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Even When Healthcare Has a Clear Price Tag, Are We Getting What We Pay For?

By OWEN TRIPP

Move over, GLP-1s. This year the healthcare spotlight is on alternative plan design. Alternative health plans offer cost transparency and a consumer-friendly shopping experience. But can the capabilities under the hood deliver on quality and value? Though it may not sound buzzworthy, it has the potential to trigger a seismic shift in the commercial insurance market.

After years of disappointing returns and unmet promises from traditional insurance models, innovators and big-name insurers themselves are doubling down on alternative plans aimed at reducing healthcare costs through preferred care pathways with transparent pricing. Though these plans come in many flavors, common features include tiered networks, variable copays, care steerage, and an emphasis on primary and virtual care — often packaged in a digital-first (and AI-powered) “shopping” experience. 

Alternative plans seem like a win-win. For consumers struggling with surprise bills and medical debt, replacing confusing deductibles and coinsurance with predictable copays offers much-needed peace of mind. For employers facing the highest increase in healthcare costs in 15 years, getting their workforce on a trusted path to quality feels like a sure bet.

There’s a catch, though: Alternative plans won’t help much if they lead people to the same old, fragmented healthcare experience. Innovative cost-sharing and a slick front-end experience must be backed by high-quality clinical care, dynamic population health management, and personalized engagement that represent a significant upgrade from what’s been delivered to date.

Otherwise, signing up for an alternative plan will be a lot like buying a shiny new smartphone, only to discover that its operating system only supports a handful of outdated apps.

Alternative plans: what must be under the hood?

While cost transparency and a streamlined shopping experience offer immediate benefits to consumers, it’s the deeper capabilities and levers under the hood of alternative plans that will drive long-term value and create an alternative model worth embracing.

1. A primary care-led integrated care model

Most insurer-led alternative plans are built on top of existing care delivery networks (and existing provider contracts), often leading people to well-worn pathways and settings, including those that have produced status-quo outcomes for people and minimal cost improvement for employers.

Alternative plans need to create new dynamics around primary care, removing access barriers, creating flexibility and incentives, and repositioning expectations for provider interactions. Simply doing more of the same is inadequate. A true primary care-led plan is one that creates new channels and opportunities, dedicates time for immersive one-to-one discovery, and empowers physicians to lead people to quality across the network based on individual needs — supported by data, technology, and system-wide connections.

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Brick by Brick by (Smart) Brick

By KIM BELLARD

I’m an innovation junkie, the further out there the better, but every so often it’s good to be reminded that just because a company has been around for a while, innovation is still possible.

Two examples: LEGO® and Kodak.

Let’s start with LEGO. If you are around any small children – and perhaps not even all that small – you probably have seen them playing with Legos. Legos have been around, in various incarnations, for longer than I’ve been alive, and that’s saying something. Most adults watching kids assemble their Legos probably have two reactions: “gosh, I wish they’d make them even more complicated” (note to the oblivious reader – that was sarcastic), and “well, at least they’re not on their screens.”

So I bet a lot of us have a slightly surprised reaction to Lego’s announcement Monday Jan 6th to CES 2026: LEGO SMART Play™.

The key innovation is the SMART Brick, which “is packed with technologies that bring play to life including sensors, accelerometers, light sensing and a sound sensor as well as a miniature speaker driven by an onboard synthesiser, and much more, in addition to easy wireless charging.” All that is powered by a custom chip, which is smaller than one of the studs on a LEGO brick.

The LEGO Group states: “Without any setup, SMART Bricks are magically ‘aware’ of each other’s positions and orientations in 3D space, thanks to a novel, high-accuracy, magnetic positioning system. They can also communicate via a self-organizing network that adapts to play. Advanced onboard systems let SMART Bricks comprehend and interact with each other, as well as the fans building with them.” “Magic” in this context meaning Bluetooth.

Nerdist calls it “the most exciting innovation in screenless play ever,”  

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The Dimensions of Artificial Intelligence in the Healthcare Industry

By STEVEN ZECOLA

On December 19th, the Department of Health and Human Services (“HHS”) issued a Request for Information seeking to harness artificial intelligence (“AI”) to deflate health care costs and make America healthy again.

As described herein, AI can be used in many dimensions to help lower healthcare costs and improve care. However, to achieve significant breakthroughs with AI, HHS will need to completely revamp the regulatory approach to drug discovery and development.

Dimension #1. Incorporation of AI into Drug Discovery

The biggest benefit to the healthcare industry’s performance from AI is achievable from drug discovery. Accounting for the costs of failures, the average FDA drug approval costs society almost $3 billion and takes decades to reach the market from its inception in the lab. 

In contrast, AI identifies potential treatments much faster than traditional methods by processing vast amounts of biological data, uncovering hidden causal relationships, and generating new actionable insights.

AI is particularly promising for complex, multifactorial conditions – such as neurodegenerative diseases, autism spectrum disorders, and multiple chronic illnesses – where conventional reductionist approaches have failed.

In the short-run, HHS should direct its grants toward AI-generated basic research, with a particular emphasis on the hard-to-solve illnesses. At the same time, the FDA should be putting into place a new approval system for AI-initiated programs to enable breakthrough treatments in a compressed timetable. 

Dimension #2. Incorporation of AI into the Drug Development Process

Simply relying on AI for drug discovery, while subjecting its advances to the current approval process would undermine the use of the technology. 

Rather, improvements from AI can already be had in fulfilling the exhaustive regulatory documentation requirements, which today add up to as much as 30% of the cost of compliance.

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Father Christmas Reminds Us We Can Do Better Than This

By MIKE MAGEE

The Ghost of Christmas Past, in the form of Surgeon General C. Everett Koop, has returned this season to torture one RFK Jr who refuses to fully share life saving vaccines with children. In the encounter, the ghostly Koop reviews a time 37 years ago when citizens came together to celebrate separating scientific fact from fiction with life-saving effects.

Beginning in 1988, the United States, along with the rest of the world, had formally acknowledged and celebrated World AIDS Day on December 1st each year – that is until 2025. At President’s Trump’s direction the State Department, and with HHS support, turned their back on an inconvenient truth – the Republican early record on HIV/AIDS. Let’s channel the truth-telling Surgeon General from Christmas past and remember this telling story.

On June 5, 1981, the CDC reported 6 cases of Pneumocystis carinii associated with a strange immune deficiency disorder in California men. Drs. Michael Gottlieb and Joel Weismann, infectious disease experts who delivered care routinely for members of the gay population in Los Angeles, had alerted the CDC. Inside the organization, there was a debate on how best to report this new illness in gay men.

The vehicle that the CDC chose was a weekly report called the Morbidity and Mortality Weekly Report or MMWR. So as not to offend, the decision was made to post the new finding, not on page 1, but on page 2, with no mention of homosexuality in the title. Almost no one noticed.

On April 13, 1982, nine months after the initial alert, Senator Henry Waxman held the first Congressional hearings on the growing epidemic. The CDC testified that tens of thousands were likely already infected. On September 24, 1982, the condition would for the first time carry the label, AIDS – acquired immune deficiency syndrome.

The new Surgeon General, C. Everett Koop’s focus at the time, along with the vast majority of public health leaders across the nation, was not on a new emerging infectious disease, but rather on the nation’s chronic disease burden, especially cardiovascular disease and cancer being fed by the post-war explosion of tobacco use. He had already surmised that the power of his position lie in communications and advocacy.

One month after his swearing in, he appeared on a panel to release a typically boring Surgeon General update report on tobacco. He was not intended to have a big role. When Koop rose to deliver what all thought would be brief, inconsequential remarks, he wasted no time disintegrating the lobbyist organization, the Tobacco Institute. For print journalists in the audience, he was clear, concise and quotable. For broadcast journalists, he was a dream come true – tall, erect with his Mennonite beard, in a dark suit with bow tie, exuding a combination of extreme confidence and legitimacy mixed with “don’t mess with me” swagger.

As Koop would later say, after that, “I began to be quoted as an authority. And the press from that time on was all on my side… I made snowballs and they threw ‘em.” The other thing that Koop noticed early was that the Reagan Administration didn’t shut him down. That was surprising since Koop’s major supporter in a year long confirmation battle (the AMA opposed his appointment) was NC arch-conservative Senator Jesse Helms.

Add to Jesse’s wrath, R.J. Reynold’s CEO, Edward Horrigan, complained directly to Reagan about Koop’s “increasingly shrill preachments. Cigarette consumption in the US was in free fall. By 1987, 40 states would have laws banning smoking in public places; 33 states had bans in public transportation; and 17 already had eliminated workplace smoking.

Still Reagan didn’t shut him down. Now everyone from public schools to medical groups to women’s associations to civic enterprises wanted him. And beginning in late 1982, he arrived in full regalia, in a magnificent Public Health Service, Vice-Admiral’s uniform with ribbons and epaulettes. And his aide, also in uniform, always carried with him a bag of buttons for distribution which read, “The Surgeon General personally asked me to quit smoking.”

But in the most pressing public health challenge of the day, HIV/AIDS, the department was AWOL. Koop was actively sidelined by top Administration officials. Not surprisingly, the situation deteriorated rapidly. Everyone was feeling the heat, including the CDC, who removed funding for AIDS education after being accused of promoting sodomy by conservatives.

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Why AI Still Isn’t Fixing Patient Referrals—And How It Could

By NAHEEM NOAH

A Call from the Black Hole

Three months into building Carenector’s facility-to-facility platform, I got a call that crystallized everything wrong with healthcare referrals. A hospital social worker, who was already using our individual patient platform to help families find care, had been trying to coordinate an institutional placement for an 82-year-old stroke patient for six days. She’d made 23 phone calls. Sent 14 faxes. The patient was medically cleared but stuck in an acute bed costing $2,000 per day because no one could confirm which skilled nursing facilities had open beds, accepted her Medicaid plan, and had stroke rehabilitation capacity.

“I love what you built for patients,” she told me, “but when I need to do a facility-to-facility transfer, I’m back to faxing. Can’t you fix this workflow, too?”

She wasn’t wrong. We’re in 2025, and despite billions poured into health IT and breathless AI promises, referring a patient often feels like stepping back into 1995. Earlier this year, THCB’s own editor Matthew Holt documented his attempt to navigate specialist referrals through Blue Shield of California. The echocardiogram referral his doctor sent never arrived at the imaging center. When he needed a dermatologist, his medical group referred him to a provider who turned out not to be covered by his HMO plan at all. “There is a huge opportunity here,” Holt concluded after his odyssey through disconnected systems, “even though we’ve got now a lot of the data…to integrate it and make it useful for patients.”

Clinicians make over 100 million specialty referrals annually in the U.S., yet research shows that as many as half are never completed.

Here’s what we’ve learned after a year of operation: we built a consumer-facing platform that helps individuals and families find care providers matching their needs, insurance, and location—it now serves over 100 daily users, including patients, social workers, and discharge planners. But solving individual care searches is only half the battle. The institutional referral workflow—hospital to skilled nursing facility, SNF to rehab center, clinic to specialist—remains trapped in fax machines and phone tag because no one redesigned the actual coordination process.

That’s what we’re building now. And the question haunting us isn’t why we don’t have better tools? It’s why billions in AI investment left the institutional referral workflow virtually unchanged?

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To Improve Health, Design for Agency

By DAVID SHAYWITZ

Agency — the conviction I can shape my future — is a vital driver of human health and human potential.

It is also the factor overlooked by most digital health platforms.

University of Pennsylvania psychologist Martin Seligman, who has spent decades studying this, says agency boils down to the belief “I can make a positive difference in the world.” People with high agency believe there is something they can do next that might help – and then they actually try.

As Seligman emphasizes, the moments when we “try hard…persist against the odds…[and] make new, creative departures” are precisely when agency is at work. That extra effort and sustained determination — not just the mindset — shows up as improved performance, greater achievement, and enhanced health.  It also manifests as resilience, enabling us not only to recover from adversity but (ideally) to bounce back as an even better version of ourselves.

GLP-1s highlight the power and promise of newfound agency.  For many living with obesity, past attempts at weight loss reinforced a “cycle of despair” – trying harder mostly meant failing again. With the advent of GLP-1 medicines, many found that their weight would come down — and stay down.  Oprah Winfrey called the feeling “a relief, like redemption, like a gift.”

The deeper change is psychological: for the first time in years, effort feels rewarded. GLP-1s unlock an agentic dividend: the motivational boost that comes from finally being able to take control of your health. That surplus sense of possibility can be channeled into the familiar health basics — moving more and sleeping better — but also, often more importantly, into how we show up in our relationships and communities, in the enthusiasm we bring to our hobbies and pursuits, into the totality of experiences that make life so meaningful.

Agency is the motivational currency of health, the ATP of behavior change – it lets success in one domain drive progress in others.

Connected fitness platforms have a similar opportunity. Each discrete achievement — finishing a class, riding three times in a week, noticing that the stairs feel easier or the back hurts less — is a small proof of “I can do this.”  

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Brown and Toland weighs in on the $34.94 Labcorp test. (Part 6)

By MATTHEW HOLT

I know you all care, so I am giving a 6th update on the telenovela about my Labcorp bill for $34.95.

The very TL:DR summary of where we are so far is that in May 2025 I had a lab test to go with the free preventative visit that the ACA guarantees, but I was charged for the lab tests and I was trying to find out why, because according to CMS I should not have been.

For those of you who have missed it so far the entire 5 part series is on The Health Care Blog (1, 2, 3, 4 & 5). Feel free to back and read up.

When we left the scene on Sept 9, Blue Shield of California had finished their 30 day investigation and their rep read me the letter they sent me (that I couldn’t open due to their secure email not working). The letter told me that Brown & Toland Physicians, the IPA that manages my HMO, was going to investigate. Today I got a text from Blue Shield alerting me to a secure email and I got all excited, but it was nothing to do with this. And of course I should have heard from Brown and Toland in October or November.

So I decide to pick it all up again, and I called Brown & Toland Physicians or actually Altais which is the holding company that owns them and Blue Shield. I got through the phone tree and eventually got, “leave your number and get a call back” which actually happened not too long later.

The very nice rep tried to figure out my case and told me this:

On 8/14/2025 Mike at Blue Shield called Brown and Toland and asked for the original claim to be reviewed (1430201). I am pretty sure Mike is the nice man from the Executive Admin office at Blue Shield we met in part 2 (or was it part 3?).

On 8/29/2025 the benefits department at Brown and Toland finished their review and reported that the original lab test wasn’t coded as preventative lab services by One Medical, so that the co-pay of $34.95 was correct. ($34.95 was the total agreed payment for all the tests, charged at a total of $322.28. And as it was less than my $50 copay, LabCorp only charges the patient for the total, not the $50!)

Meanwhile, that 30 day Blue Shield investigation was still going on. It ended up with them asking Brown and Toland to investigate. Presumably as a direct result of that, on 9/9/2025 Kelly from Blue Shield called Brown and Toland and sent them the $34.94 claim asking them to review it. (Again, as it turns out, as they just had reviewed it on 8/29/2025).

“So what happened?” I asked today.

My rep told me that whomever at Brown and Toland spoke to Kelly on 9/9/2025 didn’t get or didn’t put in correctly the claim reference number, and so when they passed it on to the adjuster in the benefits department it couldn’t be worked on, and so nothing happened since then. So much for their 30 day investigation!

However my nice rep today told me the results of the 8/29/2025 benefits analysis which as previously mentioned was that when Labcorp got this claim submitted it was NOT coded as preventative. So the solution is that One Medical needs to change the diagnosis or CPT codes and resubmit the corrected order at Labcorp so that Labcorp can bill Brown and Toland for these as preventative services, and presumably get its $34.95 directly from them. As of now, that’s it.

I am of course girding my loins and preparing to ask One Medical to re-submit that lab claim with the preventative codes.

Meanwhile, I mentioned to my nice rep that I had two subsequent tests that I was not billed for. One was a Fit test in which One Medical sent me home with a kit to scoop my poop. That seems definitely to be preventative as it was to test for colon cancer. The other was a set of tests for low iron ordered during my preventative care visit because my iron levels looked a little low. My guess is that doesn’t fit the preventative category and I should have paid for that.

You may recall that iron test was billed at $0 and neither me nor the Labcorp rep who was working the case with me quite understood why.

Turns out Brown and Toland think that I should have paid a co-pay for both of those tests. The Fit test billed on 5/18/25 was $15.60 (1537124). By the way, Brown and Toland is getting a good deal as the cash price Labcorp charges consumers for that is about $90! The iron test was billed at $60.79.

You’ll recall my lab copay is $50, so Labcorp should have been charged me the lower of the copay or the actual total. Which is $15.60 for the Fit test and $50 for the iron test.

I got no charge for either.

By the way, I would like to show you the EOB from Blue Shield, but as they cancelled and reinstated my insurance last month, their online site has wiped all my EOBs!

So I agreed with the Brown and Toland rep when she suggested that they investigate the $15.60 bill for the Fit test to see if there should be a co pay, and I may hear from them in 30-45 business days.

And just to square the circle I will (probably) ask One Medical to resubmit the claim!

And yes this is all totally ridiculous and it all indicates why health care is so overly complex and why no consumer can figure out what is going on.

CODA: Meanwhile I was contacted by a journalist asking about ChatGPT being used to to sort out and protest medical bills. So I went down that rabbit hole a little too.

Matthew Holt is the founder and publisher of THCB

The Dartboard Toss and the Algorithm

By GEORGE BEAUREGARD

How A.I. could have personalized my 2005 cancer journey

I don’t think I’m in the minority of Baby Boomer physicians when it comes to my curiosity and ambivalence about the progressing application of A.I. in medicine. But that curiosity isn’t just prospective, it’s retrospective too. In 2005, I became an outlier who perhaps needed something other than the standard of care for a disease.

During the fall of 2005, I first saw a single drop of blood hit the toilet water while I was urinating in my bathroom. After hitting the water, the rose-colored bead slowly sank, twisting and contorting, dissipating like a puff of smoke. The evidence was fleeting—gone in seconds. If I were a spectator rather than the source, I might have admired its visual artistry. There was no associated pain.

A single thought ran through my mind: Did I just pee blood? I thought I had perhaps imagined it.

I was 49 years old and didn’t have what were considered risk factors for kidney or bladder cancer: smoking, obesity, advanced age, high blood pressure, or exposures to cadmium, trichloroethylene, or herbicides. But I was adopted and lacked any knowledge whatsoever about my family history. Did I have a grim genealogy? What was perhaps significant, however, was that both of my adoptive parents had developed different types of urogenital cancer. That led me to speculate that environmental factors related to materials in our house and/or the land it sat on or around it had perhaps played a role.

I tried to dismiss any concerns, but the adage “painless hematuria is cancer until proven otherwise” ran through my mind in chyron-like fashion.

The episodes continued and worsened, prompting an ultrasound, the report of which read: “…a soft tissue density is seen in the base of the bladder toward the right. While this could represent thrombus, I cannot rule out a primary mucosal lesion. The lesion measures approximately 4 X 5 cm in diameter.”

I consulted a urologist colleague, who performed a cystoscopy. His comment about what he saw: “As you know, you have a mass in your bladder. I got a very good view of it. It’s pretty angry-looking, so I suspect it’s not benign. I tried to remove as much as I could. It would’ve been pretty risky to scrape deeper and risk puncturing your bladder. I know I didn’t get all of it.” A TURBT soon followed. The pathology showed a high-grade urothelial carcinoma extensively invading the lamina propria and muscularis propria. There was multifocal lymphovascular invasion, so I probably had a more advanced subgroup than the localized SEER stage.

At that time, the relative five-year survival rate for stage II muscle-invasive bladder cancer was about 45 percent.

Overwhelmingly, bladder cancer is an age-related malignancy. So, there I was, 49 years old, with a cancer whose median age of incidence—septuagenarians— was much older than mine. A WTF moment.

One that started me thinking about how much time I had left.

So, I had cancer, but in some ways felt cautiously optimistic. I had access to Boston-based academic centers and specialist colleagues who were willing to see me quickly, and good insurance.

But getting the diagnosis was only the beginning. I saw three expert urologists, each of whom recommended a radical cystectomy, small bowel resection, and construction of an orthotopic ileal neobladder. Convergence. Certainty for me.

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Travis Rush & Kala Weeks, Reperio

Reperio Health is trying to really boost the delivery of at home health testing, including not only weight and blood pressure but also cholesterol, obesity and blood sugar. Having use the kit and done an at home demo, I’m pretty interested to see if this can be a front-end telehealth service to get the average middle aged adult into a preventative health checkup. (Here was my experience)

I spent some time at the HLTH conference back in October talking with Travis Rush, CEO and Kala Weeks, VP Marketing to discuss how it works, who they are targeting and what their metrics are. And how they think this will roll out — Matthew Holt

Let’s get moving on AI-discovered treatments

By STEVEN ZECOLA

Recursion Pharmaceuticals announced results today for one its AI-discovered treatments. I was pleased to see the large, sustained reduction in polyps attributable to its treatment for Familial Adenomatous Polyposis.  Recursions’ oral medication will be viewed by the traditional scientific and regulatory community as “promising”.

On the other hand, I was disappointed not to see/hear any reference to the savings of the cost to society from this treatment and a vague reference to working with the FDA in 1H2026.  Quite frankly, the urgency seemed to be lacking.

Currently, treating FAP is an expensive, lifelong endeavor for the 50,000+ survivors. Early detection strategies cost $10k+ and late detection $37k+. The cost to treating metastatic colorectal cancer (for which FAP predisposes) can be extremely high, up to $300,000.  Overall, the cost to society from FAP easily exceeds $1 billion per year, or more than $15 billion on a present value basis.

This medication should not be subject to any further regulatory delay.  There is enough information now on efficacy and safety to have Recursion more forward with a broad application of this treatment, while continuing test dosage levels and stratifying the patient population.  The alternative is more needless cost and suffering.

Steve Zecola sold his web application and hosting business when he was diagnosed with Parkinson’s disease twenty three years ago.  Since then, he has run a consulting practice, taught in graduate business school, and exercised extensively

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