Leading a safety-net hospital means navigating a unique tension: serving everyone who walks through your doors, regardless of their ability to pay, while maintaining the operational discipline needed to keep those doors open. It’s mission-driven work that requires clinical excellence, financial pragmatism, and a genuine commitment to meeting patients where they are—not just medically, but socially and economically.

In a recent episode of The BetterCare Podcast, EvidenceCare CEO Bo Bartholomew sat down with Dr. DeAnn Bullock, Chief Medical Officer at Nashville General Hospital, to discuss how she and her team balance these priorities every day.

Dr. Bullock wears three hats—CMO, Emergency Department Medical Director, and Medical Director for the Sexual Assault Nurse Examiner (SANE) program—and brings nearly two decades of experience serving Nashville’s most vulnerable populations.

What emerged from the conversation wasn’t just a story about safety-net care. It was a practical blueprint for how any health system can build equitable programs, improve clinician workflows, and simplify an overly complicated system for patients and providers alike.

Some quotes have been lightly edited for clarity and brevity.

Ep 32 – Delivering Care Where It’s Needed Most – Dr. DeAnn Bullock (Nashville General Hospital)

From emergency medicine to hospital-wide leadership

Dr. Bullock’s path to the CMO role started in a place that teaches you to say yes first and figure out the details later: the emergency department.

“Everything rolls down to the ED. Everything comes through the front door,” she explained. “It’s a 24/7 job. It doesn’t close, and so when people need things done, they call on the ED.”

That experience—managing constant demands, supporting teams under pressure, and solving problems in real time—became the foundation of her leadership philosophy.

When Nashville General needed a full-time CMO, Dr. Bullock had already spent years building trust across the organization. She’d served as quality director, then ED medical director for over a decade. She understood the hospital’s patients, its clinical teams, and its community role.

And then COVID hit less than a year into her CMO tenure.

“Really just kinda jumped in the fire and kept it moving,” she said matter-of-factly.

That willingness to step into challenges, combined with deep operational knowledge, has made her an effective bridge between frontline clinicians and executive leadership.

What equitable care looks like in practice

Nashville General’s mission is straightforward: To improve the health and wellness of Nashville by providing equitable access to coordinated patient-centered care, supporting tomorrow’s caregivers, and translating science into clinical practice.

But living that mission requires more than clinical care. It means addressing the full spectrum of patient needs—from transportation and food insecurity to insurance navigation and medication access.

When Dr. Bullock answered what equitable care means at Nashville General, her answer was concrete:

“Equitable care in our space means that everybody has access to the resource in which they need, however they need care. And that’s different for everybody.”

Nashville General has built an ecosystem of support services that go far beyond traditional hospital offerings:

Transportation: A donated van (“the CHAD van”) originally intended for oncology patients now serves anyone who needs a ride to appointments, helping reduce no-show rates across the board.

Food pharmacy: Patients can shop for food based on their medical conditions, working with dietitians to select items for diabetic diets, oncology nutrition needs, or other health requirements.

Meds-to-beds: Upon discharge, medications are brought directly to patients’ bedsides—no trip to the pharmacy required.

Clothing closet: Staff keep jackets, socks, and cold-weather gear on hand for patients who need them.

Community care team: A multidisciplinary team of case managers, social workers, and nurse practitioners provides ongoing support for patients with chronic conditions or frequent ED visits, checking in weekly to ensure they have medications, understand how to take them, and can get to follow-up appointments.

What was most striking about these programs is that they weren’t designed because of a new payment model or external mandate. They exist because the team recognized gaps and filled them.

“We’ve never done it for payment,” Dr. Bullock said. “People, whether they have everything they need, don’t have everything they need… people want to be heard, understood, and really want to know that somebody is there to help them.”

Building foundational service lines and community partnerships

Safety-net hospitals face a unique operational challenge: unlimited demand meets limited resources.

Dr. Bullock described it plainly: “We are a city safety-net hospital, and our goal is to take care of every Nashvillian no matter what their ability to pay is. And so with that, we aren’t a for-profit system. We do have some limitations around budgeting.”

The strategy? Focus on foundational services that a general hospital needs to provide, ensure those services are appropriately staffed with committed clinicians, and build community partnerships for everything else.

“We really try to build the foundation of those service lines so that we can keep as many people within our system that we can,” she explained.

For services Nashville General can’t provide directly, partnerships with other health systems become critical. The goal isn’t just to transfer patients out—it’s to ensure they feel welcomed at the receiving facility and can return to Nashville General when appropriate.

Listening first: How to improve workflows without adding burden

One of the themes consistently voiced by Dr. Bullock was the importance of listening to clinicians before implementing changes.

“You have to talk to the clinicians. You can’t assume what they need,” she said. “I spend a lot of time with my clinicians in our organization. What do you need? What are the challenges? How can we make this better?”

This approach isn’t just good leadership—it’s practical. Clinicians hear directly from patients about gaps in the system: phone lines that don’t work, referrals that fall through, prescriptions that can’t be filled.

“When they come back to tell you that, you’ve got to be able to prioritize and listen and say, okay. I’m hearing this four or five times. What’s the challenge?”

The EMR consolidation story

About a year ago, Nashville General completed a major EMR transition, moving from separate systems for clinics and the hospital to a single platform (Oracle/Cerner Community Works).

The goal was to eliminate fragmentation and improve care coordination.

“Our EMR was a huge obstacle to us being able to really navigate between our different places of care for our patients. We had our clinics on one, our hospital on another. Things weren’t talking to each other.”

The results have been significant:

• • Clinicians can complete notes more efficiently
  • Care teams can review complete patient histories across settings
  • Orders can be placed and appointments scheduled before patients leave
  • Communication with other health systems improved dramatically

“The workflow of the clinician is better. They’re able to get their notes done easier. We can send notes to other places. They can now read through and figure out what was happening. You know, we can put in orders and have an appointment made before the patient leaves.”

Of course, no EHR implementation is perfect. There are still challenges with specific workflows and integrations. But Dr. Bullock’s team addresses these through ongoing collaboration between IT and clinical staff, building order sets tailored to specific service lines and units.

The CMO role: Listening, mediating, and seeing the whole system

When Dr. Bullock was asked what she wishes more CEOs understood about the CMO role, her answer centered on flexibility, patience, and the unique position CMOs occupy in a health system.

“The chief medical officer role is different everywhere you go,” she acknowledged. “But I think at the end of the day, from a clinician standpoint, your clinicians are looking to your CMO for the clinical support that they need in doing their job appropriately.”

The CMO must navigate both sides: serving as part of the administrative leadership team while also being the clinicians’ advocate.

“Listen first, speak last, say the least amount of words. You’ll come out with the most information.” – Dr. DeAnn Bullock

This philosophy guides how Dr. Bullock approaches problem-solving. Sometimes she’s asked to solve a problem immediately. But often, the best solution emerges when she creates space for people to talk through challenges together.

The CMO also sees the organization from a systems perspective that individual departments or units can’t always access.

“I think one of the big parts of what I do is seeing it from a higher level, but also a whole hospital perspective. How does it affect everybody? How does this downstream effect everybody, not just my department or my unit?”

Looking ahead, Dr. Bullock’s priorities center on strengthening core service lines with committed clinicians, deepening partnerships with Meharry Medical College (where Nashville General serves as the primary teaching hospital), expanding community partnerships with other health systems, and changing external perceptions of Nashville General.

Advice for emerging physician leaders

For physicians considering leadership roles, Dr. Bullock offered straightforward guidance: keep an open mind to unexpected opportunities, be a continuous learner, and think about the bigger picture.

“Sometimes we don’t see kind of the forks in the road, and sometimes those forks in a road can open brand new doors. So what I say to that is if you have the capacity and you have the ability and there’s any interest, say yes.”

On the constant learning required: “Every single day is a new day for me. Every single day, I learn something. I think that’s one of the things I actually love about this role is that there’s always something that comes across your plate.”

And on the mindset shift leadership requires: “Part of leadership too is that you sacrifice a lot. You do the work and you do the good. All the rest of it will come.”

The magic wand question: Make healthcare simpler

When asked what she’d fix in healthcare if she could wave a magic wand, Dr. Bullock’s answer was immediate: “I think we just have to make it less complicated. It’s too complicated for the patients. It’s too complicated for the providers.”

She pointed to the maze of insurance plans, formulary changes, prior authorizations, and coverage gaps that patients—and clinicians—must navigate daily. The problem affects everyone, but it’s particularly acute for patients transitioning to Medicare who suddenly face multiple plan options and coverage decisions.

“There’s a huge opportunity to make this simpler for the patients. It’s just really hard for them, and we’re not really winning any battles by making it harder for them each and every day.” – Dr. DeAnn Bullock

Key takeaways for health system leaders

The conversation with Dr. Bullock surfaced three critical lessons for healthcare leaders:

Programs that address social determinants of health aren’t “nice to have”—they’re essential to clinical outcomes. Nashville General’s holistic approach recognizes that medical treatment is only part of the equation. Transportation, food access, and medication affordability directly impact clinical success.

Listening to clinicians before implementing changes avoids wasted effort. Too many health systems roll out initiatives designed in conference rooms without input from the people who will actually use them. Dr. Bullock’s approach—spending time with clinical teams, prioritizing based on recurring feedback, and involving IT in workflow design—produces solutions that stick.

Safety-net hospitals deserve more recognition and support. These organizations serve as the backstop for the healthcare system, caring for patients others can’t or won’t see. They do it with limited resources, complex patient populations, and financial constraints that would sink many for-profit systems.

Great leaders make the complex simple. That applies to strategy, to operations, and to patient experience. Dr. Bullock and her team at Nashville General are doing that work every day—simplifying care access for vulnerable populations, streamlining workflows for busy clinicians, and building partnerships that strengthen the entire Nashville healthcare community.

Listen to the full conversation with Dr. DeAnn Bullock on Episode 32 of The BetterCare Podcast to hear more about her leadership journey, safety-net operations, and practical strategies for building equitable care programs.

At the 2025 Nashville Healthcare Sessions Conference, Jason Zachariah, EVP & COO of Lifepoint Health, sat down with Bo Bartholomew, CEO of EvidenceCare, to discuss the unique challenges facing rural healthcare, the promise of AI-driven innovation, and what it means to lead with both ambition and humility in today’s complex healthcare landscape.

Some quotes have been lightly edited for clarity and brevity.

Ep 31 – Leading a Diversified Health System – Jason Zachariah (Lifepoint Health)

From Mayo Clinic Roots to Healthcare Leadership

Jason Zachariah’s path to leading operations at one of America’s most diversified health systems began in a small Minnesota town, watching his father—a cardiologist who immigrated from India—practice medicine in the shadow of Mayo Clinic. That early exposure to world-class rural healthcare shaped his understanding that exceptional care isn’t reserved for urban centers.

“I saw what really good healthcare looked like and what a small town like Rochester, Minnesota, could do when it came to rural healthcare,” Jason recalled, referencing Mayo Clinic’s origins with a father, his son, and some nuns who built an organization that would rival the best healthcare in London, New York, and Vienna.

After initially pursuing pre-med studies at Duke and later earning his MBA from Northwestern, Jason’s career took him through biotech and eventually into hospital operations. A pivotal moment came when Kindred Hospitals offered him a CEO-in-training program with a two-year timeline to leadership—significantly faster than the six-to-seven-year tracks at other major systems.

That decision set him on a course through post-acute care, long-term acute care hospitals, and rehabilitation facilities, eventually leading him to Nashville and his current role at Lifepoint Health.

A Uniquely Diversified Health System

Today’s Lifepoint Health is far from a traditional health system. Under Jason’s leadership, the organization operates 60 acute care hospitals, soon-to-be 60 rehabilitation hospitals, 25 behavioral health facilities, and 900 clinics across the country.

This diversification strategy sets Lifepoint apart in an industry where most systems expand through traditional acute care acquisitions or outpatient centers. “David [Dill, CEO] likes to say we like to do the hard with heart,” Jason explained, describing the company’s commitment to serving underserved populations across multiple care settings.

The behavioral health focus is particularly significant given America’s mental health crisis. Meanwhile, Lifepoint’s rehabilitation hospitals serve an aging population with an average age of 72—a demographic increasingly choosing to age in place in rural communities rather than relocating to expensive retirement destinations.

Servant Leadership in Action

When asked about his leadership philosophy, Jason emphasized servant leadership, humility, and creating a family atmosphere within the organization.

“I believe so much in getting behind your people and giving your team the credit but also making sure you’re skilling them in the right ways.”

This approach resonates particularly well in rural communities, where Lifepoint’s “folksy” culture—as Jason described it—aligns with local values. The focus on inclusion and belonging extends from executive suites to bedsides, creating an environment where outcomes improve because people feel connected to something larger than themselves.

Reflecting on his career, Jason takes pride in the hospital presidents, CEOs, and senior leaders he’s been mentored by along the way. “It’s been fun to see how you create that family atmosphere,” he noted, crediting CEO David Dill with recognizing and fostering those same values.

Innovation That Empowers Clinicians

At the Sessions Conference, one presentation particularly caught Jason’s attention: Rob Allen, CEO of Intermountain Healthcare, discussing how Microsoft’s AI-powered ambient listening technology achieved a 40% reduction in nursing documentation time.

“I’m happy if I can get a 10% reduction,” Jason admitted. “If they’re achieving 40%, I’m calling our CIO immediately.”

This reaction exemplifies Jason’s approach to innovation—not innovation for its own sake, but tools that directly empower clinicians and improve their daily work.

“If your caregivers are bought in and they’re seeing the value of the innovation, they’re really the ones that are going to make all the good stuff happen.”

Real-World AI Applications: Palantir and Beyond

Lifepoint has made significant investments in Palantir’s Foundry platform, applying technology originally developed for counterterrorism to solve healthcare’s fragmentation challenges. With a potpourri of EMR systems, laboratory information systems, and back-office platforms across 60 hospitals, Lifepoint needed a way to connect disparate data sources.

The results have been transformative. Nurse supervisors now use tablets powered by Palantir to see real-time hospital throughput—from transfer center to emergency department to PACU—replacing the clipboard and paper-in-smock approach of running multimillion-dollar facilities.

“They can see where all those flows are coming in a consolidated way,” Jason explained. “That’s changing our length of stay, changing our patient experience scores, and honestly, saving lives.”

Perhaps most impressive is Palantir’s sepsis detection system, which proactively alerts physicians and nurses by analyzing lab values, vitals, and imaging data. The impact is significant: for every hour a septic patient goes without intervention, their chance of survival drops by 10%. By reducing intervention time by several hours through automated alerts and enhanced bundle compliance, Lifepoint is directly improving mortality and readmission rates.

Dispelling the Myth of Hospital Wealth

One myth that frustrates Jason is the perception that hospital systems are “flush with resources and cash.” This misconception surfaced during recent legislative debates, including discussions around the One Big, Beautiful Bill healthcare reform proposals.

The reality is far different, especially for rural and behavioral health providers. “Rural healthcare is tough. Behavioral healthcare is tough,” Jason noted, pointing to Rush University Medical Center CEO Omar Lateef’s comment about operating on low margins despite running one of Chicago’s largest safety net hospitals.

The challenge is compounded by rising costs—from professional fees for clinical staff who deserve fair compensation for their training and burden of care, to supplies and implants—while hospitals serve as the “catch all” in the healthcare system.

“We’ve got to do a better job telling the public how vital we are to the health and infrastructure of every community in this country, and that we need to be resourced appropriately for it,” Jason emphasized.

Leading Through Paradox

When asked about recent reading that influenced his thinking, Jason pointed to a book on Abraham Lincoln’s leadership during the Civil War. The parallel to healthcare leadership was immediate and powerful.

“You see someone dealing with so many contrarian things at any given time—trying to defeat your enemy and still preserve the union, waging battle while thinking about humanity and equality,” Jason reflected. “I take that to healthcare. We talk about no margin, no mission. We talk about growth and expansion, but our frontline caregivers want to know they’re doing a good job for that patient right in front of them.”

This paradox—balancing organizational growth with individual patient care, margin with mission, innovation with bedside presence—defines modern healthcare leadership. Lincoln’s example of “leading with kindness while being fair and firm” resonates with Jason’s approach to what he calls “inclusive growth.”

“Everyone has to feel they’re a part of something bigger than themselves,” he said, whether through personal clinical ladders, leadership development, or organizational expansion that benefits communities.

The Path Forward

As Lifepoint Health continues expanding its rehabilitation and behavioral health footprint—adding another 10 facilities next year alone—Jason remains focused on the fundamentals: servant leadership, clinician-centered innovation, and serving underserved communities.

The healthcare landscape continues to present headwinds, from OPEC-driven cost pressures to the “silver tsunami” of an aging population with multiple comorbidities, regulatory challenges, and reimbursement constraints. But Jason sees these challenges as opportunities to demonstrate what healthcare leadership can accomplish when it embraces both ambition and humility.

“History always has the ability to teach us lessons for the future, especially with great leaders like Lincoln,” Jason concluded.

A fitting reflection from a leader working to prove that rural and behavioral healthcare can achieve world-class outcomes when properly resourced, thoughtfully led, and powered by innovation that truly serves clinicians and patients.

Listen to the full conversation with Jason Zachariah on Episode 31 of The BetterCare Podcast to hear more about Lifepoint Health’s approach to rural healthcare, AI implementation strategies, and lessons in servant leadership.

Hospitals don’t need more AI hype. They need outcomes. In my conversation with UnityAI CEO, Dr. Edmund Jackson on The BetterCare Podcast, we explored where AI is dependable today (scribes, computer vision in radiology, voice and reasoning agents for scheduling), what still belongs in the lab, and how healthcare organizations can pilot agentic scheduling safely with governance, patient-first design, and low-risk use cases that improve access and revenue.

We recorded during Nashville Healthcare Sessions, a week when every hallway conversation seemed to include AI. Our aim was to cut through the noise and focus on what’s working in real healthcare operations, what is still experimental, and how leaders can create measurable value without boiling the ocean.

Some quotes have been lightly edited for clarity and brevity.

Ep 30 – Scaling Operational AI across Healthcare – Dr. Edmund Jackson (UnityAI)

Where AI is already delivering dependable value

1) Documentation and ambient scribing.
Drafting notes and required elements from clinician speech.

2) Computer vision in radiology.
Targeted, workflow-aware assistance that speeds reads and reduces miss risk.

3) Voice and reasoning agents for scheduling.
This is UnityAI’s focus. Edmund walked me through a typical patient interaction:

“What we do is we make an AI and it calls you and it says, ‘Hey Amy, you saw your orthopedic surgeon yesterday. She’s ordered an MRI of your knee. I’m calling from the radiology clinic. Can I get you in this week?’

‘No.’

‘How about next week? Nine o’clock? I’ll get you at Sunny Hills. Oh, you can’t make Sunny Hills? How about Misty Waters?’

It’ll have that conversation and schedule you. It’ll handle multiple schedules… so it gets you on the calendar.”

What’s different here isn’t the “chat.” It’s the booking.

“We don’t script it so much as give it goals and boundaries and parameters. ‘This is what the schedule looks like. This is what’s available. Your job as an AI is, in a friendly way, to schedule this patient.’ That’s very different from the IVR systems we’re used to.” – Dr. Edmund Jackson

Patients are accepting it more than you might expect:

“Less than ten percent of our calls end up being escalated to a live agent to be handled.”

And the team sweats details that matter for patient experience:

“We have so many details that need to be right. You know, things like how the AI reads a phone number. Teaching the AI that cadence so that it’s natural for the listener is the kind of thing we’re detailing out every single day.”

On disclosure, UnityAI leans transparent, to still let callers know they’re speaking with an AI agent.

4) RPM when paired with real workflow.
Devices alone are not enough. Devices plus escalation rules and coverage models are.

Governance that builds trust

We spent time on first principles, because that’s where AI projects succeed or fail.

“First rule for us is we don’t do anything clinical… We strictly stick into operations.”

“We’re very deliberate around having humans in the loop, at least in a management loop.”

“There’s a risk surface… so we do continual tests on all of these calls. Is it doing the right thing? Is the experience right?”

Said differently: start on the operations side (scheduling, navigation, outreach, benefits checks), monitor like a managed service, and keep your audit trail tight.

The right first use case (and why it matters)

If you need a fast, low-risk proof point with financial impact, Edmund recommends focusing on referral follow-up and appointment reminders:

“People think the quickest thing is the right place to start. It’s not. It’s the lowest-risk thing… In healthcare, the primary issue is risk.

We’ll work with a client where there’s a backlog of referrals. They’re usually unable to get to all of them in time. We’ll say, ‘You work your priority patients and give us the rest, and the AI will call those patients.’

It’s effectively free because you weren’t going to get there anyway. Then the AI can get them scheduled and move them through. If that isn’t the case, we’ll do things like referrals or reminders. Very low-risk things with very small technical integrations.”

This is not innovation theater. It’s a practical access play that should lift show rate, days-to-schedule, and referral close rate without adding FTEs.

What surprised me most

I went into this conversation thinking “AI for access” was primarily a staffing story. It still is, but what stuck with me is how much of it is a patient dignity story. When an agent reaches me quickly, knows my options, and gets me scheduled without bouncing me around, it respects my time. That’s not a shiny feature. That’s the healthcare experience we all say we want.

I also appreciated the simplicity of the mental model: give the agent clear goals and boundaries, then measure whether it did the job. Not “Can it talk like a human?” but “Did more patients get on the calendar sooner?” That shift—from novelty to outcome—is where I think hospitals will feel the real impact.

And the small experience details matter. The cadence of how a phone number is read. The tone on a reschedule. The clarity that it’s a virtual assistant with a quick path to a person. None of those headlines will grab attention on a conference stage, yet they’re exactly what builds trust at scale.

What I’m watching next

Three things I’ll be paying attention to as this space matures:

• • Acceptance paired with transparency. Patients seem far more open to capable help than we assume, especially when we’re upfront about what the assistant is and offer an easy handoff to a person. I want to see more systems report those acceptance and escalation rates alongside access metrics.
  • Agentic work beyond scheduling, but still operational. Scheduling is the obvious beachhead. The next wave I’m watching is navigation, pre-visit preparation, and benefits checks—still on the operations side, still measurable, still respectful of clinical boundaries.
  • Leaders managing AI like a service line. Not a lab project. Not a one-off pilot. A managed, monitored service with sampling, SLAs, and clear ownership. In my world, that’s how you turn a promising tool into dependable capacity.

A simple takeaway

If there’s one lesson I’m carrying into planning, it’s this: scale outcomes, not hype. Start where risk is low and value is obvious. Keep the patient experience front and center. And evaluate AI by the most practical measure we have in access and ambulatory operations: more people getting the care they need, sooner.

If you want to watch the full conversation, watch the video above or listen to the episode of The BetterCare Podcast here.

The integration will power the next generation of real-time, automated bed status guidance and documentation into physician workflows.

Integrated directly into the EHR, AdmissionCare helps streamline patient status decisions and documentation across four hospitals.

EvidenceCare ranked No. 1,897 Overall and Among Top Healthcare Companies in the U.S.

Just a couple months ago, I wrote about the potential financial threats that Medicaid reform could pose to hospitals under proposed federal legislation. At the time, the One Big Beautiful Bill (OBBB) hadn’t yet passed, but now it has. And with it comes sweeping changes that will impact coverage, compliance, and reimbursement for years to come.

To help healthcare leaders move from speculation to strategy, we invited Darin Gordon, Founding Partner of Speire Healthcare Strategies, President & CEO of Gordon & Associates, and former Director and CEO of TennCare, on The BetterCare Podcast. With more than two decades leading and advising Medicaid programs across the U.S., Darin provided clarity, caution, and actionable guidance on what hospitals must do now.

Whether you’ve read the initial policy overview or are catching up for the first time, this conversation goes deeper into OBBB’s operational and financial implications, and how hospitals can prepare.

Some quotes have been lightly edited for clarity and brevity.

Ep 29 – Medicaid Reform and the One Big Beautiful Bill – Darin Gordon

The Medicaid Backstory: Expansion, COVID, and Enrollment Swells

Darin began by grounding the conversation in the basics. Created in 1965, Medicaid was designed to fill a gap in coverage for low-income individuals not eligible for Medicare. Over time, it evolved—especially after the ACA’s expansion to childless adults up to 138% of the federal poverty level.

Fast forward to the COVID-19 pandemic: in an effort to maintain coverage during the public health emergency, states were required to pause eligibility redeterminations. This “freeze” caused Medicaid enrollment to surge past 90 million enrollees. While the intent was to protect access during a crisis, it left many states with outdated rolls and unmanageable costs.

Now, the OBBB seeks to course-correct—but not without introducing a new set of challenges.

OBBB: What’s Changing, and Why It Matters

The One Big Beautiful Bill introduces a number of policies aimed at controlling Medicaid growth and tightening eligibility standards. As I noted in the earlier blog post, these changes were always likely to squeeze hospital revenue, especially for those serving low-income and rural populations. Darin’s insights from the podcast confirm those risks and lay out what they look like in practice.

1. Work Requirements Become Law

Adults ages 19–64 who are deemed “able-bodied” must now work, volunteer, or participate in job training for at least 80 hours/month to remain eligible for Medicaid. While many in this group already meet those criteria, Darin emphasized that the real complexity lies in verifying compliance—especially for volunteer hours and education.

States are still awaiting federal guidance on how to administer these rules, and the administrative burden could be significant.

2. More Frequent Eligibility Checks

Eligibility redeterminations will move from annual to semi-annual by the end of 2026, and new cost-sharing provisions will allow for up to $35 in copays per visit for non-exempt adults.

These measures may reduce improper enrollment, but Darin warned they could also create churn—with patients cycling in and out of coverage, complicating care continuity and hospital billing.

3. Provider Tax Caps Will Shrink Funding Pools

Nearly every state uses provider taxes to fund Medicaid and draw down federal match dollars. Under OBBB, expansion states will see their provider tax caps phased down from 6% to 3.5% by 2032.

This is a critical shift, and one I previously flagged as a threat to hospital sustainability. Darin confirmed that these taxes often fund rate enhancements or supplemental payments. As states lose flexibility in this area, hospitals could see real reimbursement reductions.

4. DSH Cuts Are Finally Moving Forward

After years of delay, Disproportionate Share Hospital (DSH) payment cuts are now scheduled to begin October 1, 2025, reducing federal allotments by up to 50% in some states. These cuts were originally tied to the assumption that ACA expansion would reduce uncompensated care but that hasn’t played out evenly across states.

Darin cautioned that safety net hospitals in non-expansion or under-resourced areas are particularly vulnerable, and hospitals shouldn’t assume the cuts will be delayed again.

A Time-Sensitive Opportunity: $50B in Rural Provider Relief

One bright spot in the legislation is the $50 billion Rural Provider Relief Fund, to be distributed between 2026 and 2030. But there’s a catch: states must apply by December 2025, and hospitals need to begin collaborating with state agencies now to influence how those funds are allocated.

Darin urged rural hospitals not to wait. “Don’t spend too long workshopping the perfect plan,” he said. “Start the conversations with your Medicaid agency early—before the application is locked in.”

The federal government is expected to release a menu of proven funding strategies for states to consider, but states will have room to propose their own. That means hospital voices can shape the direction if they engage soon enough.

Four Steps Hospitals Should Take Today

Darin’s recommendations for hospitals were clear, pragmatic, and urgent:

1. Engage Your Medicaid Leaders—Now

Whether through associations or direct conversations, hospital executives need to be in the room. Waiting for finalized guidance could mean missing the opportunity to shape how policy gets implemented in your state.

2. Collaborate Around Rural Relief Applications

States will need hospital input to submit strong applications for the Rural Provider Relief Fund. Come to the table with creative, locally relevant ideas, even if they’re still in development.

3. Prioritize What Matters Most

As provider tax flexibility shrinks, hospitals should work with Medicaid agencies to identify which funded programs are most essential. Don’t say “everything is important”—come with clear priorities and potential trade-offs.

4. Innovate Around Value

Though OBBB doesn’t directly advance value-based care, budget pressures may drive states to explore alternative payment models that reduce cost and improve outcomes. Hospitals should be ready to participate in these conversations.

Learning from the Past to Build a Smarter Future

During his TennCare tenure, Darin oversaw one of the most efficient Medicaid programs in the country. His leadership was marked by constant budget pressures but also innovation.

“In 20 years of public service, there wasn’t a year we didn’t have to make reductions… But those challenges forced us to rethink how we deliver care and to collaborate with providers differently.” –Darin Gordon

That spirit of open dialogue, regional customization, and data-driven solutions will be essential now. Whether it’s understanding how the new rules apply to your population, preparing for funding cuts, or shaping the rural relief strategy, the time to act is now.

Closing Thoughts

In my earlier blog, I asked: Will new Medicaid policies put hospital margins at risk?

Now we know the answer: yes, unless hospitals act early, engage their state partners, and adapt their financial and operational models to a changing Medicaid landscape.

This isn’t just about surviving new regulations, it’s about seizing influence while it’s still possible.

To watch or listen to the full episode, check out Episode 29 of The BetterCare Podcast.

Key OBBB Deadlines to Watch

Date	Policy Change
Oct 1, 2025	Medicaid DSH payment cuts begin ($8B/year)
Jan 1, 2026	Mandatory cost-sharing begins for some Medicaid adults
Dec 31, 2026	Eligibility checks must be semi-annual; retroactive coverage reduced
Dec 2025	States must apply for the $50B Rural Provider Relief Fund
2027–2031	Provider tax caps in expansion states phased down to 3.5%

What Hospital UR & Revenue Cycle Teams Need to Know

A Brief History of Precertification

Prior authorization (PA), originally known as precertification, began in the 1960s and expanded significantly during the rise of managed care in the 1990s. Its intended goals were to:

• • Contain healthcare costs

  • Limit unnecessary utilization

  • Ensure appropriate use of high-cost services

Despite these aims, PA has become an increasingly complex, fragmented, and burdensome process. Today, it is a leading driver of care delays, administrative waste, and provider burnout—with surveys indicating over 90% of physicians reporting delays in patient care due to PA requirements.

Some of the services affected are:

• • Advanced imaging (MRI, CT, PET)
  • Elective surgeries
  • Behavioral health (IOP, residential)
  • Specialty biologics and infusions
  • Cardiac diagnostics/tests
  • DME (wheelchairs, CPAP machines)
  • Inpatient admits from ED require concurrent authorization

Clinical variation remains one of the most under-appreciated drivers of inefficiency and cost in healthcare. Behind every excess test, unnecessary admission, or prolonged length of stay lies a variation in practice—often unintentional, sometimes unavoidable, but frequently addressable.

For health systems striving to improve quality and reduce cost, understanding and acting on clinical variation is not just a data exercise—it’s a cultural transformation.

I’ve had many conversations with clinical leaders around this topic, but in a recent episode of The BetterCare Podcast, I had the chance to go deep with someone who’s been doing this work for decades—Dr. Michael van Duren.

Michael has led variation reduction efforts at large systems like Sutter Health, and in our conversation, he shared a refreshingly honest look at what it takes to make real progress. What follows is a summary of that conversation, along with my reflections and takeaways for health system leaders who want to tackle variation meaningfully.

Some quotes have been lightly edited for clarity and brevity.