Healthcare strategy in the gray space where clinical, commercial, and product meet.
Original analysis from Erik Abel on payer mechanics, market access, value-based care, and product commercialization. Peer-level research written for the operators and investors who need the picture, not the slogan.
The Medication Access Paradox
Two rails, one prescription, and the population health blind spot nobody chose.
The same prescription can travel an insurance rail that is data-rich or a cash rail that is invisible to the payer. The gap between them distorts population health for exactly the members whose adherence matters most.
Read the analysis →The Value Committee Moats
P&T and VAC optimize separate P&Ls. The consolidated number is nobody's job.
The payer world's medical-pharmacy divide was imposed from outside. Health systems built an equivalent one from the inside, where a formulary saving can hide a larger loss across the OR, the blood bank, and the ICU.
Read the analysis →West Virginia at a Strategic Crossroads
A strong balance sheet, weak fundamentals, and one design flaw linking tax, industrial, and education policy.
A $370 million surplus and a $1.46 billion reserve sit on the nation's weakest fundamentals. A PESTLE assessment of a state whose binding constraint is not capital, it is working-age, healthy, skilled people.
Read the assessment →Enforcement at the Seams of Vertical Integration
What the 2026 docket is actually testing.
Ten matters across seven business lines in one enterprise. Three legal frameworks, the Anti-Kickback Statute, FTC Section 5, and ERISA Section 406, have converged on the handoffs where integrated healthcare captures value.
Read the analysis →The Death Penalty Nobody Applies
Structural accountability and the enforcement gap at the center of American healthcare.
A hospital that seriously violates Medicare conditions loses its contract, a terminal penalty. No equivalent reaches an enterprise integrated across plan, PBM, pharmacy, provider, and in-home assessment.
Read the analysis →The 340B Rebate Pilot Doesn’t Reach What ACP Is Asking For
HRSA is fixing a manufacturer transparency gap. ACP is asking for covered-entity accountability.
The revised 340B Rebate Model Pilot and ACP's policy brief both target the same $100 billion program, but two different problems. The pilot leaves ACP's core recommendation untouched.
Read the analysis →Inertia by Design
When innovation outpaces coverage logic.
Prior authorization and level-of-care rules are healthcare infrastructure, yet they live in proprietary criteria across three opaque layers. Novel therapies are disproportionately exposed, and the result is passive non-adoption.
Read the analysis →AI-Guided POCUS Has a Market Access Problem
Novice operators. Expert-level accuracy. No reimbursement pathway.
Novice operators using AI-guided cardiac ultrasound reached 96.2% sensitivity and 99.8% negative predictive value for low ejection fraction. State licensure, CPT coding, and HEOR still block deployment at scale.
Read the analysis →The Heart Failure We Don’t Count
The economics count only diagnosed disease. Four in five patients upstream stay invisible.
Administrative data begins at diagnosis, which means it begins at Stage C. The Stage A and B population carrying the disease upstream never enters the count, and the lens itself becomes the crisis.
Read the analysis →The PBM Formulary Writes the Prescription
Four-pillar heart failure therapy returns $3,600 to $6,900 per patient each year. Benefit design suppresses it anyway.
A patient with preserved ejection fraction heart failure usually receives spironolactone before finerenone. Price decided that, not the evidence. Prior authorization and copay design suppress a regimen that pays the plan back.
Read the analysis →Prior Authorization Transparency
The metrics regulators want versus the metrics that move clinical alignment.
Technology enhancements are real, but the bigger picture is being missed. Prior authorization and utilization management have created burdens of national merit. Significant regulatory and data transparency gaps still block clinically led, justified coverage frameworks across payer lines of business.
Read the analysis →The Health Plan as a Complex Adaptive System
An interactive walkthrough of payer architecture, regulation, and emergent behavior.
Many recognize the complexities of care delivery. Few recognize the complexities behind the walls of health plans, their operations, and their regulations. This brings that forward illustratively.
See the framework →Dental Insurance and Price Transparency
A market on the verge of disruption if services and products align for innovation.
Price transparency has been pursued to expose consumerized paths for shoppable services. The dental space is an adjacent market with greater disruption potential. It already runs more like concierge care, and dental insurance value delivery has grown stale.
Read the whitepaper →PQA at the Inflection Point
PQA has payer reach no clinical organization can match. The opportunity is to accelerate evidence activation across professional societies.
Twenty years in, the Pharmacy Quality Alliance sits at a structural position nobody else holds: direct CMS connectivity, Star Ratings influence, and operational payer reach. The opportunity is to become the connective tissue between guideline development and operational quality measurement.
Read the analysis →Workforce Health as Corporate Strategy
Workforce clinical risk is an enterprise issue, not a benefits expense.
Corporate strategy is built around predictable risks, yet workforce clinical risk is largely absent from the conversation. Average tenure of three to five years gives employers a strategic horizon that insurers and Medicaid plans structurally lack.
Read the analysis →What “Lowest Net Cost” Is Missing
Two-thirds of plan sponsors lack a lowest net cost biosimilar strategy. The metric itself is also incomplete.
Net cost optimization without total cost accounting creates selection incentives that increase downstream medical spend. This piece builds the framework plan sponsors need to evaluate biosimilar strategy beyond the formulary negotiation.
Read the analysis →Biosimilar Non-Medical Switching
Not all non-medical biosimilar switches carry the same risk. A stratified clinical reference across 13 scenarios.
Risk stratification from treatment-naive initiation to high-stakes neurologic disease, drawing on RCT data, registry studies, and clinical society guidance across rheumatology, gastroenterology, and oncology.
View the reference →So Pharmacists Want to Be a Provider
The infrastructure gap three decades of advocacy has failed to close.
Why provider status remains unresolved despite strong clinical evidence, and how the MSO-PC operating model closes the gap between clinical capability and reimbursement infrastructure.
Read the analysis →The Compensation Cascade
Why value stops at the health system and rarely reaches the physician.
Only 9% of primary care and 5% of specialist pay is tied to value metrics. The structural gap between payer VBC contracts and physician employment agreements explains most of what stalls value-based care at the point of care.
Read the analysis →The Imaging Gap Nobody Built
Advanced imaging has a ceiling. The floor is missing.
The debate about the newest scanners asks whether ultrasonic CT is as good as MRI. The right question is what happens in the gap before patients reach advanced imaging at all. A commercial and clinical case for patient-centered longitudinal imaging infrastructure.
Read the analysis →What PREVENT Prevents
The payer harmonization gap across cardiovascular-kidney-metabolic care and beyond.
Three major 2025 to 2026 guidelines now anchor cardiovascular treatment thresholds to a PREVENT score that clinicians can compute and the payer adjudicating the claim cannot. The data infrastructure gap is structural, and the stakes just got higher.
Read the analysis →Heart Failure’s Stage A & B Blind Spot
The upstream patients coding and risk adjustment cannot represent.
The 2022 guideline redefined Stage B as pre-HF and asked clinicians to catch structural disease before decompensation. The ICD-10 vocabulary still traces to 2013. The at-risk patient maps to no risk weight, and the codes that earn weight assert a heart failure these patients do not yet have.
Read the analysis →The Imaging Value Journey and Delivery Matrix
Who actually owns each of the 15 requirements to deliver imaging at scale. An interactive supplement.
Follow a patient from population risk to population health and see where the imaging industry shows up and where it disappears. Companion to the Pathway Illusion analysis.
Explore the matrix →The Pathway Illusion in the Imaging Industry
Why imaging vendors cannot orchestrate what they were never built to coordinate.
The sector has converged on care pathway language. The structural foundation to deliver it was never built into the OEM model. This piece maps the infrastructure gaps, the organizational fault line, and the platform participant role that creates defensible value instead.
Read the analysis →Utilization Management & Prior Auth
Symptoms of illogical system failures, not just a technical problem.
The US spends $93.3 billion a year on utilization management, yet 75% of prior authorization appeals are overturned. UM is a system-logic problem, and prior authorization is only its most visible symptom.
Read the analysis →Quality’s Fragmentation & Translation Gap
How professional organizations can own payer value measurement.
Decades of claims-based quality measurement underdelivered. FHIR, USCDI, and TEFCA now make executable, clinically real measures possible, and professional organizations are positioned to lead or be led.
Read the analysis →No pieces match this lens yet. New analysis is in the pipeline.
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