Independent health care firms build their own AI while Medicare and Medicaid tighten the rules
A briefing on home care, home health and hospice, physician groups, behavioral health, and specialty networks for anyone about to meet the people who run them.
Since May 2026, Medicare has frozen new home health and hospice enrollments nationwide, New York has cut its autism therapy rate for the third time in a year, and Medicaid work requirements begin around January 2027. Eleven leaders on our list are answering by building their own AI, keeping their firms out of private equity's hands, and selling care to employers, health plans, and hospitals rather than one patient at a time.
The short version
Six kinds of firm, one problem: someone else sets the price. Medicare, state Medicaid programs, and insurers pay for most home care, hospice, physician, and therapy work. More
Demand is rising while payers cut and audit. Home care jobs have grown 44% since February 2020. Medicare froze new hospice enrollments, and states cut autism therapy rates. More
Five changes mark the innovators: building their own AI, staying owner-controlled, selling to employers and health systems, living with audits and rate cuts, and redesigning the caregiver job. More
Eleven leaders on our list are already making these changes, and three more outside it run firms owned by physicians, workers, or a nonprofit. Each profile ends with a question to ask. More
Doctors and hospitals refer for free; platforms charge. Paying for Medicare referrals is a crime, while therapists and home care agencies pay for leads. More
Leaders want to talk about staff, payers, and what AI took off their plates. Mixing up home care and home health, or asking why they don't raise prices, marks an outsider. More
How the business works
Six kinds of firm sell care by the hour, the visit, the day, or the member
Outsiders lump several businesses together as "healthcare services." They share two things: most of their cost is people, and most of their prices are set by someone else. Medicare sets home health, hospice, and physician rates by annual rule, states set Medicaid rates, and insurers negotiate the rest. Home Health Care News CMS
Kind of firm
What it sells
Who pays, and how
A typical price
On our list
Non-medical home care
Hours of help with bathing, meals, and company at home
Medicaid pays about two-thirds of home care; families, long-term care insurance, and the Department of Veterans Affairs pay the rest. Billed by the hour.
$35 an hour, the national median in 2025 CareScout
Jeff Salter, Daniel Stringer
Home health and hospice
Skilled nursing and therapy for people who can't leave home; care at the end of life
Medicare, by 30-day period for home health and by day for hospice
$2,038.22 per 30-day period in 2026; $236.35 a day for routine hospice care from October 2026 HHCNCMS
Steven Gonzalez
Physician-owned groups
Visits and surgery (orthopedics), emergency department coverage, and dental care
Insurers, Medicare, Medicaid, and patients, per service from a fee schedule
Medicare pays $33.40 per relative value unit in 2026, the multiplier behind every fee CMS
Frank Aluisio, Yogin Patel, Greg White
Behavioral health and autism therapy
Therapy and psychiatry visits; applied behavior analysis (ABA) for autistic children, often 20 to 40 hours a week
Insurers, Medicaid, and employers, per visit or per 15-minute unit
New York Medicaid pays $9.63 per 15-minute unit of ABA from October 2026 BHB
April Koh, Dan Frogel, Doreen Granpeesheh
Specialty networks and benefit managers
Networks of chiropractors and physical therapists, review of care before it happens, digital programs, and employer mental health benefits
Health plans and employers, per member per month or per member who uses it
$65 for a virtual physical therapy session through American Specialty Health PR Newswire
George DeVries, April Koh
Home medical supplies
Breast pumps, sleep apnea machines, and other supplies shipped to patients
Insurers and Medicare, per item, after checking coverage and paperwork
Set by insurer contracts and Medicare fee schedules
Casey Hite
Home care and home health are different businesses, though many firms sell both. Home care is non-medical help that Medicare generally doesn't cover; home health is skilled care a doctor orders.
Medicare pays well for some patients and poorly for others
Medicare's own advisers found that freestanding home health agencies earned a 21.2% margin on traditional Medicare patients in 2024, but only 5.0% across all payers. The advisers recommended a 7% cut. MedPAC Hospices earned 8.0% on Medicare in 2023: 13.7% at for-profits and -1.3% at nonprofits. MedPAC Private Medicare Advantage plans and state Medicaid programs pay less, and they pull the all-payer margins down.
Private equity owns a growing share, but most firms are still owner-run
42.2% of US physicians worked in a practice their doctors owned in 2024, down from 60.1% in 2012, and 6.5% worked in one owned by private equity, according to the American Medical Association (AMA). Medical Economics Private equity firms staff at least 27% of US emergency departments. PESP Researchers counted 574 autism therapy centers owned by private equity in 2024. Disability Scoop In home care the long tail is founders, families, and franchise owners. The biggest deal of 2025 was an insurer buying a provider: UnitedHealth closed its $3.3 billion purchase of Amedisys in August. HHCN
The economics in 2026
Demand keeps rising while payers cut rates and police enrollment
52.9%of Medicare patients who died in 2024 used hospice, a recordsource
$35national median hourly price of non-medical home care in 2025source
75%annual caregiver turnover in home care, Activated Insights' 2025 benchmarksource
42.2%of physicians in practices their doctors own, down from 60.1% in 2012source
Notable change
Medicare froze new home health and hospice enrollments nationwide
On May 13, 2026, the Centers for Medicare & Medicaid Services (CMS) announced a six-month moratorium on new Medicare enrollments for hospices and home health agencies, and suspended payments to about 800 providers in Los Angeles. CMS
By September, Medicare had revoked the enrollment of about 800 of the roughly 1,500 hospices in Los Angeles County. The moratorium's first term ends November 13, and CMS can extend it. Arnall Golden Gregory Operators who play by the rules say the audits hit them too. Hospice News
So what: Firms that follow the rules were caught in the same review. Steven Gonzalez's HealthView, in Los Angeles County, kept operating on its own cash while its payments were held. Ask hospice and home health leaders how they show they're one of the good actors, and whether the freeze changed what they plan to build or buy.
The Bureau of Labor Statistics (BLS) counts jobs in each part of the industry every month. The chart shows which parts grew fastest after the pandemic.
Home care jobs have grown 44% since February 2020, more than three times as fast as jobs in physicians' offices
So what: Care is moving out of clinics and into homes and therapists' offices, and the workforce has followed. The fastest-growing lines are paid mostly by Medicaid and commercial insurance, the payers now cutting rates. Ask a leader whether their growth comes from more patients or from more staff to serve the same ones.
Home care for older and disabled peopleTherapists and other practitioners' officesHome health carePhysicians' officesDentists' offices
Bureau of Labor Statistics (BLS) monthly payroll survey, all employees, seasonally adjusted, as published in October 2026 after annual revisions; the latest two months are preliminary. Each line is divided by its February 2020 level. "Therapists and other practitioners" covers offices of mental health practitioners, physical and occupational therapists, chiropractors, and others; home care is the BLS category "services for the elderly and persons with disabilities." In April 2025 home care jumped by about 110,000 jobs in the same month home health fell by about 69,000, which looks like jobs moving between the two categories rather than new hiring. Hover for each month; click or tap for details.Show as a table
The number of Americans aged 85 and older is projected to grow 59% from 2025 to 2035
So what: Aide jobs grew 97% in the last ten years, faster than the oldest age group, yet the median aide still earned $17.21 an hour in 2025. BLS expects about 760,500 openings a year, mostly to replace people who leave. The next ten years are projected to bring more of the people who need the most help. Ask a home care leader what they pay, how long aides stay, and what the 2027 Medicaid changes do to both.
Americans aged 85 and older (millions)
Home health and personal care aide jobs (millions)
Population: Census Bureau estimates (2010-2020 intercensal, then Vintage 2025), summed by single year of age; 2030 and 2035 (lighter bars) are from the Census 2023 national projections, which run below the latest estimates. Aides: BLS Occupational Employment and Wage Statistics, May of each year; before 2019 the count adds home health aides and personal care aides, and the series excludes the self-employed and workers hired directly by families. The 2017 jump in personal care aides is in the BLS data. BLS projections. Sources for each year are in the table.Show as a table
Medicaid is shrinking. The Congressional Budget Office estimates the 2025 budget law cuts more than $1 trillion from Medicaid by 2034. Hooper Lundy One estimate has 311,879 fewer people eligible for Medicaid home care by 2034. McKnight's Home Care Work requirements for adults covered by the Medicaid expansion start at the turn of 2027. Virginia JCHC
Private Medicare plans squeeze harder than Medicaid. 56.2% of home-based care leaders named Medicare Advantage the payer putting the most pressure on them, against 31% for Medicaid, and 75% had limited admissions from some payers in the past year. HHCN
Autism therapy rates are falling. New York's third cut in 12 months leaves its ABA rate about 50% below early 2025. BHB Indiana capped lifetime hours, and federal auditors found improper payments in every state they checked. Hall Render Barnes & Thornburg
Physician pay is flat. Medicare's 2026 rate rise included a one-time 2.5% boost that expires, so the 2027 proposal cuts the rate 1.68%. McDermott+ In a June 2026 poll, 47% of medical groups reported revenue up and 36% down. MGMA
What is changing
Care firms are changing how the work gets done in five ways
The common thread is control. With payers setting prices and staff scarce, leaders are taking back what they can: their own software, their own ownership, and their own channel to customers.
From 2023 to 2026, the firms changing most are doing one or more of five things. The first three match the three groups of leaders on our list, and each cuts across the six kinds of firm.
1. Building their own AI
Firms are pointing AI at paperwork, phones, and insurance checks rather than at care. 81% of physicians now use AI at work, up from 38% in 2023. AMA Aeroflow Health says AI voice agents cut its call volume 10% to 15%, and ApolloMD is rolling AI documentation across its emergency departments. Aeroflow The AI Journal Health systems set the pace: Sutter Health went from a 100-user pilot of the AI scribe Abridge in 2024 to every clinician in 2026. Abridge
On our list: Casey Hite, Jeff Salter, Steven Gonzalez, Yogin Patel.
2. Staying owner-controlled
Private equity's debt-financed roll-ups hit a wall in 2023, when the physician staffing company Envision and the autism provider CARD (Center for Autism and Related Disorders) both went bankrupt. Becker's ASC NBC News Independent groups are building scale without selling. Three of the largest physician-owned orthopedic groups formed PELTO Health Partners in 2023 to share services without outside capital. Proliance Surgeons PepperPointe lets dental practices consolidate into groups their dentists own. PepperPointe
On our list: Greg White, Frank Aluisio, Doreen Granpeesheh, Daniel Stringer.
3. Selling to employers, plans, and health systems
Mental health and musculoskeletal firms grow by signing institutions that enroll thousands of people at once. Hinge Health, which sells exercise therapy to employers, expects $732 million to $742 million in 2026 revenue. Fierce Healthcare Spring Health bought the therapist network Alma, and Thriveworks put its clinicians inside a 30-hospital system. Spring Health Thriveworks
On our list: April Koh, Dan Frogel, George DeVries.
4. Living with audits and rate cuts
Payers and regulators are checking more claims before they pay them. Medicare began requiring approval in advance for selected procedures in six states in 2026, through a model called WISeR whose vendors share in the savings. KFF Physicians handle about 40 prior authorization requests each a week. AMA
5. Redesigning the caregiver job
Home care loses about three in four caregivers a year. HHAeXchange Immigrants are a third of the home care workforce, and about 330,000 Haitians are losing their permission to work as Temporary Protected Status ends. PHI The 19th A 2024 Medicaid rule will require 80% of home care payments to go to worker pay from 2030. LeadingAge
The innovators
Eleven healthcare services leaders on our list are rebuilding how their firms work
Eleven healthcare services leaders are among The Originals. Most run firms that founders, physicians, or partners control, and each has made a dated, costly change to how the work is done. The highest scorers are April Koh of Spring Health (7.1), Casey Hite of Aeroflow Health (6.7), and Greg White of PepperPointe Partnerships (6.4).
21 of these 22 dated moves came in 2023 or later
So what: Most of these leaders made their biggest changes after the pandemic, as staff got scarce and payers got stricter. The results are still coming in, so asking what has paid off and what hasn't is a natural way to open a conversation.
Building their own AIStaying owner-controlledSelling to employers, plans, and health systems
Each dot is one costly change to how the work is done. Click a dot for a short summary and a link to the story.Show as a table
Year
Leader
Move
Source
2020
Greg White
Nearly doubles the doctor-owned group to 92 practice locations in one day
Co-founder and CEO, Aeroflow Health · Asheville, North Carolina; privately held supplier of medical equipment billed to insurers; more than 1,000 employees in 2025
Casey is replacing the fax and phone queues behind medical supply orders with software. Aeroflow put AI voice agents on patient calls in 2024, and he describes checking each patient's coverage in real time, down to the employer group, before paperwork goes out.
“At Aeroflow, we address this by investing in real-time eligibility and benefit verification, including customization at the employer-group level.” source
Ask aboutWhich insurance and paperwork steps Aeroflow has fully automated, and what the people who used to do them do now.
Founder and CEO, Caring Senior Service · San Antonio; home care franchisor he founded in 1991, with more than 50 locations
Jeff built his own platform, Tendio, to run franchisees' scheduling, billing, payroll, and family updates, and in July 2026 won an industry innovation award for it and for the company's use of AI. He opened the brand's first Northeast office in September 2026.
“The incredible work of our team proves that combining smart technology, sound leadership principles and true compassion delivers unmatched results.” source
Ask aboutWhy he built Tendio rather than buying software, and what a franchisee's office looks like now that it runs on it.
President and CEO, HealthView Home Health and Hospice · Cerritos, California; founded in 1967; owned by him and two partners, with no private equity
Steven bought enterprise AI subscriptions for every full-time manager and, with a partner, built an internal tool called Culture AI that prepares managers for one-on-ones and tracks objectives. HealthView kept operating on its own cash reserves when Medicare withheld its Los Angeles hospice payments for review in 2026. HHCN
“At HealthView, we believe technology and systems should free people to do what matters most: provide compassionate, human-centered care.” source
Ask aboutWhat Culture AI does for a branch manager on a Monday morning, and what the payment freeze taught him about running on cash.
CEO, ApolloMD · Atlanta; independent, physician-run, and employee-owned emergency and hospital medicine group with 2,500+ clinicians and 400+ staff
Yogin, an emergency physician, runs one of the few large emergency medicine groups not owned by private equity. In 2025 ApolloMD partnered with Cleo Health to roll AI documentation across its emergency departments, starting in phases and extending nationwide.
“I'm also aware that today's health care environment is unlike anything in the last 40 years” source
Ask aboutWhat AI documentation has changed about an emergency physician's shift, and how the group decides what clinicians stop doing.
President and CEO, PepperPointe Partnerships · Lexington, Kentucky; an orthodontist who co-founded this doctor-owned dental service organization (DSO) in 2017
Greg built a DSO that practices own, rather than one that buys them. Practices consolidate into group practices owned by their dentists. PepperPointe nearly doubled to 92 locations in one day in 2020, added Virginia groups through 2025, and created three vice president roles in 2026 to support them.
“As we step into 2026, my wish for our industry is simple, but not easy: that we stop reacting to the future and start owning it.” source
Ask aboutWhat a dentist gives up and keeps by joining a doctor-owned group instead of selling to a DSO backed by private equity.
Physician President, EmergeOrtho · Durham, North Carolina; the state's largest physician-owned orthopedic practice, with more than 1,800 employees; Allison Farmer is its CEO
Frank backed the 2023 founding of PELTO Health Partners, a shared-services platform EmergeOrtho built with OrthoIndy and Proliance Surgeons as an alternative to private equity. In 2025 EmergeOrtho merged two Greensboro practices into the group.
“PELTO is founded on creating a partnership to offer an alternative to external private equity which preserves independent private practice.” source
Ask aboutWhich services PELTO's members now share that each used to run alone, and what that has saved.
Doreen and her partner Sangam Pant formed a company that bought CARD, the autism provider she founded, out of bankruptcy in 2023, after it collapsed under private equity ownership. She flattened the management structure and said she'd fund new centers from cash, not debt. In February 2026 CARD added four Phoenix centers.
“I am more committed than ever to CARD, our clinicians, and the families we serve.” source
Ask aboutWhat she runs differently now that she owns CARD again, and how a lean autism provider handles state rate cuts.
Founder and CEO, Total Care Connections · Tempe, Arizona; home care founded in 2009 with $10,000 and self-funded since; more than 1,000 team members in Arizona and Colorado, by the company's count
Daniel has built a home care company around caregiver benefits and accountability systems without outside investors, and it has completed four acquisitions. He says the firm is "not driven by outside investors or short term financial pressures." Total Care Connections
“We never set out to grow simply for the sake of size.” source
Ask aboutWhat benefits he offers caregivers that rivals backed by private equity don't, and what that costs per hour of care.
Co-founder and CEO, Spring Health · New York; venture-backed mental health company valued at $3.3 billion in 2024
April moved Spring Health from selling an algorithm to clinics to selling mental health care to employers and health plans. In 2026 she bought Alma, a network that bills insurers for independent therapists, so people keep their care when they change jobs or coverage. She also launched an AI guide that remembers a member's history.
“Mental healthcare has always been treated as a series of one-off events. Context is lost, progress resets, and momentum breaks.” source
Ask aboutWhose side Spring is on when an employer wants lower cost and a therapist in the Alma network wants a higher rate.
CEO, Thriveworks · Investor-backed outpatient mental health company with 340+ offices and 2,200+ clinicians; CEO since April 2024 after co-founding the urgent care chain CityMD
Dan is moving Thriveworks from finding patients online to working inside hospitals and primary care. He bought Synchronous Health, an AI-assisted telehealth provider, in 2024, and in February 2026 embedded Thriveworks clinicians in Ardent Health's records and workflows across 30 hospitals.
“Primary care and hospital settings have become the front door to mental health care, making behavioral integration essential.” source
Ask aboutHow a referral from an Ardent physician reaches a Thriveworks clinician, and what share of new patients now arrive that way.
CEO and President, American Specialty Health · San Diego; co-founded in 1987; manages chiropractic, physical therapy, and fitness networks for health plans
George is moving muscle and joint care from clinic visits toward self-serve digital programs and $65 virtual therapy sessions, sold to health plans with more than 100 million eligible members. American Specialty Health (ASH) says it approved more than 80% of 2025 therapy cases without a medical-necessity review by exempting proven providers.
“Preventing avoidable injuries is a critical lever for controlling MSK-related costs while supporting long-term member and employee well-being.” source
Ask aboutHow ASH decides which chiropractors and therapists skip review, and what that has done to the networks' costs.
Three leaders outside the list are making similar moves
These leaders aren't on the list. Each runs a firm owned by its physicians, its workers, or a nonprofit, and has made a change worth asking about.
Imamu Tomlinson
CEO, Vituity · Emeryville, California; physician-led and physician-owned partnership of more than 6,000 doctors and clinicians
Imamu runs the largest physician-owned rival to the emergency staffing companies backed by private equity. In 2024 Vituity led a project across 16 hospitals that cut average discharge times by about 15 minutes.
“a commitment to breaking boundaries in patient care” source
Ask aboutHow a partnership of thousands of physician owners decides on AI tools.
Jonathan Fleece
President and CEO, Empath Health · Clearwater, Florida; nonprofit network of hospice, home health, and other care
Jonathan launched the One Hospice Model in May 2025, putting seven local nonprofit hospice brands on shared quality, technology, and research support while each keeps its name.
“Families deserve hospice that puts mission before margin” source
Ask aboutWhat the seven hospices gave up to share one operating model, and what they got back.
Adria Powell
President and CEO, Cooperative Home Care Associates · Bronx, New York; the largest worker-owned home care cooperative in the US, founded in 1985
Adria leads a home care agency its aides own, and has taken its model beyond New York through a trust and a joint venture in Washington state.
“It's another mechanism for investing in the workforce” source
Ask aboutWhat worker ownership does to turnover, and what an aide-owner sees on a pay stub.
The wider field
Insurers, public companies, and AI vendors set the pace independent firms react to
A few large companies set the going rate for acquisitions, staff, and software that the leaders above have to match or work around.
Large firms and buyers
UnitedHealth Group (Optum) An insurer that also owns providers; closed its $3.3 billion purchase of the home health and hospice company Amedisys in August 2025.
LifeStance Health A public outpatient mental health company with 8,040 clinicians and $1.42 billion in 2025 revenue.
Hinge Health Sells digital physical therapy to employers and plans; listed on the New York Stock Exchange in May 2025.
TeamHealth The largest emergency department staffing company, owned by Blackstone and covering 552 emergency departments.
Companies selling the tools
Abridge AI that drafts clinical notes from a visit's conversation; now available to every clinician at Sutter Health.
HHAeXchange Runs the electronic visit records many state Medicaid programs require of home care agencies; bought its rival Sandata in 2024.
Cleo Health AI documentation for emergency medicine, being rolled out across ApolloMD's emergency departments.
How patients find a firm
Doctors and hospitals send most patients for free, while therapists and home care agencies pay for theirs
Notable change
Headway started charging therapists for the patients it sends
From October 8, 2026, Headway charges therapists $9.99 for each session with a client who found them through its marketplace, starting in Virginia, Washington, Georgia, Ohio, and Illinois. Therapists can leave the listing. ClearHealthCosts
The same year, Spring Health closed its purchase of Alma, which bills insurers for more than 26,000 independent clinicians, joining employer demand and insurance billing in one company. Spring Health
So what: Therapy platforms that were free to clinicians are starting to charge for the patients they send. Ask a behavioral health leader how many new patients come through platforms they don't control, and what each one costs.
The law shapes this market more than most. Paying anyone for a referral of a Medicare or Medicaid patient is a federal crime under the Anti-Kickback Statute, so home health agencies, hospices, and physician groups win referrals from hospitals and doctors with sales staff and fast service, not fees. Cornell LII Enhabit, a public home health company, credits faster replies to referral sources with a 3.1-point rise in the share of referrals it admits. Insider Monkey Private-pay home care and therapy are different: there, firms pay for leads.
$9.99Headway's fee per session for a client its marketplace sends, from October 2026source
$50per lead that one home care agency paid Caring.com, with about 2% of leads becoming clientssource
~7%of sales a typical home care franchise owner pays in royalty and ad fundsource
72 hrsfor Medicare Advantage and Medicaid plans to decide an urgent prior authorization, from 2026source
Firms pay three of the seven channels between patients and care
So what: Hospitals and doctors can't legally be paid for Medicare or Medicaid referrals. Health plans charge no fee but set the rate, so firms compete for those patients on speed, quality scores, and relationships. Private-pay home care and therapy pay for leads, brands, and billing. Ask a leader which channel brings their best patients and which one costs the most.
The care firm pays the channelThe care firm pays no fee
PatientAn older adult, a family, an employee, or a child's parents looking for care
→
Hospitals and doctorsNo fee from the firm
Hospital discharge planners, physicians, and case managers
They refer patients for home health, hospice, surgery, and therapy; paying them for Medicare or Medicaid referrals is a federal crime.
No fee; the firm pays for liaisons and fast intake instead. Cornell LII
Health plans and benefit managersNo fee from the firm
Medicare Advantage and Medicaid plans, Optum, Carelon, eviCore, American Specialty Health
They decide which firms are in network and approve care in advance.
No fee; the firm accepts the plan's rate and the paperwork of prior authorization. UnitedHealthcare
Employer mental health benefitsNo fee from the firm
Spring Health, Lyra Health
Employers pay the platform, which routes employees to its own clinicians or network.
No fee; therapists accept the platform's session rate. Spring Health
State Medicaid visit systemsNo fee from the firm
HHAeXchange, Sandata
Medicaid requires an electronic record of each home care visit before it pays.
No fee for the state system; agencies must record every visit. Michigan MDHHS
Therapy billing platformsFirm pays
Headway, Alma, Rula, Grow Therapy
The platform holds insurer contracts, bills for the therapist, and now sells marketplace referrals.
Headway charges $9.99 per session for clients its marketplace sends, from October 2026. ClearHealthCosts
Online referral sitesFirm pays
A Place for Mom, Caring.com, Care.com
Families search free; private-pay home care agencies pay per lead or per family placed.
$50 per lead at Caring.com in one agency's 2018 account, with about 2% becoming clients. HHCN
Home care franchise brandsFirm pays
Home Instead, Comfort Keepers, Right at Home, Visiting Angels
Local owners pay for the brand name, web leads, and software.
About 5% royalty plus a 2% ad fund at several brands, per franchise disclosure summaries. Franchise Investor Data
→
Care firmThe home care agency, hospice, physician group, or therapy practice that delivers the care
Fee levels come from laws, rules, company statements, trade press, and third-party summaries of franchise disclosures. Each links to its source.Show as a table
Channel
Examples
Does the firm pay?
What it costs the firm
Source
Hospitals and doctors
Hospital discharge planners, physicians, and case managers
No
No fee; the firm pays for liaisons and fast intake instead
Honor owns Home Instead The technology company bought the largest home care franchisor in 2021.
Spring Health owns Alma An employer mental health company now also bills insurers for independent therapists.
HHAeXchange owns Sandata The two main Medicaid visit-verification systems have had one owner since 2024.
UnitedHealth owns Optum and Amedisys The insurer that reviews therapy claims for its Medicare plans also owns a large home health and hospice provider.
Referral relationships are a payroll cost. Home health and hospice firms pay liaisons and intake staff, not referrers, and win by answering faster.
Private-pay leads are expensive. At $50 a lead and about 2% conversion, one agency's cost to win a home care client reached about $1,800 in 2018. HHCN
The payer can also be the competitor. UnitedHealth's Optum reviews therapy claims for its Medicare plans and owns Amedisys, so a provider may negotiate with a rival. UnitedHealthcare
Rules differ by payer and by state
Rule
Year
What it does
Anti-Kickback Statute (federal)
1972, amended since
Makes paying for Medicare or Medicaid referrals a crime. Cornell LII
21st Century Cures Act (federal)
2016; in force 2020 to 2024
Requires electronic visit verification for Medicaid personal care and home health visits. Michigan MDHHS
Washington referral agency act
2011
Regulates paid referral agencies for older and vulnerable adults: disclosures, refunds, and background checks. RCW 18.330
CMS prior authorization rule (federal)
2024; deadlines from 2026
Sets 72-hour and 7-day decision deadlines for Medicare Advantage and Medicaid plans. CMS
Mental health parity rule (federal)
2024; not enforced since 2025
New limits on how plans restrict mental health care are on hold while a lawsuit runs. Spencer Fane
WISeR model (traditional Medicare, six states)
2026 to 2031
Requires prior approval for selected procedures; vendors share in the savings. KFF
Four leaders run the main channels
April Koh of Spring Health, profiled above, now runs one of these channels. The four below run the main Medicaid visit-records system, the other large employer mental health company, the largest home care franchisor, and the biggest therapist billing network.
Paul Joiner
CEO, HHAeXchange · Software company that connects home care agencies, Medicaid programs, and managed care plans; CEO since 2023
Paul bought Sandata in October 2024, putting the two best-known systems that record home care visits for Medicaid under one owner. Many agencies can't get paid by Medicaid without passing through one of them.
“Now is the time to harness the power of advanced technology to truly support providers and payers with their billing needs and compliance requirements” source
Ask aboutWhat stops a company that sits between agencies and Medicaid from charging like a toll road.
Jennifer Schulz
CEO, Lyra Health · Venture-backed mental health benefits company sold to employers; CEO since January 2025
Jennifer runs one of the two largest employer mental health companies, which routes employees to its own clinicians and network. Lyra released an AI guide to members worldwide in 2026.
“The future of mental health care depends on the combination of clinical rigor and technological expertise” source
Ask aboutWhether Lyra will build an insurance-billing network like the one Spring Health bought in Alma.
Seth Sternberg
Co-founder and CEO, Honor (owner of Home Instead) · Venture-backed home care technology company that bought the franchisor Home Instead in 2021
Seth owns the best-known home care brand, whose franchise owners pay royalties for its name, leads, and software. Honor runs the franchise network on its own technology.
“What if the real opportunity for AI isn't speed, but compassion and empathy?” source
Ask aboutWhat a franchise owner gets from Honor's technology that a lead site or their own marketing wouldn't give them.
Andrew Adams
Co-founder and CEO, Headway · Venture-backed company that bills insurers for more than 90,000 independent therapists, by its own count
Andrew's company began charging therapists $9.99 per session for clients its marketplace sends them on October 8, 2026, starting in five states. Until then, therapists paid nothing to be listed.
Ask aboutHow Headway decides what a referred client is worth, and what keeps therapists from leaving the listing.
Trade-offs
Five trade-offs divide the healthcare services leaders you'll meet
Most leaders on our list have picked a side on several of these. In our reading, asking which side they picked, and why, gets to their strategy faster than asking about trends.
1Stay independent or sell to private equity
EmergeOrtho, OrthoIndy, and Proliance Surgeons built PELTO in 2023 to share services without outside capital. Proliance Surgeons
Physicians who sold their practices most often named better payment from insurers as the reason, at 70.8%. Medical Economics
AskWhat would a buyer have to offer for your partners to vote to sell, and what would you tell them?
2Take private Medicare plan patients or limit them
Freestanding home health agencies earned 21.2% on traditional Medicare patients in 2024 but 5.0% across all payers. MedPAC
75% of home-based care providers limited admissions from some payers in the past year. HHCN
AskWhich payer contracts have you walked away from, and what happened to your referrals?
3Build your own AI or buy it
Caring Senior Service built its own platform, Tendio, to run franchisees' offices. Franchising.com
ApolloMD partnered with Cleo Health for AI documentation across its emergency departments. The AI Journal
AskWhich piece of software would you never let a vendor own?
4Find patients yourself or through a platform
Thriveworks built its business finding patients online, then moved into hospitals and primary care. Thriveworks
Headway now charges therapists $9.99 a session for clients its marketplace sends. ClearHealthCosts
AskWhat share of your new patients come from your own marketing, and what does each cost?
5Pay caregivers more or protect the margin
Home care franchise leaders reported turnover near 77% and $2,600 to $5,000 to recruit each hire. HHCN
One autism therapy CEO said the only way to absorb a 20% rate cut is to cut staff pay. BHB
AskIf your largest payer cut rates 10% next year, would you cut pay, hours, or growth?
Before a first conversation
Healthcare services leaders want to talk about staff, payers, and audits
Every executive in Home Health Care News' 2026 home care forecast named workforce supply or wages first. HHCN Physician groups worry about burnout and flat Medicare pay, autism providers about state rate cuts, and hospices about audits. Most of these leaders also want to talk about what AI has taken off their staff's plates.
Six mistakes mark an outsider
Mixing up home care and home health. Home care is non-medical help, mostly paid by families and Medicaid; home health is skilled care Medicare pays for.
Asking why they don't raise prices. Medicare, state Medicaid programs, and insurers set most of their rates. New York cut its ABA rate about 50% in a year. BHB
Saying AI will replace caregivers or clinicians. Leaders aim it at paperwork and phones; one franchisor CEO said "AI agents are anything but personal." HHCN
Treating Medicaid as the only payer worry. Home-based care leaders rate Medicare Advantage as the bigger squeeze. HHCN
Joking about hospice fraud or autism therapy mills. Operators who follow the rules feel caught in the same net. Hospice News
Assuming telehealth rules are permanent. Medicare's telehealth flexibilities run only to December 31, 2027. Greenbaum
Ten questions get a healthcare services leader talking about the work
Which job in your company looks most different today than it did three years ago?
Where has AI taken work off your people, and where did you try it and pull it back?
When clinicians get time back from AI documentation, where does it go: more patients, shorter days, or something else?
How do you decide which Medicare Advantage contracts are worth keeping?
How many of your patients or clients come from your own marketing, and how many from referral sources or platforms you don't control?
How has the end of Temporary Protected Status changed your recruiting, and which roles feel it first?
Payers are asking what 40 hours a week of therapy buys. How do you show outcomes, and has that changed how you staff?
The hospice and home health enrollment freeze is up for renewal on November 13. Has it changed what you build versus buy?
What does your frontline person know about a patient that never makes it into your systems?
If you were starting the company today, what wouldn't you build?
Where they gather
Eleven events bring these leaders together by June 2027
Home care and hospice owners gather at the National Alliance for Care at Home and Home Care 100. Physician group leaders meet at the American Medical Group Association (AMGA) and the Medical Group Management Association (MGMA), and autism and behavioral health owners at the Council of Autism Service Providers (CASP) and Behavioral Health Business events.
