Value Based Care Advisory (VBCA) Podcast

Guest: Esha Mittal, Founder, The Shared Strength Project

Expert Words: Todd May, MD, Vice President & Medical Director, Health Net

Host: Alex Yarijanian

One in three young people in the U.S. live with a chronic condition, according to the National Library of Medicine — yet almost none of the funding, research, or attention going toward senior loneliness has followed youth loneliness into the room. Esha Mittal knows the gap firsthand. Diagnosed with a chronic condition in the fall of her freshman year of high school, she found that the diagnosis-based support groups meant to help her instead became what she calls "a pity party" — rooms where the illness was the only thing anyone had in common.

In November 2025, Esha launched The Shared Strength Project, a mentorship program that pairs youth and young adults living with chronic conditions with mentors matched by shared interest, not shared diagnosis. The model grew directly out of her own experience at UCSF's Wellness Center for Youth and Young Adults with Chronic Conditions, where a nurse practitioner and social worker treated her as a whole person before they ever discussed her symptoms — and where she met the mentor whose own story became the blueprint for the project.

In this episode, Esha walks through what that first isolating year actually felt like, why interest-based pairing works where diagnosis-based support groups didn't, and how a trauma-informed curriculum — built with a licensed social worker — structures every mentor meeting. We also hear from Todd May, MD, Vice President and Medical Director at Health Net, on why "youth loneliness" as a term hasn't yet made it into payer boardroom conversations — even as youth mental health broadly has.

Esha will be speaking at Behavioral Health Tech 2026 in Nashville (September 22–24, Gaylord Opryland Resort and Convention Center) on a panel about designing tools youth and young adults will actually use.

• 00:00 — Cold open: the funding gap between senior and youth loneliness
• 01:39 — Esha's diagnosis, freshman year of high school
• 03:24 — "They did not get it" — the friend-group disconnect
• 04:56 — Why the first (diagnosis-matched) support group made things worse, not better
• 07:20 — Launching The Shared Strength Project (November 2025) and the interest-based pairing model
• 09:19 — Todd May, MD (Health Net) on why youth loneliness hasn't reached payer conversations yet
• 10:33 — The UCSF Wellness Center partnership and the mentor whose story inspired the project
• 13:20 — Where to find Esha and what she's looking for next
• 13:54 — BHT2026 — Esha's panel on designing tools for youth and young adults

Esha Mittal, on the diagnosis-matched support group:

"Once we started talking about our chronic condition, it felt like that was all we could talk about. And it just became like a pity party."

Esha Mittal, on the design principle behind The Shared Strength Project:

"I chose to pair people up based on shared interest because... it would have been so valuable for me to understand myself again outside of my illness."

Todd May, MD, on payer awareness of youth loneliness:

"That term hasn't actually come up... The loneliness piece is just not getting a lot of airplay."

Per the National Library of Medicine, as cited by Esha Mittal: one in three young people in the U.S. live with a chronic condition, and 20 million American children with serious or chronic conditions face a higher risk of isolation, bullying, and mood disorders.

Esha is currently reachable via LinkedIn and is building out a project website. She's looking for opportunities to scale The Shared Strength Project beyond California.

Catch Esha Mittal at Behavioral Health Tech 2026 — September 22–24, 2026, Gaylord Opryland Resort and Convention Center, Nashville, TN.

Value-Based Care Advisory Podcast | vbcapodcast.com

Companies mentioned in this episode:

• Shared Strengths Project
• UCSF Wellness Center for Youth and Young Adults with Chronic Conditions
• Behavioral Health Tech Conference
• National Library of Medicine
• Health Net
• LinkedIn
• Gaylord Opryland Resort & Convention Center
• Value Based Care Advisory podcast

Esha Mittal

Esha Mittal is a junior at Design Tech High School living with multiple chronic conditions. She founded the Shared Strength Project in 2025, aiming to reduce isolation among youth/young adults through meaningful mentorship.

Todd May MD FAAFP

Dr. Todd May serves as Vice President Medical Director at Health Net where he provides clinical expertise for the Commercial Team. He is deeply engaged in quality improvement, population health management, health equity, advanced primary care, and implementation of innovative member engagement programs. He also provides key leadership in an innovative multi-payer initiative that promotes Advanced Primary Care in California, and another focused on improving hospital quality.

This bonus episode is the full recording of Alex Yarijanian's HBMA continuing-education webinar. It runs longer than a standard VBCA episode — treat it as a resource, not a highlight reel.

Most revenue cycle teams treat denials and underpayments as billing problems. A meaningful share of them are actually contract problems wearing a billing costume — and you can't fix a contract problem at the claims desk. This session walks through the five payer-contract provisions that generate the most downstream billing failures, a three-phase audit framework for finding them before they cost you, and a denial-routing model that keeps contract-based underpayments from getting silently written off in a clinical appeals queue.

What you'll learn:

• Why contract language — not coding errors — is where most systematic underpayment actually starts
• The five provisions to check first: fee schedule effective dates, carve-outs/exclusions, coordination of benefits, authorization & notification, and timely filing
• Why "rates effective upon execution by both parties" can quietly cost you weeks of underpaid claims
• Why vague terms like "experimental" or "time to time" in a contract are a red flag, not boilerplate
• Why state law — not the payer's internal policy — governs coordination-of-benefits primacy
• Why retroactive denial of an already-issued authorization is not just bad practice — it's against federal law for government-funded products
• A three-phase contract audit framework: highest-leakage provisions → highest-volume services → highest-friction appeal/recoupment timelines
• A three-bucket denial-routing model (clinical / administrative / contract-based) so contract-based underpayments get escalated instead of written off

Session outline:

1. Introduction — Alex's background: clinic operations, Cardinal Health/HCA, head negotiator for Humana's West Territories, then founding Carenodes to close the payer/provider information asymmetry.
2. The framing stat — a striking share of providers don't actually know what they're supposed to be paid, and contract language is where the error is born.
3. Provision 1 — Fee schedule effective dates & updates.
4. Provision 2 — Carve-outs & exclusions.
5. Provision 3 — Coordination of benefits.
6. Provision 4 — Authorization & notification.
7. Provision 5 — Timely filing.
8. The three-phase audit framework.
9. Denial routing: clinical vs. administrative vs. contract-based.
10. Close — pick your top two payers, run the checklist, renegotiate.

Resources: Contract audit checklist referenced in this session — request it at vbcapodcast.com

About the host: Alex Yarijanian is CEO & Founder of Carenodes. He spent seven years managing payer contracting operations for 600+ provider organizations across 48 states, including a prior role as leadership and negotiator for Humana's West Territories contracting and network management team.

17 minutes. That's how long Lindsay Clancy's last psychiatric visit lasted — the day before her three children died. Nine prescribers. Two hospitals. A suicide hotline called twice. And allegedly, not one person connecting the dots.

Before you listen: This episode discusses allegations from a civil complaint and public criminal-trial testimony only. We do not cover the criminal case, describe what happened to the children, or speculate on Lindsay Clancy's state of mind. None of the allegations below have been proven, and no defendant has been found liable. One named defendant has petitioned for a Massachusetts medical malpractice tribunal — a screening step, not a liability ruling. South Shore Health and the Women & Infants Health Hospitals operator have said they cannot comment on pending litigation; Astor Mental Health has not responded to requests for comment.

This is the care coordination failure hiding inside the Lindsay Clancy civil complaint (Norfolk Superior Court, filed January 2026) — postpartum psychiatric care, telehealth psychiatry's blind spots, and the reimbursement incentives nobody wants to talk about. Alex and Jasmine break down what the complaint alleges went wrong in the system, not the person.

In this episode:

• Why access without coordination isn't the same as coordinated care
• The alleged medication cascade — nine to ten prescriptions, no single clinician alleged to own the regimen
• A courtroom cross-examination over one comma in a clinical note, and what it says about documentation standards
• Two crisis hotline contacts that reportedly didn't meet the "emergency" threshold, and why postpartum psychiatric crises fall outside standard screening calibration
• 14 consecutive telehealth visits during an acute stabilization period — and testimony on what an in-person exam might have caught
• Where AI can actually help operationally, and where it can't
• Why reimbursement incentives, not individual clinicians, are the root of this gap

Hosted by Alex Yarijanian and Jasmine Singh.

#ValueBasedCare #CareCoordination #BehavioralHealth #PostpartumCare #HealthcarePolicy

Links referenced in this episode:

• risewestconference.com
• lindseyclancycase.com
• newbedfordsuicidehotline.com

Companies mentioned in this episode:

• South Shore Health
• McLean
• New Bedford

A pediatric patient in a New Jersey hospital is medically ready for discharge — equipment arranged, family ready, nursing hours authorized by the health plan. The only missing piece: an actual nurse. This episode uses that scenario to examine the structural gap between authorized private duty nursing (PDN) hours and filled hours in Medicaid managed care, why standard provider directories overstate real pediatric home health capacity, and what CMS's 2024 Medicaid managed care access rule signals for how plans will need to prove — not just claim — network adequacy going forward.

1. The Discharge That Doesn't Happen — A clinically ready child, an authorized care plan, and no nurse to staff it.
2. The Directory Problem — Why a state can show hundreds of home health agencies while only a handful actually serve pediatric high-acuity cases.
3. Authorized vs. Filled Hours — The distinction that matters most for families, and the 20–40% unfulfilled-hours range documented by MACPAC.
4. What Makes a Network a "Ghost Network" — Six reasons a directory listing doesn't equal real access.
5. Why Pediatric Home Health Is a Different Labor Market — Ventilators, trachs, feeding tubes, and why acuity narrows the real provider pool.
6. The CMS Rule — Secret shopper surveys, wait-time standards, and the shift from "is the directory complete" to "can members get care."
7. The Pediatric PDN Access Audit — A 7-step framework for MCOs to move beyond static network adequacy reporting.
8. What Providers and Advocates Should Document — Turning anecdote into evidence health plans and regulators can act on.

Companies mentioned in this episode:

• Affirmed Home Care
• Pediatrics and Adolescent Therapy Associates
• Active Pediatrics Therapy Services
• Growing Hope
• Pediatric Care for Kid Care
• Family Care Agency
• New Jersey Children's Hospital
• New Jersey Hospital Association
• Carenodes

Sources cited in this episode:

• Baxley, J. "Will increased pay solve North Carolina's home nursing shortage?" North Carolina Health News, via CityView NC.
• Brown, J. "Nurses for medically fragile kids are underpaid and hard to find. Parents want the state to step in." The Colorado Sun.
• AHA News. "OIG says MA, Medicaid managed care plans have limited, inaccurate behavioral health provider networks." American Hospital Association.
• "Ghost Network Busters." Managed Healthcare Executive.
• Fierce Healthcare. "OIG report raises red flags about maternal health 'ghost networks' in Medicaid managed care."

• MACPAC has documented that a meaningful share of authorized private duty nursing hours nationally go unfulfilled — often cited in the 20%–40% range.
• CMS's 2024 Medicaid Managed Care Access, Finance, and Quality final rule introduces secret shopper survey requirements, moving oversight from directory completeness toward actual service access.

Most revenue cycle teams are chasing the wrong fire. Persistent underpayment, denials that don't respond to appeals, patterns nobody can explain — these are often contract problems wearing a billing problem's disguise.

In this episode, Alex breaks down the structural gap between contracting and RCM that costs providers real money every day, and delivers three things you can take to your next denial review right now.

WHAT YOU'LL HEAR

• The real story behind a multi-specialty group underpaid for 12 months — and why their billing team did nothing wrong
• Why contracting and RCM live in separate worlds — and why that gap is your biggest revenue risk
• Fee schedule effective date clauses: the most dangerous amendment language in managed care contracts
• Carve-out clauses and why behavioral health denials keep looking like coding errors
• Contract dispute timelines vs. your denial management cycle — what happens when they don't match
• The one question to add to every denial review

THREE THINGS TO APPLY NOW

1. Check your fee schedule effective dates. Know the execution date on every amendment. Confirm your billing system actually flipped to the new rates. 73% of providers don't know what they're contracted to receive.
2. Map your carve-out clauses. Know which services are excluded from the base agreement and where those claims need to route — behavioral health is the most common gap.
3. Find the contract dispute window in every active agreement. If it's shorter than your internal denial cycle, that's a configuration problem costing you money today.

THE DIAGNOSTIC QUESTION

When a denial pattern doesn't respond to standard appeals, ask: Is this a billing problem or a contract problem? They need entirely different escalation paths. If your team is routing both into the same queue, contract-based underpayments are being written off — silently.

GO DEEPER: HBMA WEBINAR — AUGUST 12

Alex presents the full framework — denial categorization methodology and a contract audit checklist — live through the Healthcare Business Management Association (HBMA). 1 CEU credit available. Your Billing Problem Started in the Contract: What Revenue Cycle Leaders Need to Know Before a Claim Is Ever Filed. Presented by Alex Yarijanian

Register: https://www.hbma.org/meeting_calendar/details.php?event=3148

Checklist directly: vbcapodcast.com

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: a market entry and operational alignment commitment that happens to include a rate negotiation inside it. He walks through the six-dimension evaluation framework every health operator should run before signing anything.

On the Out-of-Network Alternative

Staying out of network intentionally can be a viable model — particularly in specialty markets where a practice can command premium rates on a self-pay or direct-pay basis. But it requires an honest accounting of trade-offs:

1. Payment at UCR (usual and customary rates) — not your billed charges, not in-network contracted rates
2. Limits on what patients can recover from their own plans, affecting your ability to attract and retain members
3. Collection burden shifts to the practice, along with associated staff time and friction
4. The No Surprises Act materially changed the out-of-network landscape for behavioral health providers in certain care settings — understand your exposure before assuming OON is a clean alternative

Key Takeaways

• Treat payer contracting as a market entry and operational alignment decision — not just a rate negotiation
• In high-concentration markets, staying out of network often means locking out of the majority of the addressable population
• Your value proposition — especially HEDIS gap closure and measurement-based care data — is a negotiating asset most practices leave on the table
• Operational alignment costs don't show up in the fee schedule. Map them before you sign
• The intersection of payer data sharing requirements and 42 CFR Part 2 is not hypothetical risk — it's real compliance exposure
• For contracts involving risk-sharing, value-based payment terms, or complex data provisions, involve experienced healthcare counsel before execution

Chapter Markers

00:00: Opening scenario — the 40-page contract lands in your inbox

01:30: Reframing the network decision — it's not a rate negotiation

02:40: Dimension 1 — Market access and concentration reality

04:00: Dimension 2 — Knowing and articulating your value proposition

05:10: Dimension 3 — Operational alignment and hidden administrative costs

06:20: Dimension 4 — Payer's past performance and claims adjudication reality

07:30: Dimension 5 — Physician profiling and measurement programs

09:00: Dimension 6 — Data sharing, 42 CFR Part 2, and compliance exposure

10:15: The out-of-network alternative — honest trade-offs

11:20: Practical takeaways and when to involve healthcare counsel

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

1. Financial Risk Readiness Define your risk corridor tolerance and downside exposure thresholds before anything else. Build a three-year proforma with utilization and trend assumptions. The CFO gut check: if trend runs 2% worse than expected, do you still survive? Secure financial guarantees and a reinsurance strategy before you submit.
2. Data and Interoperability It is not enough to collect data. CMS wants to see integrated clinical, claims, and SDOH data feeds with real-time or near real-time performance tracking. Demonstrate evidence of data-driven interventions — not just reporting. The core question CMS is asking: can you act on data, or just collect it?
3. Care Model Differentiation Define your care coordination infrastructure. Are you using RNs, community health workers, behavioral health integration? Do you have programs targeting high-cost, high-need (HCHN) populations? Are you integrating non-traditional services like doula care or CHWs? Reviewers want to see biopsychosocial care — not just medical management. Medical management alone is a red flag.
4. Network and Contracting Strategy CMS wants to see documented value-based contracts downstream — not just your arrangement with CMS. Can you push risk one step further? Do you have a specialist and post-acute alignment strategy? Note: roughly 80% of costs occur in the 90 days post-hospital discharge. Weak alignment equals leakage equals missed savings equals poor financial performance.
5. Operational Execution Plan Submit named executives and clinical leadership. Define your care workflows and escalation pathways. Provide a clear go-live and scale timeline. CMS reviewers are specifically watching for the "nice idea, no operator" red flag. They want robust operators behind every submittal.
6. Equity and Access Strategy Health disparities planning is no longer a narrative — it is a scoring mechanism. Whether or not you call it equity, operationalizing access will directly impact your financial outcomes. Integration with community-based organizations signals this. If you cannot operationalize access, you cannot succeed in this program.

THE BRUTAL TRUTH

Most organizations won't fail LEAD because they're ineligible. They'll fail because they realize too late they were never built for risk. LEAD isn't the program — it's a mirror. Start with your assumptions, not your application.

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

• 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

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