Please Help Me Fix American Healthcare!
This is a call for collaboration. I'm seeking healthcare policy experts on topics that are poised to transform healthcare as we know it within the next two years.
This is me. The weather has been delightful in the great tri-state area. However, rest assured that I haven’t been slacking off. No, sir.
I’ve been deeply contemplating how we can address the issues plaguing American healthcare.
I am a father to two daughters. Regrettably, I find myself in a position where affording every medical service they need is beyond my financial reach. For someone like me, navigating health insurance has been an excruciating ordeal.
The American healthcare system is fraught with problems, many of which I have experienced personally while desperately trying to secure care for my family.
I’m preparing an extensive educational series on how policy and innovation could transform healthcare, possibly benefiting our children and grandchildren. The content is so abundant that it could have filled a book. Yet, I am leaning towards publishing it chapter by chapter on Substack.
Policy, not innovation, drives American healthcare.
And policy is dictated by corporate interests.
Policy, not innovation, drives American healthcare. And policy is dictated by corporate interests.
Emotionally and psychologically, this is a hard pill to swallow for most of us in the digital health. But this is the unfortunate reality.
I am determined to shift this paradigm.
I’m passionate about innovations in digital health, but I must admit I’m not an expert on healthcare policy and regulations, despite having explored numerous fascinating topics over recent weeks.
Healthcare is so complex. I’m eager to learn more. I need your help.
I don’t need GPT-generated general stuff. A lot of this information, including specific cases and examples, is not even on the Internet.
As of now, AI has very limited knowledge about some intricacies of the U.S. healthcare system. Trust me, I’ve tried everything.
Currently, only humans, and very specific humans at that, know the intricate details of the U.S. healthcare policy and regulatory environment.
As an outsider to healthcare four years ago, I’ve come to know some truly amazing doctors and medical experts. Now, I’m specifically looking for people with expertise on the following topics that I believe may affect healthcare in the next two years:
🟢 Measures CMS is planning to implement to make it more difficult for insurance companies to reject claims.
🟢 The “Two Midnight” rule enforcement.
🟢 Specifics on CMS’s plans to reduce MA plan profitability.
🟢 CMS’s revamp of the prior authorization process.
🟢 What specifically CMS and OAGs are implementing to crack down on upcoding, super coding, and other risk adjustment tricks?
🟢 Risk score - details on how insurance companies game those, how much money is involved? What are the risk scores for various insurance companies, and what is the dynamics there?
🟢 Star Ratings and Gap in Care - details on how insurance companies game those.
🟢 V28 Rule. Anything anyone knows. This is a big one.
🟢 Any insights on what the plans are of OAGs and OIGs? What are they doing all day? How are they helping? Are any of those folks concerned about zero competition in the industry? Because I’m kind of convinced at this point that the DOJ and FTC are not up for the task.
🟢 Anything on the Inflation Reduction Act (IRA) and the Medicare Part D changes. Those may wipe out the whole insurtech industry, in my opinion, but I’m looking for people who know more about specifics.
🟢 Related to IRA, “copay smoothing”. What the heck is that? It’s coming in 2025, and no one really knows what it is.
🟢 Related to IRA, any details on the upcoming MA out-of-pocket changes besides what’s been in the news.
🟢 Related to IRA, anyone with knowledge of specifics of the supposed negative impact on biosimilar competition and other effects?
🟢 Are inflation-based rebates a big deal?
🟢 ACO REACH - what is going on there? Do we need it?
🟢 Any expertise on how to reform PBMs is critical. We’ve all heard Mark Cuban’s ideas. But is that the essence of PBM reform - drop everyone and do transparent PBMs? Don’t we need something more realistic to be able to pass it in Congress?
I want to pick your brain, so I’m asking for your time. I know your time is valuable.
Why these specific policy topics? Why not AI, robotics, genetics, drug discovery, or automation? Aren’t those the areas where innovation is expected to originate?
All the above are crucial to advance our healthcare. However, whether we like it or not, policy trumps innovation in American healthcare. I believe only a few people in healthcare know exactly what’s coming.
I’m convinced this learning experience will be very beneficial for anyone in the medical community, including physicians, healthcare consultants, academics, and, believe it or not, policy makers themselves. Many of them have very different incentives than the rest of us. Yet, we, physicians and patients, end up enduring the product of their policymaking. That’s the ultimate paradox.
But I think the people who would benefit the most from this knowledge of where the industry is heading and possible ways to help the industry are venture capitalists, private equity managers, and other investors.
There is an abundance of investment capital. Unfortunately, hundreds of billions of dollars have been misallocated by healthcare investors. Despite this, I maintain hope that at least VCs and PEs genuinely care about healthcare outcomes, deep down.
Capital is important.
Yet, capital is not the ultimate answer.
What is the ultimate answer? Well, that’s what I’m trying to solve in this series of research articles over the next weeks and months.
In my first forthcoming article in this series, I believe I make a very convincing point that Clover Health and the rest of the insurtech industry have little chance of surviving under the current system. I hope I’m wrong because there are some great innovators working for these companies. But facts are facts.
Also, If you don’t like me or if you think I’m a bad person, that’s fine. May I ask you to still be brave and come forward if you have worked on the above themes or know someone who is an expert?
I don’t care who is providing the information and who is publishing it, as long as we can all learn, especially those who have the power to make healthcare policy better.
In any case, please help me learn. Please help all of us learn.
Please help me fix American healthcare. Please help us fix American healthcare. Let’s work together.
Thank you! 🙏
Sergei
P.S. Connect with me here or on LinkedIn. I’m always open to discussions on both important and lighter topics.
👉👉👉👉👉 Hi! My name is Sergei Polevikov. In my newsletter ‘AI Health Uncut’, I combine my knowledge of AI models with my unique skills in analyzing the financial health of digital health companies. Why “Uncut”? Because I never sugarcoat or filter the hard truth. Thank you for your support of my work. You’re part of a vibrant community of healthcare AI enthusiasts! Your engagement matters. 🙏🙏🙏🙏🙏
I'm so thrilled and truly speechless at the amount of helpful responses and feedback I received, in response to my call for healthcare policy and innovation collaboration. I'm starting to believe in humanity again. Thank y'all! 🙏 Perhaps we can do this after all?