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D2 Solutions' survey, "Patient Access Barriers 2026," found that 21% of patients delayed starting a prescribed medication because of confusion or access problems, and 47% said a lack of transparency left them anxious and uncertain. Dean Erhardt says the prior authorization rejections behind many of those delays are largely administrative rather than clinical, and they often come back with no reason given. Medical Economics Senior Editor Richard Payerchin sat down with Erhardt, president and CEO of D2 Solutions, a health care consulting and technology company that works with drug manufacturers, pharmacies and payers on market access and patient support. Erhardt explains how errors as small as a mismatched ZIP code get submissions thrown out, why guidance from payer call centers changes from one call to the next and what patients still don't know about manufacturer copay and affordability programs. He also weighs labor against technology costs for smaller practices, makes the case for upskilling staff around artificial intelligence (AI) and describes how primary care physicians could reach patients in health care deserts by setting aside time for telehealth. Music Credits: Her Name by Cephas - stock.adobe.com A Textbook Example by Skip Peck - stock.adobe.comEditor's note: Episode timestamps and transcript produced using artificial intelligence (AI) tools.0:00 – 0:40 | Cold open. Erhardt on what a newly diagnosed patient hears from everyone involved in getting a medication approved. 0:40 – 1:44 | Introduction. Austin Littrell introduces the episode and the guest. 1:44 – 3:47 | Meet Dean Erhardt. Erhardt describes D2 Solutions' start in consulting in 2008 and his earlier career on the payer, distributor and pharmacy benefit manager (PBM) sides of the industry. 3:47 – 5:34 | Why prior authorizations stall. Denials often come back with no reason given. Erhardt says delays of days are an infrastructure problem, and some manufacturers see products held up for as long as three to four weeks. 5:34 – 7:38 | Catching errors before they're submitted. Payer call center guidance varies from one call to the next. Erhardt explains how matching each payer's requirements for a given product and flagging errors as small as a mismatched ZIP code prevent rejections. 7:38 – 10:16 | What patients go through. Erhardt describes patients fielding conflicting calls from the physician's office, the pharmacy and the payer, practices needing as many as nine calls to reach them and patients who never learn about copay and affordability programs. 10:16 – 12:08 | Options for smaller practices. Erhardt weighs labor against technology costs, points to staff turnover as a hidden expense and says training on a new platform should take about 15 minutes. 12:08 – 13:01 | P2 Management Minute. Keith Reynolds shares practice management tips and invites listeners to submit their own workflow ideas. 13:01 – 16:08 | Can technology offset the workforce shortage? Erhardt expects dramatic shortages by 2030 and says people nearing retirement now are more comfortable with technology than the generation before them. He points to digital therapeutics and wearables as part of care delivery. 16:08 – 18:03 | Upskilling staff around AI. Erhardt's horse-and-buggy case for training, and why a couple of classes a year can keep a practice's skills from falling behind the technology. 18:03 – 20:56 | What comes after AI scribes. Virtual consults that put a distant physician in a rural exam room, AI call centers and why Erhardt thinks patients are 12 to 24 months from being comfortable with AI agents. 20:56 – 22:40 | A volatile year for drug access. Erhardt points to PBM reform, revamped manufacturer contracts, growing lists of non-covered drugs and the risk of a race to the bottom on biosimilar prices. 22:40 – 24:26 | Behind the "ask your doctor" ads. Erhardt describes enrolling patients in manufacturer programs straight from TV ads and screening them before they reach a physician. He estimates about 30% of patients don't have a primary care physician. 24:26 – 25:54 | Direct-to-patient models and primary care. Erhardt says patients will drive the shift toward virtual care based on convenience, and that they'll decide how they want to receive care. 25:54 – 27:46 | Investing in primary care. Health care deserts, physicians 75 miles away and the case for setting aside telehealth time for patients who can't take hours off work. 27:46 – 28:54 | What the survey says about access. Erhardt on the patient who learns they have a disease that costs $250,000 a year to treat and doesn't know what to do next. 28:54 – End | Closing thoughts and outro. Payerchin thanks Erhardt, and Littrell wraps the episode.

Nearly two decades into the push toward value-based care, Dan D'Orazio says the industry isn't much further along than it was when the effort began. He says value-based programs are still pegged to fee-for-service, and the fee-for-service revenue hospitals collect routinely outweighs the penalties meant to move them off it. Medical Economics Managing Editor Todd Shryock sat down with D'Orazio, CEO of Sage Growth Partners, a Baltimore-based health care strategy and marketing firm. D'Orazio explains why remote monitoring of implantable cardiac devices stalled long after the technology was ready. He also explains why he doesn't expect artificial intelligence (AI) to fix incentives that were never a technology problem, and what capitation and Maryland's global hospital budgets can and can't do outside an integrated system. He makes the case that physician-led accountable care organizations are one of the few places value-based care is working, and explains why he expects incremental gains at best from here. Music Credits: Sleepy Sunday by Buurd - stock.adobe.com A Textbook Example by Skip Peck - stock.adobe.comEditor's note: Episode timestamps and transcript produced using artificial intelligence (AI) tools.0:00 – 0:12 | Cold open. D'Orazio on where value-based care is headed. 0:12 – 1:12 | Introduction. Austin Littrell introduces the episode and the guest. 1:12 – 2:41 | Where value-based care actually stands. Todd Shryock welcomes D'Orazio, who says the industry isn't much further along than it was in 2008 and 2009, and not for lack of effort. He weighs 10 to 20 years of value-based care against 80 years of fee-for-service. 2:41 – 5:45 | Why the shift stalled. Value-based programs are still pegged to fee-for-service, and the incentives to stay put outweigh the penalties. D'Orazio uses remote monitoring of implantable cardiac devices to show that the barrier was never the technology. It was the workflows, liability, staffing and alert fatigue around it. 5:45 – 9:28 | Penalties vs. revenue. D'Orazio says readmission penalties are small next to what hospitals still collect under fee-for-service, and that most of what drives a patient's health sits outside a physician's control. 9:28 – 14:23 | Why payers and the government keep pushing it. Costs keep rising and employers are bearing them. D'Orazio says even online scheduling runs into directory data, interoperability and physician templates. He adds that short commercial plan tenure undercuts the long-term incentive value-based care depends on. 14:23 – 15:17 | P2 Management Minute. Keith Reynolds shares practice management tips and invites listeners to submit their own workflow ideas. 15:17 – 18:32 | Can AI solve it? AI is only as strong as the data beneath it. D'Orazio sees real gains in administrative automation but says AI won't change fee-for-service, incentives or patient behavior. 18:32 – 21:41 | Capitation's comeback. Integrated systems like Kaiser Permanente and Geisinger can make it work. D'Orazio walks through the underwriting, data and care coordination capitation demands, and why several health systems have exited the health plan business. 21:41 – 23:55 | The Maryland model. Maryland pays its hospitals through global budgets, an approach D'Orazio says is returning through a CMS model. He explains how it changed hospital behavior and why commercial insurers and employers can't easily replicate it. 23:55 – 27:45 | Where health care is headed. D'Orazio expects incremental gains at best. He points to physician-led accountable care organizations outperforming hospital-led ones and calls for a rebirth of independent physician leadership. He names end-of-life spending and prior authorization as problems that won't unwind easily. 27:45 – End | Closing thoughts and outro. Shryock thanks D'Orazio, and Littrell wraps the episode.

In a Buzz Health survey of prescribers, 54% said patients often or very often fail to start therapy because of cost, but only 17% said prescription abandonment is highly visible in their workflows. Joseph Kleiman, president of Buzz Health, says the gap comes down to connectivity: prescriber, pharmacy and health plan systems that still don't share data. Medical Economics Managing Editor Todd Shryock sat down with Kleiman to talk through the survey, which included prescribers and electronic health record (EHR) workflow leaders. Nearly all prescribers in the survey said seeing insurance and discount prices side by side in the EHR would be extremely or very valuable, and when cash or discount pricing was available at the point of prescribing, it was chosen most often. Kleiman explains why that doesn't necessarily make insurance the worse deal, what it costs patients and practices when price comparisons happen after the visit, and what he would tell the primary care physician who has stopped trying and tells patients to search for a coupon. He also weighs in on the role artificial intelligence (AI) could play and whether federal attention on price transparency is moving things in the right direction. Music Credits: Ocean Calm by Cephas - stock.adobe.com A Textbook Example by Skip Peck - stock.adobe.comEditor's note: Episode timestamps and transcript produced using artificial intelligence (AI) tools.0:00 – 0:15 | Cold open. Kleiman on cash prices and surprises at the pharmacy counter. 0:15 – 1:14 | Introduction. Austin Littrell introduces the episode and the guest. 1:14 – 2:23 | Why patients don't start therapy. Todd Shryock welcomes Kleiman, whose company's survey found 54% of prescribers say patients often or very often fail to start therapy because of cost. Kleiman says the problem persists because prescriber, health plan and pharmacy systems still don't share data. 2:23 – 3:15 | Closing the feedback loop. Only 17% of prescribers said prescription abandonment is highly visible in their workflows. Kleiman says fixing that takes systems that deliver results in one centralized location, and that it hasn't been a priority rather than something anyone opposes. 3:15 – 4:04 | Pricing inside the EHR. Nearly all prescribers said side-by-side insurance and discount pricing in the EHR would be valuable. Kleiman says nothing is standing in the way, and the technology can already deliver real-time pricing at the point of prescribing. 4:04 – 5:12 | Cash price vs. insurance. When cash or discount pricing is shown at the point of prescribing, it gets picked most often. Kleiman says insurance isn't necessarily the worse option, but prior authorization and deductibles create friction that surfaces at the pharmacy. 5:12 – 6:10 | The cost of sorting out prices after the visit. When price comparisons fall to staff or patients after the appointment, Kleiman says the uncertainty leads to abandoned prescriptions. 6:10 – 7:04 | Primary care's role in affordability. Kleiman says primary care physicians want an active role, and connecting pharmacy, prescriber and health plan will let them play a bigger part in the prescription journey. 7:04 – 7:56 | P2 Management Minute. Keith Reynolds shares practice management tips and invites listeners to submit their own workflow ideas. 7:56 – 8:46 | A message for health systems and administrators. Kleiman says the technology is there and isn't difficult to implement, and that better adherence helps costs for practices and health plans. 8:46 – 9:40 | For the physician who's given up. Kleiman on patients quoted one price who find another at the pharmacy, and his message that solutions now exist through the EHR and health plans. 9:40 – 10:33 | Where AI fits. Kleiman says AI can play a big part, but data sharing must be permitted and the work done carefully in a heavily regulated industry. 10:33 – 11:21 | Are things getting better? Kleiman points to CMS and legislative action on price transparency and says the remaining work is tying systems to a single source of truth. 11:21 – 12:00 | Final thoughts. Kleiman urges pharmacies, prescribers and health plans not to push pricing transparency aside. 12:00 – End | Outro. Littrell wraps the episode and points listeners to Medical Economics and Physicians Practice coverage of the MGMA Annual Conference in San Antonio, Sept. 27-30.

Public comments on Medicare's proposed 2027 physician fee schedule closed Sept. 14 with a provision on the table that would pay 50% for one of two services when a patient gets an office visit and a procedure on the same day. Anders Gilberg, senior vice president of government affairs at the Medical Group Management Association (MGMA), joins Physicians Practice Managing Editor Keith Reynolds to explain what that would look like in the exam room, why budget neutrality rules keep pitting specialties against one another and what the bipartisan Patients First Act would change.  They also cover the mandatory Ambulatory Specialty Model that starts Jan. 1 with its participant list still unpublished, what else is sitting in the lame-duck pile and the AI policies Gilberg says every practice should have in writing. The final 2027 fee schedule is expected on or about Nov. 1. Music Credits:Cozy Evening Coffee Time by BJBeats - stock.adobe.comA Textbook Example by Skip Peck - stock.adobe.comEditor's note: Episode timestamps and transcript produced using artificial intelligence (AI) tools.0:00 – 0:23 | Cold open Anders Gilberg on patients being asked to come back the next day for a procedure. 0:23 – 1:29 | Introduction Austin Littrell previews the episode and MGMA's centennial Annual Conference in San Antonio, Sept. 27-30. 1:29 – 1:59 | Meet Anders Gilberg Keith Reynolds welcomes Gilberg back on the day public comments closed on the proposed 2027 fee schedule. 1:59 – 4:41 | The one change MGMA wants Another conversion factor cut is in the rule, but Gilberg says the change CMS can make on its own is dropping a proposal to pay half for one of two services billed the same day. He walks through a dermatology example and the Same Day Care Coalition's opposition. 4:41 – 5:56 | The Patients First Act The bipartisan doctors caucus bill would tie annual fee schedule updates to the Medicare Economic Index, rework budget neutrality and reform quality reporting. 5:56 – 8:06 | Why CMS can't fix budget neutrality alone The $20 million trigger is written into law. Gilberg points to a 2024 add-on code whose use was overestimated by roughly $1 billion, a cut physicians never got back. 8:06 – 9:19 | The quiet part: practice expense Practice expense values cover overhead, and Gilberg explains why keeping the lights on, paying staff and buying supplies makes this an administrator's issue. 9:19 – 11:10 | The Ambulatory Specialty Model starts Jan. 1 Gilberg says practices aren't ready because the participant list still hasn't been published, and notification is expected to run through a portal each physician checks individually. 11:10 – 12:13 | P2 Management Minute Keith Reynolds shares practice management tactics and invites listeners to send in their own, then turns to the lame-duck session. 12:13 – 13:45 | Will Congress fix the cut? Gilberg on why modest cuts are harder to fight than big ones, drawing on his experience with the SGR years. 13:45 – 15:38 | What else is in the lame-duck pile The work geographic price index floor and the expiring alternative payment model incentive bonus, plus why a retroactive fix in the new year is the outcome nobody wants. 15:38 – 18:51 | AI guardrails inside the practice Governance, written policies on what gets typed into tools like ChatGPT, HIPAA and malpractice exposure under laws already on the books, and keeping the human element in the physician-patient relationship. 18:51 – 19:39 | What to watch next The final rule is expected on or about Nov. 1, and Gilberg says practices won't know until the 11th hour whether the same-day cut survived. 19:39 – 20:36 | San Antonio Keith and Gilberg on the MGMA Annual Conference. 20:36 – end | Outro

In a national survey of more than 1,200 practicing physicians, 47% said they often or always lacked the time to give patients optimal care, and 27% said they had already left a job because of moral distress. Rebecca Schoon, Ph.D., one of the authors of the Physicians for a National Health Program report behind those numbers, says the patients her team heard from in Oregon could see what was happening to their doctors and did not blame them for it. Medical Economics Senior Editor Richard Payerchin sat down with Schoon, an associate professor of public health at Pacific University and a board member of Health Care for All Oregon, a nonprofit that advocates for universal health care. Schoon helped lead the report's Oregon case study. Schoon walks through the acquisitions of Oregon practices by Optum, Amazon and private equity firms, the noncompete clauses and visit quotas she says drove physicians out of the Eugene area, and the 2025 state law that restricts corporate control of medical practices. She also explains how moral injury reaches physicians in independent practice through prior authorization, denials and paperwork. Then she turns to Oregon's effort to design a statewide universal health care plan and to what patients told researchers about longer waits and the toll of fighting their insurers. The full report, "Moral Injury in Medicine: The Human Costs of Practicing in a Profit-Driven System," is available from Physicians for a National Health Program, and the Universal Health Plan Governance Board posts its meetings and materials online. This conversation was recorded before the board voted in August to push the deadline for its plan from Sept. 15 to Dec. 1. Music Credits: Cup of Coffee by Ionics - stock.adobe.com A Textbook Example by Skip Peck - stock.adobe.comEditor's note: Episode timestamps and transcript produced using artificial intelligence (AI) tools.0:00 – 0:29 | Cold open. Schoon on what patients in Oregon's focus groups said about their physicians. 0:29 – 1:52 | Introduction. Austin Littrell introduces the episode and the guest, with an update on the Universal Health Plan Governance Board's deadline. 1:52 – 3:12 | Meet Rebecca Schoon. Richard Payerchin welcomes Schoon, who teaches health policy and health systems at Pacific University and works on policy reform with Health Care for All Oregon. 3:12 – 5:38 | How the study came together. Physicians for a National Health Program paired a national physician survey and focus groups with an Oregon case study and patient focus groups run by Health Care for All Oregon, with funding from the Robert Wood Johnson Foundation. Schoon defines moral injury as the tension between clinicians' ethical obligations and the for-profit constraints of the current system. 5:38 – 8:24 | Financialization comes to Oregon. Optum's acquisitions of Oregon Medical Group in Eugene and The Corvallis Clinic, the physician resignations and two-year noncompete clauses that followed, and deals by Amazon and private equity firms for clinics in Portland, Bend and Redmond. 8:24 – 12:22 | How Oregon pushed back. Oregon's corporate practice of medicine ban dates to a 1947 state Supreme Court ruling, but corporate owners found ways around it, most recently through management services organizations. Schoon describes how Health Care for All Oregon worked with state Rep. Ben Bowman (D-Oregon) on the 2025 law that has been called the strictest in the nation, which also limits noncompete clauses. 12:22 – 15:04 | Moral injury in independent practice. Physicians in corporate settings are bound by limits set by management services organizations. In independent practices, Schoon says moral injury comes more from prior authorization, denials, step therapy and paperwork. 15:04 – 15:56 | P2 Management Minute. Keith Reynolds shares practice management tips and invites listeners to submit their own workflow ideas. 15:56 – 19:39 | Oregon's path to universal health care. A 2019 legislative task force, the 2022 ballot measure that added access to health care to the state constitution as a fundamental right and the nine-member Universal Health Plan Governance Board designing the plan. The board has since moved its September deadline to Dec. 1. 19:39 – 23:05 | Paying for it. Draft options include income, payroll and corporate taxes. Schoon argues most Oregonians would save compared with what they pay in premiums, deductibles and copays. She contrasts billing in countries with universal health care, which she says takes seconds, with the months an American practice can spend chasing a single payment. 23:05 – 28:15 | What patients told researchers. Appointments limited to one health issue, longer waits after specialists left the Eugene area, repeated denials that took a psychological toll and patients who sympathized with doctors whose hands were tied. 28:15 – End | Closing thoughts and outro. Payerchin thanks Schoon, and Littrell wraps the episode.

A clinical artificial intelligence (AI) tool costs little to run and can be billed many times over, while fee-for-service rates are set on the clinician time and effort a service is expected to take. Caroline Pearson says that math is why AI could push health care costs up rather than down, and that remote patient monitoring already shows what it looks like. Medical Economics Managing Editor Todd Shryock sat down with Pearson, executive director of the Peterson Health Technology Institute, a nonprofit that evaluates the clinical and economic value of emerging health technologies. Pearson draws the line between assistive AI, which a supervising physician deploys, oversees and bills for, and autonomous AI, which delivers some care on its own. She explains why liability for an autonomous prescribing tool currently runs through the physician's malpractice insurance and what would have to change to move it to the vendor, how Medicare's new Access Model lets technology companies get paid with no physician in the mix, why accountable care organizations (ACOs) have been slower to adopt AI than their incentives would suggest, and what she means when she says technology doesn't need a living wage. Music Credits:Paper Cranes by Buurd - stock.adobe.comA Textbook Example by Skip Peck - stock.adobe.comEditor's note: Episode timestamps and transcript produced using artificial intelligence (AI) tools.0:00 – 0:27 | Cold open. Pearson on why technology doesn't need a living wage. 0:27 – 1:35 | Introduction. Austin Littrell introduces the episode and the guest. 1:35 – 1:55 | Meet Caroline Pearson. Todd Shryock introduces Pearson and the Peterson Health Technology Institute's report on paying for clinical AI. 1:55 – 2:24 | The takeaway for physicians. The potential is real, the incentives to adopt are not, and the payment models available now risk raising health care costs. 2:24 – 3:37 | Why fee for service inflates the bill. Rates are set on clinician time and effort, but the marginal cost of running a tool is low and it can be billed many times over. Pearson points to remote patient monitoring as a live example. 3:37 – 4:18 | More patients, or more revenue per visit? Seeing more patients would stretch the workforce further. The concern is revenue per visit rising without more patients seen or better outcomes in those visits. 4:18 – 5:47 | Assistive AI vs. autonomous AI. Assistive tools are deployed, overseen and billed by the supervising physician. Autonomous tools deliver facets of care on their own, with medication prescribing and hypertension titration as the nearest examples. 5:47 – 6:38 | P2 Management Minute. Keith Reynolds shares practice management tips and invites listeners to submit their own workflow ideas. 6:38 – 7:47 | Getting paid to review the algorithm. Remote patient monitoring codes already pay physicians to review AI analysis of patient data. Pearson on setting the right value for oversight payments and keeping clinicians cognitively sharp as they use the tools more. 7:47 – 8:39 | Who is liable when it goes wrong. Prescribing tools generally operate under the physician's malpractice insurance, which makes it the physician's liability. Pearson on the push to move that to the vendor and the legal infrastructure that doesn't exist yet. 8:39 – 10:20 | Cutting the physician out of the payment. Medicare's Access Model pays technology companies directly for chronic care management, and Doctronic is piloting prescribing in Utah. Pearson on preserving the physician's role and setting a payment level that reflects what the technology actually costs. 10:20 – 11:25 | Why ACOs haven't bought in. Risk-based models need evidence of better outcomes and lower total cost rather than a revenue play, and Pearson says the evidence available has not been compelling enough. 11:25 – 12:26 | Change management is the other half. Redesigning workflows and rethinking how clinicians spend their time, at the system level and the individual level. 12:26 – End | Closing thoughts and outro. Shryock thanks Pearson, and Littrell wraps the episode.

Thirty-three states now restrict the corporate practice of medicine to some degree, and lawmakers in several more are moving to tighten those limits. Wayne Winegarden, Ph.D., says the crackdown is aimed at the wrong target. Medicare physician payments rose 12% between 2000 and 2022 while the cost of running a practice climbed nearly 48%. Medical Economics Associate Editor Austin Littrell sat down with Winegarden, a senior fellow in business and economics at the Pacific Research Institute and director of the institute's Center for Medical Economics and Innovation. Winegarden argues that inflation functions as a tax on independent practice, and that state bans on management services organizations land almost entirely on independent physicians because hospitals are typically exempt. He explains why he considers California's Senate Bill 351 a better model than Oregon's Senate Bill 951, what separates an MSO partnership that preserves independence from an acquisition with the paperwork rearranged, what the early evidence shows about prices after an MSO deal, and why he thinks independent practice survives the next decade even as the warning siren gets louder. Winegarden's policy brief, "How Government Policy Is Consolidating the Practice of Medicine," is available from the Pacific Research Institute. Music Credits:Distant Memories by Buurd - stock.adobe.comA Textbook Example by Skip Peck - stock.adobe.comEditor's note: Episode timestamps and transcript produced using artificial intelligence (AI) tools.0:00 – 0:32 | Cold open. Winegarden on inflation as a tax on independent practice. 0:32 – 1:51 | Introduction. Austin Littrell introduces the episode and the guest. 1:51 – 3:07 | Another year of the payment gap. CMS has proposed a 2027 physician pay cut alongside a raise for hospital outpatient departments. Winegarden on the accumulation of frustration, the financial difficulty of managing it and the psychological question of whether it ever gets better. 3:07 – 4:52 | The counterfactual. If Medicare payment had tracked inflation since 2001, how much consolidation never happens. Winegarden says the exact number isn't knowable, but that removing a major driver removes its influence, and that the problem is government policy putting a finger on the scale rather than consolidation itself. 4:52 – 7:30 | Site-neutral payment and the inflation tax. Why site-neutral passes on cost savings alone, why indexing physician pay to inflation is the harder sell, and the penny-wise, pound-foolish math of what it costs to keep practices open. 7:30 – 9:58 | What counts as an independent practice. The traditional definition is a doctor-owned or controlled practice. Winegarden calls MSOs a hybrid and argues that the experimentation is the point. 9:58 – 12:32 | Partnership or acquisition. Control over decision-making is the dividing line. Winegarden on the bean counter in Pennsylvania writing rules for a patient in Oregon, and what an MSO has to deliver to be worth the affiliation. 12:32 – 13:24 | P2 Management Minute. Keith Reynolds shares practice management tips and invites listeners to submit their own workflow ideas. 13:24 – 15:05 | What happens to prices after an MSO deal. Better collections and firmer practice finances, prices still below hospital rates, and why not enough time has passed to know where the competition leads. 15:05 – 16:53 | Oregon's law gets its first test. An independent group used the law to fight off an out-of-state staffing firm. Winegarden says the case doesn't complicate his argument, and that Oregon's overly strict law is the reason the conflict looks the way it does. 16:53 – 18:07 | Why not extend the rules to hospitals. Binding hospitals with the same restrictions reduces competition. Winegarden wants more ideas in the market, not fewer. 18:07 – 20:06 | What a practice should ask before signing. Quality of life, compensation, how physicians spend their time and the risk they bear. Winegarden says there is still no evidence that fully independent practice is an inefficient way to deliver care. 20:06 – 22:19 | Does independent practice survive the decade. Winegarden says yes, and that if it doesn't, Medicare reimbursement and regulatory burden will be the cause rather than a better model winning. 22:19 – End | Closing thoughts and outro. Littrell thanks Winegarden and wraps the episode.

Fewer than half of physicians know the exact steps to take when a medical error occurs, according to a survey cited by Anthony Orsini, D.O. That gap, he argues, is where malpractice claims begin. Orsini, a neonatologist, founder of The Orsini Way and a member of the Medical Economics editorial advisory board, joins Medical Economics Managing Editor Todd Shryock to walk through the mistakes physicians make most often in a disclosure conversation: staying silent, getting defensive instead of transparent, retreating into medical jargon and letting body language contradict every empathetic word in the room. He explains why speculating about a cause before the review is finished is the worst move a physician can make, what the University of Michigan's shift away from deny-and-defend did to claims and liability costs, and why even a harmless error has to be disclosed. Don't miss the first episode of Conversations that Matter, with Anthony Orsini, D.O.: https://www.medicaleconomics.com/view/do-you-struggle-with-difficult-patient-conversations- Music Credits:Ambient Jazz by AurbanniAudio - stock.adobe.comA Textbook Example by Skip Peck - stock.adobe.comEditor's note: Episode timestamps and transcript produced using artificial intelligence (AI) tools.0:00 – 0:26 | Cold open Orsini on why the most empathetic words in the world fail when a physician's posture contradicts them. 0:26 – 2:00 | Introduction Austin Littrell introduces the episode, the guest and the debut of Orsini's new Medical Economics series. 2:00 – 2:35 | Meet Dr. Anthony Orsini Todd Shryock introduces Orsini and The Orsini Way. 2:35 – 7:27 | The most common disclosure mistakes Failing to disclose at all, getting defensive rather than transparent, retreating into medical jargon and ignoring nonverbal communication. Orsini cites a study finding fewer than half of physicians know the steps to take after an error. 7:27 – 9:59 | Why speculating is the worst thing you can do The brain reads nonverbal cues before words, an angry family is a normal response, and naming a cause before the review is finished routinely turns out to be wrong. 9:59 – 13:33 | What families actually want to hear Orsini says 39 states now have full or partial apology laws, and that in role-play training physicians more often over-claim fault than dodge it. A morphine dosing example shows why errors are almost always a process breakdown. 13:33 – 15:28 | The data behind transparency Orsini walks through the University of Michigan findings on claims, liability costs and time to resolution after the system moved away from deny-and-defend. 15:28 – 18:02 | Can body language be taught? Videotaped role play, the "long sitter" posture, and why a relaxed stance that builds rapport in a routine visit destroys credibility in a disclosure. 18:02 – 18:55 | P2 Management Minute Keith Reynolds shares practice management tips and invites listeners to submit their own workflow ideas. 18:55 – 21:56 | Does every error get disclosed? Yes, Orsini says, and he tells the story of a minor morphine overdose a hospital chose not to report, and what happened when the mother found out anyway. 21:56 – 24:22 | Who should deliver the news Why the physician should lead the disclosure rather than risk management or legal counsel, and how the pre-disclosure meeting should work. 24:22 – 27:11 | Be prepared before it happens Why physicians avoid training for medical errors, what resources exist for practices outside a hospital system, and Orsini's closing message. 27:11 – 27:28 | Closing thoughts and outro

Lawrence Casalino, M.D., Ph.D., M.P.H., practiced primary care for 20 years before spending six on the Medicare Payment Advisory Commission. In his recent New England Journal of Medicine essay, "Physicians, Corporatization, and the Unmeasured Quality of Care," he makes an argument most physicians will recognize from the inside: the accuracy and timeliness of a diagnosis, the trust built over years with a patient, the judgment behind sending someone to exactly the right specialist. None of it can be measured at scale, so none of it gets rewarded. Casalino talks with Medical Economics Senior Editor Richard Payerchin about the five forces he sees pushing physicians out of independent practice, what Medicare could realistically do for primary care, and his research finding that physicians score measurably higher on altruism than the general population. He also explains why he believes large organizations can't help but treat the people inside them as interchangeable, and the one question he thinks every policymaker should ask before signing off on a change. Read Dr. Casalino's essay in NEJM: https://www.nejm.org/doi/full/10.1056/NEJMp2415488 Music Credits:Rooftops by Buurd - stock.adobe.comA Textbook Example by Skip Peck - stock.adobe.comEditor's note: Episode timestamps and transcript produced using artificial intelligence (AI) tools. 0:00 – 0:27 | Cold open Casalino on what happens when physicians start to feel interchangeable. 0:27 – 1:41 | Introduction Austin Littrell introduces the episode and the guest. 1:41 – 1:59 | From the United Farm Workers to medicine Payerchin opens with Casalino's years as a community organizer before medical school. 1:59 – 3:29 | Why he chose medicine Wanting to help people directly and see the result, and why he still calls 20 years in practice an honor. 3:29 – 7:30 | Five forces squeezing independent practice No negotiating leverage with payers, an administrative burden that barely existed in 1980, EHR purchasing and support, policy uncertainty, and what physicians coming out of training now expect from their lives. 7:30 – 12:29 | What would actually help primary care Casalino on administrative relief and higher payment rates, and why he doubts independent practices will ever have the leverage to get them. 12:29 – 13:03 | The referral you can trust A car mechanic analogy for what patients lose as practices consolidate. 13:03 – 13:55 | P2 Management Minute Keith Reynolds 13:55 – 14:49 | The measurement problem Payerchin raises Casalino's New England Journal of Medicine essay and the dimensions of quality that can't be captured at scale. 14:49 – 17:00 | Inside MedPAC Casalino on the commission's bipartisan standing and how long it can take Congress to act on what it recommends. 17:00 – 17:48 | Timely and accurate diagnosis Payerchin returns to the question: how should unmeasurable quality factor into physician performance and pay? 17:48 – 22:35 | Professionalism, altruism and widgets Casalino's research finding physicians more altruistic on average than the general population, and what corporatization does to the professionalism the system quietly depends on. 22:35 – 24:11 | A test for policymakers Will this policy make physicians and staff feel more like widgets, or less? 24:11 – End | Outro

One in 21 physicians was sued last year, the lowest rate since 1973. The average payment made on behalf of a physician and reported to the National Practitioner Data Bank was $514,000, the highest on record. Both numbers describe the same malpractice market. Medical Economics Managing Editor Todd Shryock sat down with Robert White, president of The Doctors Company and TDC Group. White explains why falling claims frequency has quietly absorbed years of pressure from rising severity, and why that cushion is running out. He walks through the arithmetic of nuclear verdicts, awards above $10 million that now land somewhere in the country roughly once a week, and how a single plaintiff's verdict resets the settlement value of every comparable case that never reaches a courtroom. He also makes the case that artificial intelligence in diagnosis and treatment is the emerging exposure worth watching, and offers a blunt piece of advice about how physicians should be choosing a carrier. Music Credits:Healing Breeze by Cephas - stock.adobe.comA Textbook Example by Skip Peck - stock.adobe.comEditor's note: Episode timestamps and transcript produced using artificial intelligence (AI) tools.0:00 – 0:29 | Cold open. White on the two malpractice numbers moving in opposite directions. 0:29 – 1:33 | Introduction. Austin Littrell introduces the episode and the guest. 1:33 – 1:52 | Meet Robert White. Shryock opens on current trends in malpractice. 1:52 – 3:11 | Claims frequency at a 53-year low. One in 21 physicians was sued in 2025, down from one in five in 1999. White credits the patient safety push and tort reform. 3:11 – 4:29 | Severity has never been higher. The average payment reported on behalf of physicians reached $514,000 per closed report in 2025, up about 20% since 2022, and carriers won't know whether today's rate is correct for three to five years. 4:29 – 5:17 | Early warning signs. Severity trending up roughly 5% a year, and bellwether states showing increased claims frequency in 2026. 5:17 – 6:35 | What a nuclear verdict is. Any award above $10 million, and the 2009 book that gave rise to reptile theory. 6:35 – 8:24 | Why one loss sets the price of every settlement. Only 7% of malpractice cases reach trial and the defense wins six of every seven, but the seventh becomes the yardstick. 8:24 – 9:49 | Where nuclear verdicts are landing. Georgia recorded 11 in 2025 and 33 across four years. Illinois leads since 2015 with 58, followed by Georgia, New York, Florida, Pennsylvania and California. 9:49 – 11:10 | The consent policy. Why carriers think twice about trying any case, and why physicians rarely withhold permission to settle once they have seen the verdicts. 11:10 – 12:44 | Thermonuclear verdicts. Awards above $100 million, three already by April 2026, and the largest medical liability award on record: $963 million in Utah, decided by a judge rather than a jury. 12:44 – 16:47 | What it all means for rates. Falling frequency masked the pressure from severity for years. With frequency flat, White expects increases of 1% to 3% nationally and warns that plaintiffs' lawyers are not spending this effort for nothing. 16:47 – 17:39 | P2 Management Minute. Keith Reynolds shares practice management tips and invites listeners to submit their own workflow ideas. 17:39 – 18:43 | The specialties carrying the most risk. Cardiovascular, orthopedic and general surgery, plus obstetrics. 18:43 – 20:31 | Artificial intelligence as the next liability frontier. AI is already embedded in diagnostic imaging, and White explains why the legal system's lag is the real exposure. 20:31 – 22:48 | The question to ask before choosing a carrier. The carrier's name never reaches the data bank. The physician's does. 22:48 – End | Closing thoughts and outro. Shryock thanks White and Littrell wraps the episode.

Physicians have been effectively barred from owning hospitals since 2010, when a provision of the Affordable Care Act finished what the Stark law started. Gary Price, M.D., MBA, president of The Physicians Foundation, argues the restriction was a mistake from the beginning, built on a reading of the Dartmouth Atlas that researchers corrected 25 years ago and policymakers never revisited. He talks with Medical Economics Senior Editor Richard Payerchin about what the research actually shows on cost and quality at physician-owned hospitals, why markets that have them consolidated less than the rest of the country, and how much of the burnout physicians describe comes down to being held responsible for care they no longer control. Price also walks through the opening CMS left this spring, when the agency asked whether physician-owned hospitals should be allowed to opt into its Transforming Episode Accountability Model. Music Credits:Warm Hands by Cephas - stock.adobe.comA Textbook Example by Skip Peck - stock.adobe.comEditor's note: Episode timestamps and transcript produced using artificial intelligence (AI) tools. 0:00 – 0:16 | Cold open. Price on why the Mayo brothers could not have founded the Mayo Clinic under current law. 0:16 – 1:35 | Introduction. Austin Littrell introduces the episode and the guest. 1:35 – 2:34 | Meet Gary Price, M.D., MBA. Payerchin asks what the Affordable Care Act did to physician ownership of hospitals. 2:34 – 4:24 | What the law actually does. The Stark law came first, the ACA finished the job, and existing physician-owned hospitals were grandfathered in but barred from adding beds or services. 4:24 – 5:52 | The CMS request for information. Price explains the question about letting existing physician-owned hospitals opt into a value-based model built on episodes of care, and puts their share at 5% to 6% of hospitals. 5:52 – 6:56 | What policymakers feared in 2010. Cherry picking, lemon dropping and the assumption that physician-owned hospitals would take only the healthiest, cheapest patients. 6:56 – 8:22 | What the research found instead. A 2023 study co-funded by The Physicians Foundation and the Physician Advocacy Institute found almost no difference in patient acuity or social status, and Medicare costs 7% to 15% lower. 8:22 – 9:05 | "The most expensive piece of equipment in the hospital". How the policy world came to treat the physician's pen as the source of cost variation. 9:05 – 10:45 | Where that idea came from. Price traces it to a reading of the Dartmouth Atlas around 2000, and to a researcher whose zip code analysis found income, not physician behavior, tracked with cost. 10:45 – 11:57 | A clarification on cost. Payerchin asks what the income finding implied about billing. Price says the figures were Medicare costs, not out-of-pocket. 11:57 – 14:11 | Consolidation, and the burnout it feeds. Markets with physician-owned hospitals consolidated less. Price connects the loss of physician control to the frustration doctors describe daily. 14:11 – 15:02 | P2 Management Minute. Keith Reynolds shares practice management tips and invites listeners to submit their own workflow ideas. 15:02 – 16:34 | Does the request for information signal a real shift? Price calls it the first opening in 15 years, but notes the same 2010-era assumptions are written into the questions. 16:34 – 17:42 | The practical problems. Participating hospitals might need to add beds they are legally barred from adding, and the model ends in 2030. 17:42 – 19:23 | Legislation, and the case for physician-led management. Several bills sit on Capitol Hill with no action, and physician-owned hospitals charge cash-paying patients 47% less. 19:23 – 21:22 | Who is supposed to own the hospitals? Certificate-of-need laws, the corporate practice of medicine, and Price's observation that private equity investors face no equivalent bar. 21:22 – 23:46 | What ownership looks like at the bedside. The test a physician orders, the administrator who says it is not on the approved list, and where the core frustration begins. 23:46 – 24:41 | A lesson from the 1970s. The question Price asked residents before approving a test. 24:41 – 26:14 | Does overutilization still happen? Price says yes, driven by financial incentives, and argues the real fraud is large-scale rather than bedside. 26:14 – 29:07 | Connecticut as a case study. Two systems control most of the care in the state. Price describes being told an insurer would negotiate only with hospitals. 29:07 – 31:14 | Why bigger is not cheaper. Price argues health care has no economies of scale and points to administrator growth far outpacing clinicians. 31:14 – 32:57 | "It mystifies me". Why physician participation is treated as intrinsically bad in health care and nowhere else in the economy. 32:57 – 33:38 | Closing thoughts. 33:38 – End | Outro.

Three Current Procedural Terminology codes for immunization counseling on days when no vaccine is administered, 90482 through 90484, took effect Jan. 1, 2026. They were built to capture the time a physician spends on a conversation that ends without a shot. CMS does not pay for them, and most private payers do not either. Medical Economics Associate Editor Austin Littrell sat down with Sarah C. Nosal, M.D., FAAFP, president of the American Academy of Family Physicians and a family physician who has practiced in the South Bronx for nearly two decades. Nosal points family physicians to the AAFP's 2026 immunization schedules, developed with input from other medical organizations and the Vaccine Integrity Project. In this episode, she explains why most childhood doses are still given in a primary care office, what a practice gives up when it stops stocking and starts sending patients to a pharmacy, and how she handles a visit that opens with exemption paperwork instead of a question. Read the full written Q&A with Nosal. This conversation was recorded before the Aug. 10 executive order calling for universal childhood vaccine recommendations to cover 11 diseases rather than 18. Nosal does not address the order here. Music Credits:Coffee Shop Sketches by Buurd - stock.adobe.comA Textbook Example by Skip Peck - stock.adobe.comEditor's note: Episode timestamps and transcript produced using artificial intelligence (AI) tools. 0:00 – 0:20 | Cold open. Nosal on the one thing every parent walking into the exam room has in common, whether they came for a shot or an exemption. 0:20 – 1:49 | Introduction. Austin Littrell introduces the episode and the guest. 1:49 – 2:23 | Which schedule to work from. Nosal points family physicians to the AAFP's recommendations, developed with other major medical organizations and the Vaccine Integrity Project. 2:23 – 3:25 | What shared decision-making actually means. More vaccines sit in that category than a year ago. Nosal argues it describes what family physicians already do at every visit: answer the questions, offer the information the patient did not know to ask for, and let them decide. 3:25 – 5:15 | Does stocking vaccines still pencil out. Vaccines are expensive and reimbursement is the common complaint, but most childhood doses are still given in a family physician's office. Large networks with capital and in-house pharmacies have squeezed the smaller practices. 5:15 – 6:11 | The counseling codes nobody pays for. Practices can document the work and use the codes. CMS does not reimburse them, most private payers do not either, and the AAFP is still advocating. 6:11 – 7:30 | When a family brings exemption paperwork. Nosal's approach: acknowledge the form, ask what they are thinking, and partner instead of argue. 7:30 – 9:13 | Where the AAFP lands on staggered schedules. The full regimen at each scheduled appointment. Nosal will not turn a family away for declining, but says most parents choose the traditional schedule once they have had the conversation. 9:13 – 10:04 | P2 Management Minute. Keith Reynolds shares practice management tips and invites listeners to submit their own workflow ideas. 10:04 – 11:52 | What actually moves a parent. Setting the expectation months ahead rather than at the visit, then walking a family through the specific worry until they talk themselves out of it. 11:52 – 13:18 | Longitudinal relationships under pressure. Consolidation, panel size and short visits are eroding the model. Nosal describes working around it in an under-resourced community by treating the whole family as the unit of care. 13:18 – 14:49 | What a practice loses at the pharmacy counter. Pharmacies often will not vaccinate infants or children, registry reporting is inconsistent from state to state, and patients end up with records nobody can reconcile. 14:49 – 15:56 | Why she does not say "hesitancy". Nosal closes on parents who are not hesitant so much as working from information that does not line up. 15:56 – 17:04 | Closing thoughts and outro. Littrell thanks Nosal and wraps the episode.

In June 2025, dozens of health insurers pledged six fixes to prior authorization. A year later, the AMA found that just 24% of physicians say denials are consistently reviewed by an appropriately qualified clinician, and Colin Banas, M.D., M.S.H.A., chief medical officer of DrFirst, says the process is as bad as ever. Physicians Practice Managing Editor Keith Reynolds sat down with Banas to go through the pledge commitment by commitment and to look ahead to Jan. 1, 2027, when the CMS Interoperability and Prior Authorization final rule stops asking payers to cooperate and starts requiring it. Banas explains what has to be built by then, where he expects the deadline to break down and the two things a practice can do this month to be ready. Music Credits:Sky Drifter by Cephas - stock.adobe.comA Textbook Example by Skip Peck - stock.adobe.comEditor's note: Episode timestamps and transcript produced using artificial intelligence (AI) tools.0:00 – 0:10 | Cold open. Banas previews the episode's central worry: that digitizing prior authorization may not fix a process that was broken by design. 0:10 – 1:14 | Introduction. Austin Littrell introduces the episode and the guest. 1:14 – 1:32 | Meet Colin Banas. Keith Reynolds introduces DrFirst's chief medical officer and returns to his skepticism from a year ago. 1:32 – 2:56 | Who's watching the watchmen? Banas says he feels vindicated, and explains why: almost all the evidence that the pledge is working comes from the insurers who made it, with no external validation. 2:56 – 4:57 | The six pillars. What insurers actually committed to, from qualified clinical review of appeals to standardized electronic prior authorization and real-time approvals. 4:57 – 8:50 | What actually got delivered. Banas goes pillar by pillar. Only 24% of physicians report seeing specialty-matched review, the reduction claims are self-reported, and two of the six commitments were federal mandates already in motion. "It feels like taking credit for something that you were going to have to do anyway." 8:50 – 11:24 | "It's as bad as ever." Prior authorization friction has passed EHR friction as physicians' leading administrative complaint. Rooms with fax machines, clinical teams running six browsers for six payers, and what Banas calls a non-unified, wasteful experience. 11:24 – 13:32 | What has to be built by 2027. The four APIs every player in the ecosystem needs, and why the medical benefit and the prescription benefit are on separate tracks. 13:32 – 14:37 | P2 Management Minute. Keith Reynolds shares practice management tips and invites listeners to submit their own workflow ideas. 14:37 – 16:56 | The retrospective prior authorization. Why finding out at the pharmacy counter is "almost insanity," why the best prior authorization is the one that never happens, and why Banas wants the process as transparent as a pizza tracker. 16:56 – 18:41 | Where the deadline breaks down. Banas points at payers and vendors first and enforcement second, drawing the parallel to the early years of the information blocking rule. 18:41 – 19:33 | If the pipes get built and nothing changes. What persistent delays would prove about how the whole system is incentivized. 19:33 – 21:48 | Credit where it's due. Activated patients, payers expanding gold carding, and why taking 80% of the work off a practice's plate still counts as meaningful progress. 21:48 – 23:15 | Two things to do this month. Get a straight compliance answer from your EHR or e-prescribing vendor, and start tracking approvals, denials and reversals now so you have a baseline to measure against. 23:15 – 24:46 | Closing thoughts and outro. Banas asks to do it again in six months and ends on a positive note. Littrell wraps the episode.

Independent practices know technology is what keeps them independent. They just don't trust the technology they have. Veradigm surveyed 360 leaders at independent ambulatory practices, including 210 physicians, and found 79% call technology essential to staying independent while only 64% are confident their current tools can deliver. Aaron Ledbetter, solutions and growth strategist at Veradigm, joins the show to explain what sits inside that gap: denied claims that take one to two weeks to surface, payer contracts multiplying faster than the staff to manage them and a labor market where physicians are the hardest position to both recruit and retain. He also makes the case that the electronic health record is about to stop being a system of record and start being a system of work. Medical Economics and Veradigm are hosting a live virtual event on the same subject, "The State of the Independent Practice in 2026," on Wednesday, Aug. 26 at 2 p.m. EDT: https://globalmeet.webcasts.com/starthere.jsp?ei=1770655&tp_key=bf8dd29613&sti=mjhpopup&utm_source=mkt_layer&utm_medium=popup&utm_campaign=ME+State+of+Independent+Practice+8.26&utm_content=news%7Ctopics%2Ftechnology%7Ctopics%2Findustry-trends%7Ctopics%2Fvalue-based-care%7Ctopics%2Fpractice-management Music Credits:Sky Drifter by Cephas - stock.adobe.comA Textbook Example by Skip Peck - stock.adobe.comEditor's note: Episode timestamps and transcript produced using artificial intelligence (AI) tools. 0:00 – 0:32 | Cold open. Ledbetter previews the episode's central claim: the electronic health record is about to stop recording what happened and start doing the work. 0:32 – 1:33 | Introduction. Austin Littrell introduces the episode, the guest and the Aug. 26 Medical Economics and Veradigm virtual event. 1:33 – 2:27 | Meet Aaron Ledbetter. Ledbetter describes Veradigm's clinical and revenue cycle work with independent practices, and his own path through value-based care consulting in Washington, D.C., direct work with CMS and CMMI on model design and payer contract negotiation for roughly 1,600 clinicians at a New England ACO. 2:27 – 4:16 | The confidence gap. Seventy-nine percent of practice leaders call technology essential to staying independent; 64% trust the tools they have. Ledbetter attributes the gap to tools aging out mid-adoption, an arms race with payer technology and the administrative weight of a growing book of payer contracts. 4:16 – 5:52 | Why practices walk away from acquisition talks. Twenty-six percent of practices surveyed reached serious acquisition negotiations before deciding to stay independent. Ledbetter says strain gets them to the table, whether administrative, operational or financial, and what pulls them back is the belief they can still solve it with better tools. 5:52 – 7:06 | Why a denial takes two weeks to surface. Ledbetter calls it a symptom of a lagging operating model, with detection, root cause analysis and resolution scattered across different people and different systems. Fifty-eight percent of practices run a hybrid revenue cycle split between internal staff and outside vendors. 7:06 – 8:17 | Denial drivers across the whole revenue cycle. Eligibility errors, missing data and coding mismatches all trace back to information that wasn't captured, was captured incorrectly or didn't surface early enough. Ledbetter argues against fixing one stage in isolation. 8:17 – 9:08 | P2 Management Minute. Keith Reynolds shares practice management tactics and invites listeners to submit their own. 9:08 – 10:56 | Scale doesn't insulate. Eighty-two percent of practices reported increased financial pressure and 60% called that increase significant. Larger practices feel it as volatility driven by payer complexity, solo practices feel it as a staffing problem, and Ledbetter argues both are expressions of a shrinking margin for error. 10:56 – 12:31 | What's different about AI this time. Ledbetter grants that physicians are right to be skeptical and names app fatigue as a real problem, then makes the case that ambient documentation and background automation of prior authorization, reporting and denial follow-up move the electronic health record from a system of record to a system of work. 12:31 – 14:03 | The administrative barrier to value-based care. Nearly half of respondents named administrative requirements the top barrier to value-based care participation, ahead of clinical complexity and financial risk. Drawing on his ACO contracting experience, Ledbetter describes tracking the differences between arrangements as work that takes a small army, and argues technology should automate quality measure tracking and surface care gaps before the visit. 14:03 – 15:34 | Automation as a recruiting advantage. Physicians ranked hardest to both recruit and retain. Independent practices can't match a guaranteed employed paycheck, but Ledbetter argues automating documentation, denials and prior authorization buys the work-life balance that decides where a physician lands. 15:34 – 17:30 | Running independence as an operating model. For practices with little or no administrative staff, Ledbetter says the answer isn't hiring but choosing technology that surfaces the right signals in days instead of months. He also expects more independent practice associations banding together for leverage with vendors and payers. 17:30 – 19:02 | The inflection point. Health care has spent years throwing people at manual problems and adding complexity in the process. Ledbetter's closing case is that this is the first moment technology can look at the entire system of work at once. 19:02 – [runtime] | Closing thoughts and outro. Littrell thanks Ledbetter, points listeners to the full Q&A and the report, and reminds the audience about the Aug. 26 virtual event.

GLP-1s broke the traditional pharmacy benefit, and a growing number of employers are responding by buying brand drugs straight from the manufacturer and cutting the insurer and pharmacy benefit manager out of the transaction entirely. Jay Bregman, founder and CEO of Andel, joins Medical Economics Associate Editor Austin Littrell to explain how the model works from the prescriber's side: the script still starts with the patient's own physician, still travels over Surescripts and still reports back into the chart. What changes is everything after that, including a fixed employer contribution in place of a prior authorization. Bregman also addresses the part that matters clinically, which is what happens to a patient's negotiated price when they leave the job or the employer stops contributing, and where a benefit built on employment leaves the patients it doesn't cover. Music Credits:Soft Morning by Cephas - stock.adobe.comA Textbook Example by Skip Peck - stock.adobe.comEditor's note: Episode timestamps and transcript produced using artificial intelligence (AI) tools. 0:00 – 0:31 | Cold open Bregman on why coverage on paper rarely means access in practice, and why even an approval may not survive the next plan year. 0:31 – 1:40 | Introduction Austin Littrell introduces the episode and Jay Bregman, and frames direct-to-employer purchasing as one of several channels now routing around the pharmacy benefit. 1:40 – 2:06 | Meet Jay Bregman Bregman describes Andel as a cooperative marketplace connecting plans, drug manufacturers and members on a single network. 2:06 – 3:37 | What direct-to-employer purchasing actually is Andel acquires rights to brand drugs from the manufacturer at a discount, which Bregman says it earns by removing utilization management, prior authorization, formularies and rebates. Employers pay a cash contribution, from $100 per fill up to the full cost, and carve the drug out of the traditional plan. 3:37 – 5:06 | Why GLP-1s became the entry point Bregman argues utilization broke conventional coverage for this class, calling GLP-1s the wildfires and hurricanes of pharmacy, and says the carve-outs being built for them are scaffolding for other drugs. 5:06 – 6:15 | From prescription to doorstep Patients keep their own physician, the script goes to Andel's non-dispensing pharmacy over Surescripts, and eligibility, payment and shipping run automatically. No telehealth requirement, no limited network. 6:15 – 7:26 | Where the treating physician fits Bregman's case that the model re-empowers the prescriber, and his argument that the administrative layer it removes was never adding clinical value. 7:26 – 8:16 | Does anything change at the point of prescribing Andel built its own pharmacy, NPI and Surescripts integration so it appears in any EMR. By Bregman's account, a physician sends the script exactly as they would to any retail pharmacy. 8:16 – 9:07 | P2 Management Minute Keith Reynolds shares practice management tips and invites listeners to submit their own workflow ideas. 9:07 – 10:06 | Does the fill land in the chart Because the order travels through Surescripts, it reports back like any other prescription. Bregman says a free data exchange API also lets plans reconcile out-of-pocket spending and accumulators, which he frames as the dividing line from direct-to-consumer channels. 10:06 – 11:20 | Cost and experience versus the pharmacy benefit Bregman claims fewer than 2% of members get access even when a plan covers GLP-1s, and argues a predictable monthly out-of-pocket beats an approval that may not hold next year. 11:20 – 12:49 | What happens when the job ends The access cliff. Bregman says COBRA may let some plans continue the benefit and that portability between employers is on the roadmap, but acknowledges that for certain drugs the negotiated price disappears once the employer contribution stops. 12:49 – 13:42 | Where Medicare fits None of Andel's products are designed for Medicare. Bregman points to the commercial market as the company's focus and to the patients government programs don't reach. 13:42 – 14:37 | What Bregman wants physicians to know His pitch to prescribers: the platform treats the prescriber's decision as final and doesn't challenge it with prior authorization or utilization management. 14:37 – 15:19 | Beyond GLP-1s Bregman says the first non-GLP-1 agreement is signed and more drugs are expected on the platform within six months, and asks prescribers for direct feedback. 15:19 – 16:47 | Closing thoughts and outro Littrell thanks Bregman and wraps the episode.