NerdMDs StackBytes #5

🎧 StackByte Episode Summary (Ep #5 – “Health Delivery 2.0”)

Drs. Adam Carewe and Dale Gold distill Carewe’s recent Substack essay on rebuilding U.S. health-care economics from “sick-care” to true health delivery. Citing Medicare fee-schedule cuts, exploding costs, and tech tailwinds, they argue that incremental margin hacks are dead; only a wholesale redesign of the payment-and-care stack can keep providers solvent and patients healthy. Carewe lays out six structural “moves” — from killing fee-for-service to making data liquid and shifting hospital-level care into the living-room — and closes with three 90-day action items any operator can start today. (Read the full essay on the NerdMDs Substack).

🔹 00:00 – Welcome & Why This Matters

The hosts frame the chat as a “10-minute power session” translating Carewe’s Substack into audio, warning that the current system is on a financial “burning platform.”

🔹 01:22 – From Sick-Care to Health Delivery

Carewe stresses that keeping people well is now an urgent necessity for survival, not a nice-to-have. A fresh 2.9 % CMS fee-schedule cut against CPI + 5 % cost inflation shows why tweaks won’t cut it.

🔹 02:48 – The Six Moves Overview

He introduces six radical moves and warns: “Your margin … won’t save you. Your model will.”

1️⃣ Kill Fee-for-Service (02:48)

Volume is “officially on hospice.” Providers must swap RVUs for population-health upside payments.

2️⃣ Pay for Risk, Not Visits (04:03)

Capitation already touches 14 % of U.S. spend — double four years ago — and mastering RAF coding plus prevention is now table stakes.

3️⃣ Make Data Liquid (05:33)

The January 2025 TEFCA rule imposes $1 M fines per blocked record, forcing open FHIR APIs and edge-analytics at the bedside.

4️⃣ Regulated Code Speed (07:14)

New FDA “living-algorithm” guidance lets adaptive AI into care if every weight update is version-controlled and explainable—“transparency equals clearance; opacity equals 483-letter hell.”

5️⃣ Shift Care Home-First (08:41)

Remote sensors + 24/7 command centers turn the couch into the new ward, with hospital-at-home DRGs capturing full reimbursement.

6️⃣ Retail Keeps Us Honest (10:10)

Amazon-style “one-click, same-day, transparent-price” expectations mean health systems must match retail convenience or be replaced.

🔹 11:19 – Three Immediate Plays

Plot your risk runway (how many PMPM lives can you manage in 12 months).

Open the pipes: map every data silo and unblock within 90 days.

Restage site-of-care: move one DRG home this quarter, three next.

🔹 12:24 – Closing Reflection

The episode ends urging listeners to ask what “studs are showing” in their own organizations that signal it’s time to smash, sweep, and rebuild toward a system that actually pays for health.

Notable Quote: “Transparency equals clearance; opacity equals 483-letter hell.”

Get full access to Rewskidotcom by Adam Carewe MD at rewskidotcom.substack.com/subscribe