I work in the gap between what medicine can see and what the system will pay for.

The recognition gap

Medicine keeps learning to see more. The system that pays for care cannot recognize most of it.

A 2022 guideline redefined Stage B heart failure and asked clinicians to catch structural disease before decompensation. The vocabulary they have to document it in still traces to 2013. The at-risk patient maps to no risk weight, and the codes that do carry weight assert a heart failure the patient does not yet have. Clinicians can now compute a cardiovascular risk score that the payer adjudicating the claim has no way to process.

That is the gap I work in, and it is everywhere once you know to look. Clinical capability exists and the reimbursement infrastructure does not. Value contracts change upstream and the incentive never arrives at the point of care. An entire sector adopts care pathway language without building the coordination that language implies.

At Caption Health, the product was cleared and clinically valid and still had no route to a patient, because no one pays a device to exist. So we built an operating model around it, an MSO-PC structure that turned a diagnostic product into a commercially offered clinical service. That structure is what made national scale possible, and it is what anchored the acquisition.

I write about this pattern continuously. It runs through a growing body of research across payer mechanics, imaging, cardiovascular care, pharmacy economics, and quality measurement.

Bedside to war room to boardroom

At the bedside

Cardiothoracic critical care. I managed anticoagulation and mechanical circulatory support, and wrote the guidelines the rest of the hospital followed. Clinical credibility is not a credential you cite. It is whether the room settles when you start talking.

In the war room

Bundled payments. An ACO built from nothing. Utilization management for millions of members, where the work was finding where capability and data standards diverge and pointing the roadmap at the gap. This is where you learn that most healthcare strategy dies in the space between what a contract promises and what a workflow will tolerate. I built in the record itself rather than describing it in a deck, which is a different kind of knowing.

In the boardroom

A cleared device with no route to a patient, turned into a commercially offered clinical service, scaled nationally, carried through an acquisition. Different vocabulary. Same problem.

One thing worth naming, because it is rarer than the rest. Medical affairs and commercial are normally separate functions with separate leaders and real tension between them. Evidence gets built that does not answer the buyer's question, and commercial teams make claims the evidence cannot defend. I have run both, at the same time, inside a regulated manufacturer. Doing that compliantly is the part people underestimate.

Where that gets applied

• Market access and reimbursement
• Utilization management and prior authorization
• Integrated evidence planning
• Medical affairs and commercialization
• Value-based care and bundled payments
• AI diagnostics and SaMD
• Clinical decision support
• Interoperability and EHR architecture
• Coverage policy and coding strategy
• Payer economics