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Ran Shul, K Health

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K Health started life as symptom checker and spent a lot of time working with Elevance/Anthem. But in recent years has become a sophisticated LLM tuned to patients and now is working exclusively with major health systems as a front door including Mayo, Cedars Sinai and now Atlantic Health providing PatientGPT and Virtual Primary Care. I had Ran Shul, Chief Product Officer come on THCB Spotlight to show how K Health is being used in various ways across health systems. He showed me various demos and I also asked him about the relationship with Epic, and what the future of care delivery with LLMs is going to be. Ran thinks we might need more doctors not less!–Matthew Holt

This was such a great discussion I wanted to publish the transcript. The way I do that is to copy the YouTube-generated transcript and drop it into Claude to smooth it over. I then read it, and if I think it’s made an error, I dip back into the video and listen to what actually happened and make a correction. This is all to say: I think this transcript is pretty accurate, but it might have a bunch of AI- and human-generated mistakes.

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Institutional Betrayal: HHS’s Failure to Decarbonize the Healthcare Industry (Part 2)

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By DAVID INTROCASO

This is Part 2 of David Introcaso’s review of the attempt by the Biden admin to do something about the massive carbon footprint of the US health care system. If you haven’t read part 1, start here.

Discussion

Under Secretary Becerra, HHS’s effort to decarbonize healthcare amounted to passive obstructionism or at best an exercise in performative guilt.

Inarguably, the climate crisis constitutes a permanent Public Health Emergency (PHE). Yet, Becerra refused to declare one. His Surgeon General, Dr. Vivek Murthy, whose job was to generate debate and build consensus concerning significant public health issues, failed to make climate breakdown or healthcare’s contribution to it a priority. HHS never signed an agreement with the EPA nor with the Department of Energy. It was striking Becerra failed to say anything about the Securities and Exchange Commissions’ 2022 proposed climate disclosure rule despite knowing the highly-leveraged healthcare industry faces significant climate-related financial risk exposure. 

Because Becerra also failed to obtain Congressional funding for OCCHE, until it was eliminated in 2025 OCCHE was largely relegated to producing monthly “Climate and Health Outlook” reports that attempted to identify where the next climate disaster would threaten the public’s health.

Per a White House call to action, in April 2022 Becerra announced a voluntary climate pledge program that constituted patented greenwashing. Pledgees would self-report, were not required to use Energy Star and the program lacked oversight and enforcement.   

A month later Becerra announced an Office of Environmental Justice. It too was never funded. The OEJ did produce an Environmental Justice Index that scored by census track environmental, health and social vulnerability. Possibly a good idea in theory but in reality, as a potential climate redlining tool it threatened to formally sanction climate apartheid. 

The 2021 White House EO also directed major agencies to develop climate resilience plans. Becerra would have been wise to ignore the directive.  Instead, HHS published a Climate Action Plan that pledged to make a “concerted effort to enhance resilience.” It’s worth noting building resilience is now widely promoted despite presenting insurmountable and distressing problems. Resilience requires ceaseless adaptation to and recovery from an endless cycle of climate-charged disasters. Because resilience assumes climate harms are endemic, they are made acceptable. People are forced to live in permanent danger because there is no alternative to ecocide capitalism. Resilience teaches apathy, hopelessness and fatalism. It is anti-human agency, a form of subjectification. As value free, it is an attractive political policy allowing for infinite deferral. Resilience allows institutions like HHS to abdicate responsibility, apologizes for exploitative resource use and licenses a disaster-ridden world. Refusing to envision any alternative future, resilience is nihilism. 

Becerra could have at minimum calculated healthcare’s annual carbon footprint. Either on its own or in cooperation with the EPA, HHS could have at least conducted source attribution, sentinel site or randomized stratified sampling studies, exploited proxy data, etc. 

More productively, Becerra could have exploited the 1946 Administrative Procedures Act’s “good cause” exemption.  This would have allowed Becerra to publish an interim final regulatory rule, that would take effect immediately, requiring hospitals under COP to at minimum publicly report Energy Star scores.

CMS’ effort was non-existent.

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America Is Running Out of Doctors

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By EMANUEL SARKEES

Most people assume that when they need a doctor, a doctor will be available. That assumption is getting harder to hold onto. Right now, more than 83 million Americans live in highlighted Health Professional Shortage Areas, which is the government’s official notice that where they live does not have enough physicians to meet basic healthcare demand. That is not a projection of something yet to come. It is the situation today, and the numbers are moving in the wrong direction.

The Association of American Medical Colleges projects the United States will face a shortage of up to 86,000 physicians by 2036. The National Center for Health Workforce Analysis puts it even higher, projecting a shortage of 124,180 physicians by 2027 and 187,130 by 2037. The two organizations use different methods but they land in the same place. The country is training, retaining, and deploying far fewer physicians than its growing and aging population needs.

What makes this worth paying attention to right now is not just the size of the problem. It is the fact that this shortage was not some unavoidable outcome. It was built, step by step, and then never was corrected before the damage became permanent.

How the System Built This Problem

The most important driver that most people have never heard of is the residency cap. In 1997, Congress froze the number of Medicare funded graduate medical education positions, which are the residency slots that medical school graduates need to complete before they can practice independently. The system largely preserved the existing distribution of residency positions, which also resulted in preserving an imbalance in the physician workforce. Adding more residency positions does not guarantee that new physicians will enter the primary care specialties or communities where they are actually needed. The result is not a shortage of physicians, but a mismatch between the specialties being trained and what types of physicians the country needs. Medical school enrollment has grown since then. Residency slots have not kept pace. The result is a bottleneck where qualified graduates cannot finish their training because there are not enough funded positions available. Without more residency funding, the final step in the physician training stays limited no matter how many students start medical school.

Medical debt makes the problem worse in a way that directly shapes where physicians end up practicing. The average medical school graduate carries more than $216,000 in student loan debt by the time they finish their education. By the time residency and fellowship training wraps up, which can be six to eight years later, that number has often grown. When a new physician is carrying a quarter million dollars in debt, the decision about where to practice is not made on the factor of where patients need the most help. It is made for the reimbursement system where primary care physicians earn significantly less than procedural specialists, and where rural practices operate on margins that make competitive salaries hard to offer. This is not a flaw in individual physicians. It is math, and the system sets it up this way.

Burnout is the third piece to the puzzle.

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Institutional Betrayal: HHS’s Failure to Decarbonize the Healthcare Industry (Part 1)

By DAVID INTROCASO

The Problem

From an anthropocentric perspective, the climate crisis is fundamentally a threat to human health and survival. 

The US healthcare industry significantly contributes to this threat. US healthcare’s greenhouse gas emissions (GHG) annually account for over 600 million metric tons of carbon dioxide equivalents or ~10% of total US annual GHG emissions.[1] If US healthcare was its own country, it would rank ~12th worldwide in carbon pollution. 

Tragically, the industry and the US Department of Health and Human Services (HHS), responsible for regulating the healthcare market, remain committed to climate breakdown.  

The Solution

There was a sense of relief in 2020 when the National Academy of Medicine (NAM) announced its commitment to decarbonize the industry. The NAM’s silence had been difficult to understand in part because the National Academy of Sciences had recognized climate-related public health problems as early as 1966.  That year, NAM President Dr. Victor Dzau launched the Academy’s Grand Challenge on Climate and Health. The initiative was defined by a scoping paper drafted by Dr. Don Berwick, a former CMS Administrator, and two colleagues.  The authors wrote, “as the climate change public health catastrophe smolders, the US Healthcare system largely fiddles.” “Rather than ‘doing no harm,’ healthcare is fueling the carbon fire.” They recommended healthcare leaders “respond effectively to climate change,” by measuring “HEALTH outcomes as much by the environmental and public health impacts of our work as by the outcomes of particular patients.” “The healthcare sector must,” they concluded, “reduce its carbon footprint by 50%, in absolute terms, by 2030 compared to a 2010 baseline.” The recommendation aligned with a United Nations’ 2018 report that concluded reducing GHG emissions by this percent would provide a 50-66% chance that global warming would be limited 1.5°C above pre-industrial levels and thereby avoid irreversible climate tipping points.

In September 2021, Dr. Dzau announced a NAM and HHS co-chaired effort titled the “Action Collaborative on Decarbonizing the US Health Sector.” HHS was prepared because per an early 2021 White House Executive Order titled, “Tackling the Climate Crisis at Home and Abroad,” HHS Secretary Xavier Becerra had announced one month prior the creation of HHS’s Office of Climate Change and Health Equity (OCCHE). During his OCCHE press conference Becerra promised, “we’re going to use every tool at our disposal” to decarbonize the healthcare industry.

Motivations

There are several reasons why decarbonizing the healthcare industry has enormous significance.

With a market cap of upwards of $7.5 trillion, US healthcare, arguably the largest industry in the world’s largest economy, is exceptionally energy intensive being resource heavy in buildings, technology and labor. Equipment, lighting, strict ventilation, plug-in loads and high-occupancy mean hospitals are ovens even when outside temperatures are below freezing.

The industry is equally energy inefficient. The ten-year running average ending in 2025 of hospitals EPA Energy Star certified was 88, or less than 1.5% of an American Hospital Association-estimated 6,100. Operating rooms are particularly energy sinks accounting for ~50% of a hospital’s GHG emissions largely because of significant use of disposable medical supplies.   

High entropy healthcare was nowhere near decarbonizing much less accounting for its GHG emissions. While total US GHG emissions decreased by ~5% between 2010 and 2018, healthcare’s increased by ~6%. Research published in 2022 concluded healthcare “lags far behind in terms of [climate] sustainability, management and disclosure,” because “there is no sector-wide push from academic or industry leaders, government . . . regulators . . . or payors.”

Fossil fuel combustion exposes everyone, everywhere to innumerable and unrelenting health harms. Effectively everyone worldwide breathes substandard air accounting for upwards of ~8 million deaths annually. A study published in 2018 concluded 58% of estimated excess US deaths are due to fossil fuel use. A study published in 2022 concluded an equal percent of infectious diseases are aggravated by climate-related hazards and pathways.

GHG emissions pose a meta-problem, an underlying problem about a problem. Absent their removal, every healthcare policy effort to improve access, equity, quality, spending, value and utilization are compromised.   

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When “Paying Correctly” Means Paying Nothing: How to Make Medicare Advantage Accountable

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By FRANK LEAHY

This is the second of two pieces. The first told the story of “Rick,” a 77-year-old Humana Medicare Advantage member who nearly lost his sight in a months-long runaround over a retinal detachment. This one asks what his case reveals, and what would help fix it.

The runaround was exhausting – the hold times, the repetition, the new voice on every call. But the most disturbing moment wasn’t any of that, and it wasn’t a denial. It was a justification. The claims that paid his surgeon $0.00, a Humana representative explained, were “paying correctly based on the contract loaded.”

Hold onto that sentence, because it reframes everything. What nearly cost Rick his sight was not one careless adjuster or one unlucky claim. The system did what it was built to do. It was designed so that a 77-year-old losing sight in one eye, and the surgeon who saved it, could end up with nothing – and no understandable way to make it right.

No understandable way is the heart of the problem. When a privately insured patient gets an unfair out-of-network bill, federal law hands their doctor a referee: the No Surprises Act, which lets a provider force a fair payment through arbitration. But that law was written for commercial insurance and never reached Medicare Advantage. On paper, Rick’s surgeon was already owed at least the standard Medicare rate; Medicare Advantage’s own rules say so. But he was paid nothing – and unlike a commercial patient’s doctor, he had no arbitration, no referee, no way to force the issue. What finally worked was a letter to Humana’s CEO and board of directors – a lever that shouldn’t have been needed.

Not an Outlier

Rick’s is just one case among a very large number. In 2023, Medicare Advantage insurers reviewed roughly 50 million prior-authorization requests and denied about 6.4% of them. Only 11.7% of those denials were ever appealed – and of the ones that were, more than 80% were partly or fully overturned. When four of five challenged denials get reversed, the obvious question is how many of the unchallenged ones were wrong too. (Source: KFF, 2025.) The federal Office of Inspector General has repeatedly found Medicare Advantage plans denying or delaying care that traditional Medicare would have covered.

What Rick’s case adds to those numbers is texture. His problem was never that his care was judged unnecessary – it was eventually authorized. His problem was that the rules were invisible and the process had no owner. No one told him a referral was required until he’d already failed to get one. The primary care doctor who was listed on his Humana Medicare Advantage card was a stranger in another state. The insurer’s own directory listed specialists who didn’t take the plan. Every answer contradicted the last, and nothing was ever put in writing. He was expected to navigate a maze whose walls appeared only after he’d walked into them. And when the maze finally produced a number, the number was $0.00 – for a surgeon the same insurer confirmed, on a recorded line, was in network.

Three Fixes That Can Help

There are many big proposals about how to fix health care in America, but I’m going to propose three narrow, unglamorous fixes that answer the simple question: Would it have helped Rick at the time of his accident?

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The Pandemic Risk of “What I’ve Never Seen Before”

By MIKE MAGEE

The world of medical science largely closed ranks last month in defense of Tony Fauci. Dr. Fauci had been hauled before the Senate Homeland Security Committee to face hostile entrapment by long time critique Senator Rand Paul of Kentucky. Taking no chances, his lawyers had the former head of NIH’s Infectious Disease division plead the 5th to avoid entrapment, fines, and even imprisonment.

It has been five years since Dr. Fauci appeared on MSNow (formerly MSNBC) and encourage viewers to “keep an open mind” when it came to “gain-of-function” research and the origins of the Covid pandemic. Since then, a 2025 WHO report stated “As things stand, all hypotheses must remain on the table.” That includes the possibility that the viral tragedy resulted from the inadvertent release of a genetically engineered virus from the Wuhan, China, laboratory of Shi Zhengli, a virologist trained at the University of North Carolina.

The risky experiments, termed “gain-of-function” studies, were justified as super-secure, safe, predictive, and preventive. Shi returned to her labs in 2018 and 2019 with grant funding from the National Institute of Allergy and Infectious Disease and the Department of Defense via an intermediary, the New York based non-profit EcoHealth Alliance,whose funding was retracted in 2024.

Their coordinator-in-chief was one Peter Daszak. Daszak is known for adopting militarized terms in the battle against global infectious diseases. In 2020 he wrote in the New York Times, “Pandemics are like terrorist attacks: We know roughly where they originate and what’s responsible for them, but we don’t know exactly when the next one will happen. They need to be handled the same way — by identifying all possible sources and dismantling those before the next pandemic strikes.”

Daszak’s argument that risks involved in Shi Zhengli’s Wuhan bat virus research were justified as defensive and preventive was convincing enough to the NIH and the Department of Defense that his EcoHealth Alliance was funded from 2013 to 2020 (contracts, grants, subgrants) to the tune of well over $100 million – $39 million from Pentagon /DOD funds, $65 million from USAID/State Dept., and  $20 million from HHS/NIH/CDC.

Daszak’s position within the scientific community was controversial. In fact, in 2014, a group of concerned scientists called the Cambridge Working Group issued this statement: “Accident risks with newly created ‘potential pandemic pathogens’ raise grave new concerns. Laboratory creation of highly transmissible, novel strains of dangerous viruses, especially but not limited to influenza, poses substantially increased risks. An accidental infection in such a setting could trigger outbreaks that would be difficult or impossible to control.”

All of this, it seems, would be “old news” except for last week’s dramatic announcement that “For the first time, scientists have used artificial intelligence to create new kinds of viruses, raising hopes for medical advances while also raising the disturbing possibility that the technology could someday be used to invent dangerous pathogens.”

It has been 23 years since scientists first constructed a synthetic viral genome. But Evo, a creative science AI newcomer, produced by OpenAI has apparently broken new ground – on its own. Well not completely. Its’ masters primed the pump by feeding the AI engine with nine trillion nucleotides (the human genome has 3 billion) obtained from millions of diverse species.

The scientific engineers focused down on a well-known virus that is generally active primarily in attacks on the bacteria, E-coli. It’s called Phi X-174. It has been utilized for some time in genetic engineering exercises. But in this case, it (along with some 15,000 close chemical relatives), was feed into Evo with the instruction to create new novel viruses of its own. 

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“We’re Sorry, That’s the Policy”: How a Medicare Advantage Runaround Nearly Cost a Senior His Sight

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By FRANK LEAHY

On a gray February morning, I sat in my office in Inverness, in rural northern California, with the phone pressed to my ear, jotting down notes and Humana reference numbers. Across the table, my new friend Rick, 77, waited anxiously, struggling to follow the conversation. Nearly deaf and now partially blind, Rick had lived with a detached retina for weeks. Time was running out to save his vision.

I was determined to get Rick the surgery he needed. But as hours turned into days and days into weeks, I found myself ensnared in the kind of bureaucratic maze familiar to millions of Americans with Medicare Advantage plans.

This is the story of a vulnerable senior and his advocate, caught between doctors, clinics, and insurers at the hard edge of Medicare Advantage – America’s privatized Medicare system. It is a story of denials, delays, and a rulebook no one would explain – and of the human cost when a system is built to save money, not sight. It is also a story about how and why it took seven months, and a letter to a Fortune 500 CEO, to get one surgeon paid.

“I Just Want to See Again”

Rick’s world had been shrinking for years. Hard of hearing and living on less than $1,200 a month in Social Security and SSI, he split his time between Colorado and a friend’s spare room in rural California. With no family nearby, no internet, and only a battered flip phone, he relied on friends for help.

In mid-November 2024, Rick fell out of bed, striking his head and injuring the left side of his face. He shrugged off the pain, but over the following weeks his vision blurred, then faded. “I thought it would get better,” he said. “But it just kept getting worse.”

I met Rick in late December 2024. He told me about his fall, the injury, and that he could no longer see out of his left eye. It was clear how serious his situation was, and how much support he needed, so having recently retired I had the time to help him. But it was nearly too late. After weeks of back-and-forth with Humana, I finally got him in front of an ophthalmologist, who diagnosed a retinal detachment – a medical emergency where prompt treatment is essential to prevent permanent blindness.

Getting that treatment would prove far harder than I could have imagined.

The Medicare Advantage Trap

Rick was enrolled in a Humana Gold Plus HMO, a Medicare Advantage plan based in Colorado. Why Humana? Pure happenstance. He had been shopping at a Walmart in Colorado when a man “who seemed nice” signed him up. Like a lot of older people, Rick didn’t know the difference between Medicare Advantage and Original Medicare with a Medigap supplement – or why that difference would come to matter so much.

Like more than half of all Medicare beneficiaries, Rick had been drawn to a private plan by the promise of extra benefits and lower costs. The catch is that Medicare Advantage plans are built on narrow provider networks and strict rules about where and how you get care. For snowbirds, part-time residents, or anyone who lives in more than one state, those rules can become a trap.

My first call to Humana set the tone:

“I searched for a doctor on your website. I found one and called them. They say they don’t take Humana, even though your website says they do,” I told a representative, reading from my notes. “Can you find one for me?”

“You can, but I need Rick on the line.”

“He’s right here.”

“Okay, but I also need additional documentation…”

The runaround had begun.

The Rules No One Explained

To get surgery, Rick needed a referral to a retina specialist. No one at Humana told us that at the start. We learned it the way we learned every rule in this process – by hitting a wall, calling back, and being told, after the fact, that we had failed to do something no one had mentioned.

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Big Bucks, No Whammies: Patient Access Was Never the Finish Line

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By STEPHEN FARBER

If you grew up in the 1980s, you probably remember Press Your Luck. Contestants stood in front of a flashing game board chanting, “Big bucks… no Whammies… STOP!” hoping the next square held cash instead of the mischievous cartoon character that erased everything they had won.

For years, assembling your own medical history felt remarkably similar.

You knew you had been treated at one hospital years ago, had imaging performed somewhere else, saw specialists who later retired, and changed insurance more than once along the way. One patient portal showed part of the story. Another required a password you hadn’t used in years. A medical records department offered to mail you a PDF after you completed a release form. Somewhere there was still a CD that no computer in your house could read. None of this meant your information had disappeared. It simply meant that putting it together depended almost as much on persistence as process.

That has always been one of healthcare’s great ironies. The industry became exceptionally good at documenting encounters. Every office visit, laboratory result, prescription, imaging study, discharge summary, and insurance claim was carefully preserved somewhere. What it never became particularly good at was helping individuals assemble those encounters into a coherent picture of their health over time.

For years, most of us accepted that as an unavoidable consequence of a fragmented healthcare system. In reality, it reflected a combination of technical limitations, business incentives, and regulatory uncertainty that made sharing information far more difficult than creating it. Patients often became the courier between organizations because there were few practical alternatives.

Quietly, that has begun to change.

While much of the industry’s attention has shifted toward artificial intelligence, another transformation has been taking place beneath the surface. The 21st Century Cures Act, Information Blocking regulations, standardized FHIR APIs, CMS interoperability requirements, and the continued evolution of TEFCA have collectively changed the trajectory of patient access. None of those developments solved the problem on their own, but together they have created an environment in which individuals can retrieve far more of their own health information electronically than was practical only a few years ago.

Although we’re still in the early stages, the technology has matured to the point where individuals can increasingly assemble and steward their own longitudinal health record. That changes the conversation. For much of the past decade, patient access was largely a policy discussion centered on whether people should have meaningful electronic access to their own information. Increasingly, the more interesting question is what becomes possible once they do.

As the market has evolved, complementary approaches have emerged. Some companies focus on helping individuals retrieve records directly from the organizations that hold them. Fasten Health is an interesting example because it begins with a simple premise: individuals should be able to assemble a record they control. Other organizations focus on discovering where records exist through exchange networks, while infrastructure companies simplify connectivity so developers can build applications without creating thousands of individual integrations. These approaches solve different problems, but they increasingly reinforce one another instead of competing.

That convergence has quietly moved the industry across an important threshold. For years, success was measured by our ability to collect fragmented data. Standards had to mature, regulations had to evolve, organizations had to expose information electronically, and software developers had to build practical ways of retrieving it. Much of that work occurred outside public view, but together it has made something increasingly realistic that once felt aspirational.

Bringing information together is a significant achievement because it gives people, often for the first time, a more complete picture of their interactions with the healthcare system over many years. A longitudinal health record tells us where someone received care, what diagnoses were made, which medications were prescribed, and what procedures were performed. Those are essential building blocks, but they rarely explain why decisions were made, what alternatives were considered, who participated in those conversations, or what mattered most to the individual at that point in life. Records preserve information extraordinarily well. Context has always been more difficult to preserve.

Healthcare has good reasons for operating around encounters because that is how care is delivered, documented, and reimbursed. People, however, experience their lives as a continuous story in which one decision influences the next, often over decades.

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Hospital Price Transparency Legislation Will Burden Poor and Rural Patients   

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By DAVID INTROCASO

Last month the House Energy and Commerce and the Senate Health, Education, Labor and Pensions (HELP) committees passed three hospital price transparency (price T) bills by a combined vote 90-22. Afterward, HELP Chair, Dr. Bill Cassidy, stated he was ‘optimistic” and “confident” price T legislation would be enacted by the Congress this session.

Over the past decade federal policymakers have concluded price T will constraint or moderate hospital prices. In theory, the logic is straight-forward. By requiring hospitals to publish machine-readable files and consumer-friendly negotiated and cash rates for “shoppable” hospital services, transparency or disclosure will expose significant price variation empowering patients to comparison shop. In turn, this will spur hospital price competition and bend the healthcare cost curve.  

Because research published by several major medical and health policy journals has concluded HHS’s 2021 price T regulation has failed, the Congress has decided to weigh-in by codifying and expanding HHS price T regulations.

This assumes much. Per Ken Arrow, medical care is not a typical commercial or market commodity. Think: information asymmetry. Clinical diagnoses are often emergent, unpredictable and accompanied by acute physical and emotional distress. Focusing on price ignores or excuses the fact that in functioning markets prices are largely determined by costs. Here, they are largely ignored even though hospital prices are poorly and unpredictably correlated to costs. Price T also tends to lead to tacit collusion where hospital prices converge or what is the price ceiling increasingly becomes the price floor.

More specifically, price T presumes B2B or business-to-business transactions, here moreover ERISA plan – hospital contracting, are the product of a functioning hospital market. Based on this false assumption, price T skips passed B2B to B2C, or to the business-to-consumer market where the consumer is expected to identify favorable hospital prices. 

It is well-documented hospital concentration/consolidation has erased competition. There are simply price setting hospitals and price taking plans and patients or consumers. It’s no surprise that commercial plan hospital rates are on average north of 250% of Medicare and rates for common procedures can vary ninefold across hospitals.    

For these reasons, when evaluated from a health equity perspective, price T disproportionately places the responsibility and burden on poor and rural patients. (As an aside, this year the Congress invited at least 11 expert witnesses to provide price T testimony.  None addressed and/or had health equity expertise.)     

Among other substantial cognitive and financial burdens, these populations are already time poor, likely already face healthcare-related financial burden or vulnerability, experience higher rates of emergency care, have comparatively limited health literacy particularly when faced with opaque and intimidating cost estimates, are frequently confronted by a digital divide in accessing online estimator tools or downloading multi-gigabyte machine-readable files requiring broadband internet. For these and other reasons their response frequently is to delay or forgo care altogether. As a de facto buyer-beware mechanism, price T can act as a deterrent.

Price T also assumes geographical density and provider substitutability. In rural America single hospital systems or Critical Access Hospitals (CAHs) often serve as the sole provider within a ~100-mile radius. For a rural county resident, knowing that a hospital 75 miles away charges $250 for an MRI is largely irrelevant. Geographic distance, lack of public transit and travel costs negate price differentials. Imposing strict price T compliance requirements backed by increasingly severe civil monetary penalties for non-compliance can unintentionally strain negative margin rural providers by in part diverting personnel and capital toward maintaining data feeds.

For these populations particularly, with nowhere else to go, price T is a paradox. With information without options, it’s an oxymoron. With transparency in a concentrated market, it’s a distinction without a difference, serves as a signal for dominant hospitals to drift toward higher prices or a is non-sequitur by attempting to apply a demand side shopping remedy in a supply side monopoly. Price T can however serve as an essential prerequisite allowing even the most vulnerable to shop their way to affordable healthcare if it is paired with guardrails that create a functioning market or one with systemic accountability. This can be accomplished if the Congress decides to take the necessary step and like emerging drug pricing policy require the use of external reference pricing.  Hospitals or any supplier cannot be allowed to control price and also serve as an objective judge of it.    

David Introcaso is a healthcare research and policy consultant based in Washington, D.C

Prior Authorization

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By EMANUEL SARKEES

Most people have never heard of prior authorization until it personally stops them from getting care they actually need. The way it usually goes is pretty straightforward: a doctor sees a patient, figures out what is wrong, decides on a treatment, and writes the order. Then everything stops. Before anything can actually happen, the insurance company has to sign off. What makes this so frustrating is that it is not really one problem. It is a bunch of problems stacked on top of each other, where each one makes the next worse. Doctors lose hours, patients lose access, outcomes suffer, and the people who built the system are not the ones dealing with what it does to real patients.

Insurance companies say prior authorization is about preventing unnecessary care and keeping costs down. That argument has some logic to it on paper. But what the process actually looks like day to day has very little connection to that original idea. Doctors are drowning in paperwork, patients are waiting on treatments their physicians already approved, and outcomes are worse because of delays that did not have to happen. It was built to contain costs. What it is containing instead is care, and the patients on the receiving end had no say in how any of it was designed.

How It Works and Why It Doesn’t

A physician submits a request to an insurance company before prescribing a medication, ordering a procedure, or sending a patient to a specialist. The insurer looks at it and decides yes or no. That decision is supposed to come from a qualified medical professional who actually reviews the clinical picture. The data suggests that is not really what is happening.

The AMA’s 2025 physician survey found that the average doctor handles 40 prior authorization requests every week, eating up roughly 13 hours of their time. Almost two full working days every week are spent on paperwork instead of patients. Ninety-five percent of physicians surveyed said prior authorization gets in the way of necessary care. Seventy-nine percent said patients give up on treatment entirely because the process is too much or the approval never arrives.

What that produces is not an inconvenience. It is documented harm. A Johns Hopkins systematic review from September 2025 went through 25 studies and found prior authorization tied directly to disease progression, unnecessary hospitalizations, longer hospital stays, and lower survival rates in cancer patients. One in four physicians said a prior authorization delay had caused a serious adverse event for a patient, including permanent impairment or death. A RAND analysis from July 2025 pulled specific cases, including a kid with newly diagnosed Type 1 diabetes waiting in a hospital bed for approval on basic insulin, and an infant in respiratory distress turned away because a medication that was not even indicated had not been given first. These are not flukes. They are what happens when administrative decisions consistently override clinical ones with no real accountability in the process.

Who Gets Left Behind

Prior authorization does not land the same way for everyone. Low income patients and Medicaid patients face the highest denial rates and have the fewest realistic options when a denial comes through. Appealing takes time, paperwork, and persistence that is hard to maintain when you are working multiple jobs or dealing with a language barrier. For a lot of people the appeal never gets filed. The treatment gets dropped.

A 2025 KFF Health Tracking Poll found that 58% of insured adults who needed specialized care ran into a delay or denial because of prior authorization. For lower income patients that number is higher, and the consequences are more serious because there are not many alternatives when the answer is no. This fits a pattern that keeps showing up across American healthcare. People without insurance face it when they cannot afford to walk in the door. Low income patients face it when something is technically covered but impossible to access. Insured patients now face it when their doctor has already made the call and an insurance company decides differently. The wall keeps appearing in different places. It keeps stopping the same people.

The Promises Being Made

Some things have actually changed and it is worth acknowledging that.

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