Peterson says fee-for-service and autonomous clinical AI are a bad combination — pay per unit and you’ll get more units. The same logic decides who keeps the half hour an ambient scribe hands back. (The Big Thing, below.)
The House VA Committee voted 19–0 to subpoena Larry Ellison after the VA’s EHR ceiling went from $10B to $27B with 17 of 170 sites live.
🔮 My bet: the number that ends up mattering isn’t $27B, it’s cost-per-site — and someone reads it into the record before Thanksgiving.
Northwell moved subspecialty match rates from under 50% to over 85% and time-to-intervention from 74 days to 30. The metric changed before the model did.
🎧 Podcast: The 229 Podcast — “If I Took It Out Today, Would an Outcome Change?” — three informatics leaders on the scorecard that decides whether your pilot scales, and why a clean 12-month ROI isn’t a required dimension.
🧭 The Curbside
“Payers have to expose a Provider Access API in January. Does that give me anything?”
Short answer: Yes — a data source you’ve never had, four months out.
What changed / Evidence: CMS-0057-F requires impacted payers to stand up a FHIR Provider Access API by January 1, 2027, letting in-network clinicians pull their patients’ claims and clinical data from the plan. Four APIs, one deadline. The commercial signal that the plumbing is real is running the other direction first: on September 1, 1upHealth launched a product that lets plans pull clinical data out of provider EHRs over FHIR — sold on Star Ratings, with Capital Health Plan first in.
Builder read / Watchout: Your EHR-embedded app has never seen the claims history or the prior-auth record. After January it can. But “payer has an endpoint” and “endpoint returns something usable” are separated by a claims-to-FHIR mapping layer — and the plans that are already good at pulling clinical data across that seam are the ones most likely to serve something back.
😤 “Payers will ship a compliant endpoint that returns almost nothing.” Probably, at first. Build against it anyway — the ones who under-ship in January are the ones Star Ratings force to fix it by summer.
🔬 The Big Thing
Who actually keeps the thirty minutes?
The Peterson Health Technology Institute published a warning this week that reads like a footnote and isn’t one: run autonomous clinical AI through fee-for-service rules and you may raise spending without improving outcomes. Pay per unit, get more units.
That’s the whole question the ambient scribe category has mostly avoided.
Scribes are sold on giving clinicians time back, and the early data support it — burnout fell from 51.9% to 38.8% within a month of adoption in a six-system study.
But finance doesn’t buy well-being. They buy conversions: minutes into visits, or minutes into richer coding.
We already ran this experiment. Human scribes spent twenty years inside fee-for-service, and a meta-analysis of 39 studies found throughput up about 0.3 patients per hour and RVUs up 0.55 per hour.
Efficiency that meets a volume incentive gets absorbed as volume. It’s the Jevons paradox — today’s saved thirty minutes becomes the baseline tomorrow’s schedule is built on.
Here’s the part to sit with. One vendor publishes a case study claiming roughly $13,000 in incremental annual revenue per clinician. The strongest measurement to date — a UCSF study of 1,565 physicians across 1.2 million encounters — found about 1.81 RVUs per week, or roughly $3,044 per physician per year.
Fourfold. The time side is wider: a five-center JAMA study measured documentation time down about 16 minutes a day against the 60 to 100 minutes the vendor playbooks assume.
A system that paid expecting $13,000 and is seeing $3,044 has every reason to chase the difference — and once the vendor is paid, closing the gap is the buyer’s problem.
The ratchet bites at one intersection: fee-for-service payment, employed clinicians on productivity targets, documentation-heavy specialties. Remove any one and it weakens. Which is exactly why PHTI is arguing about payment design and not about models.
The number that will matter is burnout the quarter after the targets reset. Nobody has scheduled that measurement.
😤 “This is anti-AI concern trolling. Burnout went down. Take the win.” The burnout number is real and I’d deploy on it tomorrow. The argument isn’t that the tool doesn’t work — it’s that the tool works and the contract decides who collects.
😤 “Nobody is re-baselining anyone’s schedule.” Not yet.
😤 “What’s a builder supposed to do about compensation design?” Instrument for it. Does your dashboard report minutes saved — which finance will convert — or minutes protected, which somebody has to defend? Most tools have never been asked to tell those apart.
📡 Builder’s Radar
Congress just subpoenaed the man whose company runs the VA’s chart
The House Veterans’ Affairs Committee voted 19–0 to subpoena Oracle chairman Larry Ellison and CEO Mike Sicilia after the VA moved to extend its 10-year, $10 billion EHR contract by another $17 billion. Oracle declined to send anyone to testify. Seventeen of 170 medical centers are live since 2020.
Twenty-seven billion dollars, and the software was never the expensive part.
😤 “Government IT is always like this.” Sure. And every builder pitching a health system right now is quoting an implementation timeline built on the same assumption the VA made in 2018.
The agent layer doesn’t dissolve the system of record. It cements it.
Two pieces landed the same day from opposite directions. Brendan Keeler argues antitrust doctrine structurally can’t reach a system of record — market definition is unsettled, B2B share data unobtainable, and the SSNIP test collapses when switching costs dwarf any price increase. His read: information-blocking enforcement is already doing more real work than the FTC’s inquiry will.
John Lee, MD makes the product-side version: when the AI layer becomes the interface, something still has to be the auditable source of truth — and owning that base layer beats owning the interface on top of it.
If both are right, the agent era makes the incumbent harder to displace and easier to regulate. Neither is what the disruption thesis predicted.
They stopped optimizing for the next open slot
Northwell piloted subspecialty matching that moved match rates from under 50% to over 85% and cut time-to-intervention from 74 days to 30 — by measuring “time to appropriate care” instead of “time to next available.”
The model is the boring part. Changing the denominator is the intervention.
🔮 Where this lands: the first health system to publish a mismatch rate next to its wait time will make everyone else look bad on purpose — and I think that happens within a year.
⚡ Quick hits
Thyme Care closed over $125M past a $2B valuation and spun up a parent entity for separate operating businesses — biosimilars and trial accrual first. Navigation was supposed to be a service line. The bottlenecks it routes around turned out to be businesses.
Boston Scientific resumed shipping most products more than a week after the cyberattack that halted distribution. Almost nobody can name which clinical workflow has a single-vendor device dependency until the boxes stop arriving.
🎙️ From the Pods
🎙️ The 229 Podcast — “If I Took It Out Today, Would an Outcome Change?”
Informatics leaders from Children’s Hospital of Philadelphia, Banner Health and ThedaCare describe scorecards where financial ROI is one dimension among four — and where a safety intervention can scale without one.
💡 Builder take: Ask your champion what evidence would make them stop. If they can’t answer, your pilot has no ending, only an expiration.
🔇 Speaker Blindspot: Survivorship bias — every framework described comes from a system mature enough to have one. The systems drowning in vendor pitches are drowning because they don’t.
🎙️ Relentless Health Value — “Why Should a Plan Sponsor Care About the 340B Charity Program?”
Shawn Gremminger walks the plumbing: roughly $68 billion runs through 340B, second only to Part D — and no statute requires hospitals to reinvest the spread into charity care, nor tracks whether they do.
💡 Builder take: If you touch drug acquisition cost, the discount-versus-rebate fight determines your data model. Build it model-agnostic; the rebate pilot has been enjoined once already.
🔇 Speaker Blindspot: Composition fallacy — “hospitals” is treated as one actor, but a rural disproportionate-share hospital and an academic system with contract pharmacies run opposite programs under the same statute.
💡 BTW
💡 BTW: The motion to subpoena Larry Ellison came from Rep. Maxine Dexter, MD — a pulmonary and critical care physician who practiced at Kaiser Permanente Northwest for fifteen years and was the first woman to chair the Northwest Permanente board. The person asking Oracle why 17 of 170 sites are live has personally used an EHR.
You have a unique combination of skills, experience and values. So do great things! … and tell me about them at kevin@clinicians.build.
— Kevin & AI
(please verify content for yourself, partially AI generated and may contain errors)