Improving Healthcare Finance

Earnings Calls of UnitedHealth Group, Aetna, a CVS Health Company, Cigna Healthcare and Elevance Health/Anthem, Inc. All Discuss the SAME 2 Drivers of Their Growth: 1) #Government Programs (i.e. Medicare Advantage and Medicaid Managed Care) 2) Increased Script Count for Their #PBM Businesses... More Prescriptions = More Money. #Employer Health Plans are NOT Mentioned on Any of these Investor Calls as a Source of Growth for Health Insurance Companies. Contrast that Lack of Priority with the $14B in Digital Health Venture Capital and Private Equity Investment in Companies That Create Innovative Solutions for Employer Health Plans. Why the Disconnect? Answer: Health Insurance Carriers are '#FastFollowers' of Healthcare Innovation for Employers Because They Need Their Services for Employers to be 'Just Good Enough' to Retain them as Clients. The Insurance Carriers Then Use These Employer Plans to Negotiate #High Cost Commercial PPO #AllowedAmounts from Hospital Systems that are +200% of Medicare in Exchanged for #Low HMO Allowed Amounts Equal to Medicare. The Insurance Carriers Then Run Their #MedicareAdvantage and #Medicaid Managed Care Members Through Those Much Better HMO Contracts to Monetize Their Growing Government Business. Sources at AHealthcareZ YouTube Channel HERE: https://lnkd.in/giu2ds6k

A broker told a 165-person company they were "too small" for self-funding. That broker made $72,000 annually keeping them fully-insured. The company switched anyway and saved $340,000 in Year 1. Here's what "too small" actually meant. Fully-insured premium: $1.44 million annually. Renewal at 8.9%. The CFO asked about self-funding. Broker's response: "Companies your size can't handle catastrophic claims. One $500K cancer case could sink you. Fully-insured is safer." What he didn't say: His $72K commission was the same either way. But self-funded meant actual work—managing claims data, vendor relationships, quarterly reviews. Fully-insured meant forwarding emails and collecting checks. They brought in a second advisor. Level-funded structure: $103,000 monthly fixed payment covering admin, stop-loss, and expected claims. Total: $1.236M annually. Year-end actual claims: $847,000. Surplus refund: $73,000. Effective cost: $1.163M vs. $1.57M renewal. Savings: $407,000. The real win? Visibility. They discovered 6 employees with chronic conditions weren't getting proper care management. Added health coaching and medication monitoring. Year 2 claims for those employees: down 34%. Better health outcomes, lower costs. Also found their PBM charging undisclosed $180-per-claim admin fees. Renegotiated them out. Another $94,000 saved annually. Two-year savings vs. staying fully-insured: $763,000. "Too small for self-funded" means "I don't want to do the work." Most 50-250 employee companies can self-fund successfully with proper structure and stop-loss coverage. The question isn't size. It's whether your advisor will actually work. You're not too small for transparency. You're not too small for control. You're not too small to deserve an advisor who earns their commission.

Turns out the best investment opportunities in healthcare are hiding in nausea, gallstones, and constipation. In recent conversations with several large healthcare private equity funds, the consensus is clear: GLP-1 drugs like Ozempic, Wegovy, and Mounjaro are not just transforming obesity care. They are quietly creating a secondary gold rush in treating the side effects of weight loss. And it is not small. More than 6 million Americans are already on GLP-1s. Global GLP-1 sales are expected to exceed 130 billion dollars annually by 2030. Up to 40 percent of patients experience significant gastrointestinal side effects. Around 5 to 7 percent end up with gallbladder complications. Sarcopenia is now a real concern. Mental health utilization among GLP-1 users is rising by nearly 20 percent. Fertility clinics are seeing double-digit growth from GLP-1-related cases. So while everyone is applauding the miracle of weight loss, the savviest investors are looking at the flip side. They are rolling up GI clinics, expanding ASC platforms with cholecystectomy capacity, funding digital fitness and nutrition programs to fight muscle loss, backing behavioral health services for body image and binge relapse, and building analytics tools to help payers track it all. It is not just a new drug. It is a new healthcare economy. I have unpacked this trend in detail in my latest white paper: a playbook for investing around the GLP-1 explosion by targeting the ripple effects no one is talking about. Because in healthcare, what goes down (appetite) must come up (utilization of something else). #PrivateEquity #Healthcare #GLP1 #OzempicEconomy #HealthTech #DigitalHealth #VentureCapital #ObesityCare #PEInvesting

As a physician and advocate, I've seen the stark realities of healthcare inequality up close. It's a multifaceted challenge, deeply rooted in socioeconomic disparities, systemic barriers, and historical injustices. Yet, it's not insurmountable. We have the tools, the knowledge, and the collective will to forge a more equitable future in healthcare. The path forward involves a holistic approach: 1️⃣Embrace Preventative Care: Early intervention can prevent conditions from escalating into serious diseases. Community-based health education and accessible preventative services are key. 2️⃣Expand Telehealth: Telehealth can transcend geographic and transportation barriers, making healthcare accessible for all, but we must ensure it's equitably deployed. 3️⃣Diversify the Healthcare Workforce: A workforce that reflects the diversity of the population it serves can improve patient outcomes and trust. 4️⃣Advocate for Policy Change: Systemic change is essential. We need policies that ensure universal healthcare access and tackle the social determinants of health. Change won't happen overnight, but each step brings us closer to a healthcare system defined by its inclusivity and equity. Let's work together to make healthcare a right, not a privilege. #HealthcareEquity #SystemicChange #PreventativeCare #Telehealth #DiversityInMedicine #PolicyChange

🔥 Monday Mornings With Michelle - CA wildfires, can something good come out of this tragedy? 🔥 In the wake of the utter devastation happening in Los Angeles, there is a lot of press being paid to the fact that some of the biggest names in homeowners insurance, like State Farm and Allstate, decided to stop writing policies in the state. With the magnitude of the devastation, if nothing changes, many of the remaining carriers may have no choice but to exit the market. This isn't just about corporate decisions—it’s a wake-up call for the state’s insurance market. Here are the three main reasons why insurers are leaving: 1️⃣ Rising Catastrophic Risks: Wildfires in California are more frequent, intense, and expensive than ever before. Insurers are paying billions in claims, outpacing the premiums they collect. 2️⃣ Regulatory Constraints: California's Proposition 103 makes it tough for insurers to adjust rates based on future risks. They're stuck using historical data that doesn't reflect the increasing challenges from climate change and rising costs. 3️⃣ Soaring Costs: Rebuilding after a disaster isn’t cheap. Construction costs, labor, and reinsurance rates are climbing, leaving insurers with losses higher than premiums. What can be done to fix this? Here are some solutions to stabilize the market and ensure homeowners can get the coverage they need: ✅ Wildfire Risk Mitigation: Invest in better land management and incentivize homeowners to adopt fire-resistant materials and maintain defensible spaces around their properties. ✅ Rate Regulation Reform: Modernize regulations to let insurers use forward-looking models and climate data to set rates that reflect today’s risks. ✅ State-Backed Reinsurance: Create a public-private partnership to spread catastrophic risks and stabilize the reinsurance market. ✅ Consumer Education: Help homeowners understand how to protect their homes and why premiums may increase due to rising risks. ✅ Fair Plan Improvements: Strengthen California’s insurer of last resort to ensure coverage remains available for high-risk areas. This situation is complex, but the stakes are high—for homeowners, businesses, and the state’s economy. We need bold, collaborative solutions to create a sustainable insurance market in California. What are your thoughts on this crisis? Let’s start a conversation about the changes we need to see. #Insurance #California #Wildfires #ClimateChange #Innovation

18-20% annual increase - that's the rate at which healthcare costs are rising. It's a number that should make every business leader pause and think. This surge in healthcare expenses isn't making headlines, yet it's a critical issue that's slowly eroding the value of our employee health insurance plans. If we're not increasing our Group Health Insurance (GHI) coverage every three years, we're effectively reducing our employees' health protection. Here's why: ➤ Technological Leap: The medical field is transforming. We've moved from X-rays to MRIs in what feels like a blink, and each leap brings better care but at a premium. ➤ Facility Upgrades: Even smaller hospitals now feature cutting-edge equipment, driving up expenses. ➤ Pharmaceutical Costs: New, life-saving drugs enter the market at high prices due to extensive R&D investments. ➤ Operational Expenses: Rising real estate costs for medical facilities and competitive salaries for healthcare professionals contribute to overall cost increases. The math is simple. Over three years, we're looking at a 50-60% increase in healthcare costs. Our GHI plans need to keep pace, or we're shortchanging our teams. I've seen the consequences firsthand: Employees facing crippling medical debts. Delayed treatments due to coverage gaps. Stress that impacts not just health, but productivity and loyalty. The solution isn't complex, but it requires commitment: ➤ Audit your GHI plans annually. ➤ Increase coverage limits every three years, aiming for at least a 50% bump. ➤ Educate your team on their coverage – awareness is half the battle. ➤ Partner with insurers who understand this new landscape. As leaders, we don't just manage businesses – we safeguard our people. In this era of skyrocketing healthcare costs, that means taking a hard look at our GHI plans and making sure they're not just good on paper, but good in practice. It's about that woman in operations who beat cancer without bankrupting her family, or the guy in IT whose child got the specialty care they needed. The companies that act now will set the standard for employee care in the years to come. The question is: Will you be one of them? #PolicybazaarforBusiness #HealthcareCrisis #Employeebenefit #grouphealthinsurance

This Pune hospital crashed through 3 different owners in just 6 years & made each one richer than the last. The hospital is Sahyadri Hospitals, one of Maharashtra’s largest healthcare chains. Here’s how the ownership changed over the years: → 2019: Private equity firm Everstone Capital acquires Sahyadri for ~₹1,000 crore. → 2022: Ontario Teachers’ Pension Plan (OTPP) buys it for ~₹2,500 crore. → 2025: Temasek-backed Manipal Hospitals acquires it for ~₹6,400 crore. Same hospitals, same cities & mostly the same doctors treating patients every day. So what exactly were investors paying for? They were buying things that take years to build in healthcare: → doctors whose names bring patients to the OPD → referral networks across cities → patient trust  → a hospital brand families rely on during critical moments These are invisible assets. They rarely show up on balance sheets, but once they exist, they become extremely valuable. Investors see them as a scalable healthcare platform. Expand locations, add specialties, improve utilisation and the same hospital suddenly generates far higher profits. That’s how valuations jump. And Sahyadri isn’t an isolated story. Between 2022 and 2024, India’s healthcare sector saw 594 M&A and PE deals worth over $30B. Yet PE-backed chains still control only 15–20% of India’s private hospital beds. Which means the real consolidation wave in Indian healthcare is still ahead. Because in the end, the true value of a hospital isn’t just the building. It’s the trust built by doctors and patients over years & that trust is one of the most valuable assets in healthcare 🩺

Health insurance premiums are rising 7%, and the expectation is that employers will be increasingly open to novel approaches to controlling costs. This is an opportunity for physicians and healthcare innovators to collaborate with employers to build mutually beneficial solutions. Smart docs (and other clinicians) will stay ahead of the curve and differentiate themselves by embracing direct contracting, value-based arrangements, and transparency in outcomes and pricing. At the same time, many of the hassles of dealing with commercial payors can be reduced (prior auths, denials, complicated RCM, and other admin burdens). Such arrangements need not be the purview of ivory tower Centers of Excellence only. Success in these programs requires support and infrastructure that may not currently exist for many practices looking to enter such arrangements. Enter health tech and digital health companies. Setting up systems and processes to collect and report data (including PROMS), enhancing patient communication and engagement, and extending the office/hospital/ASC visit to the home are all critical components of succeeding in direct contract/value-focused arrangements. Sure, there are plenty of conveners and care navigation companies out there. But lowering the barrier of entry for high quality community docs and giving them the tools to succeed in these programs is a big opportunity. We also have plenty of companies (especially in MSK) looking to drive value through avoidance of low quality, low value interventions and serve as a layer between employees and traditional HC. IMO, that won't be enough going forward. Employers don't want fragmented point solutions that lose track of the patient when they fall outside the capabilities of an offering. The ability to interface with brick-and-mortar healthcare and support the entire patient journey provides much better ROI. The government, for its part, should learn from what innovative employers and healthcare providers are doing. Instead of more CMMI programs with spurious outcomes and failed bundled payment schemes, CMS should explore its own version of direct contracting -- in collaboration with high value healthcare providers. (The last part is key). There's no reason these arrangements only have to be available to people who get insurance through their employer. The need is as big or bigger in the Medicare population. Instead of doubling down on Medicare Advantage (and its questionable value prop to both patients and docs), CMS should be watching closely what forward thinkers are doing here. #medicine #healthcare #valuebasedcare #vbc #directcontracting #health #healthcareinnovation

The Hidden Cost of Private Equity in Healthcare: Lessons from Steward's Collapse Don Berwick and I recently had a sobering conversation with Dr. Gregg Meyer for our podcast #TurnOnTheLights about what happened at Steward Health Care in Massachusetts, and it's a story every healthcare leader needs to understand. As Dr. Meyer explains on the program, here's one way that private equity has been operating in healthcare: borrow massive amounts of money at low interest rates, acquire healthcare assets, then chase returns high enough to service that debt. It's a model built on leverage and investment philosophy, not on care delivery. But Steward's story reveals something even more troubling. This wasn't really about healthcare at all—it was about real estate arbitrage disguised as hospital management. As costs got squeezed to service the debt, something insidious happened on the ground. Surgeons would start procedures only to discover the supplies needed to complete them weren't available. In one case, a patient needed a prosthesis during surgery—there was only one left, no back up plan if something went wrong! Dr. Meyer described how providers simply got used to it. They called it "normalization of deviance"—when the unacceptable gradually becomes accepted because you're forced to adapt just to keep caring for patients. The circular logic of private equity then accelerated the collapse: Steward was forced to sell their real estate to a real estate insurance trust, which leased back the land to the hospitals at rates that ultimately drove them into bankruptcy. By May 2024, Massachusetts was facing a true public health emergency. Thanks to important work establishing an incident command structure, six of eight hospitals were transferred to nonprofit systems. But two closed permanently. Communities lost access to care. Patients were displaced. Clinicians were traumatized. We need to ask ourselves: What kind of healthcare system do we want? One optimized for financial returns, or one designed for human flourishing? The Steward collapse isn't just a cautionary tale. It's a call to action. #HealthcareLeadership #PatientSafety #HealthEquity #SystemsThinking