The Grand Roundup: Anti-tiering contracts and the OhioHealth ruling, Thoreau/Ensemble update, 340B and Eli Lilly, OpenLoop's D2C play, Cleveland Clinic on AI trust, and more

The Grand Roundup: Anti-tiering contracts and the OhioHealth ruling, Thoreau/Ensemble update, 340B and Eli Lilly, OpenLoop's D2C play, Cleveland Clinic on AI trust, and more

Kevin and Martin by discussing the OhioHealth DOJ settlement and what banning anti-tiering, anti-steering clauses in hospital contracts could mean for employer plan design, narrow networks, and upstart insurance models. They talk about the $12B Ensemble Health Partners deal: what it says about the RCM market's appetite for holistic versus point-solution approaches, and where it might fit into Matt Holt's broader Thoreau acquisition agenda. The Clover-Stars recalculation gets a full breakdown: what the judge sided with, what CMS did next, who won, and the uncertainty now rippling through payer teams, provider comp models, and the whole vendor ecosystem built around Star scores. Martin digs into the 340B program via Minnesota's annual state report, explaining Eli Lilly's decision to freeze discounts for non-compliant hospitals, the FQHC access problem at the center of it, and whether a rebate model actually helps or just punishes the safety net players the program was designed for. And Kevin walks through OpenLoop's Shopify-for-telehealth launch, what it would actually mean if anyone with an audience could create a D2C GLP-1 brand in hours, and why the economics of that model are an interesting question. Then JD Friedland, Executive Director for Ventures at Cleveland Clinic, joins to walk through how one of the country's flagship health systems is thinking about AI deployment. JD talks about what Cleveland Clinic has actually built with ambient listening, clinical trial enrollment via Dyania, and surgical documentation through Theator. He gets into the data consortium question—why your institution's data is most valuable when you’re an early contributor—and the liability and brand risk that makes health systems cautious about deploying forward-facing AI solutions they don't fully control. Brought to you by Ursa Health: Join HTN, Atlas Oncology Partners, and Ursa Health this Wednesdsay, June 24 at 12pm ET to dive into specialty value-based care. Register to attend and receive the recording: luma.com/htn-ursa-atlas [http://luma.com/htn-ursa-atlas] Links referenced OhioHealth / DOJ Settlement: https://www.justice.gov/opa/pr/justice-department-requires-ohiohealth-stop-using-anticompetitive-healthcare-contract-terms [https://www.justice.gov/opa/pr/justice-department-requires-ohiohealth-stop-using-anticompetitive-healthcare-contract-terms] Minnesota 340B Report: https://www.health.state.mn.us/data/340b/docs/2025report.pdf [https://www.health.state.mn.us/data/340b/docs/2025report.pdf] For more from Health Tech Nerds, subscribe to our weekly newsletters: https://www.healthtechnerds.com/subscribe

The tasks AI should take off doctors' plates — and the ones it shouldn't | Hashem Zikry (Counsel Health)

Hashem Zikry is a practicing emergency physician at UCLA, a researcher focused on unnecessary ED utilization, and the medical director for clinical research and policy at Counsel Health — which, this week, began integrating Oura biometric data into clinical decision-making for the first time. That combination of roles gives him an unusual perspective on the question everyone is asking: what should AI actually be allowed to do in clinical care? He also speaks about regulation — the current state-by-state landscape ranges from Utah's live AI sandbox to New York and Colorado bills that would sharply limit patient-facing AI — and Zikry argues a federal floor would accelerate innovation rather than constrain it. On the Oura partnership, he pushes back on the concern that wearables drive unnecessary utilization, contending that access to a clinician at the point of data — not just the data itself — is what changes the demand curve. Brought to you by Ursa Health: Join HTN, Atlas Oncology Partners, and Ursa Health on June 24 at 12pm ET to dive into specialty value-based care. Register to attend and receive the recording: luma.com/htn-ursa-atlas [http://luma.com/htn-ursa-atlas] Links referenced Hashem’s LA Times story: https://www.latimes.com/opinion/story/2026-04-25/ai-democratize-medicine-regulation [https://www.latimes.com/opinion/story/2026-04-25/ai-democratize-medicine-regulation] Follow Hashem on LinkedIn: https://www.linkedin.com/in/hashem-e-z-87243529a/ [https://www.linkedin.com/in/hashem-e-z-87243529a/] For more from Health Tech Nerds, subscribe to our weekly newsletters: https://www.healthtechnerds.com/subscribe

How Alignment Health gets health systems to come to them | John Kao (Alignment Health)

Thirty-five years into Medicare Advantage, John Kao sees the V28 correction as a pricing reset, not a structural rupture. Plans that invested in clinical care delivery are emerging from it better positioned than those that leaned on coding and prior auth. He expects MA to capture 65–70% of the senior market within the next decade — and argues the current administration's push on program integrity is accelerating, not threatening, that trajectory. The second half of the conversation turns to health systems. Hospitals that are over capacity are coming to Alignment Health not out of ideological alignment on value-based care, but because reducing senior admissions frees up beds for commercial patients who reimburse at higher rates. Alignment's pitch is that it can deliver on that operationally — 142 acute admissions per thousand versus original Medicare's roughly 250 — while also moving market share into the system. The business case, he argues, makes the ideological one unnecessary. Brought to you by Ursa Health: Join HTN, Atlas Oncology Partners, and Ursa Health on June 24 at 12pm ET to dive into specialty value-based care. Register to attend and receive the recording: luma.com/htn-ursa-atlas [http://luma.com/htn-ursa-atlas] Links referenced Follow John on LinkedIn: https://www.linkedin.com/in/johnkao1/ [https://www.linkedin.com/in/johnkao1/] For more from Health Tech Nerds, subscribe to our weekly newsletters: https://www.healthtechnerds.com/subscribe

The Grand Roundup: $12B Matt Holt/Ensemble deal, Hawaii's payvider bet unravels, PwC's highest commercial trend in 18 years, Clover Stars win, clinical AI regulation, and more

Kevin and Martin chat about Matt Holt's return with a reported $12 billion bid for Ensemble Healthcare Partners. They unpack what it means that Thoreau, Holt’s AI-forward play, is interested in a business whose CEO explicitly pitched a more human-centric approach to RCM. From there, they do a deep dive into what’s going on in Hawaii: HMSA's decade-long VBC experiment is unraveling, providers have done a complete 180 on whether they want it, and the state is now pushing a payvider merger that makes even less sense given the backdrop. Kevin traces it all back to the same payer-provider adversarial dynamic playing out across the country. Then they take a look at PwC's 2027 commercial trend report, which projects a 9% increase in medical costs, the highest in 18 years, with AI-driven billing optimization leading the charge, followed by behavioral health volume, GLP-1s, No Surprises Act fallout, and hospital services inflation. The politics aren't subtle: AI that helps providers bill more is innovation, while AI that helps payers deny more is bad. They also touch on recent stock moves for Clover and Alignment as signs that managed care is trending upward again. John Kao, chairman and CEO of Alignment Health, joins to explain why he always says not to bet against Medicare Advantage. He walks through what's made Alignment's California model work, why expanding outside the state is harder than it looks, and how health systems are increasingly coming to them — not the other way around — because keeping MA patients out of beds is good for all parties. Hashem Zikry from Counsel Health closes the show with a discussion on clinical AI regulation. He frames the current U.S. landscape as a laboratories-of-democracy experiment — Utah running a live sandbox, New York and Colorado pulling back — and argues the federal government should set a floor, not a ceiling. He also breaks down Counsel's new partnership with Oura, which this week begins integrating biometric data into clinical decision-making for the first time, and pushes back on the concern that wearables just generate more utilization. Brought to you by Ursa Health: Join HTN, Atlas Oncology Partners, and Ursa Health on June 24 at 12pm ET to dive into specialty value-based care. Register to attend and receive the recording: luma.com/htn-ursa-atlas [http://luma.com/htn-ursa-atlas] Links referenced PwC report: https://www.pwc.com/us/en/industries/health-industries/library/behind-the-numbers.html [https://www.pwc.com/us/en/industries/health-industries/library/behind-the-numbers.html] Follow John on LinkedIn: https://www.linkedin.com/in/johnkao1/ [https://www.linkedin.com/in/johnkao1/] Hashem’s LA Times story: https://www.latimes.com/opinion/story/2026-04-25/ai-democratize-medicine-regulation [https://www.latimes.com/opinion/story/2026-04-25/ai-democratize-medicine-regulation] Follow Hashem on LinkedIn: https://www.linkedin.com/in/hashem-e-z-87243529a/ [https://www.linkedin.com/in/hashem-e-z-87243529a/] For more from Health Tech Nerds, subscribe to our weekly newsletters: https://www.healthtechnerds.com/subscribe

The billing problem is actually an affordability problem | Seth Cohen (Cedar)

Seth Cohen runs Cedar, which sits inside the bill-pay workflow for health systems across the country, meaning he sees the patient collections reality that most hospitals are still processing. Most providers still sort patients into commercial, government, and self-pay, a taxonomy that made sense 15 years ago and doesn't anymore. ACA premium churn is quietly flipping commercial AR to self-pay retroactively, Medicaid redeterminations hit January 1st, and the average hospital is already collecting about 40 cents on every patient dollar owed. For a $5B system, that's $250M in net income lost annually. Seth argues that the billing problem has quietly become an affordability problem, and that the fix isn't better statements or more outreach—it's meeting people where they actually are. 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 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] For more from Health Tech Nerds, subscribe to our weekly newsletters: https://www.healthtechnerds.com/subscribe