it actually is...

CMS has posted the LEAD (Long-Term Enhanced ACO Design) model application materials. Preliminary scoring is due April 27, 2026. Full applications are due May 17, 2026. LEAD replaces ACO REACH in 2027 and runs as a 10-year demonstration with enhanced payments and care coordination flexibility.

Most ACO applications fail before they're submitted — not because organizations are ineligible, but because they were never really built for risk. This episode breaks down the six scoring domains, in order of importance, that CMS will use to evaluate your application.

WHAT WE COVER

Rate sheets don't tell the whole story.

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

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 finan...

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...

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...

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 co...

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:

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.

Welcome back to the Value-Based Care Advisory podcast! In this episode, host Alex Yarijanian delves into the significant updates and strategies for 2026 in the Medicare Advantage space. He covers essential news and policy changes, including a 5% increase in Medicare payment rates, the scaling back of supplemental benefits, and the permanence of telehealth for behavioral health. Alex also discusses updates to the Medicare physician fee schedule, redesigned enrollment forms, new health risk assessment requirements, and the transition to a new risk adjustment model. Learn how these changes will impact care delivery, compliance, and strategy, and discover what it takes to...

In this episode of the VBCA podcast, host Alex Yarijanian delves into the often overlooked yet crucial aspect of leadership: emotional labor. Discover how managing emotions plays a pivotal role in negotiations and leadership effectiveness. Alex shares personal experiences and insights on how emotional labor can be both a powerful tool and a silent tax on leaders, especially for those challenging dominant norms. Tune in to learn how to harness emotional intelligence to build trust and lead with empathy and strength.

Takeaways:

This podcast episode delves into the intricate relationship between mindfulness meditation and its profound implications for healthcare leadership. We explore how mindfulness practices not only enhance emotional well-being but also significantly improve the quality and effectiveness of leadership within healthcare settings. Through a rigorous examination of scientific evidence, we elucidate the neurological benefits of mindfulness, demonstrating its capacity to modulate stress and foster cognitive flexibility, thereby enabling leaders to navigate the complexities of their roles with greater composure and efficacy. Furthermore, we provide practical mindfulness training techniques that can be seamlessly integrated into the daily routines of healthcare professionals...

How Health Tech Startups Can Win at Managed Care Contracting: Insider Strategies for Scalable Payer Partnerships.

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...

This conversation explores the historical context of childbirth, the current state of maternal mortality in the U.S., and the emerging role of doulas in modern maternity care. It highlights the paradox of high maternal mortality rates despite advanced medical technology and discusses how doulas can improve outcomes and reduce costs in the healthcare system.

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

Takeaways:

The podcast delves into the complexities and challenges of the American healthcare system, arguing that it often prioritizes profit over patient care. Through the lens of investigative journalism from More Perfect Union, the hosts explore how companies like CVS Caremark and pharmaceutical giants manipulate the system to maximize their profits, often at the expense of those they are supposed to serve. They highlight the troubling trend of Medicare Advantage plans cherry-picking healthier patients to boost their bottom line, leaving those with greater needs reliant on traditional Medicare. The discussion also uncovers the hidden influence of consulting firms like McKinsey...

What Every Provider and Innovator Must Know Going into 2025:

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...

Welcome to this eye-opening episode of the VBCA Podcast, where we tackle one of the most pressing yet underreported issues in healthcare: hidden fees, surprise bills, and the alleged cartel controlling out-of-network reimbursements.

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:

This episode explores the rising tide of healthcare startups pursuing value-based care (VBC) with ambitious visions to improve patient outcomes and lower costs. However, without a robust patient acquisition strategy, many founders find themselves struggling to meet volume requirements, maintain contracts, and deliver quality care. Through candid dialogue and practical insights, host Alex Yarijanian addresses these pain points and offers actionable advice for navigating the competitive healthcare market.

Segment Highlights

Startup Realities in Value-Based Care

This podcast episode dives deep into the complexities of mental health parity and the implications of the Mental Health Parity Act. The conversation emphasizes the necessity for behavioral health services to be treated with the same level of care and coverage as physical health services, addressing the ongoing disparities in treatment and reimbursement practices.

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...

This episode is also available as a blog post: https://healthcare-wiki.com/2022/03/12/changing-demographics-value-based-care/

The system used to pay for health care today does not encourage the integration of health care and social care, nor can it adequately adapt to the trending shift toward value-based payments for care — paying for better quality and better health outcomes. New financing approaches are needed to enable the health care sector to engage in activities that strengthen social care and community resource.

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

No two states are alike in how telehealth is defined and regulated. While there are some similarities in language, perhaps indicating states may have utilized existing verbiage from other states, noticeable differences exist.

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...

During the 2019 legislative session, Florida passed Chapter 2019-137, Laws of Florida, which establishes standards of practice for telehealth services, including patient evaluations, record-keeping, and controlled substances prescribing. The law also authorizes out-of-state health care practitioners to perform telehealth services for patients in Florida. Signed by the Governor on June 25, 2019, this law became effective on July 1, 2019.

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 t...

California Governor Gavin Newsom on September 25 signed Senate Bill 855, Health coverage: mental health or substance use disorders, into law. The law increases health and disability insurers' coverage obligations for mental health and addiction diagnosis, prevention, and treatment in the state.