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Tag: Providers

  • Medicare Policy Shouldn’t Be Made in the Shadows

    Medicare Policy Shouldn’t Be Made in the Shadows

    As a rheumatologist, I treat rheumatoid arthritis (RA) and other complex autoimmune diseases. If you have or happen to develop one of these diseases, I am thankful that science has delivered amazingly effective targeted therapeutics and biologics in recent decades. While highly effective, these treatments come with a high economic cost, so I have grown accustomed to daily battles with commercial insurance plans to get working-age patients the treatments they need. While horror stories abound regarding commercial insurers, Medicare has traditionally been a more predictable partner for my older patients. Medicare reimbursement is low — an issue worthy of a separate commentary piece — but comes on time, typically without the hassle and administrative delays of prior authorizations, assuming we use our therapeutics within FDA-approved dosing and indications.

    On top of these existing challenges here in the Midwest, providers recently won a battle we did not expect to have to fight with a Medicare administrative contractor (MAC). The story deserves scrutiny from legislators and regulators nationwide. 

    Medicare beneficiaries rightly assume, as have I, that policy spells out the services they are entitled to receive. Lawmakers in Congress establish patients’ benefits in law, while the Centers for Medicare & Medicaid Services (CMS) develops the national rules and policies to implement them. MACs fit into this process by administering those rules regionally (with some discretion), but they are not supposed to privately create new substantive conditions of payment.

    Recently, the MAC overseeing Kentucky and Ohio began auditing and denying claims for intravenous Orencia, a biologic drug used to treat RA, citing a “lack of medical necessity.” The policy affected more than a hundred patients who had mostly been on Orencia for a decade or more. These patients were forced to stop or delay treatment or switch therapies, which resulted in serious RA flares. MAC administrators had decided that most patients on intravenous Orencia, covered under Medicare Part B, should instead receive subcutaneous Orencia, covered under Medicare Part D and often at substantially higher out-of-pocket cost. 

    The decision was made without a formal notice-and-comment process. In fact, this requirement does not even appear in the Medicare guidance cited for this decision. Worst of all, it effectively forced dozens of patients off a life-changing therapy.

    Thanks to outreach from clinicians, national advocacy organizations, angry patients, and congressional representatives, this policy was walked back. Or at least, we think so. There was no announcement of a reversal. Instead, the MAC covering Kentucky and Ohio quietly revised a fact sheet on its website, removing language that preferred subcutaneous over intravenous dosing. 

    This whiplash has been devastating to my own small clinic, however, as the MAC continues to withhold the equivalent of roughly three payrolls’ worth of payments for treatments we rendered in good faith during this period. They have also not answered repeated inquiries about whether denials issued under the now-removed standard will be reversed. 

    This situation exposed several problems that need to be addressed before this happens to other MACs, Medicare beneficiaries and clinicians:

    1. The current system allowed one medical director’s opinion to acquire the force of Medicare policy without an effective check. This violates the Supreme Court’s decision in Azar v. Allina, which limits the government’s ability to create substantive Medicare payment standards through informal guidance. Yet it still took months of work, worry, and countless hours distracted from providing clinical care to get the issue elevated to a level where the policy was reconsidered. 

    2. There is inadequate accountability and little transparency within MAC operations. After an initial call with the MAC medical director to raise this issue, we went for weeks with response and no clue as to where our appeal stood. Providers didn’t know how to “correctly” care for our affected patients. When the disputed language did quietly disappear from the fact sheet, there was no public explanation, formal announcement, or directive regarding claims already denied. 

    3. There is no clearly identified chain of command to move a critical issue of patient harm from a regional MAC to CMS. As an experienced advocate, I leveraged my relationship with my congressional representative and the American College of Rheumatology to elevate this issue to CMS, but what if I hadn’t had those relationships? Our system should not require physicians to become experts in Medicare law and policy just to ensure the Medicare system follows its own rules.

    Medicare beneficiaries deserve better. While in this case we’ve been able to protect access to intravenous Orencia, this experience exposed flaws that extend far beyond one drug or one MAC contractor. We should all be concerned that MACs are increasingly making unilateral decisions that negatively impact patient access. Medicare policy should be transparent and include appropriate notice and stakeholder input. And when a contractor gets it wrong, there should be a clear and rapid way to stop the harm to patients, their relationship with their doctor and the doctor’s practice. A patient’s access to Medicare-covered care should never depend on whether their physician can find someone in Washington willing to intervene. Something must change.

    Author bio:

    Dr. Chris Phillips is an American College of Rheumatology leading rheumatologist and owner of Paducah Rheumatology.

    Photo: Stas_V, Getty Images

  • Pediatric Innovation Isn’t a Small-Market Problem, It’s an Incentive Problem

    Pediatric Innovation Isn’t a Small-Market Problem, It’s an Incentive Problem

    pediatric kids children

    The case for investing in children’s health should be self-evident. As a society we have a responsibility to invest in the next generation, and few investments carry greater long-term benefit than helping children reach their healthiest possible futures.

    When we diagnose and treat conditions early, we do more than improve a child’s health in the moment. We are altering the trajectory of their entire life: development of their personal confidence, resilience, mental wellbeing, learning capacity, and in many cases, also reducing decades of downstream public and private healthcare costs.

    Yet, pediatric innovation remains chronically and systemically undervalued in healthcare.

    That is not because the market for pediatric healthcare is small, it is because the incentives are misaligned. The cost of treating a child’s condition is incurred immediately. However, when early pediatric interventions are effective, their benefits often compound over decades.

    No single stakeholder is incentivized to properly and accurately consider the full return on early pediatric interventions and support their adoption. The average tenure of a person staying on the same health plan is two to three years. As a result, private insurers are focused on cost savings that will be realized within that time frame, which for pediatric treatments especially, may only represent a small proportion of the overall benefit.

    On the public insurance side, children are largely covered by Medicaid, and while pediatric health is a central tenet of Medicaid’s mission, the program is too often hamstrung by its structure. Unlike Medicare, which is entirely financed at the federal level, Medicaid is jointly financed between the federal government and each individual state. The program is often left underfunded, as its budget is subject to annual appropriations decisions by state legislators who have limited fiscal flexibility. Priorities are constantly changing, making long-term planning next to impossible for Medicaid decision makers.

    That misalignment has consequences well before a new technology ever reaches a payer’s desk. When long-term pediatric outcomes are undervalued, the ripple effect moves backward through the entire innovation pipeline, shaping what gets funded, what gets studied, and what ultimately reaches patients.

    Investors, wary of uncertain reimbursement and lower near-term returns, often direct capital toward adult indications with clearer paths to market. Drug and device developers may follow the same logic, deprioritize pediatric programs or skip pediatric studies. The result is a self-reinforcing cycle: limited investment leads to fewer pediatric success stories, which then reinforces the false perception that pediatric markets are too small or too risky to justify meaningful investment.

    This is why pediatric innovation in healthcare must be evaluated differently.

    Payers should require robust clinical evidence to make responsible coverage decisions. But the decision making framework for pediatric products should reflect the unique realities of childhood conditions: the value of early intervention, the long-term costs and consequences of undertreatment, and the potential for a therapy to alter a child’s life path before preventable challenges become permanent ones.

    Policy leaders should also examine whether existing pediatric coverage pathways are actually keeping pace with modern innovation. In theory, we already have a powerful mechanism for this: the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit. Under federal law, EPSDT mandates that Medicaid-enrolled children receive all medically necessary services to correct or ameliorate important pediatric conditions, regardless of whether those services are explicitly covered in a state’s standard plan. It is a visionary policy designed to ensure that no child is left behind by the structural limitations of our healthcare system. In practice, awareness of the EPSDT benefit among Medicaid beneficiaries is low, and Medicaid plans need to do more to streamline the approval process for EPSDT-covered technologies.

    Investing in pediatric care is not simply a moral imperative. It is one of the most practical long-term investments the healthcare system can make.

    The question is not whether children’s health is worth the investment, that answer is self-evident. The real question is whether our healthcare ecosystem has the foresight to correct these incentive structures before another generation of children bear the cost of our delay.

    Photo: Suriyapong Thongsawang, Getty Images

    Scott Xiao

    Scott Xiao is the co-founder and CEO of Luminopia, a therapeutics company developing software-based interventions at the intersection of ophthalmology and neuroscience. Luminopia’s lead product is a novel FDA-cleared prescription digital therapeutic for amblyopia, the leading cause of vision loss in children, affecting approximately 1 in every 30 children. Scott founded Luminopia after leaving Harvard University at age 17, inspired by a classmate’s experience with amblyopia and the limitations of traditional treatment. He has led the company from early development through clinical validation, regulatory clearance and national commercialization, with the therapy now prescribed to more than 12,000 patients by 1,300+ providers at 600+ top eye institutes, children’s hospitals and private practices. Under his leadership, Luminopia became the first FDA-cleared virtual reality–based treatment for any medical condition. Scott has also spearheaded Luminopia’s real-world evidence strategy, including the development of the PUPiL Registry, which has been instrumental in securing both FDA label expansion and major payer coverage decisions. Scott has been recognized on Forbes 30 Under 30 list in Healthcare, MIT Technology Review Innovators Under 35, and Modern Healthcare’s 40 Under 40. Luminopia was also named one of TIME’s Best Inventions of 2023. Scott is a strong advocate for the role of technology in improving patient engagement and outcomes and is focused on expanding Luminopia’s pipeline to address additional neuro-visual conditions, including strabismus and vision loss following stroke or traumatic brain injury.

    This post appears through the MedCity Influencers program. Anyone can publish their perspective on business and innovation in healthcare on MedCity News through MedCity Influencers. Click here to find out how.

  • Vitalize Secures $31M To Help Hospitals Manage Labor, Capacity

    Vitalize Secures $31M To Help Hospitals Manage Labor, Capacity

    money growth fundraise

    Vitalize, an AI platform that helps hospitals manage labor and capacity, announced Tuesday that it raised $31 million in Series A funding.

    The platform functions like an “air-traffic control” system for the healthcare workforce, according to Veeraj Shah, co-founder and CEO of Vitalize. It coordinates scheduling, staffing and patient capacity. It supports processes across inpatient, ancillary and ambulatory care settings.

    “Labor accounts for 50-60% of hospital operating costs, yet many health systems still manage staffing and capacity through manual, disconnected processes,” Shah told MedCity News. “Vitalize is helping move these operations from manual and reactive to automated and predictive, reducing administrative burden and unnecessary labor costs while improving patient flow.”

    The Series A round was led by Oak HC/FT, with participation from Norwest, .406 Ventures, Constellation Ventures, Y Combinator, Rock Health Capital and MemorialCare Innovation Fund.  Vitalize declined to share its total funding to date.

    “Labor is a nearly trillion-dollar line item for U.S. health systems, making it one of the largest and most underpenetrated software markets in healthcare,” said Vig Chandramouli, partner at Oak HC/FT, in a statement. “What sets Vitalize apart is that it doesn’t just surface insight – it drives action, and the ROI shows up fast. We’re thrilled to back co-founders Veeraj Shah and Sanketh Andhavarapu, and a founding team with the clinical, operational, and technical depth to capture a market this size.”

    The financing will be used to build Vitalize’s growth and deployment teams, as well as to invest in their AI models, Shah said.

    The company’s platform is achieving results, according to some clients. St. Luke’s Chief Information Officer David Pereles said the company saw a 54% reduction in premium labor spend across overtime and agency costs in just 12 weeks. Rochester Regional Health Chief Nurse Executive Dan Ireland said its clinical leaders are spending 50% less time on manual staffing and scheduling.

    Shah said the company’s ultimate goal is to “unlock healthcare’s full capacity.”

    “Our thesis is that the workforce is the key to unlocking the hardest operational challenges in healthcare delivery and enabling our system to see more patients,” he said. “After labor operations, Vitalize will move to capacity management and supply chain optimization to serve as an intelligence layer for healthcare operations.”

    Photo: Richard Drury, Getty Images

  • Trilliant Health: Misaligned Incentives Are Undermining US Healthcare

    Trilliant Health: Misaligned Incentives Are Undermining US Healthcare

    The U.S. healthcare system is facing a tragedy of the commons, in which each stakeholder is incentivized to act in their own self-interest. That is the focus of Trilliant Health’s report released on Tuesday.

    Trilliant Health is a healthcare analytics and market research firm. The report examines six trends drawn from Trilliant’s claims database, price transparency data and government and industry sources.

    “The six different trends that we cover all really tie into the tragedy of the commons, which ultimately is this idea that incentives reward individual actors for their behavior that the collective cannot sustain, and this is just something that we see throughout our healthcare system,” said Trilliant Health’s Chief Research Officer Allison Oakes. “Unfortunately, everyone in the healthcare system is really incentivized to be managing and sort of optimizing for their own revenue and profits, and no one is entirely responsible for actually improving health.”

    The six trends include:

    1. The healthcare system isn’t functioning as a system: About 70% of Americans believe the healthcare system has major problems or is in a state of crisis, and healthcare costs are continuing to rise. Employee deductibles and premiums are increasing faster than wages and inflation.

    “Americans are more concerned about affording healthcare than they are about gas, housing, utilities, and groceries. … I think this affordability issue is really starting to hit a breaking point,” Oakes said.

    2. Population unwellness is a systemic failure: The U.S. population is increasingly becoming unwell due to poor diet, physical inactivity and social isolation. However, healthcare incentives continue to prioritize sick care over prevention.

    Pediatric behavioral health visits for pervasive developmental and anxiety disorders increased substantially from 2019 to 2025. In 2025, 6.4% of children were taking five or more medications, and more than 10% of patients in 11 states received opioid prescriptions from three or more providers. 

    3. Disconnect between demand and supply: Behavioral health and primary care physician supply is lacking. By 2038, the overall physician supply is projected to meet just 87.7% of demand, with adult psychiatrists and primary care physicians facing the largest shortages at 49.8% and 80.4% adequacy, respectively.

    In addition, advanced imaging and behavioral health visits grew faster than primary care from 2019 to 2025, while consumers increasingly turned to self-testing and other nontraditional approaches to meet their health needs.

    4. Value is not incentivized, nor measured or managed: CMS uses more than 800 active quality measures, but only 27% are tied to outcomes. In addition, hospital negotiated rates show little correlation with quality, with higher prices not necessarily associated with lower 30-day mortality rates, the report found.

    5. Fraud, waste and abuse: Misaligned incentives are contributing to fraud, waste and abuse, the report shows. From 2019 to 2024, the number of for-profit hospices rose 11.2%, and nonprofit hospices fell 2%. In addition, for-profit hospices saw a 13.7% Medicare margin in 2023, versus -1.3% for nonprofits.

    6. Negative-sum game: New medications are challenging the U.S. healthcare system’s traditional reliance on higher patient and procedure volumes to drive revenue. 

    The growing use of drugs such as GLP-1s and SGLT2 inhibitors has coincided with declines in certain procedures, suggesting that medications could increasingly replace or reduce demand for costly interventions.

    Photo: champc, Getty Images

  • PBM Transparency Is Still Too Opaque — How Can Employers Rein In Drug Costs?

    PBM Transparency Is Still Too Opaque — How Can Employers Rein In Drug Costs?

    close-up studio macro shot of various pills on US dollar bills.

    Healthcare premiums are expected to jump another 9% in 2027. The cost of care is reaching a point where some are forgoing health insurance entirely. Health plans and employers are looking for a cost-relief valve wherever they can.

    Earlier this year, Congress moved to lower pharmaceutical costs, passing the Consolidated Appropriations Act of 2026 (CAA of 2026). The bill included pharmacy benefit management (PBM) reforms that would add greater transparency to the process these organizations use to price prescription medications. The legislation mandates that PBMs submit detailed semi-annual reports to employers about their rebate prices and overall spending. This has largely been celebrated as a major win for the healthcare industry. For employers, it’s a wait-and-see game, as its impacts won’t be felt until 2027.

    Ahead of the CAA of 2026 and due to settlements with the Federal Trade Commission, PBMs are shifting how they manage their revenue. Some are telling their investors directly that, despite added regulation, they expect revenue to remain the same. PBMs are doing this by restructuring how revenue is captured and keeping it within their own ecosystem under a different label. This undercuts the transparency the legislation aimed to create—before it has even taken effect.

    This means employers are trying to comparison shop in a market where all the price tags are hidden. And most can’t simply switch PBMs to find better pricing for their members. They face two structural challenges:

    ●   Contractual hurdles: Most PBM contracts require lengthy notice periods for termination. Larger employers with custom contract terms often face notice requirements of up to 12 months. In practice, that means the decision to leave must be made before most employers have even begun evaluating alternatives. And leaving a contract early means an employer who received a rebate reconciliation payment or a performance bonus may be required to return it upon early termination, essentially penalizing them for exercising their right to change vendors. Rebate reconciliation timing creates an additional financial exposure. Most PBM contracts include a rebate reconciliation period of 12 to 18 months following contract termination, during which the PBM retains the right to adjust previously reported rebate figures.

    ●   Data blockades: Upon termination of a PBM contract, employers are entitled to their claims data, but the timeline, format, and completeness of that data transfer are frequently governed by contract language that favors PBMs. Common tactics include:

    ○    Requiring expensive translation of proprietary data before a new PBM can intake it, potentially creating months-long implementation delays.

    ○    Charging data extraction fees that are not disclosed until termination is initiated, sometimes running into tens of thousands of dollars for larger plan populations.

    ○    Delaying the transfer of member eligibility files and prior authorization histories, which creates coverage gaps and member disruption at the moment of transition. For example, say a member is mid-therapy on a specialty drug with an active prior authorization; that authorization does not automatically transfer to the new PBM. The incoming PBM must re-adjudicate it, and during that window the member may face a coverage interruption.

    Switching PBMs is inherently disruptive, time-consuming, and designed to create transition friction. However, there are times when finding a better-fit PBM outweighs the roadblocks. If that time comes, here are five key areas employers should consider to lower costs for their members:

    ●   A strong foundation: Choose a PBM that employs rigorous clinical management, prior authorization, and formulary management practices. These are the primary mechanisms through which a PBM controls drug mix, ensures clinical appropriateness, and prevents unnecessary spend.

    ●   Specialty drug management: This is often the highest-yield starting point. Strategies including specialty PBM carve-outs, site-of-care optimization, and alternative funding programs can reduce specialty spend by 25% to 40% in some categories, based on documented employer case results.

    ●   GLP-1 management: Obesity-related GLP-1 clinical management programs that pair pharmacist coaching with behavioral support have shown reductions in ongoing GLP-1 utilization while preserving outcomes. Poorly structured programs may only shift costs rather than reducing them.

    ●   Biosimilar-first policies: Employers should check their PBM contract for any biosimilar-first policies that may be in place for applicable drug categories. In many incumbent PBM formularies, branded biologics remain preferred due to rebate economics, even when a biosimilar is clinically equivalent and significantly less expensive.

    ●   Transparency rules: Transparency requirements from the CAA of 2026 will compel greater fee disclosure, and employers who understand what those disclosures mean will be better positioned to act on them. The challenge is that most employers are not currently equipped to interpret what they see. That is where independent pharmacy advisors and employer-based coalition models can play a significant role.

    While momentum is growing to enact more transparency across the healthcare industry and more specifically within the PBM space, the current disclosure rules still fall short of what employers need to lower costs. True transparency means employers can see every dollar that flows through their PBM: where it originates, who retains it, and on what basis. That means:

    ●   Rebates are passed through in full and disclosed at the claim level

    ●   A PBM’s specialty pharmacy is not receiving preferential routing that generates undisclosed margins

    ●   Administrative fees are itemized and auditable

    ●   Formulary decisions can be traced to clinical rationale rather than manufacturer economics

    Healthcare continues to become more expensive, but employers don’t have to be passive participants. Even in an opaque PBM landscape, they can demand greater accountability and make more informed decisions that lower costs and improve care.

    Photo: OsakaWayne Studios, Getty Images

    Christine Johnston

    With over 20 years of experience in the PBM space, Christine Johnston
    is an accomplished pharmacy benefit leader and consultant with a demonstrated history of managing costs and improving processes for plan sponsors. She is the General Manager of MacroHealth‘s Pharmacy Solutions Marketplace and was previously the co-founder and president of Foundational Pharmacy Strategies, which was recently acquired by MacroHealth. Prior to that, Christine led a small pass-through PBM. Christine is dedicated to lowering the overall cost of care to ensure individuals do not face difficult trade-offs between essential needs and necessary medications.

    This post appears through the MedCity Influencers program. Anyone can publish their perspective on business and innovation in healthcare on MedCity News through MedCity Influencers. Click here to find out how.

  • From Distributor to Disruptor: Amazon’s Healthcare Flex

    From Distributor to Disruptor: Amazon’s Healthcare Flex

    Could this be Big Tech’s ultimate healthcare flex? For years, Amazon’s ambitions in this $4 trillion market were focused on distribution: acquire a pharmacy here, a primary care network there, and offer convenience.

    But more recently, rather than deploying capital to expand its fulfillment engine, Amazon exercised its cloud and AI muscle to launch tools that enable it to be a “front door” for consumers and patients. From the looks of it, the e-commerce giant has shifted, from competing for a piece of the healthcare journey to collapsing the entire journey into one company.

    In any case, pharma commercialization teams may need to think about Amazon less as a new distributor and more as a disruptor of how patients, prescribers, and payers connect.

    Analyzing the moves

    Big Tech has upended many industries, but the highly regulated and complex healthcare industry has seemed impervious to their influence. Judging by Amazon’s most recent forays, however, this sector may not represent an innovator’s “white whale” for much longer.

    Amazon has closed the “last mile” between writing a prescription and filling it. At One Medical clinics (Amazon’s primary care venture), pharmacy kiosks now let a patient walk out of an appointment with medication in hand, filled by the same company that just diagnosed them. Its oral GLP-1 management program, a recently introduced offering, takes this even further. 

    This year, One Medical also launched an AI-enabled assistant, with access to test results, medical history, and more. The AI agent, dubbed Health AI, can help book medical appointments or provide medical information, such as an explanation of lab results. This clearly strengthens One Medical’s abilities as a provider and can help in enhancing the patient experience all the way through drug dispensing.

    More critically to pharma, Amazon’s Health AI also automatically applies manufacturer coupons and copay assistance programs for eligible patients. On the HCP side, Amazon’s integration with DoseSpot and eNavvi places patient net out-of-pocket at the point of prescribing.

    Health AI subsequently moved beyond the One Medical app, embedding directly into Amazon.com and its mobile app, marking the first time the tool has been available at scale to general consumers, and further enmeshing the patient experience into the overall Amazon environment. These offerings are available to anyone, regardless of being a One Medical member.

    4 potential shake-ups

    The result: Screening, prescribing, fulfillment, and ongoing renewal all happen inside one Amazon-run loop. No outside touchpoint is required.

    That loop doesn’t just change where a patient enters the system and picks up a prescription. It changes the nature of a healthcare “provider,” how care is delivered (including drug fulfillment), and who sees the full picture of a patient’s care. 

    In other words, this shift isn’t just a single disruption; it’s four separate ones. Here’s the “where” and “how” of those potential shake-ups:

    • The HCP relationship: Who manages a condition over time, not just who writes the first script?
    • Channel and patient experience: Who owns the point of fill, and how seamless is the drug-fulfillment experience?
    • Price transparency and patient OOP: How much of a role does real-world price play, for both prescribers and patients, and how do coupon and copay assistance programs need to adapt?
    • Data visibility: Does the full patient journey, from diagnosis to refill, sit outside the purview of traditional pharma data sources, or is it somehow still captured? 

    The four categories aren’t equally mature. And that has real implications for where pharma commercialization teams focus first. 

    Where pharma should focus

    The first two of the above categories are already live with the GLP-1 program. That is, ongoing management of a chronic condition now sits inside Amazon’s own clinical protocol, not a patient’s existing PCP or specialist. And prescribing, fulfillment, and refill take place in a channel pharma doesn’t traditionally call upon.

    GLP-1 is a favorable starting point for this model because it’s heavily consumer-driven and manageable in primary care, so the loop doesn’t need specialist judgment to run. And the GLP-1 cash-pay models give Amazon room to control pricing directly. Moreover, weight-loss management is a long-term, recurring relationship, which is exactly the kind of retention Amazon’s model is built for. 

    Beyond the cash market, Amazon’s ability to automatically apply coupons and copay assistance offers the opportunity for accelerated product uptake, accompanied by significant downside risks to product gross-to-net.  

    If your brand touches a condition that could be managed this way, GLP-1 isn’t a case study to read with curiosity. It’s a preview. Teams should be asking if and how this loop affects prescribing and fulfillment for their therapeutic area; that’s the immediate gap to close. 

    Conditions that depend on specialist diagnosis, complex or in-clinic administration, or those with reimbursement complexity, are a much harder fit for this model (at least for now). The therapeutic areas to watch first are protocol-friendly, primary-care-managed, chronic, and with a cash-pay market underneath.

    Payers and data

    Amazon’s impact on the payer space is at an earlier stage, but the signals are worth tracking closely. Amazon has already become the exclusive home delivery pharmacy for select PBM partners, including its own employee health plan. While that’s a narrow footprint today, whether it stays narrow or expands to further erode the traditional PBM mail-order business is the open question. Every new deal is a data point worth logging.

    Data visibility is the slowest mover of the four categories, and possibly the hardest to predict. Cash-pay markets already have data holes. Adherence and outcomes in these markets have always been harder to capture, since the transaction doesn’t run through the claims and pharmacy systems pharma is used to watching. 

    The bigger exposure is what happens if this extends into broader chronic disease management. Even losing part of a patient’s journey, say the fulfillment and refill half, is enough to break the continuity pharma relies on for adherence programs and tracking the various outcome measures of marketed treatments. 

    Other industries offer a useful, if uncomfortable, reference point. Retail went through its own version of this: Vertically integrated fulfillment that started as a convenience play eventually became infrastructure that competitors couldn’t easily match on price or speed. 

    That pattern is worth keeping in mind, not as a prediction of exactly how this plays out in life sciences, but as a reminder that the “early and narrow” phase doesn’t stay that way indefinitely.

    None of this is a call to panic. It’s a case for watching the right signals. The clearest one: which therapeutic area Amazon’s loop expands into next.

    Photo: undefined undefined, Getty Images

    Adrienne Lovink

    As CEO, Adrienne Lovink is leading Beghou’s next phase of growth and building on its reputation as a trusted commercialization partner in life sciences. She is focused on expanding into new areas of client demand; advancing the firm’s data, AI, analytics, and technology innovation; and investing in its people and culture. Adrienne has over 25 years of experience partnering with pharmaceutical and medical device companies to advance commercialization, market access, forecasting, digital health, real-world data, and advanced analytics, including as a Partner at Trinity Life Sciences and Global Head of Real-World Data and Advanced Analytics at DRG / Clarivate.

    This post appears through the MedCity Influencers program. Anyone can publish their perspective on business and innovation in healthcare on MedCity News through MedCity Influencers. Click here to find out how.

  • Cybersecurity Experts to Hospital Leaders: Think Beyond Traditional Disaster-Recovery Planning

    Cybersecurity Experts to Hospital Leaders: Think Beyond Traditional Disaster-Recovery Planning


    As healthcare organizations increasingly lean on connected technology, hospital leaders need to think beyond traditional disaster-recovery planning and prepare for prolonged technology outages. That was the message of cybersecurity experts who met last week to discuss today’s most pressing threats to healthcare data and infrastructure at a healthcare summit hosted by Rubrik.

    Rubrik is a cybersecurity and data management company based in Palo Alto, California.

    The timing of this conversation is notable. Last month, senators reintroduced the Health Infrastructure Security and Accountability Act, which applies baseline minimum cybersecurity requirements for healthcare organizations, along with $1.3 billion to help hospitals bolster their defenses. In August, a cyberattack on Boston Scientific disrupted manufacturing and supply chains, highlighting how attacks can have far-reaching impacts on healthcare operations. 

    Throughout the summit, experts echoed the same concern: AI-driven cybersecurity attacks pose a new level of risk for hospitals and health systems. These supercharged attacks could disrupt clinical operations for weeks, potentially leaving patients waiting for care. 

    Nicole Perlroth, bestselling author and host of the To Catch a Thief podcast, expounded on her concerns regarding AI cyberattacks. 

    “What we can really expect is that any vulnerability or any misconfiguration or any human error that you have in managing your security estate will be discovered at machine speed and exploited at machine speed,” she said.

    John Riggi, national adviser for cybersecurity and risk at the American Hospital Association, added to the gloomy picture, calling cyberattacks on healthcare organizations a “threat to life”. He called out how these attacks can disrupt operations in every step of the healthcare delivery workflow, to the point that patient care is badly delayed – which could be life-threatening.

    When technology fails due to some design failure because it wasn’t designed securely, “but which the bad guys have exploited or found today at machine speed — when those systems go down, there is an immediate disruption and delay to healthcare delivery,” Riggi warned.

    Cybersecurity threats are also manifold in that they can come from a variety of sources: they could emanate from foreign actors in Russia, China, North Korea, and Iran who want to target healthcare entities, particularly now that AI tools offer less-sophisticated attackers the opportunity to launch significant operations. 

    Speakers suggested interventions to bolster cybersecurity within healthcare systems. They emphasized that hospitals must be prepared to operate without IT for prolonged periods of 30 days or more, and encouraged regular testing of downtime and continuity plans, as well as strengthening backup systems. 

    However, this heightened era of threats could also have a positive outcome in the future of healthcare cybersecurity.

    “Long term, I hope that we basically get to a place we’ve never been before,” Perlroth said. “That this forces us to do the things we have talked about to death over the past few years in terms of secure-by-design, formal methods, patching, backups, real time backups, backup intelligence, et cetera.”

    Photo: Traitov, Getty Images

  • FTC Sends Warning Letters to 24 Healthcare Organizations Over Price Transparency

    FTC Sends Warning Letters to 24 Healthcare Organizations Over Price Transparency

    The Federal Trade Commission sent warning letters to 24 of the “nation’s largest” healthcare services companies, citing concerns that they may be failing to provide transparent price information.

    The letters were signed by FTC Chairman Andrew N. Ferguson. The agency did not disclose which organizations it sent the letters to.

    It notes in the letter that Section 5 of the FTC Act requires these organizations to provide patients with “timely, accurate, and complete pricing for healthcare services, especially for non-emergency services that are scheduled in advance.” The agency urged the organizations to conduct a review of their pricing practices and make changes if they find they’re in violation of the FTC Act. 

    The letter also stated that price transparency is a major priority of the FTC across several sectors, including rental housing, hotels and grocery delivery services. Consumers can’t compare offerings and make informed decisions without price transparency, the letter said.

    “Price transparency is particularly critical in the hospital and healthcare setting because healthcare is often one of the most significant and financially burdensome costs consumers face,” Ferguson wrote in the letter. “Patients frequently must invest substantial time and effort to travel for in‑person visits, making it even more important that they understand costs upfront before committing to care. Moreover, hospitals and healthcare facilities can charge dramatically different prices for the same services, leaving consumers vulnerable to wide and often unexpected cost discrepancies.”

    CMS requires hospitals to publicly disclose pricing information for healthcare services through machine-readable files and consumer-friendly pricing information. They also must provide uninsured and self-pay patients with good-faith estimates of expected charges before scheduled care. However, the FTC stated that complying with CMS price transparency requirements doesn’t necessarily mean a healthcare provider is complying with the FTC Act, which may impose additional requirements. 

    The letter notes that the price of healthcare services is a “material term,” meaning “clear and conspicuous disclosures” are needed so consumers are not deceived.

    “Accordingly, failing to disclose the price of a healthcare service may be deceptive if it is likely to mislead consumers acting reasonably under the circumstances,” Ferguson wrote. “Even when some price terms are disclosed, disclosures may be deceptive when they are incomplete — such as when they omit certain charges like physician fees or facility fees, or cover only a portion of the expected care — because consumers may reasonably believe they have been provided the total cost of care. Likewise, inaccurate disclosures mislead consumers and cause substantial harm.”

    The FTC said the letters do not conclude that the recipients violated the FTC Act. 

    Photo: Oleksandr Hruts, Getty Images

  • Investing in Community Health: A New Model for Safety-Net Healthcare Innovation

    Investing in Community Health: A New Model for Safety-Net Healthcare Innovation

    Community health centers (CHCs) are one of healthcare’s most important yet overlooked care delivery establishments. Despite being a crucial link to healthcare for the communities they serve, CHCs are often asked to adopt new health technology after the fact, rather than being invited to help to shape it. 

    The launch of Facktor Ventures last week is an effort to change that dynamic.

    As a new early-stage venture fund focused on technology and services for CHCs and the broader healthcare safety net, Facktor Ventures is taking a new approach to healthcare investing: it’s structured so that the organizations delivering care on the ground collectively become majority owners of the fund as limited partners. 

    This makes them a different kind of an investment organization compared with traditional venture capital firms that have deep-pocketed entities as their limited partners.

    This distinct model gives participating organizations a mechanism to help influence investment decisions and then potentially earn returns that could be re-invested in their missions – something which can be difficult for CHCs to do given their financial constraints and competing demands on limited resources. 

    “We built Facktor Ventures so health centers and other safety-net organizations can collectively hold majority ownership as limited partners,” said Michael Ceballos, partner at Facktor Ventures, and senior director at Facktor in an interview. “That connects capital with the experience of the organizations closest to patients, giving them an opportunity to inform innovation and share in its financial success.”

    Facktor Ventures is the venture arm of Los Angeles-based Facktor, a healthcare consulting firm that works directly with more than 360 health centers to advance community-based care. Facktor Ventures plans to invest primarily at the Seed and Series A stages for companies that create healthcare software, digital health, and other healthcare services to support safety-net care. The fund’s areas of investment include patient access, revenue cycle performance, care management, workforce capacity, and cybersecurity. Ceballos declined to provide the size of the fund.

    Community health centers are nonprofit organizations that offer affordable, high-quality primary care to people living in areas where that care is difficult to access. CHCs serve 33 million Americans, and a total of 90% of their patients live at or below 200% of the federal poverty level, with many either uninsured or covered by Medicare or Medicaid. 

    These safety-net organizations face distinct needs and challenges, and more common investment strategies may overlook these realities, resulting in products and services that are poorly aligned with their needs or difficult to scale. CHCs bring firsthand knowledge of their patients’ needs and operational workflows, helping to clarify investment decisions. In this context, the investments made by the new fund could potentially have a significant impact.

    Ceballos explained in an interview why he believes this setup carries potential for CHCs to expand their missions.

    “What makes this idea so consequential is the combination of scale and ownership. Community health centers collectively form the nation’s largest primary care network, caring for millions of Americans, many with low incomes and limited options for care. When those organizations help shape innovation and have a stake in its success, the potential reaches far beyond any individual investment. We want the people closest to patients to help build the future of healthcare and the value created to help sustain their mission.”

    Rather than focusing on CHCs simply adopting technology built by others, the venture aims to drive innovation that prioritizes their most pressing needs, from reducing staff burden to improving patient access and addressing the realities of budget and insurance constraints.

    “We want safety-net patients and the organizations caring for them to influence innovation from the beginning,” Ceballos said. “The ambition is big: help the community health movement become an owner and architect of its future, with a voice in the innovation it helps make successful and an opportunity to share in the value created.”

    The idea is to change the role of community health centers in healthcare innovation. Instead of waiting for startups to build products and then deciding whether to adopt them, CHCs could help shape those products and services from the start. Facktor Ventures is putting safety-net organizations closer to the source of the capital, with hopes of producing technology that works better for the people and providers who need it most. 

  • The Biggest Healthcare Fix Might Not Come From a Vendor

    The Biggest Healthcare Fix Might Not Come From a Vendor

    Healthcare has one recurring diagnosis when it comes to software: the people who see the problem most clearly are almost never the ones allowed to fix it. A front-desk lead knows exactly which scheduling step causes no-shows. A billing manager can tell you, to the minute, where a claim stalls. But turning that knowledge into a working tool has always required someone else, like a developer, a vendor, or a build queue.

    Vibe coding is starting to close that gap, and we’re seeing the successes beginning to emerge in dental tech. The idea is simple: describe what you want in plain language, and an AI system generates a working version of it, refined through conversation instead of code. It’s spread quickly across general software development. What’s less understood is what happens when it reaches an industry where the stakes and regulations are much higher.

    Why healthcare needed this more than most

    For twenty years, fixing a broken workflow has followed the same script. A clinician or administrator flags the problem, hands it off to a software team, and waits, often a year or more, for something to come back. What comes back rarely matches what was described, because something always gets lost in the handoff between the person who understands the problem and the person who has to build around a secondhand account of it.

    That handoff exists because coding ability has always gated who gets to build software. Knowing what’s wrong and knowing how to fix it in code have been two separate jobs, held by two different people. Vibe coding doesn’t erase the second job. It shrinks how much of it you need on day one, which means far more people can now act directly on problems they already understand instead of routing that understanding through someone else.

    That distinction matters most in an industry where the shortage was never insight. Ask anyone working the floor of a dental practice or a billing office what’s actually broken, and they’ll answer instantly. It’s the 20-minute hold with an insurer. It’s the note written twice: once for the chart, once for the payor. It’s the referral that vanishes into a fax or email and resurfaces three weeks later. Nobody has ever needed convincing on what to fix. What they’ve lacked is a way to act on it themselves, in something close to real time instead of on a vendor’s roadmap.

    Faster, but also different

    The old chain — request, prioritization meeting, development sprint, rollout — usually delivered a solution well after the problem had stopped being anyone’s top concern. Vibe coding shortens that chain by letting the person who lives inside the workflow build the first working version of the fix, often in less time than it used to take to write up the request.

    In an industry where administrative burden is a leading driver of clinician burnout, that’s not just a speed gain. It changes who gets to build, and how much distance sits between spotting a problem and doing something about it.

    Guardrails have to come first, not after

    None of this holds up if it’s treated as a way around rigor. Healthcare data carries real consequences when it’s handled carelessly, and a tool that makes it easy for a non-engineer to build something can just as easily make it easy for that same person to build something unsafe, unless the guardrails are already there before they start.

    That responsibility doesn’t disappear. It relocates. It moves off the individual builder and onto the platform they’re building on. Permissions, data boundaries, and security can’t be configuration steps left to a first-time builder. They have to be the default setting, invisible until something goes wrong. Clinical accuracy carries its own version of this: automating a claims dashboard is a low-risk build, but a tool touching clinical documentation or decision support is a different category entirely, and no amount of conversational ease should let it skip validation.

    The organizations that get this right won’t be the ones that threw the door open widest. They’ll be the ones that made opening it safe in the first place.

    Already taking shape

    We’re seeing this show up in small, unglamorous ways like a dental clinic manager building the exact claims view her team needs instead of waiting on a vendor’s one-size-fits-all dashboard, or a practice leader building a reporting layout that matches how her organization actually runs, rather than reshaping her operations to fit someone else’s software. None of these, on their own, looks like a revolution. Together, they point to a new default: the person who spots the problem is the one who builds the solution, instead of a request sitting in a queue for someone who has to imagine it from a distance.

    That shift is likely to outlast any single new app healthcare adopts this year. The industry was never short on people who understood what needed fixing. What it lacked was a way to let that understanding go straight to work, without a long wait for someone else’s turn, and without trading one risk for another in the process.

    Photo: Tom Werner, Getty Images

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