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Prior Authorization

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.

Continue reading…

Universal Coverage Might Be Nice, but an AI Tax Is Necessary

By KIM BELLARD

I was amused – oh, I should be polite and say “interested” — to see a new study, led by researchers from Yale School of Public Medicine, about the benefits of a universal single payor health system. It concluded that we could save 100,000 lives annually and save some 1.04 trillion each year – some 20% of our health care spending. What’s not to like? I’m sure Bernie Sanders is already drafting the bill.

The savings come from five sources: using Medicare payment rates for all providers, using “international reference pricing” for pharmaceuticals, reducing administrative costs to Medicare’s levels, reducing fraudulent billing (“consistent with the experience of other single-payer transitions”), and reducing emergency room visits and hospitalizations due to improved access to primary care.  Good goals, all.

Steffie Woolhandler and David Himmelstein, among others, have been making these or similar arguments for decades, and they are not without merit. It is shameful that we don’t have universal coverage. It is distressing how much money we spend on healthcare. It is embarrassing that we spend so much money on administration.  It is maddening that so many people don’t get the care they need, get the wrong care, or get their care in the wrong places/at the wrong times.

We could do better, we should do better, but, if anything, we’re doing worse: more people are losing coverage, more providers are going out of business, our rates of chronic (and some infectious diseases) are going up, and we’re dying sooner.

I want to quickly point out some of the problems with the proposed sources of savings, then discuss other courses of action that might lead to these or even better outcomes.

  • Medicare payment rates: yes, a lot of money could be saved by using Medicare payment rates, but I doubt you would find many providers who would say they could survive. They make their money on private insurance rates, are lucky to break even on Medicare rates, and lose money on Medicaid. This one is not going to happen.
  • International pharmaceutical reference pricing: first, I’m not sure such a thing exists. It is true that drug prices are typically lower in other countries. Both President Biden and President Trump seized upon this, with some signs of modest success. But, as with the Medicare pricing, it would be a shock to the pharmaceutical industry to have prices slashed across the board, wiping out trillions of dollars of value and, oh-by-the-way, eventually reducing investments on new and better prescriptions.
  • Administrative costs: as a percentage of spending, Medicare’s administrative costs are lower than private insurance, but that is partly due to Medicare spending per capita being so much higher. Also, costs incurred by other agencies – e.g., Social Security or the IRS – are not always counted. But certainly the complexities of so many plan designs by so many health insurers while tracking the current eligibility of everyone is a cost that is much higher than it should be.
  • Reducing fraudulent billing: I mean, really: do people really think that Medicare does a better job of reducing fraudulent billing than United Healthcare or Anthem, much less than other countries?
  • More primary care: reducing emergency room visits and hospitalizations has been the goal of countless private health insurance efforts, such as disease management or chronic health programs, and the track record has generally been underwhelming. But the real problem is – where are we going to get all the primary care physicians to handle all the underserved people?  

So, much as I agree with the goals, count me a skeptic that single payor is going to magically make everything better.

Here’s where I inevitably turn to AI.

Continue reading…

Pre-Surgical Complications (Part 6) — The Decision

By MATTHEW HOLT

Strap in for the tale of why your hero is spending most of his life down YouTube rabbit holes of cardiology videos while blundering his way around many many medical centers and exposing many problems with American health care even before he gets close to the operating table. Yes it’s Matthew Holt’s pre-surgical complications – the complications that have arisen before he even gets his failing aortic valve fixed. And yes this is the last for now of a multi-parter! Part 1, Part 2, Part 3, Part 4 Part 5

By now I have met with expert physicians and their teams at 5 major medical centers (UCSF, Stanford, Cleveland Clinic, Cedars Sinai & West Virginia University). I have spent hours talking to the AI gods at Claude, ChatGPT and Inciteful Med, annoyed the hell out of all the cardiologists and other doctors I know, and basically got enough contradictory advice that it’s all up to me.

The main decision comes down to whether I should get a TAVR or the RAVR. And because I approached Cedars about the BELIEVERS clinical trial rather than going direct to Dr Makkar, they put me into that process. The trial randomizes patients into either TAVR or RAVR, likely performed by Dr. Dominic Emerson who is the Director of Robotic Cardiac Surgery, Smidt Heart Institute, and one of the surgeons mentioned by Dr Badhwar. (I had a quick chat with him after he called me while I was on a ski boat in Lake Tahoe, although due to the shoulder pain I had not gone wakeboarding!)

The study documentation stressed – and this was backed up unprompted by one of the study coordinators – that I could back out at any time. So if I were randomized into the RAVR cohort, I still had the choice to pull out and ask Dr Makkar to do a TAVR on me anyway, or of course go to West Virginia and get surgery there.

And of course there is still the question of how risky a TAVR on my valve will be. I did take Dr Yeung’s advice seriously, and a study that Dr Makkar oversaw back in 2020 did show that (for patients considerably older than me) the risk of all cause mortality at 2 years in bicuspid valve TAVR patients was higher with bad calcification (like me). On the other hand, Dr Makkar told me that his unpublished data between TAVR and SAVR at 5 years showed no difference. He also directly told me that I was a good candidate for a TAVR and he has done more bicuspid TAVRs than anyone else. He’s also working on techniques that break up the calcification on the “join” before the TAVR, although it’s unclear if he’ll do that in the BELIEVERS trial and to me

I originally wanted a TAVR because it was a much easier recovery than surgery. I also have two more major surgeries to go through within the next few months, and it would be a big stress on me and my family to make that three. Plus, I both would be happy to contribute to a medical study and am pretty confident that in a decade or so, cardiology will have advanced a lot more and I probably wouldn’t need open heart surgery even if the TAVR valve fails sooner than the 10-15 years I am hoping to get out of it.

So I crossed my fingers and hoped that the computer would randomize me into the TAVR group at Cedars and obviate the need for any uncomfortable decisions about pulling out of the trial. And it did. I’ll be getting it done in early September.

This isn’t exactly Lebron James making The Decision, although that show lasted only 75 minutes and also went on way too long!

Some concluding thoughts

I would obviously rather have not had to write this little memoir. But given I went through it, there are several conclusions smacking me in the face.

Continue reading…

Pre-Surgical Complications (Part 5)

By MATTHEW HOLT

Strap in for the tale of why your hero is spending most of his life down YouTube rabbit holes of cardiology videos while blundering his way around many many medical centers and exposing many problems with American health care even before he gets close to the operating table. Yes it’s Matthew Holt’s pre-surgical complications – the complications that have arisen before he even gets his failing aortic valve fixed. And yes this is a multi-parter! Part 1, Part 2, Part 3, Part 4

Claude told me that Dr Amy Fiedler at UCSF was an expert in RAMT (right anterior minithoracotomy–the non endoscopic rib entry technique). I sent a note to my original Cardiology group on the UCSF MyChart system saying that I understood she did this surgery and could I have an appointment with her? You can see from my messages with them below that the appointment was set up. 

It should not have been.

I had a very brief conversation with Dr Fiedler and almost immediately it became apparent I was wasting her time.  She told me she does not do that RAMT surgery for valve replacement and she specializes in heart transplants, and some other specialized heart surgery. I think that Claude had read the web page about her doing minimally invasive cardiac surgery and put 2 + 2  together and made 5. But to be fair her UCSF webpage didn’t give me the level of detail she gave me in the video call, and the UCSF cardiology team set up the call even though I presume someone there knows that she didn’t do the thing I was asking about. 

To be clear, Dr Fielder was very gracious and very helpful in her advice. I just felt bad for wasting 15 minutes of her time. To reiterate, the time of a cardiac surgeon is way more valuable than mine. I left telling her I hoped I would never need her services!

***

Next stop was to drive down to Palo Alto and pop into the Creamery for a chocolate malt and cheeseburger in advance of meeting Dr Yeung, the cardiologist. The med tech did a four limb blood pressure test on me and also a full 12 lead EKG. I of course had had all that earlier at UCSF, and wasn’t sure why I was having more. But anyway, she soon left saying Dr Yeung was coming.

Instead Dr Anson Lee came in. He’s the cardiac surgeon working on the valve team. He basically told me that Dr Yeung wouldn’t do a TAVR on me. Now I wasn’t expecting to see him (nor did I know who he was till I looked him up after he left the room) but we had a very helpful conversation about valve surgery and the best ways to do it. Then he went and got Dr Yeung. Together they pulled up a colorized 4D CT scan of my valve. (I assume it came from the CT I had in January). Dr Yeung showed me in precise detail why he thought giving me a TAVR now was a bad idea. (Basically too much calcification on the fused part of the leaf, and it’s too oval, which would make the procedure risky and likely not fit properly). He told me that if I had the surgery, someone would easily put a TAVR in my surgically implanted valve in 12-15 years, and that’s all I would need–unless I plan on living forever or to 100!. 

Dr Lee told me that if he was getting it done he’d have a full sternotomy, although he actually does mini-sternotomies. He also was the only person thus far to tell me NOT to do it if I am asymptomatic. His logic is that something like 1/150 patients die during the surgery so don’t have it if you don’t need it (i.e. are asymptomatic). The reason he’d want a full sternotomy for his choice of entry was to give the surgeon the least complicated shot at the valve. 

He also said that his mini-sternotomy patients can drive after 2 weeks, not 4-6. Which seems to contradict what the UCSF team told me about the same procedure.

But in my case, needing knee surgery and shoulder surgery, the shock of those on the heart would count as “symptoms”. So Dr Lee told me I should get the surgery if I was going to get the shoulder or knee fixed. But he also said that the higher echo reading might have been a false negative, and it might be years before I have symptoms.

I’m not sure my trip to Stanford left me much clearer. But the chocolate malt was damn good.

***

Next up was connecting with the oft-cited team doing RAVRs at University of West Virginia led by Dr Vinay Badhwar. Both Dr Lee and Dr Fiedler unprompted said that he was the surgeon when it came to the robot valve replacement and his email was available online. (Most doctors don’t make their email easily available). I had Claude write an email describing my clinical situation and sent it to him late one night. 

The next morning before I got up, there was a reply from Dr Badhwar in my inbox, and shortly thereafter, his team was all over me. They got my information, got access to my imaging at UCSF, and his physician assistant Amy Simsa called me a day later to describe the process. Within a week I had a video consult with Dr Badhwar and his team. In terms of responsiveness they were by far the best organization to deal with. Stanford, UCSF, Cleveland, Cedars et al could take a few lessons!

The only slight wrinkle was that I got a robocall on a Sunday from the facility telling me where to check-in to my appointment–clearly not set up for telehealth. I noted this in a brief email to his office and got a reply from a human (who I will not identify to spare their blushes) at 5.15pm on a Sunday night! I’m not sure they’re not working too hard.

Although Dr Badhwar was very modest and very keen to tell me about others working with him as he spreads the gospel of RAVR, he and his team have clearly done more of these more successfully than anyone else and are the world experts. If I want a RAVR it’s almost certain that I have to get on a plane, and so I will likely end up in Morgantown, WV–which is about an hour south of Pittsburgh for those of you who missed geography day in high school. That’s not a sentence I thought I would ever write!

***

My last (for now) call was with the CEDARS team setting up the BELIEVERS trial. I spoke with Dr Raj Makkar. He said he had done 8,000 TAVRs and more than anyone else on bicuspid patients. He disagreed with Dr Yeung and Dr Elmariah. He says that my valve was suitable for a TAVR, and he said that the risk of stroke during TAVR was less than the risk of death from SAVR. He also said that they are about to publish 5 years of data showing that the resilience of TAVR valves was the same as SAVR valves. He suggested using a 26mm valve on me, and that it would likely last 10-12 years, and that not only would he be able to do a TAVR in TAVR on that one, but he had already been doing 3rd TAVR in TAVR in TAVR. 

I asked if I showed up at his clinic but not for this trial would he have done a TAVR on me? He said emphatically “yes”. He does use the Sentinel Cerebral Protection System which essentially captures any calcification dislodged from ascending up the aorta to the brain, although my friend Claude tells me the data on whether that prevents a stroke is murky.  Frankly Dr Makkar was very self assured and had I met him at the start of this journey I wouldn’t have bothered going anywhere else! Of course, because he wants to do the trial and get that data out in the world, he wants me in the trial, and I might be randomized into the surgical group.

This is I hope the end of the pre-surgical part! With the slight exception that I haven’t actually yet made a decision about what to do!

UPDATE: Now I have made a decision in Part 6

Matthew Holt is publisher of THCB

Pre-Surgical Complications (Part 4)

By MATTHEW HOLT

Strap in for the tale of why your hero is spending most of his life down YouTube rabbit holes of cardiology videos while blundering his way around many many medical centers and exposing many problems with American health care even before he gets close to the operating table. Yes it’s Matthew Holt’s pre-surgical complications – the complications that have arisen before he even gets his failing aortic valve fixed. And yes this is a multi-parter! Part 1, Part 2, Part 3

Getting in touch 

But while knowing this stuff may be simple, actually getting to speak to the people at these medical centers is way more complicated. First you have to set up the data.

I knew they would want to see my images. The good news was that although I couldn’t see any of the images in my UCSF MyChart account, there’s a number to call on the bottom of the reports if you want to “download the image” and a very nice tech was able to upload all my images to a website that I could see called AmbraHealth (now part of Intelrad) within a couple of hours. Now I can share them with other people similar to sharing a Google doc.

But that was the easiest part.

I will spare you the blow by blow account but for example it took a long time for the people in the office of the main investigator at Cedars to figure out who the person managing the trial was so they could put me in touch with her. After I finally got to leave her a message she rang me back. I played phone tag with her for about a week. I did end up getting her email and sending out a bunch of my image reports and then she went on vacation and I didn’t hear from her for two weeks. First contact to appointment took 6 weeks.

At the same time I was trying Stanford Cardiology in order to try to get an appointment with Dr Yeung. First time I called after about 10 mins on hold I was told that I needed to have a referral. (Even though I’m on PPO style plan that doesn’t need one). 

I pinged my long suffering PCP team at One Medical and asked them for a referral to talk to Dr Yeung which they sent out. A few days later I called the cardiology team at Stanford and eventually – I mean eventually, it was literally a 10 minute hold – they told me the referral wasn’t through yet. I asked if I could get them some images in advance, they said no. They were able to set me up on MyHealth which is their equivalent of the Epic’s MyChart. Funnily enough they had information on me from an emergency room visit I made there in the 1990s. But because I did not have an appointment set up yet I was not able to communicate using the messaging function on MyHealth. 

So I called back a few days later and after another seven or eight minute hold I was told that I had an appointment set up for me and it was on MyHealth. But bizarrely the referrals and visits are buried in the “billing” section of MyHealth and then the appointment was on a sub-menu! And of course even though I could see it there was no way to communicate about the appointment. 

This was even stranger as Stanford booked me both an echocardiogram and what’s called a CT angiogram which is a non-invasive angiogram using a CT machine. I had had both of these done at UCSF within the previous month.

Continue reading…

Pre-Surgical Complications (Part 3)

By MATTHEW HOLT

Strap in for the tale of why your hero is spending most of his life down YouTube rabbit holes of cardiology videos while blundering his way around many many medical centers and exposing many problems with American health care even before he gets close to the operating table. Yes it’s Matthew Holt’s pre-surgical complications – the complications that have arisen before he even gets his failing aortic valve fixed. And yes this is a multi-parter! Part 1, Part 2

The first thing was to message the cardiac scheduling team to postpone the surgery set up for July, not least reason being because England was going to be in the World Cup final two days after that and I didn’t want to be in intensive care in case they weren’t showing the game. Yes, yes, I know Messi and the cheating FIFA refs made sure that sadly didn’t happen! 

I agreed with them to put a date on the calendar for September. But that didn’t stop a prep nurse calling me on Monday 29th June asking me about surgery on July 17th. She was most surprised to find that it wasn’t happening. Yet another time when the message didn’t quite get through.

Time to really figure out what this heart surgery involves. 

Essentially if I wasn’t watching soccer from late June onwards I was trying to figure out what was known about valve replacement surgery. It was actually hard to find out both what the data is regarding TAVRs and the varying ways that surgical valve replacement can be done. 

It turns out that going in through the chest bone, known as sternotomy, is the most usual way to do the surgical replacement of the heart valve but it’s not the only way. 

This discovery took me a lot of effort not only asking chatGPT and Claude about the process but also trying to figure out who does what. I also spent a lot of time asking for advice and honestly not getting much useful on the ValveReplacement SubReddit and looking on heartvalvesurgery.com, a website that seems to be sponsored by some surgeons and medical centers but is run by a patient called Adam Pick. I have been down the rabbit hole there and on YouTube and have more or less had to figure this out myself.

I was also reminded of the classic 1996 Fortune piece by then Intel CEO Andy Grove who was trying to figure out which approach to use to treat his prostate cancer. Basically he realized that the radiologists and the surgeons didn’t talk to each other and didn’t compare results, and he – the patient – had to figure it out from the rather poor data available, and talking to other patients on Compuserve! Well, it was 1996.

It turns out that there are several different options possibly available to me. But in terms of coordination and the patient journey, I’m not sure that we’ve come a long way since Andy Grove’s piece 30 years ago.

Continue reading…

Pre-Surgical Complications (Part 2)

By MATTHEW HOLT

Strap in for the tale of why your hero is spending most of his life down YouTube rabbit holes of cardiology videos while blundering his way around many many medical centers and exposing many problems with American health care even before he gets close to the operating table. Yes it’s Matthew Holt’s pre-surgical complications – the complications that have arisen before he even gets his failing aortic valve fixed. And yes this is a multi-parter! Part 1 here

So on the Friday afternoon I was readying for my video call when there was a car parking emergency. I had to move two Sprinter vans and a car belonging to guests who were all out apres skiing out of our driveway so my wife could get her car out of the garage to get to an appointment she had. Although I was as quick as I could, I was about 10 minutes late for Dr Beygui but he very nicely called me up wondering if I was still okay to do it, was very cordial even though I made him wait, and we had a nice chat. He basically didn’t give me any new information in this conversation and yes UCSF did get paid for it! He was mostly assuming that I couldn’t walk a couple of blocks without getting short of breath but at the end of it we agreed that because I was in good physical shape and able to go snowboarding all day I would go ahead with a knee surgery later in the summer and only come back to him when I became symptomatic. 

Starting in March I got the requisite knee imaging (I had an MRI and 2 X-rays confirming my meniscus is gone and knee was pretty trashed), met with Dr Bini and the ortho team and started prepping for the surgery later that summer–which basically meant going to the gym and doing lots of weights and resistance training on my knees.

A little later I got an unexpected call from Dr Beygui’s physician assistant who told me that he was still trying to line me up for the open heart surgery. I told him I was still keener on a TAVR. He said that I shouldn’t have a TAVR because the TAVR valves only last 5 to 7 years. Yeung from Stanford’s original report told me they lasted about 10 to 12 years. Elmariah the UCSF cardiologist said that they thought they lasted 10 plus years but there was no good data. Given you can probably have one TAVR and then have another put inside when the first one fails and then maybe even another (TAVR in TAVR in TAVR), these numbers actually matter! 

Here’s the crux of the TAVR issue. If you can add 10 + 10 + 10 that gives you another 30 years of life which sounds pretty good to somebody in their early 60s. But if you can’t get more than 5 to 7 years out of a TAVR and can only do one more “TAVR in TAVR”, then you’re getting 10 to 15 years before you need to have a very complicated open heart surgery because it’s now replacing two different artificial valves. In that case I might not survive and I wouldn’t even be old enough to be President!

As you can see this decision is starting to get a little bit complicated. 

But the good news was that I could stop thinking about it because my heart wasn’t getting worse and the orthopedics (and anesthesia) team at UCSF was happy to do the knee replacement. 

As we were all steaming down this path I got a call from Dr Beygui’s scheduling assistant. My initial agreement had been to have an echocardiogram 6 months after the last one which would actually have been after the knee surgery. I’m not sure how much coordination between the departments there was given what happened a bit later but Dr Beygui requested that I have an echocardiogram before any surgery. As I was going in anyway to have a CT in mid-June to prep for the knee surgery, I said fine.

In another great drama of American health care it turns out that my insurance had changed. For most of the first half of the year I purchased a Blue Shield of California HMO on the ACA exchange called Covered California. In May my wife got a job and we then moved over to being covered by her employer’s insurer (well, ASO TPA as it turns out) Cigna.

Cigna and the entire University of California Health system decided to have a dispute which threatened that Cigna would not cover UCSF starting on July 1st. I won’t go into the crazy logic of why an insurance plan that one buys on an annual basis starting in January has contracts with providers that expire in the middle of the year, but welcome to America. Because of this the orthopedic team moved my surgery date up into late June just 4 days after all the prep imaging including that echocardiogram.

Oh and a few weeks earlier I had had a very minor snowboarding fall going very slowly in soft slushy snow. I banged my shoulder but for some reason it didn’t get any better. I actually went and had some physical therapy which seemed to help, but as I was hanging out so much at UCSF, I also had an appointment with the shoulder specialists. They sent me for a pretty uncomfortable MRI and the result from that was that I had total tears in all my rotator cuff tendons. The recommendation for that is surgery that also has a long recovery, but if you ignore it for too long the muscles can atrophy. Claude was very depressed for me when it interpreted that MRI report!

A spanner in the works

Those of you familiar with sod’s law can guess what happens next. The result of the echocardiogram was that the aortic stenosis had gone from being severe to being very severe. The precise number was that my peak velocity went from 4.6 m/s in Jan to  5.1 m/s in June  just 4 and ½ months later.

I discussed this with my trusted health confidant and Claude guessed that this might be a problem and the anesthesia team might not want to have me get the knee surgery.

The next sequence of events reveals that nobody in American healthcare talks to each other.

Continue reading…

Pre-Surgical Complications (Part 1)

By MATTHEW HOLT

Strap in for the tale of why your hero is spending most of his life down YouTube rabbit holes of cardiology videos while blundering his way around many many medical centers and exposing many problems with American health care even before he gets close to the operating table. Yes it’s Matthew Holt’s pre-surgical complications – the complications that have arisen before he even gets his failing aortic valve fixed. And yes this will be a multi-parter!

Introduction and a decent bit of context

Last summer after a lot of back and forth I discovered that I had aortic stenosis. (I won’t replay the whole story of how the referral to the echocardiogram didn’t happen three times and therefore I nearly didn’t have the test and therefore never found out because I already have elsewhere) 

Amazingly this has nothing to do with my bad lifestyle. It’s an inherited heart disease in which the valve that governs the flow of blood between the two main chambers of your heart is starting to fail. Often that means people get very short of breath, start to faint or have severe chest pains but in my case I had none of that. What I did have was the measurement on an echocardiogram showing that my aortic stenosis was “severe” because I have what’s called a bicuspid aortic valve. This is a genetic defect that my father landed me with–well I’m blaming my father but who exactly knows as he’s dead!  

Essentially instead of having three leaves on the valve (like a Mercedes symbol) I have two and over time they’ve been steadily picking up more calcification and opening less. That means that more and more pressure is required from the heart to squeeze blood between the two chambers which is bad for the heart and by extension bad for me. That’s pretty strong agreement amongst cardiologists that if you can get this condition fixed before you become symptomatic it’s better than waiting. If you get symptomatic, it’s urgent and your chance of a heart attack and death becomes pretty high (like 25-50% a year!)

But of course it’s not that simple – either from the standpoint of getting it fixed or from the standpoint of how to get it fixed within the American health care system in all of its beauty. And you can expect it, as it’s me, to hear a lot about customer service, insurance, online access to information and of course interoperability. There might also be some AI thrown in for good measure!

Continue reading…

Is There Hope for Parkinson’s Disease Patients?

By STEVEN ZECOLA

Congress will need to amend its faltering Parkinson’s disease legislation if it hopes to achieve meaningful results.

Why Change Is Necessary

For more than 50 years, the National Institutes of Health (NIH) has pursued Parkinson’s disease (PD) research with limited success. Nearly $5 billion has been spent, yet no approved treatment exists that slows, stops, or cures the disease.

This is not a new concern. By the mid‑1990s, Parkinson’s advocacy groups had grown frustrated by the absence of major therapeutic advances since L‑dopa’s approval 25 years earlier. That frustration led to three national plans launched in 2000, 2006, and 2014. None produced meaningful breakthroughs.

Congress to the Rescue?

Congress attempted to address this stagnation by passing the National Plan to End Parkinson’s Act (Public Law 118‑66), signed July 2, 2024. The Act:

  • Calls for an integrated national strategy to prevent, diagnose, treat, and cure Parkinson’s
  • Establishes an Advisory Council on Parkinson’s Research to deliver annual recommendations to the HHS Secretary, with the first report due within 18 months
  • Requires the HHS Secretary to issue a progress assessment within 24 months

What Happened Instead

The HHS Secretary delegated implementation of the Act to NIH. As a result, the Advisory Council and HHS missed their first statutory deadlines and produced no measurable progress. NIH convened the Council’s first meeting on June 29, 2026—two years after enactment.

The meeting materials omitted information essential for forming a credible strategy, including:

  • The time and cost of the current drug‑approval process
  • Lessons learned from the three previous national PD plans
  • The role of artificial intelligence and other emerging technologies
  • Regulatory barriers
  • A comparison of federal vs. non‑federal PD research funding and coordination
  • Funding allocations across projects
  • An assessment of where industry stands on potential cures and the remaining scientific steps
  • A plan for engaging external subject‑matter experts
  • Any economic analysis

Even basic administration proved difficult. NIH collected comments from 162 individuals but posted them a month late—and did not include my submission. Despite recommendations, NIH still does not use regulations.gov, which would eliminate many of these administrative failures.

More importantly, NIH shows no recognition that the regulatory system itself is broken and imposes massive societal costs. Parkinson’s disease alone generates over $80 billion annually in direct and indirect costs.

What the Advisory Council Is Likely to Recommend

Based on the 162 public comments, the Council’s top recommendation will likely be a substantial increase in PD research funding.

More funding would be logical—but only if used efficiently. Efficiency requires acknowledging that the technology, regulation, and process must change. NIH, as currently structured, cannot deliver on that acknowledgement or those changes.

A Better Approach

Congress should not wait for the fourth national plan to fail. Instead, it should establish a private investment vehicle, funded with federal research dollars and majority‑owned by the federal government. Executive leadership should be recruited from the healthcare industry and granted a 20% carried interest, aligning incentives and ensuring accountability for research outcomes.

Congress should also require the FDA to adopt a zero‑based regulatory framework for AI‑driven applications, including collapsing the multi‑trial model and incorporating real‑time data into the review process.

Conclusion

Human brain cells are complex and fragile, and central nervous system drugs have among the highest attrition rates in medicine—approved at less than half the rate of drugs in other therapeutic areas.

Layer on the length, cost, and complexity of today’s regulatory process, and the Advisory Council’s recommendations risk becoming the fourth demonstration of how not to solve the problem. Congress should anticipate this outcome and implement a system capable of delivering real progress for Parkinson’s patients.

Hope for PD patients exists—but only if Congress acts decisively and soon.

Steven Zecola is a former technology executive and government official.  He retired 24 years ago with a diagnosis of Parkinson’s disease.   He currently is an ardent patient advocate.

A digital health company became an insurance carrier under the thin veil of a product launch

By DEEKSHA HEGDE

How to spot a fundamental business model shift from a mile away, long before the PR calls it a product launch or market expansion.

In April 2026, Progyny, a fertility and family building benefits administrator, announced Progyny Select, a supplemental health plan for small and mid-size employers (100-1,000 employees). “Pooled-risk” got me curious: did they cut a deal with an insurance carrier to back the product, or had they taken on insurance risk themselves?

Until now, Progyny had only served large, self-insured employers (1,000+ employees) as a third-party administrator. They negotiated rates with fertility clinics, routed employees to better providers, managed the claims paperwork, and took a margin while employers paid the medical bills. This product launch appeared to be a downmarket expansion to capture a segment previously untapped, but the mechanics were not apparent.

I didn’t have to look very far. It was right there in the legal disclaimer at the bottom of the press release: “through subsidiaries of Progyny Inc. with state licensure to offer supplemental coverage.” Now this really got my attention. This is a digital health company turning into an insurer. You don’t see that happen every day. I decided to do some digging.

What states have they acquired licenses in, given you need one in every state you want to operate in? Their latest 10-K, surprisingly, didn’t mention anything about their flip to the insurer model. I realized they were not required to disclose the new insurance subsidiary since it hadn’t crossed revenue thresholds by the SEC’s definition. The fully insured expansion appeared as a growth target and a regulatory risk factor. They declared the move would subject them to additional laws applicable to health insurance that do not currently apply to them.

The product landing page did mention Progyny Health Insurance Company of Washington. So I pulled the thread. Washington state incorporation records showed the name had been reserved in August 2024. Six months later, in February 2025, the entity was formally incorporated. By July 2025, Progyny Health Insurance Company of Washington had been admitted as an active health insurer by the Washington Office of Insurance Commissioner. In the second half of 2025, they filed their first few products with the regulator, all still sitting in review on the SERFF database as of July 2026. The filings also make nationwide coverage ambition explicit. So this has been stewing since August 2024, the date the name was chosen. I went on LinkedIn to check if they had any actuaries on the team. They hired an actuary in April 2023, and a second in January 2026 (who specializes in pricing insurance products) three months before the launch. 

The announcement that the press called a product launch had been a strategic transformation at least three years in the making. The SEC filings hinted at it. These four signals — an actuary hire, a name reservation, an insurance license, and active product filings with a state regulator — were sitting in plain sight the whole time. For anyone watching, just one of those foreshadowed what was coming.

I’ve been watching the market reaction since the launch. The move is still being read as market expansion downward, when it’s really business model innovation.

Why become an insurer at all?

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