# Vida Research Journal

## Session 2026-03-10 — Medicare Advantage, Senior Care & International Benchmarks

**Question:** How did Medicare Advantage become the dominant US healthcare payment structure, what are its actual economics (efficiency vs. gaming), and how does the US senior care system compare to international alternatives?

**Key finding:** MA's $84B/year overpayment is dual-mechanism (coding intensity $40B + favorable selection $44B) and self-reinforcing through competitive dynamics — plans that upcode more offer better benefits and grow faster, creating a race to the bottom in coding integrity. But beneficiary savings of 18-24% OOP ($140/month) create political lock-in that makes reform nearly impossible despite overwhelming fiscal evidence. The $1.2T overpayment projection (2025-2034) combined with Medicare trust fund exhaustion moving to 2040 creates a fiscal collision course that will force structural reform within the 2030s.

**Confidence shift:**
- Belief 2 (non-clinical determinants): **strengthened** — Commonwealth Fund Mirror Mirror 2024 shows US ranked 2nd in care process but LAST in outcomes, the strongest international validation that clinical quality ≠ population health
- Belief 3 (structural misalignment): **strengthened and deepened** — MA is value-based in form but misaligned in practice through coding gaming, favorable selection, and vertical integration self-dealing (UHC-Optum 17-61% premium)
- Belief 4 (atoms-to-bits): **complicated** — PACE's 50-year failure to scale (90K out of 67M eligible) despite being the most integrated model suggests structural barriers beyond technology

**Sources archived:** 18 across three tracks (8 Track 1, 5 Track 2, 5 Track 3)
**Extraction candidates:** 15-20 claims across MA economics, senior care infrastructure, and international benchmarks

## Session 2026-03-12 — GLP-1 Agonists and Value-Based Care Economics

**Question:** How are GLP-1 agonists interacting with value-based care economics — do cardiovascular and organ-protective benefits create net savings under capitation, or is the chronic use model inflationary even when plans bear full risk?

**Key finding:** GLP-1 economics are payment-model-dependent in a way the existing KB claim doesn't capture. System-level: inflationary (CBO: $35B additional spending). Risk-bearing payer level: potentially cost-saving (ASPE/Value in Health: $715M net savings over 10 years for Medicare). The temporal cost curve is the key insight — Aon data shows costs up 23% in year 1, then grow only 2% vs. 6% for non-users after 12 months. Short-term payers see costs; long-term risk-bearers capture savings. But MA plans are RESTRICTING access (near-universal PA), not embracing prevention — challenging the simple attractor state thesis that capitation → prevention.

**Pattern update:** This session deepens the March 10 pattern: MA is value-based in form but short-term-cost-managed in practice. The GLP-1 case is the strongest evidence yet — MA plans have theoretical incentive to cover GLP-1s (downstream savings) but restrict access (short-term cost avoidance). The attractor state thesis needs refinement: payment alignment is NECESSARY but NOT SUFFICIENT. You also need adherence solutions, long-term risk pools, and policy infrastructure (like the BALANCE model).

**Cross-session pattern emerging:** Two sessions now converge on the same observation — the gap between VBC theory (aligned incentives → better outcomes) and VBC practice (short-term cost management, coding arbitrage, access restriction). The attractor state is real but the transition path is harder than I'd assumed. The existing claim "value-based care transitions stall at the payment boundary" is confirmed but the stall is deeper than payment — it's also behavioral (adherence), institutional (MA business models), and methodological (CBO scoring bias against prevention).

**Confidence shift:**
- Belief 3 (structural misalignment): **further complicated** — misalignment persists even under capitation because of short-term budget pressure, adherence uncertainty, and member turnover. Capitation is necessary but not sufficient for prevention alignment.
- Belief 4 (atoms-to-bits): **reinforced** — continuous monitoring (CGMs, wearables) could solve the GLP-1 adherence problem by identifying right patients and tracking response, turning population-level prescribing into targeted monitored intervention.
- Existing GLP-1 claim: **needs scope qualification** — "inflationary through 2035" is correct at system level but incomplete. Should distinguish system-level from payer-level economics. Price trajectory (declining toward $50-100/month internationally) may move inflection point earlier.

**Sources archived:** 12 across five tracks (multi-organ protection, adherence, MA behavior, policy, counter-evidence)
**Extraction candidates:** 8-10 claims including scope qualification of existing GLP-1 claim, VBC adherence paradox, MA prevention resistance, BALANCE model design, multi-organ protection thesis
