You’ve probably heard the term "value-based care" thrown around in boring health policy seminars, but in the real world of high-stakes healthcare investment and federal policy, two names keep popping up like a recurring dream: Abe Sutton and Adam Boehler.
Honestly, it’s hard to talk about the current state of Medicare without talking about these two. They aren't just bureaucrats or just investors. They are the architects of a specific kind of healthcare disruption that treats the federal government like a startup and private equity like a civic duty.
The Nashville Connection and the Rubicon Leap
If you want to understand the vibe of the Abe Sutton and Adam Boehler partnership, you have to look at Nashville. This is where Boehler founded Rubicon Founders, an investment firm that doesn't just "buy" companies—it builds them from the ground up to exploit the massive shift toward value-based payment models.
Abe Sutton wasn't just a random hire there. He was a Principal who helped co-found companies like Honest Health and Evergreen Nephrology. These aren't just businesses; they are vehicles designed to take on "risk." In healthcare parlance, that means they get paid more if they keep people healthy and less if they just run a bunch of expensive tests.
Boehler has a knack for finding "evangelists" for this model, and Sutton fit the bill perfectly. Before they were making deals in Tennessee, they were essentially doing the same thing in Washington D.C.
From the West Wing to the C-Suite
The history here is kinda fascinating. During the first Trump administration, Adam Boehler was the guy tapped to lead the Center for Medicare and Medicaid Innovation (CMMI). He was the "disruptor" in chief, famously saying he wanted to "blow up" the old volume-based system where doctors got paid for every little thing they did, regardless of whether the patient actually got better.
Abe Sutton was right there with him. Sutton served at the National Economic Council and the Domestic Policy Council. He was one of the primary architects of the massive kidney care overhaul—an initiative that basically tried to move dialysis from clinics to people's homes. Why? Because it’s cheaper and patients generally like it more.
It’s a classic Boehler/Sutton move: find a massive, inefficient government spend and try to redirect it toward a private-sector solution that claims to improve outcomes.
The Return to CMMI: Sutton Takes the Reins
Fast forward to 2025, and the roles have shifted but the mission remains identical. Abe Sutton is now the Director of CMMI, the very agency Boehler once ran.
But he didn't come back empty-handed. He spent his "off-season" at Rubicon with Boehler, learning exactly where the money flows in the private sector. Now, he's implementing models like WISeR (Wasteful and Inappropriate Service Reduction) and the Ambulatory Specialty Model (ASM).
- WISeR: This uses AI to sniff out wasteful prior-authorization requests.
- ASM: This rewards specialists for heart failure and lower back pain outcomes.
- The Goal: Moving at "warp speed" to lock in these market-based reforms.
Critics will tell you this is a "looting" of Medicare or a handout to "grifters." Supporters say it’s the only way to save a bankrupt system. The truth is usually somewhere in the middle, but one thing is certain: the line between the private investment world of Rubicon and the public policy world of CMS has never been thinner.
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What This Means for the Rest of Us
Basically, if you are a doctor or a patient in 2026, you're living in a world built by Abe Sutton and Adam Boehler. They are pushing for a future where your doctor isn't just a provider, but a "risk-bearing entity."
They want Medicare to function like a high-efficiency insurance product where AI handles the paperwork and private companies like Honest Health manage the "care coordination." It’s a radical departure from the 1960s version of Medicare.
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Whether you love the idea of "Trump Healthcare 2.0" or you're terrified of private equity running your local clinic, you can't ignore the momentum. Sutton and Boehler have created a revolving door of innovation that moves faster than the traditional legislative process ever could.
Actionable Insights for Healthcare Stakeholders
- Follow the Nephrology Model: If you want to know what's coming next, look at what they did with kidney care. Expect similar "carve-outs" for other chronic conditions like oncology or cardiology where private firms can take on full financial risk.
- AI is the New Auditor: Sutton's focus on the WISeR model means AI-driven audits are no longer a "future" tech. If you're a provider, your billing and authorization data is being parsed by algorithms designed to find waste instantly.
- Nashville is the New D.C.: The center of gravity for healthcare policy has shifted. Keeping an eye on the portfolio companies of Rubicon Founders often provides a 12-to-18-month lead on what CMMI's next "innovation model" will look like.
- Embrace the "Risk": The era of fee-for-service is dying. Survival in this new landscape requires partnering with "enablers"—the very types of companies Sutton and Boehler built in the private sector—to manage the financial downsides of value-based contracts.