Healthcare is Hard: A Podcast for Insiders

Dr. Mark McClellan has served as a Member of the President’s Council of Economic Advisors, Administrator of the Centers for Medicare & Medicaid Services (CMS), and Commissioner of the U.S. Food and Drug Administration (FDA). But his experiences before, and accomplishments following these leadership roles at the highest levels of government health policy are equally important to his perspective on the healthcare ecosystem – especially during a time of rapid policy change.Dr. McClellan always intended on pursuing a medical degree and entered a joint Harvard-MIT program that took him in a slightly different direction. He ended up studying economics and the rising cost of healthcare at MIT. He ultimately earned a medical degree from the Harvard-MIT Division of Health Sciences and Technology, a Ph.D. in economics from MIT, and a master’s in public administration from Harvard’s Kennedy School.Dr. McClellan began his career at the Treasury Department in the Clinton Administration, and returned to public service under the George W. Bush Administration where he led the FDA and CMS. Today, Dr. McClellan is the Robert J. Margolis, M.D., Professor of Business, Medicine and Policy at Duke University and the founding Director of the Duke-Margolis Institute for Health Policy. His work centers on improving health care through policy and research, with a focus on payment reforms, quality, value, and biomedical innovation.With his expertise in medicine, economics and public policy, Dr. McClellan talked to Keith Figlioli in this episode of Healthcare is Hard to share his perspective on adapting to rapid change in the current healthcare landscape. Topics they discussed include:Misalignment of innovation and outcomes. While advancements in digital health are coming to market faster than ever before, Dr. McClellan says there’s still a lack of technology truly centered on keeping patients healthy. He says traditional payment methods make it hard to support this type of innovation. For example, advancements in AI are helping physicians gather information for prior authorization requests, and ambient scribing saves time with note taking and administration. But these technologies essentially help providers see more fee-for-service patients or bill for more profitable services. He argues that more outcome-oriented payments are needed to advance technology-embedded care models. The evolution of value-based care. After Congress passed the Medicare Modernization Act in 2003 to establish Medicare Advantage, Dr. McClellan became administrator of CMS at the President’s request to lead its implementation. With unique insight from leading some of the earliest VBC programs, he shared his thoughts on the speed of adoption and why it hasn’t happened faster. He discussed how early MA models needed to be based on existing fee-for-service infrastructure, his surprise that not much has changed, and his optimism that it’s finally starting to.Mobilizing private capital for public health. Private investment will be essential to support the significant changes required to improve healthcare – especially with uncertainties around future levels of government funding. Dr. McClellan explained how the Duke-Margolis Capital Impact Council (CIC) was launched to guide and improve the role of private investment in healthcare. He described how members of the council are developing and sharing practices for investors and their portfolio companies to track health value return on investment alongside financial ROI.To hear Dr. McClellan and Keith discuss these topics and more, listen to this episode of Healthcare is Hard: A Podcast for Insiders.

Dr. Josh Mandel says his first love was software. But on a whim, while studying computer science and software engineering at MIT, he took a course that opened his eyes to the world of medicine and genetics. It changed the trajectory of his career away from software – but only temporarily. He entered medical school after earning a bachelor’s degree in computer science and began rotating through Boston-area hospitals at the same time Meaningful Use accelerated adoption of electronic health records. With a background in computer science and training as a physician, Josh understood the promise of EHRs, how medical professionals would actually use them, and how to make them better. Based on his unique combination of expertise, Josh took it upon himself to begin making improvements to the systems at the hospital where he worked.Nearly two decades later, Josh is now Chief Architect for Health at Microsoft Research. In this role, he focuses on developing an ecosystem for health apps with access to clinical and research data, leading standards development for data access, authorization, and app integration.For the third and last episode in this Healthcare is Hard series, Keith Figlioli spoke to Josh about data interoperability and emerging technologies. This conversation follows previous episodes with Epic’s head of R&D, Seth Hain in Part 1, and the Interoperability Practice Lead at HTD Health, Brendan Keeler – also known as the “Health API Guy” – in Part 2.Some of the topics Keith and Josh discussed include:The standards landscape. At Keith’s request to explain the evolution of health IT standards as if he were talking to a seven-year-old, Josh breaks it down in simple terms. He outlines how structured data related to things like allergies, medications, and vital signs are well standardized today, while newer data types like genomics and imaging remain fragmented. He also explains the role of HL7, FHIR, and the Argonaut Project in shaping interoperability.How AI flips the script on standards. Josh says generative AI changed the way he thinks about engaging with the standards community. After getting an early preview of GPT-4 a few years ago, he realized that it would dramatically reduce the value of detailed data structure standards over time. He says that as AI becomes better at interpreting unstructured data, the focus will shift from formatting to governance – who can access what, and under what conditions. He described the concept of “language first interoperability” as one initiative he’s working on where automated agents query each other in the equivalent of an email or chat thread. Instead of exposing extensive details upfront, agents that can access unstructured data and understand things like medical necessity and other guardrails can send messages to each other until they make a conclusion about a specific task. This technology will increase the value of standards for data access and privacy, while reducing the focus on interoperability.Advice for startups. In a fast-moving landscape, Josh urges startups to “build and explore.” He emphasizes the importance of staying close to customers, iterating quickly, and leveraging today’s best models while keeping an eye on what’s coming next. His advice: don’t get bogged down in yesterday’s limitations—focus on unlocking value now and adapting as the technology evolves.To hear Dr. Mandel and Keith discuss these topics and more, listen to this episode of Healthcare is Hard: A Podcast for Insiders.

Brendan Keeler’s path into healthcare interoperability has been anything but straightforward. After early stints implementing Epic in the U.S. and Europe, he helped hundreds of startups connect to provider and payer systems at Redox, Zus Health and Flexpa before taking the reins of the Interoperability Practice at HTD Health. Along the way, his Health API Guy blog turned dense policy updates into plain-language guides, earning a following among developers, executives and regulators. In this episode, Keith Figlioli sits down with Keeler to examine the “post-Meaningful-Use” moment. They discuss how national networks like Carequality and CommonWell solved much of the provider-to-provider exchange problem, only to expose new gaps for payers, life-science firms and patients. Keeler says the real action right now is in three places where the biggest, most dramatic changes are about to happen: Antitrust pressure on dominant EHRs. Epic’s push into ERP, payer platforms and life-sciences services could trigger “leveraging” claims that force unbundling, similar to cases already moving through federal court.  Information-blocking enforcement. Recent lawsuits show courts siding with smaller vendors when incumbents restrict data access, a trend Keeler believes could unwind long-standing moats around systems of record. A CMS-led shift from policy to execution. With ONC budgets flat, Keeler sees CMS using its purchasing power to unblock Medicare claims data at the point of care, expand Blue Button APIs, and accelerate work on a national provider directory, digital ID and trusted exchange frameworks. Keeler’s optimism is pragmatic. AI agents may someday chip away at entrenched EHR “data gravity,” but real progress, he says, will come from steady, bipartisan layering of HIPAA, Cures Act and TEFCA foundations. He also pushes back on venture capital’s “system-of-action” thesis. Enterprise EHRs remain sticky because switching costs—massive data migration and workflow retraining—are measured in decades, not funding cycles. AI could reduce these problems, but only slowly and only if underpinned by trusted exchange standards. Zooming out, Keeler describes a policy arc that starts with provider-to-provider exchange, widens to payer and patient access, and ultimately points toward a nationwide digital ID that could streamline consent and credentialing. For innovators, his north star is clear: build for identity-verified, standards-based exchange; assume open APIs will become table stakes; and judge success by the friction you subtract from everyday care—not by how flashy the demo is. To hear Brendan Keeler and Keith unpack these issues, listen to this episode of Healthcare is Hard: A Podcast for Insiders. Please note that this episode was recorded earlier this summer, before the CMS meeting, and that some developments have occurred since then.

Seth Hain, Senior VP of Research and Development at Epic with over two decades in the industry, discusses the transformative role of generative AI in healthcare. He describes how new tools are creating an ‘agentic’ era in which software anticipates clinician needs. Hain shares insights from Epic’s ambitious Cosmos project, a dataset aimed at integrating real-world evidence into clinical practice. He also envisions a connected health grid that minimizes delays and enhances collaboration, ultimately improving patient outcomes.

Brian D. Pieninck didn’t take a conventional path to healthcare leadership. He started his career as an 18-year-old IT contractor and spent two decades working across the industry before becoming President and CEO of CareFirst Blue Cross Blue Shield. He now also serves as Chair of the Blue Cross Blue Shield Association, bringing both local and national perspective to the role. In this episode, Keith Figlioli speaks with Pieninck about what it means to lead a not-for-profit regional payer at a time of seismic change. With 3.6 million members and coverage that spans commercial, Medicare, and Medicaid, CareFirst has become a vital part of healthcare access and infrastructure across the Mid-Atlantic. Pieninck reflects how demographic shifts, rising costs, and policy uncertainty are challenging how healthcare organizations evolve, while staying focused on long-term outcomes.  Pieninck and Keith discuss: Advancing health equity as part of the community. Pieninck sees CareFirst not just as a payer, but as part of the region’s civic infrastructure, creating economic opportunities, delivering care through primary and urgent care locations, and supporting long-term health equity initiatives across Maryland, DC, and Northern Virginia. Medicaid coverage and its downstream impact. With nearly half of children in Maryland and DC relying on Medicaid, Pieninck warns that cuts or disruptions don’t reduce the need for care; they push it into higher-cost, less coordinated settings like emergency departments. The balloon effect in healthcare financing. As costs are squeezed in one area, they inflate in another. Pieninck challenges the idea that market forces can realign care efficiently. He discusses how efforts to contain spending in one area often lead to inefficiencies elsewhere, and the system ends up paying more later because early, lower-cost interventions are underfunded or inaccessible.  Innovation that simplifies the system. Through CareFirst’s innovation arm, Healthworx, Pieninick highlights the need to design a system that works for people by reducing complexity and embedding support directly into the healthcare experience. AI and infrastructure: opportunity meets readiness. With nearly three decades of experience on the technology side of healthcare, Pieninck is bullish on AI’s potential—especially now that it's available at a price point that can scale. Real progress, he notes, will depend on thoughtful governance, better interoperability, and models built around human needs. This episode offers a look at how one regional plan is thinking through the tensions between access, affordability and innovation, and what that means for the broader system.  To hear Brian D. Pieninck and Keith discuss these challenges in depth, listen to this episode of Healthcare is Hard: A Podcast for Insiders. 

Kody Kinsley has been called many things—operator, innovator, Medicaid “nerd”—but above all, he’s a fierce advocate for the health and well-being of the populations Medicaid serves. Now a senior advisor at the Milken Institute and recently North Carolina’s Secretary of Health and Human Services, Kinsley joins Keith Figlioli for a wide-ranging conversation about how Medicaid works, why it matters, and where innovation is reshaping its future. A native of North Carolina, Kinsley brings personal experience and professional depth to his perspective. Growing up uninsured, he watched his mother navigate pediatric clinics, sliding-scale providers, and supply closets offering free samples to keep her kids healthy. That formative exposure ultimately propelled him into a career spanning healthcare operations, behavioral health, public policy, and government leadership. As North Carolina’s health secretary, Kinsley led one of the country’s largest and most complex human services agencies, overseeing everything from Medicaid operations and public health to psychiatric hospitals and child welfare. He played a central role in advancing Medicaid expansion in the state—an achievement shaped by bipartisan negotiation, careful balancing of federal and state resources, and a deep understanding of the healthcare landscape. In this episode, Kinsley and Keith cover: The structural realities behind state Medicaid programs. Kinsley describes how mega-agencies like North Carolina’s bring together financing, public health, regulation, and direct care delivery—touching millions of lives daily, often invisibly. Federal-state dynamics and looming policy shifts. From federal match rates to provider taxes and budget triggers, Kinsley explains the intricacies of how money moves between federal and state governments—and what’s at stake when Congress debates Medicaid cuts or structural reforms. The human cost behind budget debates. Behind every line item is a person: whether it’s dental coverage, hospice services, or in-home care, Kinsley argues that policymakers must weigh the downstream impacts of funding decisions on real lives and long-term system costs. Bright spots and innovation. Kinsley highlights North Carolina’s “Healthy Opportunities” pilot—one of the first initiatives nationally to use Medicaid dollars for non-medical needs like food, housing, and transportation. Early results show promise, including improved outcomes and significant cost savings, suggesting a roadmap for other states. Looking forward. While political winds may shift and financial pressures mount, Kinsley remains optimistic. He points to growing public support for Medicaid and hopes the nation can move beyond divisive debates over whether healthcare is a right or privilege—focusing instead on smarter, more sustainable ways to deliver care. To hear Kody Kinsley and Keith Figlioli unpack these topics and more, listen to this episode of Healthcare is Hard: A Podcast for Insiders. 

Dr. Ali Khan has spent his career at the intersection of medicine, public policy, and value-based care. He’s also been at the forefront of some of the country's most innovative care delivery models—from Iora Health and CareMore to Oak Street Health and now Aetna, where he serves as Chief Medical Officer of Medicare at Aetna, a CVS Health company. In this episode, Keith Figlioli sits down with Dr. Khan for a conversation about Medicare’s future—and what it will take to make the promise of better, more affordable healthcare a reality. A general internist by training, Dr. Khan’s path into healthcare began with a deep curiosity about the broader systems shaping people’s health. That curiosity took him from Harvard Kennedy School to the exam room to health plans and startups focused on reimagining the primary care experience for complex, underserved populations. Throughout his career, he’s gravitated toward organizations trying to solve public-sector problems with private-sector solutions—building care models that prioritize trust, access, and long-term outcomes. Now at the helm of a Medicare Advantage program serving 4.2 million members, Dr. Khan brings a unique vantage point. In this conversation, he shares hard-earned lessons on care model design, what payers and providers need from each other, and why Medicare is at an inflection point. He makes a compelling case for a renewed focus on the fundamentals—not just risk adjustment or benefit design, but operational follow-through, last-mile care coordination, and culturally grounded team-based models that scale. Dr. Khan and Keith discuss: Building care models that hold up under pressure. From Iora to Oak Street, Dr. Khan has seen firsthand that delivering better outcomes at scale requires more than mission—it takes structural rigor. He unpacks four key dimensions—cultural, clinical, operational, and technological—and explains why lasting impact depends on aligning all of them. Whether it's equipping care teams to deliver in complex communities or building systems that can flex and scale, success hinges on getting the foundation right. Why affordability isn’t enough—and where Medicare Advantage must go next. With over half of Medicare beneficiaries now enrolled in MA plans, Dr. Khan argues it’s time to move beyond the value prop of supplemental benefits and zero-dollar premiums. The next chapter is about proving clinical excellence at scale. That means prioritizing follow-through over features—removing last-mile barriers, improving care coordination, and designing experiences people actually trust.  From transactional to transformative: the evolving role of health plans. Plans have long relied on contractual structures to drive change, but Dr. Khan believes that era is fading. To deliver on the promise of value-based care, plans must shift from passive administrators to proactive partners—investing in infrastructure, surfacing actionable insights, and enabling providers to succeed across Medicare, Medicaid, and commercial populations alike. Where AI meets care delivery. Dr. Khan reflects on the potential of AI to reduce clinical variation, improve medication management, and drive better follow-up for patients—especially those with chronic conditions. But he cautions that technology alone won’t move the needle. To truly unlock AI’s value in Medicare, plans and providers must embed it within human-centered systems, coordinate care in real time, and ensure new tools support—not replace—the relationships that matter most. As Dr. Khan notes, we’re entering a “put up or shut up” era for Medicare Advantage, where scrutiny is high and proof points matter. Yet within that pressure lies opportunity—particularly for those willing to do the unglamorous work of identifying barriers, building connective tissue, and supporting clinical teams in the trenches.

The first two episodes in this Healthcare is Hard podcast series on “Opportunities in Oncology” explored the relationship between academic medical centers and community care, with guests Dr. Stephen Schleicher from Tennessee Oncology, and Dr. Harlan Levine from City of Hope. For the third and final episode in the series, Dr. Daphne Haas-Kogan joined Keith Figlioli for a conversation that dives more deeply into patient care, innovations in care delivery and the opportunities for entrepreneurs.Dr. Haas-Kogan is Chair of the Department of Radiation Oncology at Mass General Hospital, Brigham and Women’s Hospital, and Boston Children’s Hospital. She is also the Willem and Corrie Hees Family Professor of Radiation Oncology at Harvard Medical School.Dr. Haas-Kogan received her undergraduate degree in biochemistry and molecular biology from Harvard University and her medical degree at UCSF. She completed her residency in radiation oncology at UCSF in 1997 and became vice-chair for research at UCSF in 2003, and educational program director in 2008. Dr. Haas-Kogan’s laboratory research focuses on molecular underpinnings of brain tumors and pediatric cancers. She leads large multi-institutional initiatives funded by NIH/NCI, philanthropic organizations, and industry collaborators.For this episode of Healthcare is Hard, some of the topics Dr. Haas-Kogan discussed with Keith include:The collaborative approach to care. Dr. Haas-Kogan talked about how most people with cancer struggle with many other medical issues – some predating cancer diagnosis, some precipitated by the treatment itself – and how several care teams are required to treat the patient wholistically. She also discussed how important it is for academic medical centers and community hospitals to work together, the responsibilities each holds to the patient, and the goal of making sure patients receive the same exact care regardless of location.The precision of radiation oncology. There are generally three pillars of cancer treatment. The first is surgery to remove tumors, the second is medication to kill cancer cells with drugs, and the third is radiation therapy to destroy cancer cells. Dr. Haas-Kogan described how radiation oncology is, in many ways, a combination of surgical oncology and medical oncology. It requires the precision of surgery – especially when treating a tumor close to critical structures like the brain stem or spinal cord – but can also be applied in a single day or over the course of weeks, similar to medication. She discussed how this allows for unique collaboration between academic researchers and community physicians, along with opportunities for creative workforce solutions.AI in oncology. The impact artificial intelligence has already had on oncology would have been unimaginable five or 10 years ago, and Dr. Haas-Kogan says the opportunities for entrepreneurs in the space are huge. As an example of the impact AI has already made, she talked about how radiation oncologists traditionally spend hours defining exactly what they want treated and the dose of radiation required. But now, AI is doing most of that, saving physicians precious time. She talked about how medicine is an art and how treatment like this is very nuanced, so she very often makes changes after reviewing AI-generated recommendations. But she says advancements are coming quickly.To hear Dr. Haas-Kogan and Keith discuss these topics and more, listen to this episode of Healthcare is Hard: A Podcast for Insiders.

Dr. Harlan Levine began his career practicing internal medicine but soon moved into business leadership roles at national healthcare organizations to help improve the dysfunction with payer-provider relationships that he experienced firsthand as a physician.At United Health Group, Dr. Levine joined as clinical lead of the team that launched Optum, where he subsequently served as chief medical officer for more than six years. He also led the health management practice at Towers Watson and served as executive vice president of comprehensive health solutions at WellPoint, among other roles.In 2013, Dr. Levine joined City of Hope, one of the country’s largest and most advanced cancer research and treatment organizations. City of Hope’s uniquely integrated model spans cancer care, research and development, academics and training, and a broad philanthropy program that powers its work. City of Hope’s growing national system includes its Los Angeles campus, a network of clinical care locations across Southern California, a new cancer center in Orange County, California, and cancer treatment centers and outpatient facilities in the Atlanta, Chicago and Phoenix areas.In addition to currently serving as president of health innovation and policy at City of Hope, Dr. Levine is also chair of the board of AccessHope. A spinout from City of Hope, AccessHope partners with the nation’s most prestigious cancer research centers to help make leading-edge cancer care available to all, regardless of geographical location.Dr. Levine joined Keith Figlioli for the second episode of a Healthcare is Hard series exploring opportunities in oncology. Some of the topics they discussed include:Community practice vs. academic medical centers. Delivering personalized care and giving patients access to cutting-edge treatment is equally important, yet historically difficult to balance. In the first episode of this series, Dr. Stephen Schleicher from Tennessee Oncology shared how one of the nation’s most successful community oncology practices is tackling the challenge. In this episode, Dr. Levine discussed City of Hope’s model of putting academic research at the center and connecting it with community practices. He described how City of Hope is changing the direction of cancer care – not just delivering it – by giving patients faster access to emerging science.Defining value in oncology. Dr. Levine calls himself an outlier when it comes to value-based care in oncology because he thinks the industry missed a critical first step – defining what the term means. In most circumstances, discussions around value are centered around reducing cost. But Dr. Levine points out that a cancer patient defines value very differently. They define it as survival. They think about whether or not they returned to normal functionality in normal life, and what their experience was through the entire treatment process. He says the industry needs to recognize and customize models for these unique aspects of cancer care before the term VBC should be used in oncology.AI in oncology. Dr. Levine shared his outlook for the many ways artificial intelligence will change oncology – from drug discovery to care delivery. He believes AI will completely disrupt the approach to cancer care and that the revolution will happen quickly – not in seven to 10 years, but in three to five. He talked about the ways he sees AI changing how doctors deliver care, and why he’s even more optimistic about its ability to accelerate research.To hear Dr. Levine and Keith discuss these topics and more, listen to this episode of Healthcare is Hard: A Podcast for Insiders.

Dr. Stephen Schleicher, a medical oncologist with an MBA from Harvard, delves into the complexities of oncology, exploring the intersection of clinical care, business, and policy. He highlights the urgent need for healthcare professionals to understand the business dynamics that influence cancer treatment. The conversation reveals insights into value-based care, the evolving landscape of cancer treatment, and the challenges in securing equitable access to innovative therapies. Dr. Schleicher emphasizes the importance of collaboration to improve patient outcomes in a changing healthcare environment.