Over the weekend, I caught parts of North Carolina’s 15-10 win over TCU in Dublin, Ireland and NC State’s loss to Virginia 34-8 in the ACC opener. All told, the NCAA Week Zero schedule included 8 games with few surprises but a welcome arrival to the sport’s avid followers including me.
As the NCAA commences its Week One schedule with 87 games Thursday thru Monday on tap, I find myself conflicted. I am a college football fan having watched religiously for years. Growing up in Chattanooga, Thanksgiving Day started with worship at Central Church of Christ, lunch at S&W Cafeteria downtown and Chamberlin Field in the afternoon to watch the University of Chattanooga Moccasins take on the likes of Southern MS and Furman. And News Year’s Day Bowl games were equally sacred: the Cotton, Gator, Orange, Sugar and Rose Bowls featured marque teams who’d survived to 10-game seasons and final rankings were determined by sports media. Pop would re-locate our second black and white TV to the den so we could watch 2 at once (provided the rabbit ears were aimed right). And Mimi made unhealthy Vienna sausage wraps so we never had to leave the room.
Those days are gone. That was before NIL (name, image and likeness) money poured in to lure elite athletes to the highest bidders. That was before the 5 major bowl games played on New Year’s Day morphed into 46 bowl games lollapalooza played over 45 days. That was when the Big 10 had 10 mostly midwestern teams (vs. 18 today including Oregon, Washington, USC and UCLA) and the SEC had 12 mostly southeastern teams vs. 16 today which include Teas and Oklahoma this year. And that was when a family of four could afford to attend a game: per StubHub, tickets for my most cherished contests this season will be $550 to $9093 for Texas-Ohio State September 12, and $434 for the “get in” seats to $4657 for the Michigan-Ohio State matchup November 28.
On Bill Maher Saturday night, Wesleyan University President Michael Roth answered the hyper- cynical host’ questions about the value of higher education and left-leaning faculty bias. Wesleyan is among the three “Little Ivies” (along with Amherst and Williams) where the curriculum is liberal arts, tuition is high, intercollegiate athletic competition is modest and politics is decidedly progressive—a “monoculture” per Roth. Maher questioned whether higher education today educates young adults to be informed, critical thinkers or indoctrinates leftist ideology. Roth countered that college faculty engage students to be thoughtful on issues otherwise overlooked/neglected. Maher ended ‘it’s not working.’
Their dialogue might have been about healthcare. The health system, like higher education, faces a crisis of confidence and its future is being defined by its finances. The health system’s version of NIL centers on aim now centers on business models for specialty services in modern facilities. The Big Players in both industries– consolidated hospital systems, big multi-specialty medical groups, corporate insurers and universities with Big Endowments and Big Athletic Department budgets– are doing well while others struggle.
Higher education and healthcare face extinction as we’ve known them. The public thinks their purpose has been compromised by their growing dependence on private capital—boosters, donors, investors, private equity, and corporate partners. Public money plays a small role for the Big Players. The unintended consequences are well documented—higher prices for tuition and services, variable levels of institutional quality based on access to funds, and increased polarization between have’s and have nots.
In healthcare, it’s no secret. Physicians who specialize make 3 times what primary care clinicians earn and 10 times community health worker annual wages. The 2Q earnings of the nation’s multi-hospital systems were robust per Fitch while small and independent hospitals struggled. The same dynamic holds true for nursing homes, health insurers and public health programs—Darwinian reality that money matters (sometimes too much). In healthcare, it’s manifest in a growing number of shifts…
- CMS’ crackdown on fraud, waste and abuse to protect public money is healthcare.
- Congress’ Bipartisan demand for price transparency and limits on private equity ownership of nursing homes, hospitals and medical practices.
- Court challenges to monopolistic-like business practices that control licensing, drug patents or even the CPT coding system.
- Public belief that an unforeseen medical bill will bankrupt the average household.
- The public’s growing acceptance of embracing alternative sites and methods of care and ways of paying for them.
- And recognition by industry leaders that industries like healthcare and higher education face uncertain futures.
I will watch college football this weekend and, no doubt, hear lots about star players one year removed from their previous NIL contracts. They’re usually the highest paid and best known on the team. And, for some of that team’s followers, their performance on the field will matter more than their education off the field and the academic performance of the school.
Healthcare and higher education are institutions of noble, essential purpose to society. Both face criticism they’ve lost their way and their value propositions are suspect.
Paul
PS: Last week, Dolly Parton died leaving a legacy of music and philanthropy appreciated worldwide. I first met Dolly and Carl as he inspected the paving job his company completed in my neighborhood and later as a Vanderbilt Medical Center donor ambassador. A life well-lived and worthy of respect and appreciation.
This week, a jury verdict is expected in the trial of Lindsay Clancy that will put the spotlight on postpartum psychosis — a rare, severe psychiatric emergency that causes a rapid loss of touch with reality after childbirth. It’s is not currently included in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), but there’s momentum to have it added.
Quotables
CNN on Dolly Parton: “What’s left to say about the last American sweetheart?
Dolly Parton let herself belong to everyone. Her art would’ve been enough to make her immortal, but she generously allowed millions of fans to claim ownership to her remarkable life story, all to better understand ourselves. (Surely there’s nothing I have in common with a bottle-blonde writer from the South.) In the days since her death, dozens of fans who met her only once have testified to her casual kindness. And in all of their stories, Dolly gave these strangers her time and attention and precious pearls of inspiration, like she knew her fans would repeat the story of their meeting for the rest of their lives.
But the Dolly we think we know, that self-deprecating country girl who wrote her way out of poverty to achieve sparkly superstardom, isn’t even “most of what (she) is,” she said once. That’s a lot to chew on for the people who felt like she was family. I take it to mean that Dolly Parton, the multi-hyphenate American classic, is not gone. We understand her values, even if she skirted around political labels, and can still cherish her gifts. But I’m glad that she got to keep “most of what she is” private until the end — even a national treasure is allowed her secrets.
Larger than life.”
Health Capital on private equity investments in healthcare in 2026: “Commentary through the first half of 2026 has described private equity as retreating from healthcare. The data supports a narrower conclusion. Investment in physician practice management companies (PPMCs) has fallen sharply from its 2021 peak, but aggregate private equity deal counts and disclosed capital deployed across the industry have both risen year over year. Private equity has not left healthcare. It has instead pivoted away from the leveraged physician roll-up and toward larger, later-stage, and asset-backed targets….
The first half of 2026 closes a distinct chapter in healthcare private equity. The roll-up model that produced 851 PPMC transactions in 2021 rested on inexpensive debt, permissive state law, and the assumption that assembled scale would command a multiple at exit. None of those conditions holds. What has replaced the model is a more selective market that concentrates more capital in fewer and larger assets, prices regulatory exposure explicitly, and favors targets with contracted or property-backed revenue over those dependent on physician productivity.
Whether the pivot proves durable turns on the exit environment. The platforms assembled during the 2021 peak still require buyers, and their eventual disposition, whether by sale, continuation vehicle, or restructuring, will test the valuations recorded when they were built. Those outcomes, rather than quarterly deal counts, will show what the last cycle was worth.”
Private Equity in Healthcare: Pivot, Not Retreat
HRSA analysts on quality oversight in post-acute care: “Real change will require specific policy levers, not just good intentions. CMS could require automated dispensing systems for controlled substances and high-risk medications as a condition of certification, the same way hospitals are already expected to use them, replacing the single-key mobile carts that make daily errors so easy to miss. Facilities above a certain size or complexity should be required to build pharmacist review into a daily workflow, not a monthly one. Medical director certification through programs such as PALTmed should become a uniform requirement for facility licensure nationally, rather than something left to a patchwork of state-by-state adoption. And as CMS expands VBC models, reimbursement should be tied to audited outcomes, not self-reported metrics, so facilities cannot simply learn to optimize the paperwork.
The star-rating system needs the same scrutiny: Incorporating standardized, independently verified complaint investigation data, not just inspection scores, would better capture what patients and families actually experience.
None of this works without a workforce willing to use it. Providers need real protection, not just encouragement, when they flag unsafe practices: whistleblower safeguards, backing from professional societies, and leadership that treats a flagged error as information rather than a liability problem.”
Reframing Clinical Accountability In Postacute Care | Health Affairs
Fortune on Meta Settlement: “Meta just settled a landmark child-safety case with a fine of up to $18 billion paid over the next decade, with annual payments equal to less than 1% of its 2025 revenue. Financially, that’s a victory for the parent of Facebook and Instagram, which said the 29-state lawsuit could have wiped out its entire market cap with penalties of up to $1.4 trillion. Meta doesn’t have to admit guilt and almost a third of the fine is contingent on competitors adopting similar measures.
…The defendant has cast itself as the hero in this drama. Denial of responsibility is not a license to rewrite the narrative…Much like Big Tobacco was forced to admit that cigarettes can cause cancer or Purdue Pharma was forced to stop downplaying the risks of OxyContin, this agreement now puts Meta’s core products in a negative light. That could give consumers and advertisers pause when engaging with its platforms. New restrictions could also impact future growth. The settlement removes a risk that could have toppled the business. Zuckerberg has to prove he can reduce harm to rebuild trust and reduce the risk that other lawsuits might prove more punishing.”
Meta’s $18 billion settlement won’t be enough to escape its trust problem August 27, 2026 view.mail.fortune.com
NY Times on Meta Settlement: “Don’t focus on the money, though. Mike Isaac, who reports on big technology companies, told me that right away. The penalty’s the least important part. Meta made $200 billion in revenue last year. A $17 billion fine amounts to what he called a “speeding ticket.” Wall Street didn’t see it as a crippling sum — Meta’s stock went up.
Focus on the changes instead. They run counter to Meta’s business interest, which is to keep users on its platforms for as long as possible.”
The Morning: Getting kids offline
Economist on Trump second term: “Mr. Trump, who sees himself as an alpha male to his core, was never likely to limp quietly from office. Now that his dominance is threatened, the world will find him more disruptive than ever.”
As his presidency flounders, Trump is more dangerous than ever
Riverside study on food quality and dollar store access: “Researchers mapped tens of thousands of dollar store locations against CDC health data covering the country’s largest metro areas, and what they found complicates the usual story about food deserts and food insecurity. The effect held even after accounting for income and unemployment — meaning this isn’t simply a poverty story. It’s a product story. For physicians already fielding questions about managing chronic conditions tied to diet, this research adds a new wrinkle: where a patient shops may matter as much as what they can afford. And because dollar stores still aren’t officially classified as grocery stores by the U.S. Census, this influence has largely flown under the radar of both researchers and policymakers.”
A new UC Riverside study links dollar store food quality to higher rates of obesity, high blood pressure, high cholesterol and type 2 diabetes. University of California, Riverside (UCR) — published in BMC Public Health, August 2026
Paragon study: fraud in Medicaid expansion eligibility: “Improper Medicaid expansion enrollees are those who are not eligible for the expansion program, mainly due to having income that exceeds the 138% FPL threshold. Although we have estimates of improper exchange enrollment through 2026, Medicaid data limitations mean that the most recent year we have reliable data to estimate improper Medicaid enrollment is 2024.
Combining Paragon’s estimates of improper exchange and Medicaid expansion enrollment indicates that 14.3 million people enrolled in those programs in 2024—or 34% of all ACA enrollees—were not eligible. We estimate improper enrollment in the two ACA programs cost the federal government approximately $65 billion in 2024. Improper exchange enrollment increased by more than 26 percent from 2024 to 2025—up to an estimated 6.5 million enrollees. Thus, it is likely that total ACA improper enrollment and associated improper expenditures exceeded 14.3 million people and $65 billion in 2025.”
Obamacare Enrollment Abuse Update: $65 Billion Cost in 2024 – Paragon Health Institute
Economy
Bureau of Labor: Occupations projected to add the most jobs between 2025 and 2035: Over the next 10 years, BLS projects that the U.S. economy will add 5.9 million jobs. Total employment would increase to 176.2 million, growing 3.5%– slower than the 10.9% growth recorded in the previous decade. Top
| Median wage (2025) | Job Growth (10 years) | |
| Home health care aides | $35.8k | +847.3k
|
| Stockers and order fillers | $37.3k | +250.7k
|
| Fast food counter workers | $31.2k | +223.3k
|
| Registered nurses | $97.6k | +194.7k
|
| General managers | $105.8k | +181.3k
|
| Software developers
|
$136k | +174.5k |
| Restaurant cooks
|
$37.4k | +171.4k |
| Health services managers
|
$123.9k | +155.1k |
| Nurse practitioners
|
$132.3k | +137.8k |
| Construction workers | $47.1k | +109.3k |
McKinsey: Consumer Sentiment: “In the third quarter of 2026, one in four US consumers reported feeling pessimistic about economic conditions—no change from May 2026. There was also little change to the share of consumers who reported mixed feelings (41%) and optimism (34%). Rising prices and inflation were by far consumers’ greatest concern, cited by 53% of respondents—more than twice the share who cited the second most common concern, the ability to make ends meet. At the same time, roughly a quarter of respondents said “stabilizing inflation” was among their top three reasons for feeling optimistic, reflecting a split among US consumers in their perceptions of prices.”
Holiday shopping research: Spending in 2026 | McKinsey
No Surprises Act Costs: “As discussed below, public use file (PUF) data show that the IDR system has resulted in total costs of $22.4 billion from 2022 to 2025. This includes $15.6 billion in payment amounts awarded by IDR entities that exceed in-network rates; $4.2 billion in internal administrative costs; and $2.7 billion in IDR administrative and entity fees. This estimate dramatically exceeds our previous estimate of $5 billion in total costs for 2022 through 2024. In 2025 alone, total IDR costs were $16.6 billion, an amount nearly 3.5 times higher than for 2024 alone.
These escalating costs are driven by the sheer volume of disputes (which rose by 77% from 2024 to 2025) and higher payment amounts (which rose by 264% from 2024 to 2025). Similar to our prior analysis, the IDR process is dominated by a handful of provider organizations, many of which are backed by private equity or have other conflicted profit interests. Providers also continue to overwhelmingly prevail in the IDR process, winning about 85% of all IDR disputes in 2025 with a median award of more than four times the qualifying payment amount (QPA), which is defined as the median contracted in-network rate for care.”
CMS Improper payments for lab services: Centers for Medicare & Medicaid Services (CMS) enforcement actions have stopped more than $1.6 billion in potentially improper Medicare laboratory payments:
- Savings of $732 million from 157 fraudulent providers revoked from the Medicare program;
- Over $500 million in potentially fraudulent payments halted from 185 payment suspensions from CMS’ investigation of 600 labs;
- More than $276 million recouped from 442 identified overpayments already paid out to suspect labs; and
- $127 million in potentially fraudulent payments prevented as the result of 85 law enforcement referrals from a CMS contractor.
The savings in fraudulent payments were the result of CMS’ use of advanced analytics, including Artificial Intelligence (AI) and machine-learning models, to mine Medicare fee-for-service claims, looking for unusual billing patterns and other indicators of potential fraud, waste, or abuse. AI can help identify potential laboratory fraud by learning what normal billing and laboratory activity looks like and flagging unusual combinations of testing, results, billing, documentation, and relationships that may indicate manipulation or fraudulent activity. When these analytics identify high-risk billing patterns, CMS can use that information to automatically flag claims for further review and, when appropriate, hold, reject, or deny claims before any Medicare funds are released.”
CMS Prevents $1.6 Billion in Fraudulent Medicare Laboratory Payments | CMS August 28, 2026
Hospitals
Hospitalology on hospital finances: “Fitch published its 2026 medians on audited fiscal 2025 data covering 222 rated nonprofit systems. Median operating margin rose to 1.5% from 1.1%, a third consecutive year of improvement off the 0.2% trough in fiscal 2022.
- 67% of the portfolio posted positive operating margins, up from 50% in 2022.
- Personnel costs fell to 52.6% of operating revenue from 53.5%.
- Balance sheet metrics set records: cash to debt of 188.0%from 169.2%, debt to capitalization at a historical low of 28.9%, days cash on hand roughly flat at 212.
- Capital spending hit a near-20-year high at 143% of depreciation expense.
Individual operating margins ranged from 34.4% to negative 17.3%. Fitch’s characterization of the year: fiscal 2025 “may represent a brief operational peak” which if you’ve been reading Hospitalogy you already knew that. Still, the 1.5% median remains below every pre-pandemic point in Fitch’s 20-year data set.”
Hospitalogy
CMS Improper payments for lab services: Centers for Medicare & Medicaid Services (CMS) enforcement actions have stopped more than $1.6 billion in potentially improper Medicare laboratory payments:
- Savings of $732 million from 157 fraudulent providers revoked from the Medicare program;
- Over $500 million in potentially fraudulent payments halted from 185 payment suspensions from CMS’ investigation of 600 labs;
- More than $276 million recouped from 442 identified overpayments already paid out to suspect labs; and
- $127 million in potentially fraudulent payments prevented as the result of 85 law enforcement referrals from a CMS contractor.
The savings in fraudulent payments were the result of CMS’ use of advanced analytics, including Artificial Intelligence (AI) and machine-learning models, to mine Medicare fee-for-service claims, looking for unusual billing patterns and other indicators of potential fraud, waste, or abuse. AI can help identify potential laboratory fraud by learning what normal billing and laboratory activity looks like and flagging unusual combinations of testing, results, billing, documentation, and relationships that may indicate manipulation or fraudulent activity. When these analytics identify high-risk billing patterns, CMS can use that information to automatically flag claims for further review and, when appropriate, hold, reject, or deny claims before any Medicare funds are released.”
CMS Prevents $1.6 Billion in Fraudulent Medicare Laboratory Payments | CMS August 28, 2026
Physicians
Doximity 2026 Physician Compensation Report: Based on 250,000 compensation survey responses collected over seven years, including nearly 23,000 U.S. physicians surveyed in 2025. Highlights:
- The 20 specialties with the HIGHEST(neurosurgery $829,161) average annual compensation tend to be surgical and procedural specialties. The 20 specialties with the LOWEST (pediatric infectious disease $217,891) average annual compensation tend to be pediatric and primary care specialties.
- Average annual compensation rose for nearly all specialties in 2025, led by interventional radiology and neurosurgery. Each of the top 10 specialties with the largest increase reported annual growth rates exceeding 6%. These specialties mainly include a combination of surgical and procedural specialties as well as specialists like pathology. Only one primary care specialty made it into the list. Many of the specialties in the top 10 for growth also have the highest average compensation, which may reflect a widening gap between specialties with the highest and lowest compensation this year. The only specialty that appears in the top 10 for compensation growth in both 2024 and 2025 is radiology.
- The percent pay gap between primary care physicians and specialists strong show signs of widening, running counter to the modest but consistent decline in the prior three years.5In 2025, compensation for surgical specialists was 90.1% higher than it was for primary care physicians, up from 87.3% in 2024.
- Emergency medicine physicians and ob/gyns also saw relatively larger increases to their compensation than did primary care physicians. Non-surgical specialists continued to earn significantly more than primary care physicians, though the gap narrowed slightly to 38.8%, down from 41.7% in the prior year.
- Physician compensation continued to vary widely across practice settings, led by single-specialty ($480, 961) and multi-specialty groups ($477,033). Solo practice dropped two spots to fifth highest in compensation, with the largest dip in year-over-year compensation (-3.8%) across all practice settings. Government compensation ($311,502) remained at the bottom, while urgent care centers saw the highest growth for the second year in a row. Hospitals ($454,440) and health system $451,233) were 3rd and 4th overall of 11 settings.
- Doximity surveys over the past three years point to early signs that the shortage could be reversing course. About 18% of physicians described the impact as “severe” this year, compared with 21% in 2025 and 30% in 2024. And a lower percentage of physicians reported experiencing negative effects this year than in prior years. For example, 52% of physicians reported overwork or burnout due to the shortage, compared with 63% in 2025 and 67% in 2024.
Doximity 2026 Physician Compensation Report
Trilliant Health: Physician Employment study: “Across the 700,000 physicians assessed, 59.4% are employed by a hospital or health system. Highlights:
- The share of hospital-employed physicians varies by region, from 67.2% in the Midwest to 52.4% in the South, and by state, from 83.0% in North Dakota to 31.3% in Nevada.
- The share of hospital-employed physicians also varies by specialty, from 78.8% in hematology and oncology to 26.9% in podiatry, with procedural and hospital-based specialties among the most frequently employed and office-based specialties among the least frequently employed.
- In the Chicago market, blended commercial professional E/M rates for hospital-employed physicians average $239, compared with $147 for independent physicians, a difference of $92
