Healthcare is Hard: A Podcast for Insiders

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Healthcare is Hard: A Podcast for Insiders views healthcare transformation through the lens of prominent leaders across the industry. Through intimate one-on-one discussions with executives, policy advisors, and other “insiders,” each episode dives deep into the pressing challenges that come with changing how we care for people. Hear the unique perspectives of these industry leaders to get a better understanding of what is happening today, the challenges across the healthcare ecosystem, and how innovation is really shaping the future of healthcare delivery.

  1. DC’s Ambitious Plans for Modernizing Health Tech: U.S. DOGE Service Administrator & CMS Strategic Advisor, Amy Gleason

    FEB 19

    DC’s Ambitious Plans for Modernizing Health Tech: U.S. DOGE Service Administrator & CMS Strategic Advisor, Amy Gleason

    The daughter of a hospital administrator, Amy Gleason never considered a career in the public sector – she went straight into healthcare. As an emergency room nurse, she started to see the dangers that unfold when healthcare providers don’t have access to the information they need to treat patients. Those experiences drove her towards a tech career in the emerging electronic health records space before a very personal experience altered her professional path yet again. Amy’s active and healthy 10-year old daughter began suffering unusual healthcare events, from rashes and headaches to broken bones. Eventually, she couldn’t walk. It took more than a year from the start of these symptoms for doctors to diagnose her with a rare autoimmune disease. Even then, it was an accidental diagnosis from a dermatologist conducting a skin biopsy. Amy attributes the delayed diagnosis to siloed data, not unsimilar to the challenges she experienced as a nurse and was working to solve in the EHR space. It motivated her to co-found a company focused on helping patients with chronic diseases access their data to share it with the providers and family members helping to navigate complex care journeys. In 2015, Amy’s work earned her an award from the White House for Champions of Change in Precision Medicine – her first foray into the public sector. By 2018, she entered civic service full time with a role at the United States Digital Service, which she describes as “DOGE 1.0.” In this episode of Healthcare is Hard, Amy talked to Keith Figlioli about the work she’s doing now as Strategic Advisor to CMS and Administrator of the U.S. DOGE Service, where her main mission is modernizing technology across government agencies for the millions of people who rely on federal services every day. This ranges from modernizing FAFSA and the student loan process, to improving the Visa system ahead of the World Cup, and work on various critical healthcare systems.  Some of the topics Amy and Keith discussed in this episode, include: Bold plans for a Digital Health Ecosystem. Launched in July 2025, CMS’ Health Tech Ecosystem is a public-private partnership designed as a voluntary, fast-moving alternative to slow rulemaking. Rather than years of regulation, the program uses pledges, working groups, and short development cycles to put interoperability building blocks and real patient-facing use cases in place. The goal is to get usable capabilities into the market in months – not years – let the community iterate, and have baseline use cases live by March 31, 2026 with more advanced capabilities rolling out by July.Carrots and sticks before regulation. Recognizing the limitations of regulation, Amy talked about a new philosophy for incentivizing the market to change behaviors on its own first. “Carrots” include the rural health transformation fund and the recently introduced ACCESS model, a 10-year pilot that, for the first time, lets tech-enabled services bill Medicare directly. “Sticks” include stricter enforcement of information-blocking rules.Replacing the 1970s-era Medicare claims system. Amy discussed plans to replace Medicare’s decades-old COBOL-based adjudication platform. While it’s a stable platform, it can’t support real-time processing, AI, or rapid change. To replace it, CMS is looking to commercial, off-the-shelf solutions that operate at scale so claims processing can be modernized, made real-time, and integrated with new interoperability rails. It’s a concrete example of bringing modern engineering and product thinking to government technology.To hear Amy and Keith discuss these topics and more, listen to this episode of Healthcare is Hard: A Podcast for Insiders.

    39 min
  2. Glimmers of Nonpartisan Progress: Decoding ACCESS, TEMPO and the Latest Government Healthcare Initiatives

    JAN 15

    Glimmers of Nonpartisan Progress: Decoding ACCESS, TEMPO and the Latest Government Healthcare Initiatives

    After three decades working to deliver easy, fast and cost-effective patient experiences through technology, Ryan Howells is more optimistic about the future than he’s ever been before. At a time when healthcare has been at the center of polarizing and partisan politics, Ryan is focused on an area foundational to digital health that he says draws consensus across party lines: data exchange and interoperability. Freely moving data can unlock innovation in technology, payment models, and regulation to make healthcare work better for everyone, and Ryan is extremely encouraged by the openness to ideas and volume of activity he’s seeing from the second Trump Administration in these areas. As Principal at Leavitt Partners since 2015, Ryan collaborates with the private sector, the White House, Congress, HHS, and the VHA to improve health care nationwide. For the past ten years, he has also led the CARIN Alliance, a bi-partisan, multi-sector alliance uniting industry leaders to advance the adoption of consumer-directed exchange across the U.S. In January 2023, Ryan joined Keith Figlioli on the podcast to discuss the myriad of new possibilities emerging in healthcare as a result of better access to data. In this episode, he recounts the progress and obstacles since that conversation, but more importantly, helps unpack the flurry of new activity. Topics Ryan and Keith covered include: ACCESS & TEMPO. These are the latest examples of two new government programs that Ryan believes will remove barriers to innovation. ACCESS is a CMS initiative that now makes it possible for technology companies to bill Medicare directly for digital health services – and get paid only when patients achieve specific, measurable clinical outcomes. Ryan explains how ACCESS is a breakthrough for transparency and has the potential to change contracting for digital health vendors as health system may now ask to share risk. TEMPO is a program from the FDA that complements ACCESS by allowing participating companies to bypass traditional device clearance processes through “enforcement discretion,” provided they share real time data with the FDA. Ryan explains how this oversight lowers cost and complexity for startups and accelerates the path to market for new digital health solutions.Removing administrative roadblocks. In early 2025, Ryan’s team at Leavitt Partners published a paper titled, “Kill the Clipboard” that offered recommendations to cut administrative costs, lower the burden on consumers and providers, and modernize the health care data exchange ecosystem. Ryan discussed recommendations like the need for stronger enforcement of information blocking rules and suggestions for the government to change its certification program to focus on APIs, versus functionality of EHRs. He explained how these things would allow health systems to control their own data, build cloud-based workflows, and integrate with payers and innovative companies more easily.Linchpins for data liquidity. Ryan believes that achieving true data liquidity in healthcare requires three foundational elements: a cloud-based data store, an API endpoint, and robust digital identity credentials. With these in place, he says organizations can exchange data securely and efficiently, supporting everything from public health to quality measurement and pharmacy exchange. He says these are the linchpins to finally achieve the data liquidity needed for innovation, interoperability, and improved patient outcomes.To hear Ryan and Keith discuss these topics and more, listen to this episode of Healthcare is Hard: A Podcast for

    47 min
  3. 340B Unpacked for the Holidays: Policy, Controversy, and Impact

    12/18/2025

    340B Unpacked for the Holidays: Policy, Controversy, and Impact

    Sitting at the intersection of healthcare policy, hospital finance, and patient access, the 340B drug discount program is a hot button issues in the pharmacy space. The program is critically important to providers that serve high volumes of low income and vulnerable patient populations, but it’s drawing increasing scrutiny. 340B was established in 1992 as part of the Public Health Services Act to help providers stretch scarce resources, expand services, and improve access to care for those most in need. It does this by requiring pharmaceutical manufacturers participating in Medicaid to sell outpatient drugs at significant discounts to safety net hospitals and other covered entities – including federally qualified health centers (FQHCs), HIV clinics, homeless clinics and more. Covered entities are reimbursed for the full cost of the medication and use that margin to offset losses from caring for low‑income, uninsured, and underinsured patients. It’s become a critical component to their operating budgets. The program has grown substantially since its inception, with increasing numbers of hospitals and entities participating. This expansion has led to questions about whether the program is being used as intended or stretched beyond its original purpose. Ted Slafsky – one of the nation’s leading experts on 340B – joined Keith Figlioli for this episode of Healthcare is Hard to unpack this complex and critical program. For 22 years, Ted served as president and CEO of 340B Health, a Washington D.C.-based association of over 1400 hospitals nationwide participating in the 340B program. In 2020, he started 340B Report, the only news outlet in the country focused exclusively on the 340B program. Some of the topics Ted and Keith discussed include: Balancing oversight and operational efficiency. The 340B program faces growing calls for transparency and accountability, with proposals for more detailed reporting on how hospitals and clinics use the savings. While oversight is important to ensure compliance and integrity, Ted warns that excessive administrative requirements could overwhelm providers and divert resources away from patient care. The challenge is finding a balance that promotes trust without creating an operational burden.Dispelling Myths. One common misconception about 340B is that it’s a direct patient discount program. Ted addressed this myth, explaining how the discount is intended for providers to give them more resources to reach and serve more patients. The other myth Ted addressed is how the program is described – mostly by the pharmaceutical industry – as a “markup scheme.” He doesn’t think that’s a fair depiction and explained that revenue from commercially insured patients is essential for offsetting the cost of treating uninsured and underinsured patients, making the program a lifeline for safety-net providers.An uncertain future. The 340B program faces significant uncertainty as policymakers consider major changes. Recent efforts to replace upfront drug discounts with a rebate model could strain the financial stability of small and rural providers, while federal proposals to cut Medicare Part B reimbursement add further pressure. At the same time, state legislatures are enacting a patchwork of laws to protect providers and restore contract pharmacy discounts, creating complexity across the country. Ted advises providers to not simply hope for the best. He urges hospitals and health centers to engage directly with lawmakers and their staff by inviting them to visit facilities where they can see the program’s impact and its role in supporting vulnerable populations.To hear Ted and Keith discuss these topics and more, listen to this episode of Healthcare is Hard: A Podcast for Insiders.

    35 min
  4. The Big Beautiful Maze of Health Policy and Innovation

    11/20/2025

    The Big Beautiful Maze of Health Policy and Innovation

    From being at the center of some of the most significant shifts in U.S. healthcare policy over the past two decades, Liz Fowler can offer valuable perspective in uncertain times. In her most recent government role, Liz served as director of the Center for Medicare and Medicaid Innovation (CMMI), an organization she helped create a decade earlier.  As Chief Health Counsel at the Senate Finance Committee, Liz played a major role in the drafting and passage of the Affordable Care Act (ACA) in 2010, which established CMMI. She then served as special assistant to President Obama on health care and economic policy at the National Economic Council to implement the ACA. She also played a key role drafting the 2003 Medicare Prescription Drug, Improvement and Modernization Act (MMA). Liz says she’s a public servant at heart, but credits her time in the private sector at Johnson & Johnson and WellPoint (now Elevance) for making her a more effective government leader. Today, Liz provides guidance, insight, and strategy for a broad array of health care stakeholders, including payers, health systems and providers, trade associations, technology companies and more as co-founder and managing partner of Health Transformation Strategies. Liz talked to Keith Figlioli for this episode of Healthcare is Hard to share insight and perspective as healthcare organizations navigate changing regulations, including those in the “Big Beautiful Bill.” Topics they discussed include: The ROI of CMMI. Liz explained the difficulties tracking the savings that CMMI generates. She believes the mechanisms for measuring CMMI are too narrowly defined, making it hard to capture the full impact of its work. She advocates for a broader definition of success, emphasizing that innovation is a process—one where failure can provide just as much impact and opportunity for learning.Limited bandwidth for innovation. It’s a challenging time for healthcare organizations that are scrambling to meet deadlines and ensure they’re in compliance with various regulations, including provisions of the “Big Beautiful Bill.” Liz believes this is pulling time and attention away from innovation and slowing progress toward advancing value-based care. Despite the overall constraints Liz sees with the current regulatory environment, she’s optimistic about rural health transformation funding and how that could spark some innovation.The revolution that’s not coming. Throughout the conversation, Liz reiterated that “healthcare is hard.” She cautioned against expecting sweeping, revolutionary change, noting that progress in healthcare is incremental. Drawing on her 25+ years in health policy, Liz encouraged listeners to celebrate small victories and keep pushing forward, as real transformation happens step by step.To hear Liz and Keith discuss these topics and more, listen to this episode of Healthcare is Hard: A Podcast for Insiders.

    32 min
  5. Lessons from Public Sector Leadership: Former CMS Administrator and FDA Commissioner, Dr. Mark McClellan

    10/16/2025

    Lessons from Public Sector Leadership: Former CMS Administrator and FDA Commissioner, Dr. Mark McClellan

    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.

    48 min
  6. Emerging Technologies (Part 3): Microsoft’s Chief Architect for Health on the Saga of Interoperability and AI

    09/18/2025

    Emerging Technologies (Part 3): Microsoft’s Chief Architect for Health on the Saga of Interoperability and AI

    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.

    48 min
  7. Emerging Technologies (Part 2): Past, Present & Future of Healthcare Interoperability with HTD Health's Brendan Keeler

    08/21/2025

    Emerging Technologies (Part 2): Past, Present & Future of Healthcare Interoperability with HTD Health's Brendan Keeler

    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.

    49 min
  8. Emerging Technologies (Part 1): Inside Perspectives from Epic’s Seth Hain

    07/17/2025

    Emerging Technologies (Part 1): Inside Perspectives from Epic’s Seth Hain

    Seth Hain has spent two decades at Epic, watching the electronic health record evolve from digital filing cabinet to care-delivery platform. Now he thinks the entire stack of software is being re-imagined, only this time it isn’t mobile or cloud driving the change, but generative AI.    In a conversation with Keith Figlioli, Hain explains how new tooling, cheaper compute and larger context windows are pushing healthcare toward an “agentic” era, where software can collect context, ask clarifying questions, and tee up next-best actions before the clinician even walks into the room. He argues that the real breakthrough isn’t documentation speed-ups, but the chance to embed a learning health system directly into daily workflows.  Central to that vision is Cosmos—a dataset of 15 billion encounters from more than 250 health systems that is already powering condition-specific growth charts and real-world evidence studies. The next step: piping those insights back to the bedside at scale.    Yet technology alone won’t deliver. Hain and Figlioli dig into:  A real “health grid” is starting to form. Hain envisions a network that connects life-science companies, health-system clinicians and tech builders so discoveries can move from bench to bedside without today’s data hand-offs and delays. Epic’s role is to lower the technical friction, so researchers can spot patterns, then surface the insight inside everyday workflows. The long-term bet: once the pipes are in place, bespoke therapies (even gene treatments) could be developed and delivered in one coordinated loop rather than siloed phases. Agentic AI is rewriting the user interface, not just speeding up notes. Hain argues the shift from cloud/mobile to generative agents is “noticeably different” because large-context models can listen, remember, reason and suggest next steps in real time. That opens the door to smart exam rooms that combine ambient voice, vision and wearables, and to workflows that provide clinicians with a complete picture before they walk in the patient's room. As UI layers splinter, the possibility of deep insights from longitudinal data is becoming reality, and vendors who overlook this shift will quickly fall behind.  AI as a Force Multiplier for a Shrinking Workforce. With demand still rising faster than the workforce can grow, Hain sees AI as a supplement, not a head-count replacement: think follow-up calls, patient triage or ambient documentation that frees staff to practice at the top of their license. But he’s clear that hype won’t bend the curve; the industry has to measure quality gains, time saved and patient outcomes before claiming ROI. Governance must evolve in parallel so speed doesn’t outrun safety or equity and incumbents that ignore this shift do so at their peril. Throughout, Hain balances optimism with realism: the models are improving fast, but value will hinge on measurable outcomes, thoughtful deployment, and collaboration across an industry that often works in silos.   To hear Seth Hain and Keith discuss these topics and more, listen to this episode of Healthcare is Hard: A Podcast for Insiders.

    49 min
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About

Healthcare is Hard: A Podcast for Insiders views healthcare transformation through the lens of prominent leaders across the industry. Through intimate one-on-one discussions with executives, policy advisors, and other “insiders,” each episode dives deep into the pressing challenges that come with changing how we care for people. Hear the unique perspectives of these industry leaders to get a better understanding of what is happening today, the challenges across the healthcare ecosystem, and how innovation is really shaping the future of healthcare delivery.

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