If you work in health tech, you've probably heard Camber’s name in a few sharp circles (fka Juniper), or seen their modular RCM stack in unexpected places. With Tier 1 VCs behind them, here’s what they’re building, and why it matters.

Why I Believe in Camber:

• Build for the clinics that need it most. Fragmentation isn’t a flaw — it’s the foundation. Camber leans into speed, trust, and durability in places others ignore.

• RCM isn’t back-office, it’s game theory. Camber plays offense: forecast deposits, surface risk, and fix problems before they hit the books.

• Most AI moves fast, even when we’re not sure where it’s going.
  Camber starts by cleaning the inputs, so we can see what care is actually delivered, what gets paid, and where value gets lost.

• Growth is easy, saying no is hard. Camber grows by staying clean, modular, and trusted — even when everything’s pulling it to expand faster.

Why RCM?

Revenue cycle (RCM) isn’t glamorous, but it’s the plumbing that makes everything else possible. In the U.S., even basic billing means navigating payer rules, modifier codes, and denial appeals. Small practices struggle to stay afloat, let alone grow.

While health systems have invested millions into EHR integrations and automated workflows, the mom-and-pop clinics that power Medicaid, primary care, and behavioral health are being left behind.

I’ve seen firsthand how broken RCM can drag down even well-resourced health systems. But for these clinics, this isn’t a matter of efficiency. It’s survival.

Independent practices drive access in rural and low-income markets, but they’re buried in admin drag, without the dollars or headcount larger orgs rely on.

Most vendors treat them as unscalable. Camber treats them as the starting point. They need tools that are modular, fast to deploy, and trustworthy out of the box.

They’re building an AI-first platform to automate and optimize revenue cycle for independent outpatient clinics — led by engineers and operators who know the space. Think: prior auth, eligibility checks, billing codes, and claim status — handled automatically.

Camber’s bet: that the next layer of healthcare infrastructure will be won by those who serve the messiest, most trust-sensitive parts of the system.

That’s why I sat down with Co-Founder Nathan Lee. He and the Camber team are building AI infrastructure for the long tail. We talked about provider fragmentation, trust as a wedge, and why the hardest decisions aren’t what to build, but when.

Q1: Many RCM startups are chasing large care delivery orgs. Why bet on small, independent specialty clinics instead?

Because they’re everywhere, and no one’s building for them. Fragmentation isn’t going away. In specialties like pediatric behavioral health (where we started), trust lives locally.

Independent clinics feel the most pain — and move fast to fix it. They’re led by clinician-owners: mission-driven, deeply committed to care, but not always set up to run a business. Maybe they broke off from a larger system. Maybe they’re treating a condition they’ve lived through themselves. Either way, BPOs and legacy systems aren’t serving their needs.

Hospitals are attractive — big dollars, rich data. But they’re slow. With small clinics, you can go from zero to running their whole stack in weeks. We found faster paths to data through mid-market enterprise deals.

And the tooling is different. Enterprise systems run on Epic or Athena. These clinics use specialized EMRs built on clinical need, but the RCM tools bundled with them are usually an afterthought. Our pitch is simple: we don’t touch your clinical. Let us fix your books—the part you shouldn’t have to think about.

Q2: If Camber wins, what unlocks for small clinics — not just financially, but culturally or structurally?

If we win, getting paid becomes a non-issue.

It’s like running a local coffee shop: you make someone a drink, they tap their card, and you get paid. That’s how care should feel. Automatic, not anxious.

When that stress disappears, two things unlock.

First, growth: you can take people off the waitlist, expand your team, maybe open new sites.

Second, confidence: you stop feeling like an underdog. You start thinking like an enterprise operator — because now you run like one.

That’s our worldview. Care should be personal. Infrastructure should be invisible. The plumbing should just work — and we’re here to make sure it does.

Q3: In these markets, trust is everything. What makes a clinic say: I’m willing to hand this over to you?

We earn trust by helping clinics move from playing defense to offense. RCM shouldn’t be retrospective; it should be prospective.

Most of the clinics we work with have been stuck with reactive BPOs. If deposits come in low, they’re staffed to chase down the issue. No visibility. No forecasting. Just stress.

Even a live-updating report showing where every dollar is sitting feels like a breakthrough. That transparency gives clinicians back control.

We can forecast what deposits should look like on any given day, and flag when something’s off. The same goes for claims: we don’t just report what got denied, we show what’s likely to get paid before it’s submitted.

That’s when trust develops. The tool helps you stay ahead.

Q4: RCM is where AI goes to die. How do you build flexible systems that hold up — and what’s one thing you had to build that surprised you?

Some startups use modularity to sell faster. We use it to stay disciplined — solving what’s real before chasing what scales.

Automation breaks when it’s built for a single, rigid workflow. Maybe it works for verifying benefits with a Blue Cross card. But as soon as it’s Aetna, it falls apart.

We take a different approach. Instead of building one-off flows, we build modular components — the Lego bricks of RCM. One AI agent handles a phone call. Another scrapes a portal. A third interprets an EOB. What matters is how they interface, so we can flex across edges without rebuilding from scratch.

You still need orchestration. But modularity lets us move smarter and faster. When a new exception pops up, we solve it by rearranging existing parts.

One case we didn’t expect: a regional payer’s physician roster wasn’t syncing between credentialing and billing. They kept flagging credentialed providers as uncredentialed. We automated the manual steps clinics had to take to fix it — pulling reports, placing calls, drafting emails — so things could keep moving without a human in the loop.

Q5: AI in healthcare is often inflationary — faster claims, same waste. Is Camber shifting cost curves, or just greasing the rails?

We’re not in the business of saying what care is necessary. But clinical judgment can’t work if the pipes are dirty. Our job is to clean up the inputs, so downstream decisions aren’t made blind.

A lot of waste today comes from sloppy submissions: duplicate claims, overused authorizations, concurrent claims that shouldn’t overlap. We filter that out by default. If a required field is missing, or a claim is a duplicate, we don’t submit.

The right providers should get paid. The wrong ones shouldn’t. And that starts by making sure what enters the system is accurate.

Yes, we move faster. But we also move cleaner. That’s not greasing the rails — it’s raising the floor.

Q6: What’s something that’s been unexpectedly hard in building Camber — and what do you wish more founders learned earlier?

The theme for me is focus x timing. It’s not about what to build, but when.

Healthcare is a three-stakeholder system — payers, providers, and patients — there’s infinite surface area. Once you help a provider make payroll, they start asking you to fix everything else. Not because they’re unreasonable, but because they finally trust you. If you solved this, what else can you help with?

That creates real pressure to expand too early. In behavioral health alone, you could end up building session notes, HR, payroll, accounting — and maybe one day you should. But the hard part is knowing when to say yes, and when to wait.

Great infra companies don’t just chase ARR. They apply judgment. They focus on the right things at the right time — and constantly pressure-test their direction as they grow.

In-Network Take:

Most RCM startups chase scale by selling into large groups. It makes sense on paper, but rarely lands, implements, and retains in practice.

Camber is playing a different game. It’s not automation for its own sake. It’s sequencing — like the scribes, but with faster, more visible ROI.

Help a clinic make payroll, and you don’t just win a customer. You earn the right to touch everything else. Most platforms want that kind of trust. Few are willing to earn it piece by piece.

If Camber’s right, they’ll become the financial operating layer for clinics no one else bothered to build for.

And that’s the edge: they know when to say no — to misaligned customers, premature expansions, or features that dilute the wedge. That kind of discipline is what makes infrastructure stick.

RCM isn’t sexy. But trust is. And Camber is building both, one block at a time.

💭 If this sparked something — share it with a founder, an operator, or anyone rethinking how we fund care.

Liked this one? You might also like The Ambient Scribe Stack — a breakdown on how companies like Abridge, Ambience, and DAX are going beyond the note to rewire clinical workflows. Or What WiSER Gets Right About Medicare Reform, our take on CMMI’s new innovation model putting practicality first.

In-Network is where I write about the business of care: models, margins, and the infrastructure behind how we deliver it.
→ Subscribe for sharp, honest analysis on what’s actually changing in healthcare.

WISeR in four bullets (for your boss, your deck, or your next 1:1):

• 320+ people were charged in a $14.6B federal healthcare fraud case; WISeR aims to block that kind of abuse before claims are paid

• WISeR is one example of CMMI prioritizing execution over ideology — proof that not every model needs to be a moonshot

• Providers who opt in may get faster claims and gold card status; those who don’t still face review, just with less control

• WISeR could quietly enforce site-neutral care by denying high-cost settings without touching the fee schedule

America’s largest healthcare fraud case just made headlines: 320+ people charged, $14.6B in attempted Medicare and Medicaid fraud.

In hindsight, the schemes weren’t exotic — they were obvious. One transnational group bought over 30 DME companies, stole identities from 1M seniors, and submitted fake claims; they collected nearly $1B in catheter and glucose monitor reimbursements before CMS caught on.

That’s the problem. The U.S. healthcare system is complex enough to confuse and fragmented enough to exploit. This isn’t just a fraud problem — waste alone drives up to 25% of healthcare spending today.

Enter WISeR: a prior auth demo that brings targeted, tech-enabled control to the parts of Medicare most vulnerable to abuse.

No convoluted financial scaffolding. Simplicity is the innovation.

What is WISeR?

Launching in 2026, the “Wasteful and Inappropriate Service Reduction” (WISeR) model introduces prior authorization into fee-for-service Medicare. It does this not through MA plans, but directly via third-party technology vendors, who help determine whether or not a potentially harmful procedure (i.e., a knee arthroscopy) is clinically appropriate for someone age 65+. Here’s how CMS itself is framing it:

Why Would Anyone Join?

Participation in WISeR is voluntary. Without shared savings or risk upside (which fueled the proliferation of PE-backed ACOs), it’s fair to ask why anyone would bother.

My take: opting out doesn’t mean escaping scrutiny. Providers who sit on the sidelines will still face traditional medical reviews, but without the benefit of a structured pathway. Enrolling — and laying the groundwork alongside CMS-approved vendors — could mean faster claim processing and, eventually, gold-card status later down the road.

Engage early, shape the rules, and reduce uncertainty. Opting in might be the least risky move.

How This Differs from Other Innovation Models

Compared to prior CMMI demonstrations, WISeR’s structure is unusually clean. No attribution. No benchmarks. No downside risk.

This isn’t transformation theater — and that’s a feature, not a bug.

Let’s zoom out. Most CMMI models require a leap of faith. Programs like ACO REACH, CKCC, and TEAM show promise, but their success hinges on chained logic: if behavior changes → utilization drops → costs go down. Often, that bet is on care management.

I’ve backed companies that navigate this well (like Strive and Empassion). But still, they depend on proving savings through tight execution, and many don’t share their success. Discounted benchmarks can help, but they rarely bend the cost curve on their own.

WISeR is different. It’s a single-step intervention: control inappropriate utilization, reduce spend. The outcome is built into the mechanism — not dependent on provider behavior or attribution algorithms.

From the outside looking in, this is exactly what CMMI was built for: sharp, executable, and inflation-aware.

“The Secretary shall focus on models that the Secretary determines have the potential to reduce program costs … while preserving or enhancing the quality of care received by individuals.” – Section 1115A of Social Security Act (source)

There’s a broader context too. As AI-driven tools like ambient scribes improve documentation and coding, more claims will get paid — even ones that previously would’ve been rejected.

In 2024, an estimated $31.7B (7.66%) of Medicare FFS payments were improperly paid, either over or under the correct amount (source). WISeR may be CMS’s quiet acknowledgement that inflationary pressure is no longer downstream. It’s embedded in how care is coded, approved, and paid.

The Future of Medicare Reform

Outside of the three services mentioned, it’s still unclear which CPT or HCPCS codes WISeR will target.

But reading between the lines, categories like DME, labs, imaging, and other “low value” Part B procedures look like obvious candidates.

Just a theory, but in the future, this may be about more than utilization.

CMS has already experimented with site-neutral payment through the Outpatient Prospective Payment System (OPPS), aligning reimbursement between HOPD and physician offices. This was done first for E&M visits, but expanded to certain imaging, diagnostics, and minor procedures.

But admittedly, the success here was nominal — riddled with carve outs and undercut by grandfathered HOPDs billing at higher rates.

After some proof points, WISeR could build on that philosophy. Not by impacting rates, but by denying high-cost sites when lower-cost settings are clinically appropriate.

Think site-neutral payment — without touching the fee schedule.

That might scare some folks — and to be clear, I’m not saying this is good or bad policy.

But it’s worth naming as a structural mechanism to influence site-of-service decisions.

If that’s where this is headed, WISeR may influence the fundamentals of care: site, service, sequence.

And that’s what Medicare reform should look like: less ideology, more infrastructure.

💭 If this sparked something — hit the 💜 or leave a comment. I’d love to know what’s worth unpacking next. Or forward it to someone building in the space.

Liked this one? You might also like The Ambient Scribe Stack — a breakdown on how companies like Abridge, Ambience, and DAX are going beyond the note to rewire clinical workflows. Or After the GLP-1 Gold Rush, our take on what comes next for compounders and payers in the weight loss era.

In-Network is where I write about the business of care: models, margins, and the infrastructure behind how we deliver it.
→ Subscribe for sharp, honest analysis on what’s actually changing in healthcare.

The weight loss drug market is shifting fast. Here’s what you need to know…

Bullets to sound smart with your friends (or your boss):

• Compounding peaked at ~25% of scripts — a conservative estimate

• Pharma snapped back: Novo cut Hims, Lilly sued

• ~29M Americans have tried a GLP-1 — most won’t stay on without infrastructure

• Cigna now covers 9M+ lives in a GLP-1 wraparound program

• Drug expense might pay off, if outcomes and retention hold

We used to light cigarettes to stay thin. Today, we inject. The method changed, the motive didn’t.

Smoking went mainstream before we understood the consequences. GLP-1s are doing the same: driven by demand, distributed with convenience.

But pharma is taking back the wheel:

• Novo launched cash-pay Wegovy via NovoCare at $499/month — then ended a partnership with Hims over continued off-label compounding (source)

• Lilly is offering Zepbound via LillyDirect — while suing DTC platforms in CA (source)

• Hims is hedging with a ZAVA acquisition to expand GLP-1 sales in the EU (source)

Most commentary stops at “the what.” I wanted to understand why. So I spoke with drugmakers, national payers, and investors.

The GLP-1 boom was built on speed, not science — regulatory gaps, DTC playbooks, and cash-pay demand.

That chapter is over. Now that pharma is reclaiming distribution and payers are footing the bill, the question isn’t access.

It’s retention, side effects, and proof that care was worth it.

Early winners sold access. The next will sell outcomes.

How Compounding Fueled the GLP-1 Boom

GLP-1s aren’t new. The first was discovered in the early 2000s. Trulicity made them commercially relevant in 2014. Ozempic (semaglutide) built the modern market.

Demand exploded after Wegovy’s obesity approval in 2021.

Novo and Lilly weren’t ready. Injectables are hard to scale, and neither had the infrastructure to meet demand.

Then, the FDA added semaglutide (not Lilly’s tirzepatide) to its drug shortage list in 2022. That cracked open the door. Under Section 503A, compounders could legally recreate the drug without FDA approval. The rule was meant to solve scarcity, not subsidize unmet demand. But it was misused.

These weren’t true replicas. Compounders used alternate salt forms (e.g., semaglutide sodium or acetate), not found in FDA-approved formulations.

Still, it was enough. Telehealth platforms like Hims, Ro, and MochiHealth moved quickly. An online form, a brief consult, a monthly cash-pay charge — and the drug showed up at your door.

They bypassed insurers and PBMs, capturing ~5x the margin of branded Wegovy (source).

Access was the product. And startups knew how to sell it.

How Big Did Compounding Get?

Compounded GLP-1 scripts aren’t directly tracked, but public disclosures let us triangulate a credible range. It’s popular to claim compounders reached 50%+ of total volume at peak. A more conservative approach suggests ~25%. Massive, but bounded. Here’s the math:

Total prescriptions: IQVIA and Truveta data show U.S. GLP-1 prescriptions grew from ~9M in Q4 2022 (source) to ~24M by Q4 2024 (source). Novo’s Q1 2024 earnings cited ~6.5M monthly scripts, consistent with that run-rate (source).

Novo’s estimates help bracket the range:

• Floor (~15%): In early 2025, Novo said ~1M U.S. patients were still on compounds. At three fills per quarter, that’s ~3M scripts, or ~15% share (source).

• Ceiling (~32%): Novo previously warned compounders “may have captured up to 40%” of semaglutide scripts. If semaglutide made up 80% of GLP-1 volume (before Zepbound), that implies compounded share closer to 32% (source)

Now, look at Hims: They launched compounded semaglutide in Q2 2024 and reported $225M in GLP-1 revenue through year-end (source). At a midpoint price of $299, that’s ~750K scripts over three quarters, or ~250K per quarter. That’s 4 – 5% of the estimated 6M compounded scripts at peak. If Hims — one of the most visible platforms — held just 5% of compounded volume, then 50%+ estimates for the total market probably overstate reality. But a 25% share? That holds up. And it’s still staggering.

Could it be higher? Maybe.

But ~25% is a defensible midpoint, not a stretch.

How Pharma Took Back Control

At first, compounders weren’t a major threat; Novo and Lilly benefited from the hype. But as volumes scaled, so did their losses.

“We have reduced our full‑year outlook due to lower‑than‑planned branded GLP‑1 penetration, which is impacted by the rapid expansion of compounding in the U.S.”
Former Novo CEO Lars Jørgensen, May 2025

The FDA ended the semaglutide shortage exemption soon after.

At first, Novo and Lilly played it differently:

• Novo chose offense. They had first-mover advantage, and compound exposure. As share bled, they moved fast: discounts, DTC partnerships, and cash-pay deals. Volume over defensibility.

• Lilly chose defense. Tirzepatide (Mounjaro, then Zepbound) wasn’t on the shortage list, so compounders couldn’t touch it. Lilly also had the stronger molecule and a deeper pipeline. Weight loss was strategic, not existential. They held firm: no DTC, no discounts, early payer alignment.

Then, this week, Novo terminated its deal with Hims, citing Hims’ plan to continue compounding “personalized doses” outside the branded spec (source). The clinical risk — adverse events tied to Novo’s name — wasn’t worth the extra volume.

Hims’ retort? Novo is being anti-competitive:

Who’s right isn’t the point. Novo is playing it smart.

Pharma is shifting from weight loss drugs to cardiometabolic platforms. The model: stack indications, expand labels, and reposition semaglutide and tirzepatide for broader use — heart failure, CKD, NASH, addiction. Any one of these opens the door to Medicare Part D, which still excludes weight-loss drugs under the MMA.

For my pharma savvy folks, this is the Keytruda playbook. Opdivo was first, but Keytruda won by expanding faster — 38+ approvals across cancers. Today, it’s one of the top three highest-grossing drugs on earth.

Pharma sees where the long-term value lives, but it’s not guaranteed.

Novo’s recent CagriSema data (a sema+cagrilintide combo) underwhelmed, wiping out $90B in market cap (source). The market has already priced in label expansion. Any stumble hurts.

Why DTC GLP-1 Platforms Are Struggling

Not all virtual prescribers are “DTC.” Platforms like Calibrate, Season, and even Noom Med offer coaching and lab integration, gesturing towards outcomes infrastructure.

Ro, Hims, and Mochi are different — more conversion engines than clinics. No RCM stack, no care coordination, no PCP partnerships. Great for Viagra. Risky for chronic care.

They’re clever, and they’ll keep iterating. Hims said it would keep offering compounds, so their stock jumped. But I haven’t seen a viable turnaround path:

• If Hims can legally compound personalized doses — dose flexibility won’t solve nausea, muscle-loss, or tapering needs (source).

• If Ro duct-tapes coverage — they still need to manage claims, prior auth, and retention. They’re not built for it. (source)

• If ZAVA gives Hims an international escape valve — demand exists, but price tolerance doesn’t. EU payers won’t subsidize unproven, compounded drugs. (source)

If the rise and fall here feels familiar, it is.

Testosterone therapy followed a similar arc: cultural hype, DTC boom, quiet fade. But the risks were tolerable, and the market too small to trigger regulators. Vault, Hone, and others drifted away.

GLP-1s are different. The stakes are higher, and the burden of proof is heavier. DTC isn’t equipped. And this time, the system won’t look away.

How Payers Are Building GLP-1 Infrastructure

Despite the hype, we’re far from saturation. By script volume, GLP-1s have reached 20–25M Americans. KFF polling puts it at 29M who’ve tried one, with 14M still on therapy (source). But that’s out of 260M adults — not just the 100M with obesity.

Many will need to go again. Twelve month dropout rates hit 65% for obesity and 47% for diabetes (source).

And when patients stop, the results reverse. In one trial, Wegovy users regained two-thirds of the weight within a year of stopping (source).

It’s tempting to assume payers will push back. But commercial plans aren’t just preparing to cover these drugs — they’re building infrastructure around them.

Cigna is all-in. Through Evernorth, it covers Wegovy and Zepbound for obesity, capping out-of-pocket costs at $200/month (source). Over 9M people have joined (source). To support that scale, it launched two dedicated assets:

1. EnReachRx: clinical wraparound services

2. EnGuide: a GLP-1-trained pharmacy team

They’re not alone. CVS Caremark made Wegovy its preferred GLP-1 (source). More broadly:

• Employer coverage is scaling fast: 64% of America’s largest employers now cover weight-loss drugs, up from 56% a year ago (source)

• PBMs are locking in controls: CVS Caremark, Express Scripts, Optum Rx, and Prime are adding GLP‑1s to formularies with step edits, prior auths, and exclusions (source)

We’re at a real infection point. Soon, these drugs may also have demonstrable ROI.

One Aon study found that weight loss plus comorbidity improvement offsets costs — even at high drug prices.

This tracks. Weight loss improves diabetes, sleep apnea, heart risk, and productivity. But only shows if side effects like muscle loss, nausea, and behavioral drift, are managed.

That takes real clinical support. The next winners won’t just prescribe. They’ll support, retain, and prove outcomes.

Here are a few of the players building toward that edge, and some thoughts on what matters:

• Payer-native infra is where control lives. Cigna’s EnReachRx and EnGuide show that payers want full stack oversight, and they’re building it in-house.

• Payer-aligned clinics are sticky but still early. Knownwell, Calibrate, and Sequence offer outcomes and trust. But PCP FFS economics and brick-and-mortar burn are headwinds.

• Cash-pay clinics are loud but capped. Without payer alignment, Season and Noom stay small, or get boxed out.

• Clinical contributors are overlooked but essential. Nutrition, PT, and behavioral support shape adherence, even if they don’t prescribe.

• The MSO chassis is still missing. GLP-1s don’t fit Aledade’s mold — slower ROI, higher drug risk, and heavier infra needs than your typical ACO.

• Infra builders quietly shape. Prior auth and retention ops are invisible until they break. Zus or Commure could become the rails beneath everything.

What Comes Next for GLP-1 Formulations

Getting the script is easy. What comes after — side effects, behavior change, clinical infrastructure — is still being built.

This phase won’t be the last. Orals, long-acting injectables, and combos are on deck.

The first wave of GLP-1s broke open access. The next will decide who owns the model.

Here are a few ways future formulations could shift the market:

1. Oral (Rybelsus 2.0, better semaglutide formulations)

   1. What changes: Easier to prescribe and adhere to, but worse tolerability

   2. Where it moves: Into primary care → lower friction, tighter payer control

   3. Strategic shift: More access, same adherence problem

   4. Risk: Higher churn, more side-effect driven dropout

2. Next-gen combos (e.g., GLP-1 + GIP + amylin, muscle-sparing)

   1. What changes: Better outcomes, better tolerability

   2. Where it moves: Into specialist-aligned care models → deeper payer integration

   3. Strategic shift: Drugs become platforms — unlock long-term value

   4. Risk: Slow coverage without strong RWE; clinical complexity slows uptake

3. Long-acting or micro-dosages (e.g., monthly injections, microneedle patches)

   1. What changes: Improved tolerability, better adherence

   2. Where it moves: Possibly back toward DTC models if access outpaces infra

   3. Strategic shift: Less patient burden, potential wedge for intermediaries

   4. Risk: Manufacturing lag or cost may stall rollout; regulatory catch up needed

As new formulations come to market, expect bundling logic to follow. First-gen GLP-1s may serve as the access wedge — volume-driven, high-cost, tightly controlled. Next-gen combos, with better outcomes, get positioned as the upgrade. Think Humira-to-Rinvoq: maximize total revenue under the curve, even if it means discounting your lead drug to drive adoption of what’s next.

That’s the revenue strategy, outcomes TBD.

We solved access. Now we have to earn it.

At least until the next formulation arrives.

If you’re building in this space — payer-side, platform-side, or somewhere in between — reach out. Would love to hear how you’re thinking about what’s next.

💭 If this sparked something—hit the 💜 or leave a comment. I’d love to know what’s worth unpacking next. Or forward it to someone building in the space.

Liked this one? You might also like The Ambient Scribe Stack — a breakdown on how companies like Abridge, Ambience, and DAX are going beyond the note to rewire clinical workflows.

In-Network is where I write about the business of care: models, margins, and the infrastructure behind how we deliver it.
→ Subscribe for sharp, honest analysis on what’s actually changing in healthcare.

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In-Network is a strategy newsletter for people building and fixing U.S. healthcare: operators, founders, policy leads, and investors.

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But it shows up in inboxes and team threads when the work gets serious.

I’m David Ohta — a healthcare investor and operator. In-Network has been featured in Health Tech Nerds and is quietly read by people working across care delivery, infrastructure, and policy.

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🧠 Ambient scribes: A reasonable bet, with conditions — Why Abridge’s $5B wedge might be real — even if the TAM isn’t.

💊Why insurance makes your prescription more expensive — How generic drugs stay overpriced, and who benefits.

💸The healthcare 401K — how a regulatory shift is giving people more control over their insurance.

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TL;DR: Ambient scribes are the rare AI tool doctors actually like. But most of them still fail to scale. This post breaks down what works, what breaks — and what might actually stick.

Bullets to sound smart with your friends (or your boss):

• Clinicians love it. Boards fund it. That kind of alignment is rare and powerful

• The TAM today is small (~$2B). Expansion into CDI, APPs, and revenue cycle is necessary, but not guaranteed

• The product is easy to copy. Defensibility will come from depth, not speed

• Every next move—horizontal or vertical—introduces friction. Abridge has to pick its battles wisely

• At $5B, the clinical note is the entry point, not the business

The Easy Part Is Over

Just months after closing a $250M Series D ($2.75B), Abridge is reportedly raising another $300M – this time at a $5.3B valuation, led by a16z. A 2x step up, and a 45x multiple on contracted revenue. For a note-taking tool. In a market with a few hundred enterprise buyers.

Unhinged? Yes. Off the mark? Not really.

What makes ambient scribes compelling isn’t the tech. It’s the rare alignment of incentives. Clinicians want relief from the EHR. Boards want to show they’re doing something with AI. That kind of top-down, bottom-up pull is unusual, and explains why adoption has progressed quickly.

But that alignment is only the beginning. The core market to date—low-acuity providers at enterprise hospitals—isn’t big enough to support a $5B+ outcome. To scale, scribe companies like Abridge will need to shift horizontally into messier care settings or vertically into new modules of the tech stack. Ideally, both.

The future depends on scaling beyond primary care, and beyond the note.

What Is An Ambient Scribe?

It’s easy to over-intellectualize “AI” in healthcare. But ambient scribes are simple. These tools record clinician-patient conversations and generate structured clinical notes in real time. Audio is typically captured through a mobile device, and synced directly into the EHR. Some products (like Abridge) are embedded inside Epic with a built-in record button. Others run as standalone apps that sync notes back after the visit. But the core is the same: the doctor talks, the note writes itself.

Why Scribe Adoption Is Moving Fast

The numbers fueling the hype: time saved, quality kept, burnout down.

The pitch is simple, and mostly true. AI scribes save time, improve note quality, and reduce burnout. And unlike most tools in healthcare, physicians actually want to use them:

• Time savings: Even at Kaiser, one of the more efficient systems, NEJM found that AI scribes saved 40 to 70 seconds per note (NEJM). That sounds small, until you scale it. Across 300K uses (in a year), 3,000 to 6,000 hours were saved.

• Increased note quality: Using the PDQI rubric, AI-generated notes scored 4.20 out of 5, just shy of human-authored notes at 4.25 (ARXIV). In low-acuity settings where most scribes are used today, that gap likely doesn’t matter. But in high-acuity settings, like emergency medicine or surgery, the models sometimes missed nuance or failed to capture follow-up planning.

• Reduced physician burnout: Stanford physicians using DAX saw a 1.9-point drop in burnout (on a 0 -10 scale). At UPenn, “pajama time” dropped 30% (JAMIA, JAMA). Fewer clicks. Fewer late nights.

Studies aside, these aren’t hypothetical wins. 85% of Abridge users said they’d keep using it (NEJM). One Kaiser physician put it more bluntly:

“You’d have to take it away from my cold, dying hands.” (BOND)

A Rare Moment of Alignment

In the past five months, Abridge’s contracted ARR exploded from $50M to $117M. Even outside of healthcare, that growth isn’t normal. Only a handful of companies have scaled to $100M ARR this fast (BVP). Abridge did it in under two.

Why? Because demand is coming from both ends of the org chart. Boards need a credible AI story. Clinicians want relief from the EHR.

Compare that with the last big infrastructure rollout: EHRs under HITECH. Adoption was mandated, compliance-driven, and painful.

Ambient scribes are the opposite. They’re voluntary. They work. And they’re landing just as TEFCA goes live, bringing 1K hospitals onto a shared data exchange. Now, notes aren’t just recorded. They’re portable, standardized, and auditable.

This is a rare opportunity: a product people want, solving a problems systems are finally read to fix.

Everything Beyond the Wedge Gets Harder

The TAM is limited. Defensibility is shaky. Logical adjacencies introduce friction.

Even with this traction, Abridge’s path won’t be smooth. A few reasons why I believe that’s the case:

1. The Current Market Is Too Small

AI scribes are a feature, not a platform. At $2.5K per physician per year, the high touch market (large AMCs and regional systems) tops out around $1.6B. Add in lower-priced SMB deployment, and the total physician TAM rounds out at ~$2.1B.

That’s real revenue opportunity. But it’s not enough to support a $5B+ outcome without more.

Nearly 80% of that value sits in enterprise health systems. Smaller orgs make up more headcount, but they lean toward cheaper tools like Freed, Heidi, DeepScribe, or Suki.

Importantly, even these TAM estimates assume stable pricing, which may not hold. As adoption normalizes, willingness to pay will compress.

Some providers are already trialing “good enough” ambient tools at half the price. One IDN I spoke with pitted DAX and Abridge against each another to pick the cheaper option.

To justify a $5B+ valuation, Abridge has to expand:

Vertically, into new modules like pre-charting, CDI, and dispute resolution. If even one of these commands similar pricing to scribing, the market gets meaningfully bigger.

Horizontally, into new user types (like 475K APPs, which could expand TAM by $500M at $1K per head) and more complex settings like specialty care and inpatient.

The wedge is real. But the ceiling remains low, and could drop further.

2. Product Defensibility Is Thin

LLM transcription quality is improving fast. Voice-to-note isn’t hard to build anymore. And with low switching costs and no database lock-in (unlike EHRs), these tools are vulnerable. If another vendor integrates better, runs cheaper, or just feels smoother, clinicians will switch.

Like the TAM ceiling, the obvious product-led-growth move is to go deeper: upstream into pre-charting, or downstream into CDI and revenue workflows. But that introduces new risks:

Clinician trust: Once a scribe starts suggesting codes or nudging for follow-ups, it starts owning the clinical narrative. What was once helpful becomes intrusive. If the note becomes a scorecard, will clinicians still opt in?

Platform tension: The deeper these tools go, the more likely they are to compete with the EHR itself. For now, Abridge has made Epic stickier. But the closer it gets to billing and compliance, the more likely it is to trigger conflict..

It’s not just about which module Abridge builds, but about which frictions they’re willing to absorb—a tradeoff we’ll unpack more in the next section.

Depth may build the moat, but it also pokes the bear.

3. Growth Looks Painful In Every Direction

The wedge worked. But the core market is small, and the product alone won’t scale it. Abridge and others will have to expand: horizontally into more complex care settings, and vertically, into higher-stakes infrastructure.

Regardless of direction, you run into the same wall: clinical complexity and institutional friction.

The first exhibit below maps illustrative horizontal limits; where LLM performance and workflow complexity start to break down. The second outlines verticalization risk; how defensibility increases, but so does political exposure, as companies capture more of the tech stack.

There’s room to grow, but no obvious path. Every move beyond the note invites resistance from clinicians, vendors, or from the system itself.

What Everyone’s Talking About, And What Actually Matters

Plenty of smart people are skeptical. But most of the concern is pointed at the wrong risks. Below are the takes I hear most often, and why I think they miss the real threat or might be misreading the signal.

1. “DAX is going to win this”: They should, but they aren’t. Abridge only slightly trails in size. That tells you something. Microsoft’s product has been slow to deploy and often feels clunky. In this market, product quality still matters.

2. “Older physicians won’t adopt this”: Some won’t, and that’s fine. But many are. This market isn’t built for the last generation of clinicians; it’s being built for the next one. Imagine what Gen Z resident will think when they’re handed a working scribe day one.

3. “Hospital sales cycles are too long”: They are, but Abridge is proving urgency and narrative can compress them. The contract growth speaks for itself. This is a distribution machine.

4. There’s no clear financial ROI: True, in the narrow sense. The original pitch—save time → see more patients → boost revenue—doesn’t work in every setting. Many systems don’t profit from E&M visits. But that misses real lever: clinician retention. In margin-squeezed systems, keeping burned-out staff is its own kind of ROI. And over time, bundling scribes with revenue-generating modules like CDI will help close the financial gap.

5. Models will hallucinate and make clinical errors: That’s not the real concern today. Scribes summarize what was said; they don’t invent diagnoses or suggest care plans. But as these tools expand into prompting, pre-charting, or CDI, the line between note-taker and decision maker blurs. And once the scribe starts shaping the record, the risk isn’t just hallucination. It’s attribution. Who’s responsible when something goes wrong?

A Reasonable Bet—With Conditions

The raise is aggressive, but far from irrational. If Abridge were just a scribe tool, it wouldn’t pencil.

But as a wedge into structured data, revenue infrastructure, and long-term clinician retention? Then it starts to make sense.

The path forward is far from guaranteed. The market is smaller than people think, the current product is easier to copy than it looks, and every expansion vector introduces friction.

Still, ambient scribes might be the only product in healthcare that clinicians genuinely love—and boards are willing to fund. That’s what makes it investable.

To earn that $5B valuation—and the $15–25B outcome it implies—Abridge will need to scale like few have. For context: Epic generated $4.9B in revenue in 2023.

The money isn’t in the note. It’s in what the note unlocks: speed, structure, scale, and staff who don’t quit.

💭 If this post sparked something—comment or hit the 💗 so I know what’s worth unpacking next. Or forward it to someone building in the space.

Enjoyed this one? You might like The Healthcare 401(k), a breakdown of ICHRA adoption trends, market dynamics and the startups enabling a new era of employer-sponsored insurance.

In-Network is where I write about the business of care: models, margins, and the infrastructure shaping how we deliver it.

Bullets to sound smart with your friends (or your boss):

• ABA grew to ~$5B by treating therapy as billable time, not an optimal outcome. Huey flips the script with short, virtual coaching sessions led by parents—not 20–30 hrs/week in clinic.

• Built for engagement: Huey meets families at key stress points—post-diagnosis, entering school, or adolescence—driving adherence and long-term use.

• Power of parent-led care: Within six months, most Huey families hit clinical goals like improved compliance and fewer meltdowns—without overloading parents.

• Better outcomes, lower costs: Over 80% of children reach goals using ~1‑2 hrs/week of coaching. Less burnout, lower spend per result—and families report higher confidence.

How ABA Therapy Took Over Autism Care

A $5B industry built for scale

A child is flagged for signs of autism. The family waits four months for an evaluation. When therapy finally begins, the behavioral tech quits. The next one is late, so progress stalls. The bill hits five figures. Insurance covers only part of it.

At home, parents are juggling IEPs, sprinting between jobs, and calming a sibling who doesn’t understand why their brother gets all the attention.

Each year, over 100,000 families begin this journey. More than 2.4 million children in the U.S. have an autism diagnosis. And that number keeps rising.

For the last decade, autism services have been dominated by a single model: Applied Behavioral Analysis (ABA). Delivered in-clinic and billed by the hour, ABA grew into a $5B+ industry with the support of private equity, who under-wrote its recurring revenue and rapid patient growth (BACB).

But that model’s tailwinds are fading:

• The workforce is breaking: Turnover has peaked: 65% attrition for RBTs and 30% for BCBAs.

• Gross margins are contracting: Though Medicaid rates have risen, they haven’t kept pace with demand. Job postings for RBTs and BCBAs are up 131% and 58% respectively (BACB).

• Payers* are pushing back: At $90 / hour, 20 hours of weekly therapy adds up to ~$90K per year. With inconsistent access and limited outcomes data (even from groups like the NIH) that cost is hard to justify.

Note: * ABA is a pediatric service, so payers haven’t cut it outright. But in the past two years, cost containment has escalated: shorter prior-auth cycles, visit caps, and fee schedule freezes in states with previously elevated rates. United has tightened reauthorization requirements, and Q1 2025 earnings from Centene and Elevance cite rising Medicaid MLRs and heavier utilization management in outpatient care—though few name ABA explicitly.

Right as patient demand reached all-time highs in 2023, investor appetite cooled. Blackstone-backed CARD filed for bankruptcy. Elemy went through four rounds of layoffs before abandoning direct care.

This slowdown couldn’t come at a worse time. The CDC’s latest report estimates 3.2% of children have autism, 3x the prevalence reported two decades ago.

But as the old model buckles, investors are backing a new class of ABA provider—one betting on virtual delivery and parent-centered design as the more scalable, exit-ready path. (BH Business).

Huey Health is one of them. And it’s not alone. A new standard of care is emerging—less behavioral, more developmental—and built around families, not just therapists.

Here’s how some of these emerging clinical models compare:

Huey sits at the right end of that spectrum. Its core programs—RUBI, Compass, and Parent-Led ABA—reduce hours and cost. But more importantly, they deliver: Over 80% of Huey clients meet their clinical goals, as tracked by networks like Catalight.

We spoke with founder Raffay Mirza about the system Huey is rebuilding—and why he believes the future of autism care starts at home.

ABA was Built for Billing, Not Care

How CPT codes, staffing economics, and narrow licensure shaped the wrong system for families

For Raffay, the inefficiencies in autism care were personal. In Australia, where his father works as a disability planner, families are assigned a care coordinator after diagnosis to build a two-year care plan, which covers behavioral therapy, SLP, OT, family counseling, and feeding. Really, anything that’s needed.

“It’s holistic,” Raffay said. “Services are based on individual need, reimbursed through a national fee schedule. There’s no need to anchor care to a specific diagnosis to get paid.”

Then he moved to the U.S.

“Here, you’re handed a diagnosis, plus a list of in-network providers if you’re lucky,” he said. “The system centers insurance coverage, not the child’s needs.”

ABA’s meteoric rise was fueled by a wave of state-level insurance mandates, beginning in the late 90s and culminating in coverage requirements across all 50 states by 2019 (Autism Speaks). “Families come in asking for ABA after reading about it online,” Raffay said. “But what might help more is speech or executive function support. Not 30 hours of in-clinic therapy.”

Leading with CPT codes has structural implications for labor. For example, in California the Business & Professions Code restricts BCBAs to working only with children with autism, and only on narrow interventions. Clinicians are locked into code-driven services.

“Parents often need coaching,” Raffay said. “But under current rules, the only professionals who can bill for that are LMFTs or LCSWs.”

For providers, a billing-first world presents different challenges. “The reimbursement model doesn’t work unless you’re playing for volume,” Raffay said. “To get any leverage with payers, you need to offer network access. So, you’re scaling hours, or selling the business.”

For years, ABA operators relied on this fragile equation: long treatment arcs, high authorized hours, and predictable reimbursement. The model looked scalable, but it was predicated on razor-thin margins, high staffing ratios, and flawless execution.

With that balance falling apart, even well-run practices are stuck selling to the next roll-up.

But this is more than a money problem. It’s a fundamental challenge with the model. “ABA can be a helpful modality for high-acuity needs,” he added. “But it was never meant to carry the system on its own.”

The Case for Parent-Led Autism Care

A model that meets families at inflection points and builds around the one constant in a child’s life

For Huey, the leading edge begins at home.

“When families begin with an in-clinic RBT, the mindset is passive—services are being done to me,” founder Raffay Mirza said. “When we flip it, parents realize: I have a role to play. The mindset shift drives long-term adherence.”

In traditional ABA, parents often wait for professionals to ‘fix’ the child. Huey makes it clear from the start: you’re in the driver’s seat.

It’s intuitive. Parents already spend more time with the child than any provider ever could. Huey builds around that truth—with three structured programs:

• RUBI, for parents of younger children with disruptive behaviors

• COMPASS, for teens and young adults navigating executive function, routines, and independence

• Parent-led ABA, for a small proportion of children with high-acuity needs

All are delivered via virtual coaching sessions, coupled with tools families can use between visits: visual schedules, role-play scripts, token boards, and individualized behavior plans.

Beyond structure, Huey leans into timing—showing up to meet families at key transitions—after diagnosis, during school entry, or when burgeoning adolescence surfaces new challenges.

“Those windows are critical,” Raffay said. “We urge our payers to help us reach families before the system grinds them down.”

That said, Huey’s model isn’t for every household. Success depends on having a consistent, engaged caregiver. Without that foundation, things fall apart.

“We serve Medicaid families every day,” Raffay said. “This isn’t concierge care. But it does require parental buy-in.”

“The goal here isn’t labor arbitrage,” he added. “It’s a bet that parents—when equipped properly—can do more than we’ve allowed them to.”

Other models have tried to formalize that instinct. Forta experimented with paying parents to deliver care. They’ve since pivoted, but that’s a different wager entirely.

“It hasn’t been well-received,” Raffay said. “You shouldn’t have to professionalize your love for your kid just to get help.”

Autism Care Built to Last

Better margins. Better outcomes. No burnout.

Huey’s model offers something rare in autism care: resiliency. Two of the most volatile inputs in autism care—clinic real estate and RBT labor—are all but neutralized.

Staffing seven hours of direct therapy per day is unheard of (no more 75% utilization targets). Hitting those numbers requires near-perfect staffing. One no-show, late hire, or RBT dropout can collapse the entire week’s margin.

Instead, Huey care teams spend a few focused hours coaching families and preparing custom materials. The unit of care isn’t the session. It’s the parent’s ability to keep things going after the session ends.

The result? Happier clinicians → better retention → better care → improved outcomes.

And the economics hold up; Huey’s margins look more like a SaaS company than a service provider.

On outcomes, light doesn’t mean loose. Goals are defined up front and tracked in collaboration with partners like Catalight, which approves every care plan and reviews outcomes across a range of family-reported and observational metrics.

“We don’t just track tantrum reduction or routine compliance,” Raffay said. “We measure how well the parent is implementing the strategy over time. That’s the intervention.”

This shift in the center of gravity—from provider to parent, from hours to agency—is more honest. Payers want value, and families want trust. This is where they meet.

The Future of Autism Care – If Huey’s Right

From high-hour to high-context. Built for the arc, not the episode.

Huey doesn’t treat autism as an episode of care. It isn’t trying to replace ABA either.

It’s trying to deliver what ABA was supposed to unlock: modular care that flexes with the family—starting with RUBI after diagnosis, shifting into COMPASS during adolescence, layering in higher-touch programs if needed. Families and payers step in when life changes; and step back when it doesn’t.

Consider LaRo—a young boy who had already spent three years in traditional ABA. His family came to Huey with no practical strategies. Within six months of RUBI, they’d hit every clinical goal: fewer meltdowns, stronger compliance, and a parent confident enough to carry the work forward without constant supervision.

And it matters—to families navigating jobs, tech gaps, and language barriers. To clinicians who want to stay in the field. To payers who want results without breakage.

If Huey scales as intended, autism care won’t revolve around authorizations or leases.

It’ll revolve around the people already doing the work.

That’s not just more human. It’s how care should have worked all along.

Not sponsored—just a model that deserves attention. If you’re building, investing, or operating in this space, you can reach Raffay at raffay@joinhuey.com.

Bonus: The New Autism Care Landscape

Huey is part of a broader shift that rethinks not only who delivers care, but how it’s designed, reimbursed, and scaled. Here’s how that landscape is taking shape:

💭 If this sparked something—hit the 💜 or leave a comment. I’d love to know what’s worth unpacking next. Or forward it to someone building in the space.

Liked this one? You might also like The Ambient Scribe Stack — a breakdown on how companies like Abridge, Ambience, and DAX are going beyond the note to rewire clinical workflows.

In-Network is where I write about the business of care: models, margins, and the infrastructure behind how we deliver it.
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Bullets to sound smart with your friends (or your boss):

• Opacity drives PBM profit — even insurers don’t see the full flow, and three firms control 80% if the market

• Spread pricing skims the middle — PBMs pocket the difference between what plans pay and what pharmacies receive

• Employers are waking up — auditing contracts, carving out benefits, and backing unbundled models like Blue Shield’s $500M shift

• Cost Plus, SmithRx, and others are attacking the model — rebuilding trust in a $450B market overdue for a reset

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Why does my Amazon prescription cost $3 cash—but $10 with insurance?

“Why does insurance sometimes make my medication more expensive?”

A few healthcare-savvy friends asked me recently, and none of us could explain it clearly.

Behind every prescription is a choreographed system: drug manufacturers, wholesalers, PBMs, pharmacies, and payers—each optimizing for their own economics. Each player adds value and extracts it.

Prescription drugs now make up the third largest category of U.S. healthcare spend, nearly $450B annually or 9% of total (CMS 2023).

What follows is a map of how a pill gets to your hand, and who profits along the way. First, we’ll unpack who pays whom, and for what. Then, we’ll break down the models reshaping that structure. Finally, we’ll explore why the shift is happening now and where it might lead.

The Pharmacy Value Chain: Who Touches Your Script?

Let’s start with the basics. There are five key players we need to name (six, if you count the patient). First, the supply chain—entities that physically handle the drug:

1. Manufacturers: Develop the drug and set a list price (e.g., Pfizer)

2. Wholesalers: Buy drugs in bulk from the manufacturer, distribute to pharmacies (e.g., McKesson)

3. Pharmacies: Dispense drugs to patients via retail locations or by mail (e.g., CVS)

Then, we have the benefits infrastructure—layers that govern access and pricing:

1. Pharmacy Benefit Managers: Negotiate rates with manufacturers, manage formularies, and process claims (e.g., OptumRx)

2. Health Plans / Insurers: Pay claims, contract with PBMs, set member cost-sharing (e.g., UnitedHealthCare)

While the drug itself flows one way (manufacturer → wholesaler → pharmacy → patient), the money moves in multiple directions.

Payments, rebates, and fees snake upstream through the system, obscured from view. The price the patient pays rarely reflects the true production cost, or even what the pharmacy was reimbursed.

The diagram below traces these flows, mapping who does what, who pays whom, and where value is extracted along the way.

Even on paper, the system looks disorderly. Several steps in the funds flow introduce serious misalignment:

• Skittle 4: Manufacturers pay rebates to PBMs for formulary placement, but patients rarely benefit. For example, Ozempic may have a $935 list price and a $400 rebate. Yet, the patient’s 20% co-insurance is still based on the full list price ($187). PBMs often retain 5–10% of those rebates, without disclosing the true share to the plan.

  (The % of rebates retained is still up for debate. In its 2023 SEC filing, Express Scripts revealed retainment of 5%. Historical analyses from the Drug Channels Institute suggest rebate retention reached as high as 27% over the past decade).

• Skittle 5: PBMs often reimburse pharmacies less than what they charge the health plan, pocketing the spread. Third-party audits have documented spreads of $20 per script, though in conversations with PBM challengers, we’ve heard estimates as high as $60 per fill (Source).

• Skittle 2: The health plan (i.e., the employer in a self-funded setup) receives only partial insight into what they’re paying. Even when rebates are shared, the retained portion (the “rebate spread”) and network fees, including per claim deductions paid by pharmacies (Skittle 6) to remain in preferred networks, are invisible to the plan sponsor.

  (Network fees can take the form of administrative or performance-based claw-backs, and while amounts vary, CMS and others have flagged them as a key source of hidden PBM margin.

These aren’t edge cases, they’re systemic. And at the center of them all? The PBM.

PBMs: The System Behind the System

Pharmacy Benefit Managers (PBMs) are among the most powerful, and least understood, middlemen in the drug supply chain. Sitting between manufacturers and payers, they shape not just what medications are covered, but how they’re priced, accessed, and reimbursed.

Their job is twofold: 1) manage the drug benefit and 2) find margin within it.

PBMs provide real services. They design formularies, negotiate with manufacturers, process claims, and contract with pharmacies. Many also operate their own mail-order and specialty pharmacies.

But alongside these functions, PBMs profit from structural opacity in ways that patients, employers, and even brokers rarely see.

Three friction points (as explored visually in the skittles we referenced before) highlight how incentives can quietly drift out of alignment:

• Spread pricing means PBMs keep dollars that could benefit the plan (or the patient): Plans are billed more than PBMs pay pharmacies.

• Rebate optimization means PBMs don’t choose the lowest-cost drug: PBMs are incentivized to prioritize higher-cost, branded drugs with larger rebates (paid by manufacturers) over cheaper alternatives.

• Pharmacy networks are governed by their willingness to pay PBMs, not by patient access or convenience: Pharmacies pay PBMs for preferred status, shaping networks around financial relationships, not access or value.

These aren’t side effects. They’re embedded features (not bugs) of the model. Critics say PBMs are incentivized to drive up costs and restrict access. Defenders argue they prevent fraud and negotiate better net pricing.

The real problem? Employers don’t know what they’re buying—or whether they’re getting a good deal. Some have started using audit tools (e.g., Artemis, Truveris, Rx Savings), but those are Band-Aids, not a fix for structural opacity.

(It doesn’t help that many brokers guiding employers also receive overrides or commissions from the PBMs they recommend.)

PBMs aren’t going away, but their margins (and mystique) are finally under fire.

That tension is exactly what new pharmacy models are targeting: less complexity, more control.

What’s Emerging: New Pharmacy Models

Disruptors don’t follow one playbook. They’re reimaginging different parts of the pharmacy stack, solving different problems with different models. Here's a quick taxonomy:

Disruptors are segmenting along strategic theses:

• Transparent PBMs (e.g., SmithRx) align with employers by eliminating spread pricing and charging flat admin fees.

• Direct-to-consumer platforms (e.g., Cost Plus Drugs) bypass insurance entirely, using transparent pricing as a trust wedge.

• Coupon tools (e.g., GoodRx, SingleCare) sit atop legacy PBMs, monetizing price discovery via referral fees and coupon spread.

• Horizontal plays are emerging—analytics, affordability tools, and fulfillment layers that integrate across benefit stacks.

The common bet? That clarity, not leverage, defines the next generation of pharmacy winners.

For an illustrative example, take Sertraline, the generic version of Zoloft and one of the most prescribed antidepressants in America (40M scripts in 2022).

A 30-day supply of Sertraline often costs more with insurance ($15 - 20) than it does with cash ($10.69 via Cost Plus Drugs) (source).

Here’s how the two models compare:

The key difference? Cost Plus cuts out the PBM entirely by buying directly from the wholesaler and fulfilling as the pharmacy.

While most associate spread pricing with high-cost specialty drugs, it’s most extreme in generics. Acquisition costs are so low that PBMs can charge $10 for a $2 drug and pocket the difference.

Estimates suggest spreads reach 30% on generics and 5–10% on specialty drugs. A $20 distortion on a single fill might seem minor, until you remember there are over 40M sertraline scripts written each year.

If this kind of markup exists on one of the cheapest generics, imagine what’s happening with injectables, GLP-1s, or oncology meds…

Why Now? Five Forces Colliding

The pharmacy value chain isn’t just inefficient, it’s unsustainable. Five forces are converging to accelerate change:

1. Specialty Drug Costs Are Soaring

U.S. prescription drug spend topped $800B in 2024, a increase of 10% year-over-year. Nearly half of that comes from specialty drugs (source). GLP-1s alone are projected to reach a $100B+ global market by 2030 (source). Employers want alternatives with more control.

2. Employers Are Fed Up

Self-funded plans face 6 – 9% annual increases in pharmacy spend—over 20% for plans with significant GLP-1 utilization (source). Broker incentives only deepen that misalignment.

3. PBM Margins Are High and Under Fire

The Big Three PBMs—CVS Caremark, OptumRx, and Express Scripts— control 80% of the market and earned $1.4 billion through spread pricing—charging health plans more than they reimbursed pharmacies for the same drugs (FTC). A 2024 lawsuit now alleges anticompetitive practices.

4. Disruption Has a Blueprint

As of 2025, Blue Shield of California dropped CVS Caremark and rebuilt its pharmacy stack through braided offerings from Cost Plus, Amazon, and Abarca. Despite being a major plan with scale and bargaining power, it expects to save $500M annually. If they were overpaying, smaller buyers likely are too.

5. Patients Are Asking Better Questions

Platforms like GoodRx and Cost Plus have changed expectations. Many now realize insurance isn’t always the cheapest (even if they don’t understand why).

That said, the answer isn’t one winner. It’s a set of clearer models, each solving a different piece of the puzzle. Some will scale. Others will specialize. But all are competing on the same thing: trust.

The Road Ahead: Not One Winner, But Many

No single model will fix the pharmacy system.

• Cash-pay platforms work for consumers but fragment care

• Transparent PBMs help employers but rely on pharma rebates

• Vertically integrated giants have scale but wrestle with cost vs. access

What’s clear is this: the pharmacy stack is unbundling. And companies that clarify rather than obfuscate will earn trust and market share.

If the last decade was about building scale and leverage, the next one might be about something else entirely: clarity.

💭 If this sparked something—hit the 💜 or leave a comment. I’d love to know what’s worth unpacking next. Or forward it to someone building in the space.

Liked this one? You might also like The Ambient Scribe Stack — a breakdown on how companies like Abridge, Ambience, and DAX are going beyond the note to rewire clinical workflows.

In-Network is where I write about the business of care: models, margins, and the infrastructure behind how we deliver it.
→ Subscribe for sharp, honest analysis on what’s actually changing in healthcare.

Two years ago, when my sister’s test results came back “inconclusive” for the third time, I didn’t just worry—I did what any anxious “finance guy” would do. I made a spreadsheet.

• Column A. Specialists and office phone numbers (today, there are seven across three different academic medical centers).

• Column B. Office visits, labs, and other “technical” encounters (40 and counting).

• Column C. Direct quotes from our health plan EOB, reassurance the visit would be covered.

What started as a dashboard quickly evolved into a labyrinth of medical jargon. In time, I added a Google Drive to capture referrals, treatment plans, and a symptom tracker.

I didn’t choose to become my sister’s care navigator. Like the ~38M other Americans supporting loved ones through complex medical journeys, I became one out of necessity (AARP).

Now, a new Medicare benefit seeks to professionalize this role through Principal Illness Navigators (PINs), transforming how Medicare beneficiaries experience care coordination—and birthing a significant market opportunity in the process.

Principal Illness Navigators Explained

Introduced October of 2024, PINs are a fresh Medicare benefit covering professional care navigation services for patients with serious, high-risk conditions lasting at least three months (CMS). Notable disease areas include cancer, HIV, or substance-use-disorders, but the CMS notice seems to cover a variety of conditions. Use cases in initial years will vary.

So why did CMS add these benefits now? For that, we can thank the GUIDE program, CMMI’s latest model aimed at improving outcomes for patients with dementia. Like most wrap services offered by value-based providers and MSOs, early feedback suggests effective navigation can compress spend + improve outcomes (Performance Year 1 ends in June 2025).

Federal support for this market is exciting for patients & families, but also for providers + investors. This is a billion-dollar market.

Let’s do some quick math. Of the 33.5M Original Medicare beneficiaries, ~36% have four or more chronic conditions (CDC). A conservative 12.2M may qualify for PIN.

CMS added four new HCPCS codes; two for PIN navigators (60 min G0023, 30 min G0024) and two for peer support (60 min G0140, 30 min G0146). Sixty-minute codes bill at a base rate of $72, 30 min at $36. 60 min codes are capped at 1x per month, while 30 min codes are uncapped but must be “justified and documented.”

Let’s assume maximum utilization: 12.2M people, twelve 60 min visits per year, twelve 30 min visits per year, all billed and collected 100%.

Shooting for the moon gets us a ~$15B+ bucket of spend. And though utilization will never reach this peak (I expect CMS to tighten eligibility criteria in the coming years), remember this doesn’t include MA. Expect non-SNP MA plans lacking similar supplemental benefits to follow OM’s lead. Success here may eventually trickle down and reach Commercial insurers.

Who’s Building Solutions

In terms of folks chasing the opportunity here, there are three key plays we’d like to quickly highlight, each with their own unique angle on PIN:

1. Solace Health: Marketplace, MSO model directly connecting certified care navigators with Medicare beneficiaries, focused on back-office support (i.e., credentialing, billing, licensing).

2. Guideway Care: Care navigation and SDoH platform integrated with hospital workflows, partnered with health systems to focus on reducing re-admissions.

3. Innovacer: Interoperability platform supporting care teams by automating admin tasks + identifying high-risk patients, ripe for expansion into actual service delivery.

Of these, I like Solace’s approach. The thesis mirrors Headway, Finni Health, and other non-MD MSOs.

1. Acquire patients (D2C, PCP partners, health systems, post-acute, etc.)

2. Create a high-performing network of fragmented providers who can serve them

3. Market that network to payers with broad network adequacy needs

4. Build back-office admin, benefit from scale (credentialing licensing, billing, and more)

But unlike Headway or Finni, who both have benefited from PE focus on behavioral health and ABA, there are significantly less care navigators than behavioral health professionals (tens of thousands vs. closer to ~1M psychiatrists, psychologists, MH counselors, social workers, etc.).

And one could argue that care navigators are much closer to 1099 contractors (working on behalf of physicians) than solo practitioners utilizing MSOs as a tool for co-building a private practice.

Candidly, I’m not in love with single-threading any business in healthcare—the potential for FWA here means stroke of the pen risk is real.

Regardless, expect the number of care navigators to skyrocket in the years to come.

The Road Ahead

My sister isn’t covered by Medicare. For now, she’s stuck with me (+ the captive care navigator from our private insurer).

She also lacks a definitive diagnosis, another layer of complexity in our navigation challenges.

But for millions of Medicare beneficiaries and their families, PIN represents a monumental shift—from navigation as a burden to a federal benefit. It acknowledges what patients have known for decades: coordination is care.

As the program scales, we’ll likely see rapid innovation in how these services are delivered, measured, and optimized. The most successful companies won’t just chat and facilitate appointments; they’ll fundamentally reshape how patients experience our fragmented system.

And for investors watching this space, that’s a story worth following closely.

The final pulse:

• MA had its biggest year ever (34.6M lives) and continues to grow, just slowly at 4% vs. 7-10% seen historically

• Degrading MA benefits + PPO plan departures led to Original Medicare’s first ever growth year in recent memory, netting +200K new lives

• Though national for-profits continue to dominate MA share (particularly United + Elevance), startup plans with patient-centered benefits packages now cover ~2% of all MA lives

• In the near-term, SNP plans will be payers’ growth lever; enhanced PMPM payments benefit top-line, and D-SNPs are particularly interesting (the effective utilization of Medicaid dollars à savings on Medicare)

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Current State of Play in MA

Last year, several market headwinds emerged for Medicare Advantage.

• Rising utilization, particularly unmet demand for ortho + CVH outpatient surgeries

• Surging MLRs, approaching 90% vs. historical 85%

• Low rate increases from CMS (3.7% avg increase)

• Growing regulatory scrutiny around financial levers (RADV audits, more prior auth)

The above led to carriers signaling their intent to slow (or even contract) their MA books for the 2025 Performance Year.

We have the data now. And though MA growth is slowing down, that takeaway alone is the tip of the iceberg. Here are the key points to know:

• Medicare Advantage growth has indeed fallen from 7-10% p.a. rates down to 4%

• That said, MA still achieved a record number of total beneficiaries (34.5M) and eclipsed 50% penetration nationwide (with 50%+ penetration in 27 states).

• Original Medicare enrollment grew for the first time in 5+ years, adding 200K new beneficiaries incentivized by expanded coverage and minimal premium growth

• Despite plan departures, MA market share remains with for-profit carriers (vs. provider-sponsored, non-profits, the Blues); this year, United and Elevance grew much more than Aetna, and Humana lost 10% of total membership

The resurgence of Original Medicare (OM) is the headline. In addition to the media’s ongoing critique of MA, OM’s comeback could be attributed to several intrinsic factors:

1. Benefit reductions in MA plans: More than 60% of MA plans reduced supplement benefits, including OTC meds, transportation, and meal services (source).

2. Improvements to OM benefits (with low premium increases): OM expanded coverage, including mental health benefits (covered marriage counselors, family therapists), cardiovascular risk assessments, and care navigators (PIN). Premiums only rose slightly ($175 à$185 a month) (source).

3. MA PPO plan departures: More than 1.8M members were enrolled in 2024 plans not offered in 2025. The vast majority of departing plans were PPOs offered by Humana + CVS (source). The proliferation of PPO plans in recent years (to attract membership) seems to met an end.

United and Elevance are this year’s victors; startup plans show promise

In terms of competitive distribution, things are less exciting. 70%+ of MA lives still live with for-profits, whose market share continues to grow at a steady +1% per year. Though other carrier types are indeed growing membership, these gains only allow them to maintain current share (i.e., provider-sponsored plans (8%), non-profits 98%), Blues (11%).

Amongst the for-profits, United and Elevance are the winners of this year’s AEP, capturing 50%+ of total net new lives. Aetna captured just 9% of total new lives, while Humana saw active deterioration of their book (CMS / others consider Elevance a “for-profit” plan as a publicly traded company).

The most exciting development here is that (despite Oscar’s departure and the sale of Bright’s MA plan to Molina), startup plans now comprise ~2% of total MA lives. The leading edge for these folks is patient-centered, culturally competent benefit packages that effectively speak to consumer needs.

These are just the highlights; for more numbers than you probably need, Chartis has a fulsome competitive analysis here.

Moving Forward, Plans Will Double Down on SNP

SNP is the new growth frontier; it’ll be the “MA” of the last decade in the years to come.

Broader deceleration in standard MA is revealing the relative opportunity in Special Needs Plans (SNPs), which reached critical mass this year and eclipsed 7.2M lives (17% 5-yr CAGR).

Now, 1 out of every 5 individuals in MA is now enrolled in a SNP. And apparently, 50% of this year’s new MA enrollees elected SNPs (source).

D-SNP remains the prevailing model (83% of total), but the jump in C-SNP to 1.1M lives (+68%) is both staggering and unsurprising given what we know about the proliferation of chronic care needs (i.e., heart disease, diabetes).

Like many, I’ve been a loud proponent of SNPs for years. High acuity patients with chronic conditions, institutional care requirements, or dual-eligible status receive a more individualized MA product focused on care coordination and resource alignment.

For payers, network construction, claims adjudication, and ultimately MLR management here are undoubtedly more complex than with boiler-plate MA. Which is why SNPs received less attention in prior years. Standard MA was enough to make a buck.

But with CMS rate increases below par, the enhanced payment opportunity of SNPs (either through higher risk-adjusted payments for I and C-SNPs or braided Care + Caid funding for D-SNPs) is too attractive to turn down.

(I didn’t forget about PACE programs – but more on that in a future post…)

The usual suspects here are already committed, with the top five plans capturing 75%+ of the total market. More specifically, United has a nationwide I-SNP of 50K+ lives, Aetna has a Florida D-SNP w/20K lives, and SCAN’s maintains a California C-SNP w/15K lives), but we’ve also seen exciting activity from disruptors. To highlight a few, Zing, Curana, and Belong.

This is an area to watch in the days to come.

MA’s Next Chapter: From Volume to Value

Regardless, the challenges are only just beginning. STAR ratings are on the decline, with only 64% of plans earning 4+ stars (down from nearly 80%). Only 2% of members are now in 5-star plans (lawsuits incoming on how these are calculated).

As Medicare Advantage transitions from its high-growth adolescence to a more measured maturity, the industry faces both consolidation and innovation. While traditional growth levers may be weakening, specialized offerings for complex populations represent the frontier of opportunity. For payers willing to invest in the capabilities needed to serve these populations effectively, the future of MA remains bright—not despite its challenges, but because of them.

Bonus: Will the Trump Admin Help Or Hurt MA?

MA was a hot topic coming out of Dr. Oz’s confirmation hearing last week. The question on everyone’s mind: what will the Trump admin do with MA?

Of course, Trump was a strong proponent of MA during his previous term. Currently, nothing suggests this next term will be any different.

Setting aside the fact that Dr. Oz used to sponsor MA ads (see here), his confirmation hearing highlighted the “bureaucratic processes” riddling MA, signaling support for the automation of utilization management.

“We spent about 12% of the CMS budget on bureaucratic processes, the admin of the program…I believe we have the power right now, with tech that didn’t exist from three or four years ago, to automate a lot of these processes, and preauthorization is a good example…”

Right or wrong, more pre-auth by a non-human likely means more restricted access to care.

If Trump were to accelerate Medicare privatization, we can expect:

• Rate increases through CMS’ annual notice

• The unwinding of MA marketing restrictions, including Biden-era requirements that all TV ads be approved by CMS, agent / broker compensation caps, and third-party marketing organization oversight (recorded phone calls)

• Unlikely, but make MA the default enrollment mechanism (see Project 2025)

That said, it’s now accepted by folks from both sides that the fed pays insurers 20% more for MA enrollees than it pays for similar people on Original Medicare (+$84B in cost in 2025, source).

For context, the CBO projects payment of ~$71B under the physician fee schedule (Part B) to treat OM patients in 2024 (source).

And so, to be even keeled, if Trump goes the “protect the budget” route to drive savings but slow MA further, we’d expect to see:

• Tightened rate increases, again via annual rate notice

• The end of quality bonus programs, which increase Medicare spend by $12B a year (source)

• Capped benchmarks at 100% of local traditional Medicare costs (source)

Which pathway seems more likely? I’ll let you decide.

TL;DR: ICHRA’s steady growth means we’d invest in scalable, tech-forward enablers (like Thatch) but pass on manual, “white-glove” alternatives.

• ICHRA transforms employer health insurance into a fixed reimbursement model, like how 401(k)s rapidly replaced pensions in the 1980’s and 90’s

• If the Exchange remains stable, ICHRA is theoretically a win for employers (predictable costs) and employees (flexibility and choice in coverage)

• While admittedly small (~500K lives), ICHRA has grown at 70% per year and is likely to eclipse ~3.5M+ lives by 2032—reasonable but not earth-shattering scale

• Moonshot success here is viable but sensitive—we need sustained premium growth in group options, continued tax credits, and (eventually) large employer buy-in

What is ICHRA, and why now?

For Americans, employment and healthcare are inextricably linked—of the 270M non-elderly insured, 165M (61%) receive coverage through their employer (KFF 2024).

But why do our jobs dictate the ability to receive healthcare?

In the 1940’s (post WWII), rising inflation led to government wage freezes—employers offered health insurance (and pensions) to attract and retain workers.

In the decades that followed, employer-sponsored insurance was plauded for its benefits to employers and payers alike, including:

• Natural risk distribution for payers: Workplaces have demographically diverse pools of healthy and unhealthy individuals (i.e., employment generally doesn’t correlate with health status). Carriers could manage large populations without individual underwriting.

• Significant tax advantages for employers: Insurance contributions are exempt from income and payroll tax under federal and state law (since the 1950’s).

But it’s 2025 now, and recent macro trends are eroding value:

• Premiums are on the rise, with the average cost of employer-sponsored coverage expected to increase by 7-9% (AON 2025, LendingTree 2024, PwC 2024)

• Job mobility is now common, with a median job tenure of 3 years for workers aged 25-34 vs. 10 years for ages 55-64 (BLS 2024)

• The gig economy is thriving, with 36% of U.S. workers participating as a primary or secondary job (McKinsey 2022)

New models are emerging in response.

In 2019, the fed created Individual Coverage Health Reimbursement Arrangements (ICHRA). Employees purchase their own coverage on the Exchange or directly from carriers. Employers set a budget, then reimburse the employee for premiums and qualified medical expenses.

We’ve seen movements like this before. During the 1973-74 market crash, employers couldn’t make good on pensions promised decades prior. The fed stepped in with sweeping regulations, creating the common 401(k). Employers were off the hook for lifetime payments, instead offering fixed benefits (“the match”).

ICHRA is the 401(K) of health insurance. Employers lock in fixed medical expenses to hedge against rising premiums, shifting plan purchase and admin responsibilities to the individual.

How does this benefit the employer? The employee?

Imagine group insurance like a fixed-price, corporate buffet. The employer pays the same premium for every employee regardless of their needs or preferences. Some want only a light lunch, while others require specialized dietary options, yet everyone’s “meal plan” costs the same.

ICHRA transforms this model into a flexible dining allowance. Employees have a set amount to spend on meals of their choosing from a variety of restaurants (carriers). Maybe they choose a basic plan that costs less than their allowance (and pocket the difference), or they opt for premium coverage by contributing additional funds.

Employers gain predictable costs and simpler administration, while employees receive the freedom to choose coverage that fits their needs.

How big is ICHRA today, and what can it be?

So how big can this get? Admittedly, ICHRA today isn’t a large market—though estimates vary, roughly 300—500K employees have an ICHRA available through ~25K employers across the country (HRA Data Council 2024).

This represents just a fraction (>1%) of small group (11M) and large group coverage (40M) (GAO 2024). But current excitement comes from the rapid growth rate (i.e., 70% CAGR), along with improving penetration and retention (80%+) with large and small employers alike (HRA Data Council 2024).

The demand is there, but before we can project forward, there are two more critical players to understand: 1) the payers and 2) brokers.

Exchange payers love ICHRA. Centene recently named its first president over the new ICHRA line of business. Likewise, Oscar Health is launching an ICHRA-specific billing and enrollment program (“ICHRA Connect”) to facilitate off-exchange plan purchases. This is because:

1. ICHRA means more lives in the individual market. More lives mean more premiums.

2. New lives improve the risk pool of the existing LOB. Exchange profitability has improved dramatically for Centene and Oscar (largely driven by 2021 premium tax credits which brought in healthier, middle-income lives). ICHRA lives could help even more.

Quick tangent: Large Commercial insurers remain silent (i.e., United, Elevance, Aetna). And this makes sense – why disrupt a profitable employer group market? At this point, any large-group employer interested in ICHRA might be looking to dump their “bad risk” into the individual market. This penalizes the taxpayer and the unsubsidized individual enrollee, who’ll have to pay up for the increased risk. We’ll discuss more later).

Now onto brokers; initially, they viewed ICHRA with skepticism. With commissions set at 3—6% of premium (and individual premiums lower than group plans), financial incentives appeared misaligned.

However, brokers are increasingly recognizing ICHRA’s strategic advantages:

1. Market expansion: ICHRA unlocks previously untapped lives, particularly employers with diverse workforces (part-time and seasonal staff)

2. Client development: Early ICHRA adoption allows brokers to establish relationships with growing businesses. As these companies scale, they become prospects for group coverage.

3. Operational efficiency: Modern ICHRA platforms (like Thatch) streamline labor intensive processes, like automated member onboarding, simplified plan selection, and more.

While ICHRA may yield lower margins, reduced admin burden and expanded market opportunities make ICHRAs an increasingly attractive product for forward-thinking brokers.

But back to the point, what could the market here look like in 5 – 10 years? A few triangulations below:

For our low case, take the CBO. By 2032, they estimate roughly ~2M people (including dependents) will enroll in ICHRA off-the marketplace (CBO 2024). The industry rule-of-thumb is that ~70% of individuals enroll off-exchange (they prefer to purchase plans directly from insurers / brokers, see conversation here). So that 2M equates to 2.9M total ICHRA lives.

A hyperbolic case would be the Trump admin’s projection of 11.4M total. That’s half of total exchange enrollment today, or 100% of Exchange enrollment in 2020 (prior to premium tax credits).

Historical growth rates of ~70% give us reason to believe in potential overperformance above the CBO, with a 28 – 30% growth rate leading to 3.5 – 4M lives in relatively short order. Solid scale, but not the earth-shattering scale proselytized by folks in venture-land.

What you need to believe to bet on ICHRA

Projections are great, but what will determine the migration of these lives? Regardless of strong market tailwinds, we believe five key things need to happen for ICHRA to achieve critical mass:

• Traditional options stay expensive. Over the past decade, small group enrollment has fallen at ~7% p.a. (Mark Farrah 2024), with premium increases reported above 10% p.a. for over half of small businesses (WSJ 2024). Though large group enrollment is stable (GAO 2024), premiums increased by 8%+ p.a. (PwC 2024). Continued adversity forces employers of all sizes to reconsider and view ICHRA as a viable solution.

• The Exchange stabilizes via continued premium tax credits. If PTCs vanish, upwards of ~7M people could leave the ACA. A smaller (and likely less healthy) population means premiums could grow by 75% (KFF 2024). If ICHRA is no longer a low-cost option for employers, it’s dead-on-arrival. Trump may back ICHRA for its support of small business, but ironically Republicans have voiced their dislike of the ACA. The states of West Virginia, Louisiana, Ohio, Indiana, and Tennessee saw the largest year-over-year increases in enrollment. It’s tough to predict where things land.

• Large groups convert to reach critical mass. It isn’t unreasonable to believe large employers could see the Individual Marketplace as a preferred risk pool vs. their own company – even the largest company is smaller than a state-wide risk pool. That said, folks like United, Elevance, and Humana, won’t let their most profitable LOB churn without a fight. But then again, neither did Vanguard or Fidelity, who both initially resisted the 401(K) (“a niche product for high earners”) before rapidly playing ball to avoid losing share.

Our last two drivers are more tactical.

• Exchange plan networks improve. The quality of marketplace plans remains variable. Though ICHRA will likely carve in many employees who previously didn’t receive coverage at all, one would hope that overall member growth allows for improved coverage at reasonable prices.

• Employer Adoption is made easy by third party vendors. Asking employees to enroll on the Exchange is more complex than group enrollment. Employers will require assistance from one of many ICHRA enablers to comply with federal regulations and ensure successful enrollment + reimbursement for employees.

Our final pulse

Though enrollment is small today, ICHRA is a ripe market with demonstrable market tailwinds and a clear value proposition to employers of all sizes.

Stroke of the pen risk via premium-tax credit continuation, Commercial payer resistance, and the volatility of the Exchange market may give some folks pause, but no market with asymmetrical upside exists without its fair share of caution.

We’d like scalable, tech-forward offerings with unit economics that don’t require moonshot member growth to return the fund.

Quick bonus: Market landscape

As a bonus here, we jotted down a few of the leading players in the space. In particular, we’re big fans of Thatch—their slick, employee facing tech platform + payment processing infrastructure look to be real differentiators in a space rife with manual complexity. Other players offer customizable, “white-glove” services, but we’ve found the majority to be highly manual under the hood.

• Thatch: Tech forward platform with payroll integrations (ADP, TurboTax). Automated premium payments + reimbursement infrastructure.

• Venteur: AI-driven decision engine with direct premium payments (no employee reimbursement claims)

• Remodel: Enterprise grade solution for large employers. White-glove broker partnerships + 200 HRIS integrations.

• SureCo: Large group specialist. Claimed 22% avg premium savings + compliance certainty.

• TakeCommand: Education-first platform, small business resources, Medicare integration tools.