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:

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.

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.

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

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

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).

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

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

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

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

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 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.

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:

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.

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 thrive in this evolving landscape. Tune in and prepare for the Medicare Advantage showdown of 2026!

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.

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:

• 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.

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, offering a pathway to both personal and organizational transformation. Ultimately, this discourse underscores the necessity of cultivating a mindful approach in healthcare leadership to enhance overall performance and well-being.

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

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 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

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 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