Value-based care was designed to make healthcare cheaper and better. But in the last 15 years, it has done the exact opposite. This podcast explains how VBC is implemented in real life as risk-based contracts, leading to consolidation and, in turn, higher costs across the entire economy.

Chapter Markers

• 00:00 - Intro

• 00:25 - The Misdiagnosis

• 01:45 - Value-Based Care: Background & Assumptions

• 02:20 - The Game of VBC

• 02:53 - What is a Budget/Benchmark under VBC?

• 03:22 - Gaming the Benchmark

• 04:13 - Impact on Small Practices

• 05:29 - Quick Recap

• 06:09 - Why Small Practices Matter

• 06:33 - Consolidation

• 07:39 - Types of Consolidation

• 09:06 - 1 Contract vs TCOC

• 10:29 - Effects of Consolidation

• 13:00 - Medicare Advantage & Value-Based Care

• 13:26 - VBC, Consolidation & Medicaid

• 14:40 - Conclusion

• 15:50 - The Question to Ponder?

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In this episode, I discuss why Private Equity (PE) is so interested in funding Accountable Care Organizations (ACOs) participating in Value-Based Care (VBC) contracts. I break down the math to show why PE always wins at the expense of independent physicians.

VBC Financial Simulation Model Link

Chapter Markers

• 00:00 - Intro

• 00:33 - Step 1 to 3: Setup, Pot of Gold & Infrastructure

• 03:11 - Step 4: Private Equity as Funder

• 07:08 - Step 5: Outcomes

• 10:51 - Step 6: Multi-Year Projections

• 12:48 - Final Thoughts

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Value-based care is supposed to save money, but for independent physicians, it's often a structural trap. Using a custom financial simulation model, I break down the mechanics of these contracts when well-meaning insurance companies try to help independent ACOs by funding the infrastructure costs. Discover how and why primary care physicians can go bankrupt even when they get “free money” under value-based care.

VBC Financial Simulation Model Link

Chapter Markers

• 00:00 - Intro

• 00:48 - Step 1-3: Setting up ACO, Pot of Gold, and Reality Sets in

• 03:19 - Step 4: Insurance Company as Funder

• 05:54 - Step 5: Outcomes

• 10:01 - Step 6: Multi-Year Projection

• 10:24 - Step 7: Monte Carlo Simulation

• 12:27 - Final Thoughts

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Value-based care is supposed to save money, but for independent physicians, it's often a structural trap. Using a custom financial simulation model, I break down the exact contract mechanics of what happens when independent ACOs partner with hospital systems for funding. Discover how this setup actively works against independent doctors and accelerates healthcare consolidation.

Link to access the model

Chapter Markers

• 00:00 - Intro

• 00:55 - Step 1: Financial Model Setup

• 02:07 - Step 2: Opportunity (Pot of Gold)

• 02:52 - Step 3: Cost of Running an ACO

• 04:05 - Step 4: Hospital as the Funding Partner

• 07:32 - Step 5: Year 1 Outcomes

• 14:37 - Final Thoughts on Hospitals Funding ACOs

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I created a financial simulation model to mimic value-based care contracts. This screencast explains how the model is structured, what the different variables mean, and shows some of the capabilities. It also demonstrates how a value-based care contract works in real life and often why it paradoxically increases the total cost of care.

VBC Financial Simulation Model Link

Chapter Markers

• 00:00 - Intro

• 02:20 - Step 1: Financial Model Setup

• 09:01 - Step 2: Opportunity (Pot of Gold)

• 10:46 - Step 3: Cost of Running an ACO

• 16:09 - Step 4: Choosing a Funding Model

• 19:28 - Step 5: Year 1 Outcomes

• 24:18 - Step 6: Multi-Year Projection

• 33:13 - Step 7: Monte Carlo Simulation

• 44:05 - My Thoughts Based on Model Findings

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Why is the healthcare system demanding that doctors “fix” homelessness and food insecurity during a 15-minute visit, while refusing to fund the actual solutions?

In this video, I will show you how our system has created a “social to clinical funnel” that forces doctors to answer for societal failures they cannot fix. This is the story of how a political problem became a clinical burden, driving the moral injury of modern medicine.

Chapter Markers

• 00:00 Intro

• 02:34 SDOH Enters the Clinic

• 06:51 The Words That Shift Blame

• 08:31 Policy vs Clinical Dilemma

• 09:29 Screening Without Solutions

• 11:35 Medical Abundance, Social Scarcity

• 14:31 The Choice We Refuse to Make

• 16:28 Outro

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Health Determinants At Check In

5.48MB ∙ PDF file

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PDF of the Gamma.app presentation used in the video.

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The Annual Physical is an $8 billion+ ritual. But major studies show it doesn’t reduce mortality. So why is it still the center of American primary care?

This video explores the surprising history and modern-day transformation of the “annual physical.” I trace its journey and show you:

• How the exam began not just as a medical idea, but as an actuarial tool for life insurance companies in the early 1900s.

• Why corporations and the AMA championed the exam, linking it to workplace productivity and a new “moral duty” for individuals to manage their health.

• How the visit was repurposed in the 1990s as a data collection tool to feed HEDIS quality measures.

• Why today’s “Value-Based Care” models have doubled down, turning the physical into a surveillance machine for insurance risk-adjustment and financial calculations.

Chapter Markers

• 00:00 - Intro

• 00:45 - The Data on the Annual Physical Exam

• 02:18 - Historical Origins of the Annual Physical

• 03:34 - Life Insurance and Annual Physicals

• 06:01 - Employers Embrace Annual Physicals

• 06:33 - The Perfect Storm

• 07:16 - Relationships to Data Collection

• 08:22 - Returning to Actuarial Roots

• 10:06 - Why Does the Annual Exam Persist?

• 11:44 - Annual Physical in Other Countries

• 14:01 - Outro

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Slides The Ritual Of Care

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Are healthcare quality metrics truly objective? This podcast dives into the strange history of performance measures, revealing how they evolved from clinical tools into powerful political ones used to control costs, legitimize decisions, and shift blame from systems to front-line doctors.

Chapter Markers

• 00:00 - Intro

• 01:21 - Birth of Quality Measurement

• 02:33 - Medicare’s Bargain

• 05:34 - The Pioneering Role of Private Sector in Quality Measurement

• 07:07 - NCQA

• 07:55 - The Medical Surveillance Machinery

• 08:50 - Manufacturing Blame

• 09:04 - Technocratic Legitimacy

• 10:05 - Discursive Framing

• 11:15 - Manufactured Consent

• 12:26 - The Path Dependency Trap

• 13:56 - Outro

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In this video, I explore how the rise of risk-factor medicine, combined with America’s social fragmentation, made people morally and socially responsible for their own health.

This is the 3rd article in my series “Healers to Healthkeepers.”

Chapter Markers

• 00:00 - Intro

• 01:11 - Birth of Risk Factor Medicine

• 03:14 - The Moral Transformation to “Individual Choice”

• 06:06 - Prevention Becomes Virtue

• 07:06 - Healthism

• 09:19 - The Tradeoffs

• 12:35 - Outro

Slides Everyone Is Presick

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This video explores the rise of the hospital-insurance duopoly after WW-II, especially the unintended consequences of the Hill-Burton Act. The Hill-Burton Act provided funding to build hospitals in America, cementing them as the default choice for healthcare.

This video is the second in my series “Healers to Healthkeepers,” which explores the history and path dependency that led America from building public health infrastructure to holding doctors accountable.

Chapter Markers

• 00:00 - Intro

• 01:23 - Post WW-II Hospital Crisis

• 02:29 - Hill Burton Act

• 04:39 - The Rise of Healthcare Insurance

• 08:20 - The Problems with Hill-Burton Act

• 11:49 - Outro

Slides The Cathedrals Of Modern Medicine

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This video is the first in my new series “Healers to Healthkeepers.” It explores the history and path dependency that led America from building public health infrastructure to holding doctors accountable, & blaming them for the health of the population.

This podcast looks at how America transitioned from building public health infrastructure to relying on individual treatment to improve health outcomes.

Chapter Markers

• 00:00 - Intro

• 01:14 - The Sanitary Cleanup

• 03:42 - The Germ Theory of Disease

• 04:32 - The Flexner Report

• 08:09 - The Price of Progress

• 09:49 - The Flexner Tradeoff & Public Health Blind Spots

• 10:43 - Conclusion

Slides Sewers To Stethoscopes

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This video podcast explores the root causes of obesity from the “determinants of health” point of view. I discuss why medicalization of obesity is unlikely to solve the obesity epidemic, and as a society, we have to address its root causes.

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Chapter Markers

• 00:00 - Intro

• 00:55 - Defining Obesity & Why should we care?

• 01:59 - SDOH & Obesity

• 03:13 - Commercial Determinants & Obesity

• 04:55 - Marketing Strategies to Sell Food

• 07:53 - Political Determinants & Obesity

• 09:20 - Structural Determinants & Obesity

• 10:03 - Role of Personal Choice in Obesity

• 11:22 - Pyramid Model for Obesity

• 12:21 - Outro

Slides Obesity A Symptom Of The System

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In this episode, I break down the history and controversy behind adding fluoride to water, and how it hurts vulnerable people more than the wealthy.

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Chapter Markers

• 00:00 - Intro

• 00:44 - Brief History of Community Water Fluoridation (CWF)

• 01:55 - The Misunderstood Decline in Dental Caries

• 02:32 - Modern Studies on CWF

• 04:02 - SDOH and CWF

• 04:48 - Commercial Determinants of Health (CDOH) & CWF

• 05:17 - Political Determinants of Health (PDOH) & CWF

• 06:09 - Structural Determinants of Health (StDOH) & CWF

• 06:26 - International Approach to Fluoridation

• 07:06 - Concerns with CWF

• 07:42 - Conclusions

• 08:17 - Outro

Slides The Curious Case Of Water Fluoridation

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This video is a primer on Social Determinants of Health (SDOH). I discuss how SDOH creates the illusion of healthy choices for people, but in reality, the only choices people may have are those that will lead to poor health outcomes. I take housing as an example of SDOH to illustrate why and how your zip code is more important than your genetic code.

Chapter Markers

• 00:00 - Intro

• 01:00 - Definition of Social Determinants of Health (SDOH)

• 01:55 - Dahlgreen-Whitehead Model of SDOH

• 02:19 - Relationship between Health Outcomes

• 02:44 - SDOH and Health Outcomes

• 03:23 - Example of Housing as SDOH

• 06:32 - The Illusion of Choice

• 07:57 - Outro

Slides The Illusion Of Healthy Choices

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Who profits from poor health? This video exposes how policies, power, and profit, not just biology, shape the health of entire communities.

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Chapter Markers

• 00:00 - Intro

• 00:36 - Social Determinants of Health

• 01:14 - Defining Structural Determinants of Health (StDOH)

• 02:15 - StDOH in Real Life

• 03:18 - Path Dependence & StDOH

• 03:58 - US History & StDOH

• 06:54 - Housing as an Anchor Determinant

• 10:05 - Structural Barriers vs Individual Choice

• 10:47 - Power and StDOH

• 11:33 - Summary

• 13:09 - Outro

Slides The Architecture Of Illness

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• 00:00 - Intro

• 01:18 - What are Political Determinants of Health?

• 03:28 - Connecting the dots between Voting, Government & Policy

• 04:16 - Health in All Policies

• 06:46 - Connecting PDOH, CDOH, and SDOH

• 07:42 - Role of Doctors

• 08:39 - Outro

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• When Policy Fails, Medicine Pays - Link to the written article of this podcast.

  • To participate in comments, please go to the comments section of the written article.

  • This allows me to keep all the discussions related to the same topic in one area.

• YouTube channel: Ad-supported video version.

• Audio podcast: To listen to the paid audio version of the podcast in the app of your choice, please see this support article from Substack.

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Slides When Policy Fails Medicine Pays

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• 00:00 - Intro

• 00:57 - Defining Commercial Determinant of Health (CDoH)

• 01:32 - CDoH and Primary Care

• 02:03 - Marketing & Advertising

• 02:39 - Strategic Product Pricing

• 04:43 - Corporate Influence on Policy & Regulation

• 05:43 - Recycling: A Corporate Lie

• 07:57 - Deflecting Blame & Creation of Value-Based Care

• 08:56 - Supply Chain & Labor Practices

• 10:45 - Corporate Influence on Research

• 12:33 - Trade Agreements and Health

• 13:14 - The Commercial Parasite Model

• 14:29 - Conclusion

• 15:10 - Outro

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Relevant Links:

• Chronic Conditions, Corporate Causes - Link to the written article of this podcast.

  • To participate in comments, please go to the comments section of the written article.

  • This allows me to keep all the discussions related to the same topic in one area.

• YouTube channel: Ad-supported video version.

• Audio podcast: To listen to the paid audio version of the podcast in the app of your choice, please see this support article from Substack.

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Slides Chronic Conditions, Corporate Causes

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• 00:00 - Intro

• 00:51 - Why Fax Gets a Free Pass

• 01:28 - The Workflow Advantage

• 02:55 - eFax: The Digital Evolution

• 04:00 - Health Information Exchange

• 04:46 - Secure Email

• 06:06 - Direct Messaging

• 06:59 - FHIR and APIs

• 07:46 - API Gatekeepers: The New Monopolists

• 08:38 - Conclusion

• 09:25 - Outro

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Relevant Links:

• Why Fax Refuses to Die in Healthcare - Link to the written article of this podcast.

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Slides Why Fax Refuses To Die In Healthcare

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• 00:00 - Intro

• 00:57 - Anatomy of Medication Adherence Quality Measure

• 03:07 - Rationale and Reasons for Non-Adherence

• 06:09 - Problems with Medication Adherence Quality Measure

• 00:06:15 - Oversimplication of Complex Human Behavior

• 07:23 - Filled vs Consumed

• 09:50 - Switching Medication Class

• 10:19 - Cost of Medications

• 11:05 - Patient Selection Bias

• 11:42 - Improving Performance on Medication Adherence Quality Measure

• 12:33 - Outro

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• The Madness of Medication Adherence - Link to the written article of this podcast.

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Slides Colon Cancer Screening

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Peter Attia made a recent claim that if Joe Biden had kept getting the $5 PSA screening test, his aggressive prostate cancer may have been caught early.

Well, I unpack Dr. Attia's claims in this video and show why that is not true.

If you have not watched Dr. Attia’s video, the link is below.

Relevant Links:

• Biden, Attia and Prostate Cancer - Link to the written article of this podcast.

  • To participate in comments, please go to the comments section of the written article.

  • This allows me to keep all the discussions related to the same topic in one area.

• YouTube channel: Ad-supported video version.

• Audio podcast: To listen to the paid audio version of the podcast in the app of your choice, please see this support article from Substack.

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