Provider & Leadership Perspectives
The Real Crisis Destroying US Healthcare ft. Sachin Jain
March 23, 2026
American healthcare doesn’t have a payment crisis; it has a profound leadership crisis. In this episode, Dr. Sachin Jain, President and CEO of SCAN Group, dismantles the broken culture of modern medicine and reveals how his non-profit Medicare Advantage organization is successfully flipping the script on senior care. Tune in to discover actionable strategies for aligning clinical integrity with financial sustainability, empowering you to drive meaningful change within your own health system.
Dr. Jain takes us under the hood of SCAN’s explosive growth, explaining why delegating full financial risk to provider groups is the ultimate antidote to the toxic cycle of traditional utilization management. He introduces his fascinating framework of "soft UM," challenging the industry's obsession with superficial quality metrics and exposing the "ethical erosion" plaguing profit-driven hospital boards. From designing hyper-targeted health plans for diverse populations to navigating the controversial debate over health systems dropping Medicare Advantage contracts, this conversation pushes boundaries and redefines the social determinants of health. Can we rely on corporate giants to save value-based care, or does the true solution lie in the hands of courageous, disruptive physician leaders?
If you’re ready to stop accepting the status quo and start leading with impact, hit subscribe and leave us a five-star review. Be sure to check the show notes for more information on SCAN Health Plan and additional resources on the future of healthcare innovation.
Episode Resources:
A Crisis of Leadership and Culture
Sachin H. Jain:
I don't think we have a crisis of payment or incentives like many people argue. I think that's the easy answer. I think we have a crisis of leadership.
I think everyone wants everything to change without anything changing. My mentor, Leeba Lessin, used to say, "You can't change without changing." The culture of most healthcare organizations is so broken, wherein everyone wants everything to be different, but they want their thing to be exactly the same.
Introducing Dr. Sachin Jain
Dr. Anthony Paravati:
Well, Amar, on this episode, we're joined by Dr. Sachin Jain. He is the president and CEO of SCAN Group and SCAN Health Plan, which is one of the nation's largest Medicare Advantage organizations dedicated to improving the lives of older adults.
In addition to that, he is an authoritative, very highly followed voice for healthcare policy and healthcare finance all over social media and other media outlets. Dr. Jain is a rare leader who has experience operating at various intersections in medicine, clinical medicine, policy, and health system innovation.
He did his training at Harvard and served in senior leadership roles both at CMS and at CMMI. He helped build innovative care delivery models at CareMore and Aspire Health. As we mentioned, he now leads SCAN as it expands to new models of care for seniors across the country.
Under his leadership, SCAN has grown a lot. They've grown rapidly, focusing on its founding mission of helping older adults live healthier and more independent lives. Today, we'd like to explore all the ways that SCAN is different from other Medicare Advantage plans. We'll talk about Dr. Jain's experience, how he thinks about leadership, how he works as a physician executive, and what he thinks the future of Medicare Advantage and senior care looks like over the next few years. Dr. Jain, thank you so much for joining us.
Sachin H. Jain:
Thank you so much for having me. It's great to be with you both.
The History and Mission of SCAN
Dr. Amar Rewari:
Yeah, thank you, Sachin. We've had a lot of commentary on this podcast around Medicare Advantage, but what makes SCAN unique is that it's a nonprofit plan with an explicit mission around keeping seniors healthy. I'm curious to know, what was the founding story behind SCAN and how does that mission actually show up in how the organization functions today?
Sachin H. Jain:
Not-for-profit and Medicare Advantage for the last 10 years could probably be considered an oxymoron. SCAN is different because we have an incredible founding story.
We were founded by a group of people we affectionately call the 12 Angry Seniors. These were activists, hippies in the late 70s who really wanted to age differently. They didn't want to go to a nursing home; they wanted to age in place.
They got together and formed something called the Senior Care Action Network. This was a group of racially and gender diverse older adults who banded together and said, "We can do this differently." Like every group of mission-driven people, they eventually wanted to start a Medicare Advantage plan.
That was our most recent instantiation of how SCAN is aiming to achieve its mission of keeping seniors healthy and independent. Today we have 440,000 members in California, Arizona, Nevada, New Mexico, Texas, and Washington State.
We also operate four clinical companies: myPlace Health, which is a PACE entity; Homebase Medical, which does chronic disease management and transitions of care in the home; Welcome Health, which is a primary care practice; and then Healthcare in Action, my favorite—you shouldn't have favorites—is our medical group that's focused on taking care of people in the streets, many of whom are actually older adults.
It's been an incredible journey. I've been with the organization for six years, but really I'm trying to build on the legacy of this incredible group of founders who I think set this organization up on a great path.
Delegating Risk to Providers
Dr. Anthony Paravati:
That's such an interesting founding story. You mentioned some of the components of the business already. If you had to identify something at your core operationally that makes SCAN able to deliver on the promise of making members' lives better, what would be that one thing?
Sachin H. Jain:
One thing that really sets us apart from a lot of other Medicare Advantage plans is we don't want to be in the utilization management business. We delegate the risk to provider groups who are interested in taking risk.
We give the doctors, hospitals, and health systems that want to take risk most of the money. Then they make their own decisions about what kind of care they're going to offer and what kind of care they may deny.
In many ways, I run a very boring business. We get money from the government, we delegate those dollars to provider groups, and then they manage the care of the patients. We administer supplemental benefits and provide member service and try to be a value-added partner to the medical groups.
We're really trying to get out of the business that has become so toxic in traditional Medicare Advantage plans and health insurance more broadly, which is that we don't want to be in the business of denying care. We think clinical decisions are best made closer to where care is actually delivered.
The Concept of "Soft UM"
Dr. Anthony Paravati:
That's very refreshing to hear. You mentioned the aspect of Medicare Advantage that has become a real sore point for several stakeholders, the government included, because the way most Medicare Advantage plans operate creates a vastly different experience for the senior. You all are not in that game of utilization management.
Sachin H. Jain:
We do a little bit of it. About 92% of our patients are in these fully delegated risk arrangements. 8% exist in a traditional network where we do some utilization management. I want to be super clear about that.
But our sweet spot is in this risk delegation to provider groups so that they can be the stewards of the Medicare dollar. There's an important distinction between how utilization management is done by insurance companies versus how it's done by medical groups. I call it hard UM versus soft UM.
Hard UM is your doctor tells you you need an MRI and your insurance company says, "No, you don't." Soft UM is your doctor never tells you you need an MRI in the first place because your doctor is practicing in an evidence-based way.
There's less abrasion and less friction with the patient. Insurance companies have been really good at putting themselves in between patients and doctors over the last 20 years. It's an uncomfortable position to be in. Sometimes it's the right position to occupy, but it's not necessarily the best.
We believe that medical groups should be the unit at which risk is administered and where these decisions are made. If a medical group develops a culture around thoughtful utilization, patients are not offered these things in the first place, so the care is not denied.
This is opposed to what happens in traditional insurance where it's a blank check to delivery systems. We'll just do everything and we'll get paid for everything. You both know how that plays out on the ground level. You're repeating tests that were done a few weeks ago, not because you should be, but because you can and because it might be easier than chasing down the medical records.
There's a different center of action and center of gravity when you are delegating the risk to the provider groups.
Dr. Amar Rewari:
I've never heard the concept of soft UM before, but I find it fascinating.
Sachin H. Jain:
I coined it. It's my term. I'm trademarking it today on this podcast.
Dr. Amar Rewari:
So I have to pay you for each time I say it?
Sachin H. Jain:
Exactly. Or you can be like everyone else and use it and say you came up with it. It's fine.
Dr. Amar Rewari:
How do you get to that point? You're talking about this relationship between insurance and care delivery. How do you get the providers to know that they should order that MRI to begin with?
Sachin H. Jain:
If a provider group is at full financial risk for a group of patients, they start to build a culture of resource efficiency and utilization that's aligned with clinical practice guidelines. You see this in a place like Kaiser all the time.
Kaiser owns all the premium dollar. Because of that, they're not offering patients crazy untested therapies. They're not doing the Q4 month echocardiograms that my dad had in his last several years of life that were not clinically indicated.
We're moving away from overutilization and being more parsimonious, but in ways that don't put the patient in the middle. The patient is not going to get upset about not getting an echocardiogram if they've never been offered it.
Where they start to get frustrated is if they get offered something that is overutilization by most standards, and then an insurance company steps in and says, "You don't need this thing your doctor says you need." That is the source of frustration for doctors and patients. Mature medical groups practice in this way because they have skin in the game.
Dr. Anthony Paravati:
What you say really resonates. My day job is with a very large ACO. What you described resonates exactly with how we think and the realities of taking on full risk.
Sachin H. Jain:
Culture change is hard. We're all trained to practice a particular way. We all come from different training paradigms. Then we get to a group and we first confront the business of medicine.
We realize the incentives are all distorted and payments are not always aligned with what's right for patients. What we're trying to do is create a system—not a perfect system, but better than the alternative—wherein the medical groups truly do feel some responsibility for resource stewardship.
Integrating Social Determinants of Health
Dr. Amar Rewari:
You mentioned helping people on the streets is one of your favorite programs. Regarding social determinants of health, what made you realize early on that this was where you wanted to focus and that it's central to improving health outcomes?
Sachin H. Jain:
That was always part of the founding DNA of SCAN. The Senior Care Action Network was actually a network of service providers to help people stay in the home. What is old is new and what is new is old.
Their early slides had things like transportation services and in-home food delivery—things touted as innovative today that the founders of SCAN were thinking about in the early 80s. They were part of CMS's original social HMO demonstration project.
They were the oldest and longest running instance of that project, which tested whether incorporating social determinants of health with medical services could reduce the total cost of care. The results were equivocal because the problem with social determinants interventions is that we spread them across too many people.
You'll offer rides to people who can drive. You'll give food to people who have food in their refrigerator. It's hard to show an effect when you're giving these interventions to everybody. If we were able to be more targeted, it would make a big difference.
My personal passion came from leading CareMore Health, where doctors would do heroic things like getting air conditioners into the homes of patients dehydrated in the summer or buying refrigerators for patients who couldn't store insulin. In those specific instances, it made a difference. We were able to lower the total cost of care and serve people the way they should be served.
Systemic Issues in U.S. Healthcare
Dr. Anthony Paravati:
I'm hearing how you all implement innovations that get at the realities of aging. Regarding the U.S. healthcare system, what are we doing that misses the mark so badly in this space?
Sachin H. Jain:
Everything. Do you have a couple hours? I don't think we have enough time.
I'll offer an alternate theory. I don't think we have a crisis of payment or incentives like many people argue. I think we have a crisis of leadership. Everyone wants everything to change without anything changing.
My mentor, Leeba Lessin, used to say, "You can't change without changing." The culture of most healthcare organizations is so broken because everyone wants their thing to be exactly the same.
If you look at leadership in the corporate sector versus leadership in most healthcare organizations, it's completely different. People will make hard choices in other sectors. We always split the baby. We haven't been willing to make trade-offs that leave some people worse off and some people better off.
Think about how much we've gutted primary care and delegated to specialists. Amar and I are both Indian, so we can talk about this safely: we've created a caste system in American medicine. You should see the way specialists talk about primary care.
Primary care as it's practiced today is different from how it was intended. A confident generalist should have total command of a patient's care such that specialists are brought in only when really needed. Today, a primary care doctor is just a triage engine. That's why people talk about primary care being replaced with AI.
Dr. Amar Rewari:
A counter argument would be that the level of knowledge in medicine has just grown tremendously.
Sachin H. Jain:
I agree. I was saying exactly this to my mother today. She asked why her hematologist oncologist couldn't answer why her oxygen requirement had gone up over the last six months.
I told her she needed to talk to her pulmonary doctor. She asked why the hematologist couldn't answer. I said, "Mom, she doesn't know any of the drugs that you're on. They were all invented in the last 10 years, and we were never taught them in medical school."
That's a shock to most people—how complex medicine has become. At the same time, the principles of physiology and prevention have not changed all that much. People should own more of the patient experience and we shouldn't just run referral medicine.
The Role of E-Consults and Value-Based Care
Dr. Anthony Paravati:
One innovation trying to combat that is the use of e-consults. I don't know if you've had much experience with this, Amar or Sachin.
Sachin H. Jain:
E-consults are amazing. They make confident generalists more confident. If you have a question, you're able to reach out and decide whether this truly requires a visit.
E-consults work in a risk-based environment where you're trying to manage utilization. They don't work in a health system where you're trying to maximize your top line and drive visits through a chassis.
I have a friend, Kelsey Mellard, who ran an e-consult company called Sitka. She worked explicitly with the truly risk-based groups. She didn't get commercial traction from large health systems because they wanted to drive more referral volume to specialists. They weren't interested in reducing low-value visits. Those low-value visits are a great arbitrage opportunity; they get billed at a high price and don't require many resources.
Governance and Board Incentives
Dr. Anthony Paravati:
What is it that makes healthcare systems or medical groups flick that switch and say, "We're going to act like every other business and care about what the customer wants," rather than just driving referrals to high-cost specialists for short-term revenue?
Sachin H. Jain:
Before I worked in the space, I was an academic, which allowed me to travel and meet all the brand-name health systems. I would defy you to show me one that has made the deep transformation we're talking about. A lot of it is just superficial.
The problem goes back to the governance of large health systems. They're not populated by doctors and public health experts. They're populated by local titans of industry, real estate developers, and banking professionals.
The boards measure the success of a CEO by two things: top-line growth and bottom-line growth. If your incentive is to maximize top-line revenue, the best way to do it isn't to get into some contorted ACO contract that pays you back in 18 or 36 months. It's to drive as much as you can through your fixed infrastructure.
Dr. Amar Rewari:
You've come from so many different backgrounds—academia, care delivery, government. How have those experiences helped you realize how people are operating in silos?
Sachin H. Jain:
I'm a little too young to say this, but the truth is they made me cynical. Many of us are looking for Nirvana—a place where they're doing things right. The closer you get to the center of power, you realize they're guided by primitive incentive models.
I call this phenomenon ethical erosion. Most people start out trying to do the right thing. Then over time, they start thinking about their second home in Martha's Vineyard and how to maximize the incentive program put in front of them to maximize revenue.
That's how little community hospitals became these big behemoth health systems. My father was a physician, and he never talked about inorganic growth. He was just thinking about how to take great care of patients.
Something changed where we started indexing ourselves against other industries. We applied private equity mindsets to community-based healthcare, and things have gone awry. We're in a weird dystopia. I gave grand rounds at a major academic health system about value-based care, and a prominent primary care expert asked, "What do we do if we don't have medical assistants in our offices?"
It was a good pushback. We are bringing a fork to a knife fight in many ways as physicians in the battle around the soul of American healthcare.
The Measurement Industrial Complex
Dr. Amar Rewari:
With value-based care, the problem is trying to come up with quality metrics. Are those really true quality metrics or are they just the easiest ones to assess?
Sachin H. Jain:
Let's throw most of the metrics out. They are garbage. We've created a measurement industrial complex wherein there's layers of middlemen who profit off of the infrastructure. Most improvement is around improving the measure as opposed to true quality.
We led a federal lawsuit against CMS around its star ratings because one French foreign language call was going to cost SCAN $250 million. It was a swing from three and a half stars to four stars. We argued that they applied the thresholds inappropriately and misapplied the Tukey outlier methodology to setting the benchmarks.
We prevailed in a federal court. It was a demonstration that one foreign language secret shopper should not be the swing between $250 million. Most of that money was going to our provider partners, not SCAN.
Real quality is invisible to metrics. It's whether the person answered the question and was respectful. I went to an appointment with my wife this morning for an issue she has. We went to see a nurse my wife dreads because she never answers questions.
The doctor saw I was there and pulled us into his office. It was a completely different experience. We got answers and solutions because he spent time with us. That's not going to show up in any quality metrics, but he gave a shit, and it made all the difference to me and my wife.
Targeted Products for Diverse Seniors
Dr. Anthony Paravati:
SCAN has done some amazingly innovative things. You have SCAN Affirm, which is the industry's first MA plan for LGBTQ+ older adults. You've got SCAN Inspired for women, and SCAN Allied for Asian older adults. What allowed you to create such specific products?
Sachin H. Jain:
One of the business reasons diversity matters is it's a recognition that people who are different may want or need different things from their healthcare experience. When we try to homogenize a group as diverse as older adults, a lot of nuance gets lost.
We recognize that LGBTQ+ seniors came out of the closet in the 80s during the AIDS crisis when there was a lot of stigma and trauma. They need a provider network sensitive to their issues and access to tailored behavioral health resources.
SCAN Inspired serves women who are "sandwich generation" players helping kids and grandkids while needing an extra layer of support. SCAN Allied serves East Asian older adults who often consume healthcare differently, use acupuncture or herbal medicines, and need in-language provision of care.
These products have grown gangbusters. We have over 10,000 members in the Allied product and over 4,000 in Affirm. Interestingly, the Inspired product has not grown quite as much, so we have work to do there. But it brought entities like Cedars-Sinai and UCI in-network because they were inspired by the product. It's been really good for business.
Dr. Anthony Paravati:
The traditional MA playbook for growth is aggressive marketing and risk adjustment optimization. Your strategy seems to be centered on highly tailored plan design.
Sachin H. Jain:
That's part of it. Some of it is being a better partner to our providers. We don't skimp on payments. If a for-profit plan pays 85 cents in a delegated risk arrangement, we may pay 86 cents.
As resources in MA have become more scarce, our provider partners increasingly want to work with a provider-friendly, high-rated plan. Because we've been four-plus star rated in California for 13 years, we get paid about $100 per member per month more than a three-and-a-half-star plan. If a provider group gets 85% of that, they get an extra $85 for partnering with SCAN.
Health systems are starting to rationalize the plans they partner with. Since I started at SCAN, we've gone from $2.7 billion and 220,000 members to $8.2 billion in revenue and 430,000 members.
Navigating the Medicare Advantage Landscape
Dr. Amar Rewari:
Because you're growing so rapidly, what challenges do you see?
Sachin H. Jain:
MA was the darling of this administration for a long time, and then it wasn't. The recent rate increase was essentially a pay cut in an inflationary environment. Growth and quality don't always go hand in hand, and we're committed to staying high quality.
I want to be a really big "small company," meaning we still want to have those values where every patient matters. I have given my email address to every single member. I get several emails a day from members, some happy and some unhappy. Our goal is to make every single member happy.
There's also ambivalence in the provider world because many have been treated badly by MA plans with UM and non-transparent payments. Some systems, like Scripps, are saying they don't want to participate in MA anymore.
But MA is an important part of the social safety net. Traditional Medicare with supplements is really a rich person's program. People on low monthly incomes can't afford it. We have to find a way to make Medicare Advantage work for providers, patients, and the health system.
Dr. Anthony Paravati:
The single most common question I get from finance types is, "Should we just stop taking Medicare Advantage like Scripps did?" But you can't do that in most markets.
Sachin H. Jain:
You have to try to make the economics work. First, you have to take better care of the patients. You've got to master the art of chronic disease management and manage your inpatient admission volume.
Second, you've got to enter into sustainable economic arrangements. CFOs of health systems often don't understand MA levers. They don't understand how small changes in contract terms lead to huge swings in performance.
Regarding Scripps, you could have increased the premium on the product or made benefits less generous to preserve access. Average Social Security income is about $52,000. Part B, Part D, and a supplemental policy for a couple cost about $12,000 a year. That is a quarter of their annual income. Traditional Medicare is literally not an option for them.
When you're a not-for-profit health system and you say you're not taking MA anymore, you're saying something very particular about who you serve. Your mission should be to take care of poor, frail, vulnerable people.
Dr. Amar Rewari:
It comes down to trust. Some systems argue the accounts receivable has gone longer and longer, making it hard to maintain quality. But as you said, these are economically disadvantaged populations.
Sachin H. Jain:
We have to end some of the crazy behavior in MA plans, like Part B rebate plans and irrational benefits like golf clubs. We have to get back to healthcare. This program has a real place in American society for lower-income seniors.
Dr. Anthony Paravati:
I'm going to look into whether it materially affected operating margins for those who cut out MA.
Sachin H. Jain:
It's a popular strategy being celebrated in the hospital world, but it's the wrong strategy. If anyone thinks it's right, they should call me and I will show them ways to make it work that don't involve giving up on the poor people in your community.
Advice for Aspiring Physician Leaders
Dr. Anthony Paravati:
Before we go, is there any advice you would give to the up-and-coming physician leader?
Sachin H. Jain:
One is to stay clinical as long as you can. A lot of residents think they should take an off-ramp early if they want to do business. You need credibility and real experience. I'm getting recredentialed right now at the VA in LA to be an urgent care doctor because it's important to stay close to it.
Second, don't confuse being a mediocre middle manager with being a leader. The moment requires more Marie Curie, Malcolm X, and Martin Luther King.
Be a friend to your most revolutionary colleagues. There's always that person who says the thing everyone's thinking but no one has the courage to say out loud. They often become outliers because the rest of us stay silent. Ally with those voices. You can say, "What Anthony was trying to get across is X, Y, or Z."
There's no Wizard of Oz coming to save us. We are the ones who have to save American healthcare. We have to stop holding onto the idea that Amazon or Jeff Bezos will save it. It starts with bringing integrity back to whatever part of the ecosystem you inhabit.
We as doctors are grumbling in rooms quietly instead of saying the things out loud in larger forums. Bring more courage to work and be comfortable with the fact that real leadership sometimes involves taking hits. It's not going to be easy.
Building a Legacy of Ethical Aging
Dr. Amar Rewari:
What you said about innovators being marginalized really resonates. One final question: at the end of your career, what do you hope people say about the impact you've had?
Sachin H. Jain:
I hope people say that SCAN redefined the ethics of aging in America by doing the right thing. We have the luxury in this not-for-profit setting to sometimes do things that aren't in the best financial interest of the organization but are in the best interest of the patient.
Six months ago, the president of the company and the CFO came to me about a drug, Prolia. They said we weren't covering it, but patients needed it and couldn't afford it. They said, "I think we should cover it."
I was so proud because we did the right thing for the right reasons. We will make up the million dollars it costs us somewhere else. The fact that two non-clinicians came to me and said we need to do this made me feel like we're on the right path.
Dr. Anthony Paravati:
The path you're on has clearly been demonstrated by the growth of SCAN. You're absolutely one of the good guys out there. It's been a great conversation and we thank you again.
Sachin H. Jain:
Thank you so much. It's been an honor.
