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Tag: healthcare

  • Stop selling the device, sell the outcome

    This is post 7 of 10 in the series “FabrixMed learnings”

    1. The referral is where healthcare goes to die
    2. The ED doesn’t just need more hands. It needs faster answers.
    3. The government keeps a map of where healthcare is missing
    4. Who the ED calls, and how long the answer takes
    5. We ration specialists by zip code
    6. Screening is a logistics problem, not a medicine problem
    7. Stop selling the device, sell the outcome
    8. Independence needs shared support Scheduled for November 7, 2026
    9. Pay for the answer, not the appointment Scheduled for November 14, 2026
    10. Healthcare’s last mile runs on fax machines Scheduled for November 21, 2026

    Here’s a pattern I’ve watched up close: a company builds a genuinely good medical device. They sell the box. The clinic buys the box. The box sits in a corner.

    The device worked. The program didn’t.

    Because a clinic doesn’t need a box. It needs a screening program that runs, patients identified, images taken, results read, follow-ups booked, every week, without heroics, inside the chaos of a real practice. The device is one ingredient in that. Maybe twenty percent of it. The other eighty percent is workflow: who does what, when, and how you know it happened.

    So there’s a flip available, and the smart device companies are starting to see it. Stop selling the device. Sell the outcome. Instead of “here’s a camera,” it’s “here’s a working screening program, and the camera comes with it.” One-time sale becomes ongoing relationship. The customer stops buying equipment and starts buying results.

    This is better for everyone. The clinic gets something that actually works instead of an expensive paperweight. The company gets recurring revenue instead of lumpy one-time orders. And patients get screened instead of sitting on a waiting list for a device nobody set up.

    The lesson generalizes beyond healthcare, I think. Customers never wanted your product. They wanted the outcome your product was supposed to produce. Sell that.

  • Screening is a logistics problem, not a medicine problem

    This is post 6 of 10 in the series “FabrixMed learnings”

    1. The referral is where healthcare goes to die
    2. The ED doesn’t just need more hands. It needs faster answers.
    3. The government keeps a map of where healthcare is missing
    4. Who the ED calls, and how long the answer takes
    5. We ration specialists by zip code
    6. Screening is a logistics problem, not a medicine problem
    7. Stop selling the device, sell the outcome
    8. Independence needs shared support Scheduled for November 7, 2026
    9. Pay for the answer, not the appointment Scheduled for November 14, 2026
    10. Healthcare’s last mile runs on fax machines Scheduled for November 21, 2026

    Diabetes can steal your vision. Slowly, painlessly, and, here’s the tragedy, preventably. A photo of the back of your eye catches it years before you notice anything wrong. The cameras exist. The people trained to read the photos exist. And still, people go blind.

    Why? Because the photo never gets taken.

    Follow the chain. You’re at your primary-care doctor for diabetes. Someone needs to remember you need an eye photo, find time in a chaotic day, take the photo, send it somewhere, get it read, get the result back, tell you the result, and book the follow-up if something’s wrong. That’s seven handoffs. Every handoff leaks patients. By the end, a fraction of the people who needed screening got it.

    Notice what the bottleneck isn’t. It isn’t the camera, that problem was solved years ago. It isn’t the reading, trained eyes and good software both exist. The bottleneck is the boring stuff: who does what, when, and who checks that it happened.

    I keep running into this pattern. Most of healthcare’s unsolved problems aren’t medicine problems. They’re logistics problems wearing a medicine costume. We keep inventing better cameras while patients fall through the gaps between the camera and the follow-up.

    The next breakthrough in preventive care won’t be a better algorithm. It’ll be someone who makes the seven handoffs happen without heroics, every patient, every Tuesday, no exceptions.

  • We ration specialists by zip code

    This is post 5 of 10 in the series “FabrixMed learnings”

    1. The referral is where healthcare goes to die
    2. The ED doesn’t just need more hands. It needs faster answers.
    3. The government keeps a map of where healthcare is missing
    4. Who the ED calls, and how long the answer takes
    5. We ration specialists by zip code
    6. Screening is a logistics problem, not a medicine problem
    7. Stop selling the device, sell the outcome
    8. Independence needs shared support Scheduled for November 7, 2026
    9. Pay for the answer, not the appointment Scheduled for November 14, 2026
    10. Healthcare’s last mile runs on fax machines Scheduled for November 21, 2026

    America doesn’t have a specialist shortage. It has a specialist distribution failure.

    The scarcest resource in our healthcare system is a specialist’s time. And we hand it out by geography. Live near a big medical center and you might wait days. Live in a small town or farm country and you wait months — for the same question, the same disease, the same human being in need.

    Nothing about your illness cares where you live. But everything about your care does.

    Here’s the backwards part: we make the patient travel to the knowledge. You drive three hours, take a day off work, arrange childcare — so that a specialist can look at you for fifteen minutes and often just answer a question. A huge share of specialist visits end with advice, not procedures. The knowledge was the product. The travel was pure overhead.

    Flip it. An e-consult — that’s just your own doctor asking a specialist a question electronically, doctor to doctor — moves the question instead of the patient. The specialist reads the case, gives guidance, and most of the time no visit is needed at all. Same knowledge, zero windshield time.

    We built the whole system around the idea that expertise lives in buildings. It doesn’t. It lives in people’s heads, and heads can answer questions from anywhere.

    The zip code lottery isn’t a medical problem. It’s a logistics problem wearing a white coat.

  • Who the ED calls, and how long the answer takes

    This is post 4 of 10 in the series “FabrixMed learnings”

    1. The referral is where healthcare goes to die
    2. The ED doesn’t just need more hands. It needs faster answers.
    3. The government keeps a map of where healthcare is missing
    4. Who the ED calls, and how long the answer takes
    5. We ration specialists by zip code
    6. Screening is a logistics problem, not a medicine problem
    7. Stop selling the device, sell the outcome
    8. Independence needs shared support Scheduled for November 7, 2026
    9. Pay for the answer, not the appointment Scheduled for November 14, 2026
    10. Healthcare’s last mile runs on fax machines Scheduled for November 21, 2026

    Who the ED calls, and how long the answer takes

    In my last two posts I argued that the emergency department’s problem isn’t just missing hands — it’s missing answers. Decision delay, not just doctor shortage. This week I found the data. It says I’m right, and it’s more specific than I expected.

    Here’s the setup. When an ED doctor hits a case she can’t resolve alone, she calls a specialist — a consult. Nationally, the CDC’s emergency department survey found a consulting physician was seen in 11.6% of ED visits in 2018, 13.5% in 2019, and 15.7% in 2020 — trending up. Studies that count consults requested (not just completed) put it at 20–40% at teaching hospitals. So somewhere between one in eight and one in three ED visits waits on a specialist’s answer.

    Now the part nobody talks about: who gets called, and how long each one takes. A 2026 study out of the University of Virginia tracked roughly 35,000 consults over a year and measured the one thing that matters — minutes from “we need you” to an answer the ED can act on. It is, as far as I can tell, the only detailed breakdown of its kind in the US. The CDC doesn’t record consult specialty nationally. Read that again: the country obsessively measures door-to-doctor time in every ED, but nobody nationally measures consult-to-answer time. We clock how fast a doctor arrives. We don’t clock how fast the answer arrives.

    Here is what the study found:

    Specialty called Share of consults Median wait for an answer
    Internal medicine 26.8% 90 min
    Cardiology 8.2% 164 min
    Psychiatry / behavioral health 6.7% 196 min
    Neurology 5.6% 178 min
    General surgery 5.2% 144 min
    Orthopedic surgery 4.9% 154 min
    ICU 4.0% 60 min
    Neurosurgery 2.9% 155 min
    ENT 2.4% 153 min
    Ophthalmology 2.3% 160 min
    Toxicology 0.9% 92 min

    Overall median: 108 minutes. Nearly two hours, every time, just waiting for the answer.

    A few things jump out.

    First, the psychiatry paradox. Behavioral health is only about 7% of consults — yet it has the longest wait of any specialty: 196 minutes, over three hours. And this is the specialty with the worst boarding crisis in the country: roughly 1 in 10 mental-health ED visits among Medicaid-covered youth ends in boarding for 3–7 days. The patients who wait longest for an answer are the ones who then wait longest for a bed. The delay compounds.

    Second, the pattern in the slow list. Cardiology, neurology, neurosurgery, ENT, ophthalmology, orthopedics — the longest waits cluster around exactly the specialties that hospitals struggle most to keep on call. Three out of four ED directors say their specialist on-call coverage is inadequate, and the worst gaps are neurosurgery, hand surgery, orthopedics, ENT, ophthalmology, dermatology. These are the 2am specialties: the ones nobody staffs at night because the volume doesn’t justify a full-time body. So the ED calls, and waits.

    Third — and this is the one I keep coming back to — one in five of these waits is a number the system chose not to measure. Nationally. The measurement gap is the story. You manage what you measure, and American emergency medicine has spent decades optimizing everything up to the consult order, then shrugging at the 108 minutes after it.

    I’m not pretending the data is perfect. This is one academic hospital where every admission requires a consult, which inflates the internal-medicine share. Other studies put orthopedics as high as 25% and psychiatry as high as 15% of consults. But directionally it holds: a large share of ED visits stall on a specialist’s answer, the answer takes hours, and the slowest answers belong to the hardest-to-staff specialties.

    Which brings me back to the geometry question from my last post. Every shortage program tries to move the doctor to where the patient is. But the doctor isn’t the bottleneck in this table — the answer is. A cardiology consult that takes 164 minutes doesn’t need a cardiologist relocated to the county. It needs the question to reach a cardiologist faster and the answer to come back sooner. The specialist stays put. The patient stays put. Only the consult moves.

    That’s the shape of what I’m building with FabrixMed — e-consult infrastructure that moves answers, not people, into the places and moments where the wait is longest.

    I’m still learning this world. If you run an ED, staff one, or study consult patterns — tell me what these numbers get wrong. The map is better when more people draw it.

    References

  • The government keeps a map of where healthcare is missing

    This is post 3 of 10 in the series “FabrixMed learnings”

    1. The referral is where healthcare goes to die
    2. The ED doesn’t just need more hands. It needs faster answers.
    3. The government keeps a map of where healthcare is missing
    4. Who the ED calls, and how long the answer takes
    5. We ration specialists by zip code
    6. Screening is a logistics problem, not a medicine problem
    7. Stop selling the device, sell the outcome
    8. Independence needs shared support Scheduled for November 7, 2026
    9. Pay for the answer, not the appointment Scheduled for November 14, 2026
    10. Healthcare’s last mile runs on fax machines Scheduled for November 21, 2026

    I spent some time this week on the Bureau of Health Workforce’s website, reading about how the federal government officially labels the places and people that don’t have enough healthcare. I didn’t know this machinery existed. Now I can’t stop thinking about it.

    Here’s the plain-English version.

    The government gives shortage labels to places, groups of people, or buildings that don’t have enough healthcare. The count of geographic shortage areas alone is just over 1,000 — and that’s only one kind of label. There are five, and they stack like this:

    1. Not enough doctors here. The official name is a Health Professional Shortage Area. It comes in three flavors: a whole area (a county, a neighborhood), a specific group of people (low-income families, homeless people, migrant farmworkers), or a specific building (a prison, a mental hospital). And it covers three kinds of care: basic primary care, dental, and mental health.

    2. Not enough maternity care, specifically. Inside the areas above, some places are short on the people who deliver babies and care for mothers. Those get their own sub-label: Maternity Care Target Areas.

    3. Underserved — the area or the people. Medically Underserved Areas are whole geographies (a county, a cluster of counties, city blocks) that lack basic care. Medically Underserved Populations are specific groups inside a geography — people facing money, language, or cultural barriers to care. These labels are what let community health centers get built.

    4. Doesn’t fit the boxes, but still can’t get care. The Exceptional Medically Underserved Population — for groups whose situation is unusual enough that the standard definitions miss them.

    5. The governor can just say so. A state governor can flag an area as short on providers, and that flag is what lets a Rural Health Clinic get established there.

    These labels aren’t just statistics. They unlock real things: loan repayment for clinicians who go work in these places, bonus payments, even visa waivers for foreign-trained doctors. The labels are the system formally admitting: care is missing here.

    And here’s the part I’m chewing on. Every program attached to these labels tries to move the doctor to the pin on the map. Loan forgiveness, bonuses, visas — all of them are trying to relocate a human being. But doctors are people with lives, and they mostly don’t relocate on command. That’s not a criticism; it’s just how humans work.

    What if the geometry is wrong? What if the doctor doesn’t need to move — only the doctor’s answer needs to travel? A question from a clinic in a shortage county, answered by a specialist two states away, in hours instead of months. The specialist stays where she is. The patient stays where he is. Only the consult moves.

    And the answer really is the slow part. A 2026 study of roughly 35,000 emergency department consults at the University of Virginia found the median wait from consult order to an actionable answer was 108 minutes — nearly two hours. For psychiatry, it was 196 minutes. Over three hours. Meanwhile, three out of four ED directors say their specialist on-call coverage is inadequate. The bed isn’t always the bottleneck. Sometimes it’s the answer.

    That’s the shape of what I’m building with FabrixMed — digital infrastructure that carries specialist answers into the places the map says are missing them. No relocation required.

    I’m still learning how these designations work in practice. If you know this world — a state primary care office, a rural clinic, an FQHC — I’d love to hear what the map gets right and what it misses.

    References

  • The ED doesn’t just need more hands. It needs faster answers.

    This is post 2 of 10 in the series “FabrixMed learnings”

    1. The referral is where healthcare goes to die
    2. The ED doesn’t just need more hands. It needs faster answers.
    3. The government keeps a map of where healthcare is missing
    4. Who the ED calls, and how long the answer takes
    5. We ration specialists by zip code
    6. Screening is a logistics problem, not a medicine problem
    7. Stop selling the device, sell the outcome
    8. Independence needs shared support Scheduled for November 7, 2026
    9. Pay for the answer, not the appointment Scheduled for November 14, 2026
    10. Healthcare’s last mile runs on fax machines Scheduled for November 21, 2026

    I read a staffing company’s new report on emergency departments under strain. Their numbers are real and worth sitting with. More than 69,000 emergency doctors in the US. Over 100 rural hospitals closed in a decade. Residency spots growing, yet 140 went unfilled this year, double last year’s number. Patients boarding in hallways for hours.

    Boarding means this: a patient who has been admitted still sits in the emergency department, waiting for a bed upstairs. The whole department slows down behind them.

    The report’s answer is mostly about staffing. More doctors, more flexible coverage, better retention. That makes sense coming from a staffing company, and I am not dismissing it. Short-staffed departments are real.

    But I keep coming back to something their lens cannot quite see. At 2am in a small-town ED, the binding constraint is often not another pair of hands. It is a decision that cannot get made.

    The ER doctor has a patient with a tricky heart tracing, or a wound that might need a hand surgeon. She knows what she needs: a specialist’s eyes on the case. So she pages, waits, pages again. The patient waits. The bed waits. The whole department waits behind them. That is boarding too, except no staffing plan fixes it, because the specialist she needs does not work in that building and never will.

    You cannot staff your way out of that math. There are not enough specialists to put one in every ED at 2am, and there never will be.

    What I am learning, building FabrixMed, is that this is an infrastructure problem, not a headcount problem. The question is not how to move more doctors into more buildings. It is how to move the decision to the doctor faster. Get the right eyes on the case in minutes, and the ER doctor can decide: admit, discharge, transfer. The patient moves. The department breathes.

    Lay down the rails. Run whatever trains.

    Reference: Medicus Healthcare Solutions, “A System Under Strain: Rising Demands in Emergency Medicine”.

  • The referral is where healthcare goes to die

    This is post 1 of 10 in the series “FabrixMed learnings”

    1. The referral is where healthcare goes to die
    2. The ED doesn’t just need more hands. It needs faster answers.
    3. The government keeps a map of where healthcare is missing
    4. Who the ED calls, and how long the answer takes
    5. We ration specialists by zip code
    6. Screening is a logistics problem, not a medicine problem
    7. Stop selling the device, sell the outcome
    8. Independence needs shared support Scheduled for November 7, 2026
    9. Pay for the answer, not the appointment Scheduled for November 14, 2026
    10. Healthcare’s last mile runs on fax machines Scheduled for November 21, 2026

    Your doctor says, “I’ll refer you to a specialist.” It sounds like a plan. Whether it becomes one depends on something nobody mentions: are both doctors inside the same fortress?

    Let me explain the fortresses. A health system is a company that owns hospitals and employs doctors — Baylor Scott & White in Texas is one. An IDN, an integrated delivery network, goes one step further: it owns the hospitals, employs the doctors, and owns the insurance plan. Kaiser Permanente is the classic example — they collect your premium and employ your doctor, so the whole chain is one company. The insurance side has a name too: the payer, the one who foots the bill. In an IDN, the payer and the provider are the same company.

    Now the referral. If your primary-care doctor — your PCP, the doctor who owns your overall picture — sends you to a specialist inside the same company, that’s in-network. Outside it, out-of-network. The boundary between those two words is where referrals go to die.

    Inside the fortress, things mostly work. One EHR — the electronic health record, usually Epic — so the referral lives in one chart, not a fax. The system gets paid for the specialist visit, so it wants you to complete it. The industry even has words for this: keepage when you stay inside, leakage when you don’t. And there are humans whose whole job is chasing referrals.

    But “mostly” is doing heavy lifting. The system can see the open order. It can’t make you schedule. You face a three-month wait and give up. Prior auth — the insurer’s permission slip, required before many visits — gums up the works. And the final step fails everywhere: the specialist writes a note, your PCP gets a twelve-page document in an inbox, nobody reads it, your plan doesn’t change. “Visit happened” is not the same as “loop closed.”

    And here’s the thing: most of America doesn’t live in the fortress. Community clinics — FQHCs, federally qualified health centers, the clinics that serve everyone regardless of ability to pay — rural practices, independent doctors: they refer out into the void every day. No shared chart. No keepage incentive. No coordinators. Just a fax and a hope.

    So the honest version of the claim: the referral doesn’t die everywhere. It dies at the boundary — and American healthcare is mostly boundaries.

    From first principles, then: the unit of value was never the referral. It’s the closed loop — the moment the specialist’s knowledge actually changes your PCP’s plan. Everything before that is potential energy. Build for the loop closing, not the order being sent. Measure completions, not sendings. And if you’re building for the frontier rather than the fortress, you’d better build the plumbing the fortress got for free.

  • The patient journey, end to end

    This is post 7 of 7 in the series “US Healthcare in Plain English”

    1. The cast of US healthcare, in plain English
    2. The people of US healthcare, in plain English
    3. The money trail: how a dollar flows through US healthcare
    4. The insurance card, decoded
    5. The life of a medical bill
    6. Why American healthcare costs so much
    7. The patient journey, end to end

    Enough abstractions. Let me walk one patient through the whole system — using every layer of the map we’ve built this month.

    Meet Maria, 68, retired teacher, diabetes, and a knee that’s been getting worse for two years. Fictional — but everything that happens to her happens every day.

    The PCP. Maria’s primary-care doctor examines the knee, orders an X-ray, and decides it’s time for an orthopedist. The PCP sends an in-network referral inside their health system, so it lands in the shared EHR instead of a fax machine.

    The specialist. Three weeks later — the wait — the orthopedist confirms: bone on bone, she needs a knee replacement. The surgeon’s office submits a prior auth to Maria’s MA plan. Nine days. Approved.

    The surgery. The replacement happens at an ASC — cheaper than the hospital, home the same day. The anesthesia team puts her under. The surgical techs assist.

    The coded bill. The whole encounter becomes CPT and ICD-10 codes, rides a clearinghouse to the plan, gets adjudicated. Maria’s deductible is met; coinsurance covers her share. The EOB arrives weeks later.

    Recovery. Home health nurses check the wound. A PT gets her walking again. Her PCP gets the operative note — twelve pages in the inbox — and, if the loop actually closes, adjusts her diabetes meds around the recovery.

    The bill. Two months later: the hospital’s bill, the surgeon’s bill, the anesthesia bill, the PT bills. Four envelopes, four portals, one confused patient.

    Now replay Maria’s story with one change: her PCP is at an independent clinic, out in the frontier. The referral goes by fax. The prior auth stalls. The operative note never reaches the PCP. Same medicine — completely different journey. That’s the difference between the fortress and the frontier, and it’s the whole reason this map exists.

    The full September map: the cast, the people, the money trail, the insurance card, the life of a bill, why it costs so much.

  • Why American healthcare costs so much

    This is post 6 of 7 in the series “US Healthcare in Plain English”

    1. The cast of US healthcare, in plain English
    2. The people of US healthcare, in plain English
    3. The money trail: how a dollar flows through US healthcare
    4. The insurance card, decoded
    5. The life of a medical bill
    6. Why American healthcare costs so much
    7. The patient journey, end to end

    After mapping the cast, the people, and the money, I kept hitting one question: why does all of this cost so much? America spends roughly twice what peer countries spend per person — and doesn’t get better health to show for it. Here’s what I found, and it’s not one villain.

    Prices, not volume. The first surprise: Americans don’t use much more healthcare than people in other rich countries. We just pay far more per unit. The same MRI, the same drug, the same procedure — priced multiples higher. The US is the only rich country that mostly lets sellers name their price.

    The billing machine. Thousands of health plans, each with its own rules, codes, and prior-auth forms. Providers employ armies just to bill and collect — billing staff, coders, claim fighters. (See the life of a medical bill.) It’s an order of magnitude more overhead than countries with single payment systems, and every dollar of it comes out of premiums.

    Fee-for-service. Pay per thing done, and you’ll get more things done. More scans, more procedures, more revenue — whether or not the patient is better off. The payment model is an engine for volume.

    Consolidation. Hospitals keep merging, and merged systems gain pricing power. A “must-have” hospital system in a city can name its price to health plans — and the plans pass it to you in premiums.

    Drugs. America pays the highest drug prices in the world, by far. Other countries negotiate as one buyer; the US mostly doesn’t.

    Here’s the uncomfortable synthesis: there’s no single villain because there’s no single cause. It’s the design. Every actor — the hospital, the plan, the drugmaker, the device company — is responding rationally to what they’re paid for. The system isn’t broken in the sense of malfunctioning. It’s functioning exactly as its incentives dictate. Which means the costs aren’t an accident. They’re the output.

    Previously: the life of a medical bill. Next: the patient journey, end to end.

  • The life of a medical bill

    This is post 5 of 7 in the series “US Healthcare in Plain English”

    1. The cast of US healthcare, in plain English
    2. The people of US healthcare, in plain English
    3. The money trail: how a dollar flows through US healthcare
    4. The insurance card, decoded
    5. The life of a medical bill
    6. Why American healthcare costs so much
    7. The patient journey, end to end

    You see the doctor for twenty minutes. Then a machine with a hundred moving parts starts up — and most of it is invisible to you. Here’s the life of a medical bill.

    Step 1: the visit becomes codes. Everything that happened gets translated into two code languages. CPT codes say what was done — the procedure, the test, the visit type. ICD-10 codes say why — the diagnosis. Your twenty minutes becomes a coded claim: a precise, billable description of the encounter.

    Step 2: the claim travels. The provider’s billing system sends the claim to a clearinghouse — the router that checks it for errors and forwards it to your health plan.

    Step 3: adjudication. The plan’s computer decides: pay in full, pay less, or deny. Denials happen for dull reasons — a coding error, a missing prior auth — and for sharp ones: “not medically necessary,” the plan disagreeing that you needed the care.

    Step 4: the split. The plan pays the provider its share and sends you the EOB — the receipt showing what was billed, the discount, what they paid, what you owe.

    Step 5: your bill. Weeks later, a bill arrives for your share. It’s confusing, it’s late, and it’s wrong often enough that you should always check it against the EOB.

    Step 6 (sometimes): the fight. Denials can be appealed — by the provider, or by you. A remarkable share of appealed denials get overturned, which tells you something about how many shouldn’t have been denied in the first place.

    Step back and look at it: a $200 visit sets off a Rube Goldberg machine of codes, routers, and robots — and every handoff is a place where money leaks, claims die, or patients get hurt. The bill isn’t complicated because medicine is complicated. It’s complicated because the plumbing is.

    Previously: the insurance card, decoded. Next: why American healthcare costs so much.

  • The insurance card, decoded

    This is post 4 of 7 in the series “US Healthcare in Plain English”

    1. The cast of US healthcare, in plain English
    2. The people of US healthcare, in plain English
    3. The money trail: how a dollar flows through US healthcare
    4. The insurance card, decoded
    5. The life of a medical bill
    6. Why American healthcare costs so much
    7. The patient journey, end to end

    Every American carries one and almost nobody understands it: the insurance card. Here’s the vocabulary, in the order you’ll actually encounter it.

    Premium — the monthly subscription. Paid whether you use care or not. The cover charge.

    Deductible — what you pay each year before insurance starts helping. A $2,000 deductible means the first $2,000 of care is yours.

    Copay — the flat fee per visit. $30 for your PCP, $60 for a specialist. Due at the front desk.

    Coinsurance — the percentage split after the deductible. 80/20 means the plan pays 80%, you pay 20%.

    Out-of-pocket max — the worst-case cap. Once your spending hits this number for the year, the plan pays 100% of covered care. The number that prevents medical bankruptcy — for covered services.

    Network — the list of providers your plan has deals with. In-network means discounted rates; out-of-network means you pay much more, sometimes everything.

    Formulary — the plan’s list of covered drugs, in tiers. Tier 1: cheap generics, a few dollars. Tier 4: specialty drugs that can cost thousands a month.

    Prior auth — the permission slip. For many procedures, scans, and drugs, your doctor must get the plan’s approval before you receive care. Denied or delayed here, and the care doesn’t happen.

    Referral — in the insurance sense: some plans won’t let you see a specialist unless your PCP sends you first. The gatekeeper rule.

    EOB (Explanation of Benefits) — not a bill. The receipt the plan sends after care: what was billed, the discount they negotiated, what they paid, what you owe. Read it before you pay anything.

    HSA / FSA — tax-advantaged accounts for medical spending. The HSA (health savings account) rolls over year to year and is yours forever. The FSA (flexible spending account) is mostly use-it-or-lose-it.

    Put it together and a year of healthcare has a shape: you pay the premium every month, the deductible first, then copays and coinsurance share the load, and the out-of-pocket max is the ceiling. Everything else is details.

    Previously: the money trail. Next: the life of a medical bill.

  • The money trail: how a dollar flows through US healthcare

    This is post 3 of 7 in the series “US Healthcare in Plain English”

    1. The cast of US healthcare, in plain English
    2. The people of US healthcare, in plain English
    3. The money trail: how a dollar flows through US healthcare
    4. The insurance card, decoded
    5. The life of a medical bill
    6. Why American healthcare costs so much
    7. The patient journey, end to end

    Once I knew the cast and the people, the next question was obvious: follow the money. Who pays whom, and — the question that explains everything — for what?

    Start with the basic flow. You — or more likely your employer — pay a monthly premium to a health plan. The plan pools everyone’s premiums into one giant pot. When you get care, your doctor bills the plan, and the plan pays out of the pot. You cover part of it directly: the deductible, the copay, the coinsurance. (I decoded all of those here.)

    Now the important part: how the plan pays the provider. The default setting of American healthcare is fee-for-service: a price for every thing done. An office visit has a price. A blood test has a price. An MRI has a price. Do more things, get more money. The incentive is volume — not health, volume.

    Once you see that, a lot of strange behavior stops being strange. The system doesn’t get paid to keep you healthy. It gets paid when you’re sick and receiving services.

    The alternatives all try to fix this one flaw. Capitation: the plan pays a provider group a fixed amount per patient per month, and the group keeps what’s left after delivering care. Suddenly prevention is profitable. Bundled payments: one fixed price for a whole episode, like a knee replacement — surgery, hospital, rehab, one check. Go over, you eat it; come under, you keep it. Shared savings: the ACO model — beat the budget while hitting quality targets, split the difference with Medicare.

    The umbrella term for all of these is value-based care: pay for the outcome, not the activity. It’s the direction the industry claims to be moving. The reality is messier — most dollars still flow fee-for-service, and the new models layer on top rather than replacing.

    Here’s the lens I now carry everywhere: every weird behavior in healthcare makes sense once you ask how does this person get paid. The hospital that keeps you one more day. The plan that denies the claim. The specialist who orders one more scan. Follow the money, and the mystery dissolves.

    Previously: the cast, the people. Next: the insurance card, decoded.

  • The people of US healthcare, in plain English

    This is post 2 of 7 in the series “US Healthcare in Plain English”

    1. The cast of US healthcare, in plain English
    2. The people of US healthcare, in plain English
    3. The money trail: how a dollar flows through US healthcare
    4. The insurance card, decoded
    5. The life of a medical bill
    6. Why American healthcare costs so much
    7. The patient journey, end to end

    Last time I mapped the institutions — the companies, the acronyms, the buildings. But healthcare isn’t buildings. It’s people in scrubs and white coats with letters after their names. And honestly, the people confused me more than the institutions did.

    So here’s the second half of the language lesson: the people of US healthcare, in plain English. What the letters mean, and what each person actually does for you.

    The doctors

    MD — Doctor of Medicine. Four years of medical school plus years of residency. The classic physician.

    DO — Doctor of Osteopathic Medicine. Same license, same scope as an MD in the US — different school tradition, with extra training in hands-on diagnosis.

    Resident — a doctor in training, working in the hospital under supervision. The 80-hour weeks.

    Fellow — a resident who finished and is training further in a subspecialty, like cardiology or oncology.

    Attending — the fully trained doctor in charge. The buck stops here.

    Hospitalist — a doctor whose entire practice is hospitalized patients. No clinic; the hospital is the office.

    Intensivist — the ICU doctor. The sickest patients in the building are theirs.

    The nurses — the backbone

    RN (Registered Nurse) — nursing degree plus a license. Gives meds, runs IVs, watches you around the clock. The backbone of every hospital.

    LPN / LVN (Licensed Practical / Vocational Nurse) — shorter training than an RN, works under RNs and doctors. Same word, different states.

    CNA (Certified Nursing Assistant) — the bedside basics: vitals, bathing, feeding, turning. The most hands-on job in the building.

    NP (Nurse Practitioner) — an RN with a graduate degree. Can diagnose, prescribe, and run a practice — often the primary-care provider in rural areas.

    CRNA (Certified Registered Nurse Anesthetist) — the nurse who puts you under. In many hospitals, especially rural ones, the CRNA is the anesthesia department.

    CNM (Certified Nurse Midwife) — delivers babies, women’s health.

    Charge nurse — the RN running the shift. Traffic control for the whole unit.

    The APPs — advanced practice providers

    PA (Physician Assistant, now “Associate”) — trained in the medical model, shorter than medical school. Diagnoses, prescribes, assists in surgery — works alongside doctors.

    APP — the umbrella term for NPs and PAs. When someone says “an APP will see you,” it means a highly trained clinician who isn’t an MD or DO.

    The therapists

    PT (Physical Therapist) — gets you moving again: strength, balance, walking.

    OT (Occupational Therapist) — gets you living again: dressing, cooking, daily tasks. The most misunderstood name in healthcare — nothing to do with jobs.

    SLP (Speech-Language Pathologist) — speech, swallowing, communication. Critical after strokes.

    The rest of the team

    PharmD — the pharmacist, a Doctor of Pharmacy. More than dispensing pills — they catch dangerous drug interactions that busy doctors miss.

    RT (Respiratory Therapist) — runs the ventilators, manages breathing. The heroes of the ICU nobody names.

    RD (Registered Dietitian) — food as medicine: tube feeds, diabetes diets, kidney diets.

    LCSW (Licensed Clinical Social Worker) — discharge planning, counseling, insurance fights. The person who figures out where you go after the hospital.

    MA (Medical Assistant) — the clinic frontline: rooms you, takes vitals, draws blood.

    EMT / Paramedic — the ambulance crew. Paramedics do more: IVs, medications, airways.

    Techs — rad techs take your X-rays, lab techs run your blood work, surgical techs are the surgeon’s extra hands.

    The building doesn’t heal you. The people do. And now you know who’s who when they walk in.

  • The cast of US healthcare, in plain English

    This is post 1 of 7 in the series “US Healthcare in Plain English”

    1. The cast of US healthcare, in plain English
    2. The people of US healthcare, in plain English
    3. The money trail: how a dollar flows through US healthcare
    4. The insurance card, decoded
    5. The life of a medical bill
    6. Why American healthcare costs so much
    7. The patient journey, end to end

    When I started building in healthcare, I couldn’t follow a single conversation. Every sentence had three acronyms I didn’t know. ACO, IDN, LTAC, FQHC — the industry speaks in alphabet soup, and nobody hands you a menu.

    So I learned the language the hard way: by mapping the problem statements. Who pays, who gives care, where it happens, who makes and moves the stuff, and the invisible plumbing underneath. Here’s the whole cast, in plain English, organized by what each one actually does. For each: the one-line incentive — because if you understand what someone gets paid for, you understand what they’ll do — and a real name, so the abstraction has a face.

    The money — who pays

    Health plan / payer — the insurance company. Collects premiums, pays claims. Think UnitedHealthcare, Elevance (the new Anthem), Aetna, Cigna, and the Blues. Incentive: pay out less than they take in.

    MCO (managed care organization) — the generic term for a managed-care plan. Most Medicaid isn’t run by states directly anymore; it’s run by MCOs like Centene and Molina. Most Medicare Advantage plans are MCOs too.

    Employer — most working-age Americans get insurance through work. Many big employers are “self-funded”: they pay the actual medical bills themselves and just hire someone to do the paperwork.

    TPA (third-party administrator) — does that paperwork for self-funded employers. UMR and Meritain are the big ones. Fee for service, zero risk.

    PBM (pharmacy benefit manager) — the drug middleman. Decides which drugs your plan covers, negotiates with drugmakers. Three run most of it: CVS Caremark, Express Scripts, Optum Rx. Incentive: the spread between the negotiated price and the charged price.

    MA (Medicare Advantage) — private plans that replace traditional Medicare. UnitedHealthcare and Humana are the giants. The plan gets a fixed monthly check per member and keeps whatever it doesn’t spend. Full risk, full reward.

    Medicare — federal insurance for 65+. Medicaid — federal-plus-state for low-income. CMS — the agency running both. CMS sets the prices, and the whole industry follows its lead.

    The providers — who gives care

    PCP (primary-care physician) — your main doctor, the one who owns your overall picture. The quarterback.

    Specialist — the expert your PCP sends you to: cardiologist, dermatologist, orthopedist. Deep in one area, usually by referral.

    Health system — owns hospitals, employs doctors. Baylor Scott & White, HCA, Ascension, CommonSpirit.

    IDN (integrated delivery network) — a health system that also owns the insurance plan. Kaiser Permanente is the classic: they collect your premium and employ your doctor. The fortress.

    ACO (accountable care organization) — a group of doctors and hospitals that tells Medicare: “Give us 10,000 patients. If we keep them healthy and under budget, we share the savings.” Paid for the total, not the visit.

    CIN (clinically integrated network) — independent doctors and hospitals banding together to coordinate care and negotiate as one bloc, without merging. Most big systems run one.

    IPA (independent practice association) — the older version of the CIN: independent docs contracting jointly, sometimes taking on risk themselves.

    MSO (management services organization) — does the unglamorous admin for doctor groups: billing, HR, IT, compliance. By law it can’t make clinical decisions or touch clinical money.

    FQHC (federally qualified health center) — the community clinics. Serve everyone regardless of ability to pay, get federal funding. Your neighborhood health center with a federal designation.

    Direct primary care — membership medicine. You pay the doctor directly, monthly, no insurance involved. The opt-out.

    The places — where care happens

    ED (emergency department) — the hospital ER. Urgent care — the middle ground: CityMD, MedExpress, Concentra.

    Retail clinic — the MinuteClinics inside CVS and Walgreens. Strep tests and flu shots, no appointment.

    ASC (ambulatory surgery center) — outpatient operations. Same surgery as a hospital, much cheaper building. SCA and AmSurg run thousands of them.

    SNF (skilled nursing facility) — rehab and nursing after a hospital stay. Genesis and Life Care Centers are the big chains.

    LTAC (long-term acute care hospital) — weeks-long stays for the very sick: ventilator weaning, complex wounds. Kindred built the category.

    IRF (inpatient rehab facility) — intense rehab after stroke or trauma; patients must tolerate three hours of therapy a day. Encompass Health is the giant.

    Home health — nurses and therapists who visit you at home. LHC Group and Amedisys are the national names.

    Hospice — end-of-life comfort care, usually at home. VITAS is the largest. Different philosophy: comfort, not cure.

    Dialysis center — kidney failure is its own industry. DaVita and Fresenius run most of it.

    Lab — Quest Diagnostics and Labcorp. The duopoly behind nearly every blood test.

    Imaging center — outpatient radiology. RadNet is the biggest. An MRI without the hospital markup.

    CAH (critical access hospital) — tiny rural hospitals (25 beds or fewer) that Medicare keeps alive with cost-based payments, because otherwise rural America has no hospital at all.

    DME (durable medical equipment) — wheelchairs, oxygen, CPAP machines. AdaptHealth and Lincare are the national suppliers. Nobody thinks about them until they need one.

    The supply chain — who makes and moves the stuff

    Pharma — the drug manufacturers: Pfizer, Merck, Eli Lilly, Johnson & Johnson. They invent the drugs; everyone else argues over the price.

    Distributor — the wholesalers between pharma and your pharmacy: McKesson, Cencora, Cardinal Health. Three companies move most of America’s drugs.

    GPO (group purchasing organization) — hospitals’ buying cooperatives. Vizient and Premier negotiate bulk prices for thousands of hospitals at once.

    Pharmacy — the last mile of the drug chain: CVS, Walgreens, Walmart, plus mail-order and specialty pharmacies for the expensive stuff.

    The plumbing — the invisible infrastructure

    Clearinghouse — routes insurance claims between providers and payers. Availity and Change Healthcare do most of it. Invisible until it breaks — and when it breaks, nobody gets paid.

    EHR vendor — the medical record software. Epic runs the big systems; Oracle Health (the old Cerner) runs many of the rest. The rails the industry runs on.

    RCM (revenue cycle management) — companies that do billing for providers who can’t afford their own department. R1 and Ensemble Health Partners are the big names.

    The government, as provider and referee

    VA (Veterans Affairs) — the country’s biggest IDN that nobody calls an IDN: owns the hospitals, employs the doctors, covers the members. If you served, this is your system.

    FDA — decides which drugs and devices are allowed to exist. The gatekeeper of the entire supply side.

    The one idea underneath it all

    Fee-for-service (pay per thing done — rewards volume) versus value-based care (pay for the outcome — rewards health). ACOs, MA plans, CINs — they’re all attempts to drag the system from the first to the second.

    And here’s why I’m learning all this: the customers of FabrixMed live in the provider group — ACOs, FQHCs, independents, EDs. The fortress outfits (IDNs, big MA plans) already have the incentive and the plumbing to close loops. Everyone else is the frontier. That’s the whole business in one sentence.