|
Particle vs Epic, Strive Series D, and Gaming Risk Adjustment
September 11, 2025
|
|
|
|
|
Together with
|
|
|
|
|
For the first time in history, Epic will have to face antitrust claims in court after it failed to dismiss Particle Health’s allegations that the EHR giant has been wielding its monopoly power to stifle competition.
Here’s the overly-simplified version. Particle combines health data from 270M+ patients’ medical records by aggregating “thousands of sources”… sources like Carequality.
- Carequality is effectively one of the largest health information networks, facilitating data exchange between network members (like Particle) who agree to only query patient data for “Permitted Purposes” such as Treatment, Health Operations, or Public Health Activities.
- The problem at the heart of the lawsuit arises due to the fact that Treatment is the only purpose that organizations like Epic are actually required to respond to, causing all sorts of companies to warp their true purposes to Treatment-shaped requests.
Particle vs. Epic. Particle’s case alleges that Epic used its EHR monopoly to hamstring competition in the market for “payor platforms,” which allow payors to retrieve patient data to make decisions about care and coverage.
- Last spring, Epic said that Particle was allowing its customers to inappropriately label their Carequality data requests as Treatment, then proceeded to stop responding to EHR requests from 34 Particle customers.
- Particle’s lawsuit alleged that Epic trumped up the Carequality accusations in order to block it from serving its payor platform customers.
Epic filed to dismiss all nine of Particle’s claims. On Friday, the judge sided with Epic on five of the nine claims, dismissing the allegations that Epic maintained a conspiracy to uphold its market dominance, as well as claims of defamation and trade libel.
- However, the court declined to throw out all three of Particle’s federal monopolization claims, as well as a state claim that Epic had interfered with a business contract.
- Those claims will move forward into discovery, and Epic will now have to turn over documents that can shed light on whether its practices withstand legal scrutiny.
The Takeaway
Get the popcorn ready. Epic’s motion to dismiss was only partially successful, meaning it will now have to actually admit, deny, or qualify Particle’s remaining allegations. That deadline is quickly approaching on September 16th – then the real legal fireworks can get started.
|
|
Start Getting Leads From ChatGPT and Google AI
If your healthcare company isn’t getting leads from ChatGPT and Google AI Overviews, it’s probably because your content isn’t optimized for AI search. Tely AI runs keywords and questions research, generates and publishes GEO content, and captures new leads – all on autopilot. Create your first article on us to start filling your pipeline with patients and partners from today’s lead sources.
|
|
Supporting Sustainable GLP-1 Weight Loss With Withings
Leading digital health companies and health systems are supporting safe and sustainable GLP-1 weight loss with Withings Health Solutions. See how care teams are using Withings’ suite of remote patient monitoring solutions to prevent muscle loss, combat plateaus, and drive better outcomes for their patients.
|
|
- Striving for Value-Based Kidney Care: Strive Health hauled in $550M of Series D funding to expand its value-based kidney care model that uses predictive analytics to improve outcomes for chronic kidney disease. The model involves contracting with MA plans and risk-bearing providers to take on CKD populations, identify treatment gaps, and share in the cost savings. Strive can apparently predict the month someone’s kidneys will fail with over 95% accuracy, allowing them to fine-tune preparations for the logistics and lifestyle changes that come with dialysis treatment.
- Gaming MA Risk Adjustment: The Alliance of Community Health Plans didn’t mince words in its recent report that found major payors are gaming Medicare Advantage’s risk adjustment system to reap higher payments from the government. The analysis of CMS data found that UnitedHealthcare collected up to $785 more per beneficiary than local nonprofit plans in 2023, adding up to a $6B hit for Medicare. Humana collected $423 more per beneficiary, costing Medicare another $4B, which added to the ACHP’s argument that it’s time for a complete overhaul of MA risk adjustment.
- Ascend Acquires Laudio: Ascend Learning just scooped up workforce management startup Laudio to extend its healthcare learning solutions beyond the classroom to more frontline leaders. Laudio’s platform unifies functions like employee rounding, recognition, and professional development into connected workflows with AI-driven recommendations. Those recommendations are presumably about to start including a lot more Ascend products, such as testing and certifications.
- Different-Hospital Readmissions: Vizient’s CMS Qualified Entity Public Report found that one-third of discharged patients go to a different hospital when requiring a readmission. Readmission rates were higher in urban areas than rural areas (16.7% vs. 15.4%), but rural patients were more likely to be readmitted to a different hospital (35.1% vs. 32.3%). The highest share of different-hospital readmissions were for behavioral health (61.3%) and neuroscience (55.6%), creating “invisible returns” that further complicate care coordination and outcome tracking for these specialties.
- Hyro Unveils Proactive Px: Hyro unveiled its Proactive Px outbound patient experience platform, which features a complementary capability for assisting with coverage disruptions caused by OBBBA. As the name would suggest, Proactive Px enables health systems to proactively engage patients through outbound voice and SMS AI agents designed to streamline access to care. The complementary ARMR agent (ACA Re-Enrollment & Medicaid Redetermination) is publicly available to any system looking to get out in front of OBBBA-related operational challenges.
- Brook.ai Hits HEDIS Measures: Brook.ai revealed how its comprehensive remote care platform has been helping rural providers consistently hit HEDIS quality measures by combining AI-powered engagement with human care coordination. The platform makes it easier to capture and act on key metrics like blood pressure readings, preventive screenings, and medication adherence throughout the year – allowing providers to close care gaps before year-end and protect value-based incentive payments.
- Lawmakers’ Top AI Worries: A House hearing on AI’s potential to advance U.S. healthcare offered a good look at what lawmakers actually care about as they consider new legislation governing the use of the tech. STAT broke down five major concerns raised by lawmakers, as well as commentary by expert witnesses from Stanford, Clover Health, and the American Psychological Association. Topping the list: Medicare AI denials, rural health care, and teen mental health.
- Hospital Margins Stable But Softening: Kaufman Hall’s latest Flash Report showed that median hospital operating margins are now up 4% through July, however some metrics “hint at looming financial pressures.” Patient volumes are trending up, with discharges per calendar day climbing 4% compared to 2024, and net operating revenue per calendar day also up 8%. Non-labor expenses look like the biggest headwind, with supply and drug costs up 9% and 10%, respectively.
- CommonSpirit AI Update: CommonSpirit Health shared an update on its AI use across the system, revealing that it now generates north of $100M in savings from 230+ individual AI implementations. The second-largest nonprofit hospital chain in the U.S. has reportedly been ramping up its AI investments, deploying more than 70 new solutions over the last two years. One of the keys to its success has been its EDAG committee of clinicians, risk professionals, and ethicists that meets every two weeks to review new tools and algorithms.
- Daymark Series A: Hybrid oncology care startup Daymark Health raised $20M in Series A funding to help cancer patients more easily navigate their treatment. Daymark takes a full-risk approach to payor partnerships, then supports oncologists and PCPs through a community-based team of NPs, social workers, and other partners that deliver virtual and in-home care to address the clinical and mental health needs of their patients.
|
|
Under the Hood of Navina’s AI
Navina’s AI engine harnesses over 600 proprietary algorithms to transform fragmented patient data into actionable clinical intelligence at the point of care. It’s shaped with the expertise of physicians to turn multiple data sources (EHR, HIE, claims, care gap files, etc.) into contextualized insights like suspected conditions or evidence for care gap closures – each linked back to the original source. Download the whitepaper to see examples of Navina’s AI in action.
|
|
Next Generation Ambient Tech and Agents
The ambient AI transformation is already sweeping across health systems, reducing administrative burdens and improving patient outcomes. So, what’s next? Tune into this on-demand session to learn how systems like Carle Health and Denver Health are leveraging Nabla to eliminate Pajama Time and build a future where agentic AI unlocks true workforce sustainability.
|
|
- Elevate 2025 – Medallion’s Virtual Conference Returns Sept 17: Now in its fourth year, Medallion’s annual conference is back – bringing together healthcare leaders to explore this year’s theme: Elevate the present. Reframe the future of healthcare. Hear from industry voices like Tom Lawry, author of Hacking Healthcare, UPMC Chief Medical Information Officer Robert Bart, and many more. Reserve your spot now.
- AI Science Breakthrough: Hallucination-Free Clinical Documentation: Abridge has invented a novel system to classify, identify, and eliminate hallucinations from medical documentation before they reach clinicians for final review. This technology performs 6x better than standard AI models at finding and fixing hallucinations. Abridge delivers the best-in-class ambient AI for healthcare by investing in foundational AI science and research. Read this game-changing interactive whitepaper to learn more.
|
|
|
|
|
