The Grand Roundup: Elevance CMS update, healthcare AI bundling vs. the $100B benchmark, Clover Stars ruling, D-SNP upcoding, No Surprises Act, CVS/Tennessee PBM split, and more

The Grand Roundup: Finding the optimal amount of healthcare fraud, ACA premium churn, wealthy New Yorkers are buying "med-à-terres", Zeke Emanuel on where healthcare policy reform is headed, and more

Kevin and Martin open with an unusual question: how much fraud should we actually tolerate in healthcare? News from Minnesota prompted the question, where the state just disenrolled 3,400 Medicaid providers, most not for fraud, but for incomplete paperwork. Kevin's argument is that zero-tolerance consolidates the market around whoever's best at compliance, not care. Martin mentions that we're underfunding the people who catch sophisticated fraudsters, and prior auth does actually work. They also discuss the ABA therapy workforce explosion (5X growth in behavioral techs since 2019), which the Wall Street Journal frames as a fraud story and Martin pushes back on. Then they pivot to a very different kind of story: wealthy New Yorkers are buying $5M apartments to be used as "med-à-terres" for just a few specialist visits a year, and some luxury condos now feature Atria longevity clinics. Ezekiel Emanuel—ACA architect, UPenn Vice Provost, author of Eat Your Ice Cream—comes on to talk about whether a real healthcare policy reform moment is coming. He shares the basics of the proposal he is working on drafting, and discusses about when he thinks it will be the right time for this transformative reform. He also talks about how much of U.S. GDP should go toward healthcare costs, and how the industry should use (and bill for) AI in a way that makes sense. Seth Cohen, president of Cedar, closes with a view on provider finance. Hospitals still sort patients into commercial, government, and self-pay, a taxonomy that made sense 15 years ago. Driven by that, plus numerous additional challenges, the system is not working for patients. Seth argues that the billing problem has become an affordability problem, and the fix isn't better statements—it's meeting people where they are. For more from Health Tech Nerds, subscribe to our weekly newsletters: https://www.healthtechnerds.com/subscribe Brought to you by Ursa Health: Join HTN, Atlas Oncology Partners, and Ursa Health on June 24 at 12pm ET to learn what it takes to scale specialty value-based care. Register: luma.com/htn-ursa-atlas [http://luma.com/htn-ursa-atlas] Links referenced WSJ on ABA fraud: https://www.wsj.com/health/healthcare/autism-therapy-insurance-bills-880b9dba?mod=mhp&_bhlid=14a8b4ad00b8b90f14f4e33aeb944007aa658e91 [https://www.wsj.com/health/healthcare/autism-therapy-insurance-bills-880b9dba?mod=mhp&_bhlid=14a8b4ad00b8b90f14f4e33aeb944007aa658e91] WSJ on “med-à-terres”: https://www.wsj.com/real-estate/luxury-homes/wealthy-retirees-are-buying-med-a-terres-to-be-near-their-new-york-doctors-f411c9db?mod=series_housingmarket [https://www.wsj.com/real-estate/luxury-homes/wealthy-retirees-are-buying-med-a-terres-to-be-near-their-new-york-doctors-f411c9db?mod=series_housingmarket] WSJ on longevity as an amenity: https://www.wsj.com/real-estate/luxury-homes/the-new-amenity-in-luxury-living-longevity-services-91369ca8?mod=WTRN_pos1 [https://www.wsj.com/real-estate/luxury-homes/the-new-amenity-in-luxury-living-longevity-services-91369ca8?mod=WTRN_pos1] Zeke’s article in The Bulwark: https://www.thebulwark.com/p/democrats-must-fix-medicaid-not-just-undo-trump-bbb-damage-universal-coverage-seven-principles-reform-health-care [https://www.thebulwark.com/p/democrats-must-fix-medicaid-not-just-undo-trump-bbb-damage-universal-coverage-seven-principles-reform-health-care] Seth’s LinkedIn post on ACA premiums: https://www.linkedin.com/feed/update/urn:li:activity:7453134273911455744/ [https://www.linkedin.com/feed/update/urn:li:activity:7453134273911455744/] How to contact Seth: seth@cedar.com [seth@cedar.com]

Before, during, and after GLP-1s: the role of nutrition in metabolic care | Amit Shah (Virta Health)

Prior to the wave of GLP-1s, Amit Shah has spent a decade working on reversing metabolic disease through nutrition. As a leader at Virta Health, he's experienced the impact that changing what people eat can have on type 2 diabetes, cardiovascular events, and outcomes across a surprising range of conditions. In this episode, he talks about the reality that 93% of American adults have some form of metabolic dysfunction, addresses patient preferences for medication or lifestyle changes through diet, and shares how Virta is showing that a nutrition-first approach, paired thoughtfully with GLP-1s, delivers better outcomes and lower costs for the employers and health plans. For more from Health Tech Nerds, subscribe to our weekly newsletters: https://www.healthtechnerds.com/subscribe Brought to you by: Ursa Health: Join HTN, Atlas Oncology Partners, and Ursa Health on June 24 at 12pm ET to learn what it takes to scale specialty value-based care. Register: luma.com/htn-ursa-atlas Abridge: Join Abridge's first-ever Keynote on June 11, where CEO Dr. Shiv Rao will share their biggest step yet toward saving time, money, and lives. NYC and streaming globally. Register: events.abridge.com/keynote

Why foster-connected youth fall through healthcare's cracks—and how to fix it | Michelle Turner (Here Now Health)

Michelle Turner spent years as a foster parent watching the healthcare system fail the kids in her home because the existing system wasn't built for them. She founded Here Now Health to fix that, creating a virtual mental health platform purpose-built for foster-connected youth, controlling for the many barriers they face in seeking care. She walks through the little-known world of foster specialty Medicaid plans, why this high-acuity population has attracted almost no innovation, and how Here Now Health is proving that early, consistent care is both better for kids and far cheaper than the crisis cycle states are currently funding. For more from Health Tech Nerds, subscribe to our weekly newsletters: https://www.healthtechnerds.com/subscribe Brought to you by: Ursa Health: Join HTN, Atlas Oncology Partners, and Ursa Health on June 24 at 12pm ET to learn what it takes to scale specialty value-based care. Register: luma.com/htn-ursa-atlas Abridge: Join Abridge's first-ever Keynote on June 11, where CEO Dr. Shiv Rao will share their biggest step yet toward saving time, money, and lives. NYC and streaming globally. Register: events.abridge.com/keynote Referenced: Here Now Health: herenow.health / michelle@herenow.health

The Grand Roundup: Elevance CMS update, healthcare AI bundling vs. the $100B benchmark, Clover Stars ruling, D-SNP upcoding, No Surprises Act, CVS/Tennessee PBM split, and more

News & Analysis from Health Tech Nerds Kevin and Martin open with Elevance's "thumb drive gate" CMS update, a $935 million accrual, and questions about what they ultimately owed. They debate how many $100 billion healthcare AI companies the market can support, using Commure's $7B valuation and Rockefeller-esque platform ambitions as a case study. In health law: the Clover Stars ruling and post-Chevron MA bid uncertainty, the Massachusetts AG's D-SNP upcoding lawsuit against UnitedHealthcare, No Surprises Act IDR enforcement chaos in Texas, and CVS suing Tennessee over PBM-pharmacy separation. They close by talking about Providence Health Plan and PacificSource exiting markets and the persistent struggles of regional non-profit health plans. Amit Shah, President of Virta Health, makes the case that the GLP-1 era is actually Virta's moment, with ten years of clinical data on reversing metabolic disease through nutrition showing that Virta is uniquely positioned to serve patients before, alongside, and after drug-based treatment. Michelle Turner, founder of Here Now Health, introduces the niche but consequential world of foster specialty Medicaid plans and the high-acuity, high-transiency population they serve. She explains how Here Now was built from the ground up to get kids into care fast, keep them there through instability, and give health plans a far cheaper alternative to crisis care. For more from Health Tech Nerds, subscribe to our weekly newsletters: https://www.healthtechnerds.com/subscribe [https://www.healthtechnerds.com/subscribe] Brought to you by: Ursa Health: Join HTN, Atlas Oncology Partners, and Ursa Health on June 24 at 12pm ET to learn what it takes to scale specialty value-based care. Register: luma.com/htn-ursa-atlas [http://luma.com/htn-ursa-atlas] Abridge: Join Abridge's first-ever Keynote on June 11, where CEO Dr. Shiv Rao will share their biggest step yet toward saving time, money, and lives. NYC and streaming globally. Register: events.abridge.com/keynote [http://events.abridge.com/keynote] Referenced: Commure CEO on the Sourcery podcast: https://www.youtube.com/watch?v=Vd4HHQ1l9mM Willamette Week: Inside the Collapse of Providence Health Plan: https://www.wweek.com/news/2026/05/27/inside-the-collapse-of-providence-health-plan/ Tennessee Lookout: CVS sues Tennessee: https://tennesseelookout.com/2026/05/26/cvs-sues-tennessee-over-pharmacy-benefit-manager-monopoly-law/ JAMA article on growth of provider-sponsored health plans, 2018–2023: https://jamanetwork.com/journals/jama/fullarticle/2849517?guestAccessKey=1784f8b9-4583-4e15-a622-2d458bce7e11 Virta peer-reviewed papers: https://www.virtahealth.com/research Here Now Health: herenow.health / michelle@herenow.health

How Gyde is enabling the shift from MA broker to trusted advisor | Will Johnson (Gyde)

Will Johnson, CEO and Co-Founder of Gyde, joins on the day Gyde announces the acquisition of We Know Medicare to discuss the MA brokerage market and where it's headed. Will walks through Gyde's acquisition model: buying quality MA brokerages and equipping them with a platform and support to drive organic growth post-acquisition. He contrasts this what agencies historically experienced in M&A: minimal resources post-transaction, team reorgs, and increased admin burdens. Gyde instead pitches itself as a long-term partner rather than a financial buyer. The conversation shifts to the strategic value of the broker as carriers grapple with acquisition and retention. Will's view: the best brokers are already acting as trusted advisors beyond enrollment — helping members navigate pharmaceutical issues, find physicians, and manage the broader healthcare experience. He sees that role growing as MA benefits rationalize and get more complex to navigate independently. The episode closes on his insurance unbundling thesis: as MA benefits become more focused on major medical expenses and supplemental coverage gets individualized, Will sees consumers needing comprehensive guidance across insurance, health, and wealth decisions — with Medicare as the entry point into a much broader relationship. For more from Health Tech Nerds, subscribe to our weekly newsletters: https://www.healthtechnerds.com/subscribe Brought to you by: Ursa Health: Helping value-based care organizations unlock the full value of their data. Learn more at ursahealth.com   Nashville Healthcare Sessions: join HTN and 1,400 execs from across the ecosystem Sep 13-15 in Nashville. Register at nashvillehealthcaresessions.com/register/ Referenced: Gyde Health acquisition: https://www.gydehealth.ai/resources/gyde-acquires-we-know-medicare Gyde Health: https://www.gydehealth.ai/ Will Johnson: will@guidehealth.ai