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An operator's field map · 175 pages · 12 sections
Where does the dollar go in US Healthcare?
The only thing harder than building for US Healthcare is solving how the pieces fit together. So in an attempt to pay it forward to the next founder, this is a complete 175 page dump of my understanding on how care gets authorized, coded, billed, paid, managed and regulated; with a specific founder's-eye view of where it breaks and where AI wins.
Start here
Read these three first
About 19 minutes in total · your progress: 0 of 3
- 17 min read The 90-Second Mental ModelThe whole system in one sitting — how a decision and a dollar move through US healthcare.Begin here →
- 26 min read How to Use This MapHow the 175 pages fit together, and how to read the callouts.Begin here →
- 36 min read The StakeholdersWho's who — payers, providers, members, regulators, and the middlemen.Begin here →
How to read a page
Everything in the main text is sourced. Four kinds of box sit alongside it:
In plain English
A short summary for anyone outside the industry.
Zahid's take
My opinion, from building Anterior.
Where it breaks
Friction, misaligned incentives and manual toil.
In practice
A worked scenario: what the job looks like for a nurse, biller or member.
Reading paths
Or follow the path that fits you
Each path is a short, ordered reading list.
You're a founder building in health-IT
Where the dysfunction pays, and who has the right to win it.
You work in prior auth or UM
The review machine, why it jams, and where it is heading.
You invest or operate
The size of the prize and where the returns actually sit.
You're here for the AI angle
What is automatable, who is building it, and how the arms race plays out.
The map
12 sections, in reading order
Each section builds on the one before, but every page stands alone.
- 01The StakeholdersWho pays, who provides, who oversees — and the middlemen between them.23 pages
- 02How Money FlowsPremiums, claims, fee schedules, and where the dollars actually land.17 pages
- 03Coverage & BenefitsWhat is covered, what needs approval, and how benefits are designed.11 pages
- 04Utilization ManagementPrior auth, medical necessity, and the review machine that gates care.28 pages
- 05Care Management & Population HealthManaging the sickest members and the health of the whole population.12 pages
- 06Clinical Data, Coding & InteroperabilityCodes, records, and the standards that move them between systems.11 pages
- 07Payment & Program IntegrityCatching — and preventing — the wrong dollar going out the door.10 pages
- 08Pharmacy & PBMsDrugs, rebates, and the most opaque supply chain in healthcare.10 pages
- 09Value-Based Care & RiskCapitation, bundles, and getting paid for outcomes instead of volume.7 pages
- 10Regulation & PolicyThe rules of the game: CMS, ERISA, HIPAA, and the reform wave.17 pages
- 11The Vendor LandscapeWho sells what — and where the health-IT software money is.13 pages
- 12Where It Breaks & Where AI WinsThe thesis layer: the dysfunction, the opportunity, and who wins.12 pages
Zahid Mahmood
Founder of Anterior (Healthcare AI)
Who wrote this
I founded Anterior in 2022 to take on the spiralling healthcare administration crisis by building AI to automate the clinical and administrative work behind prior authorization and utilization management. I've spent years shipping software inside the plumbing of US healthcare — the claims, the codes, the criteria, the denials.
Zahid built ChatGPT for doctors and nurses before ChatGPT was an idea in Sam Altman's head. Now when you go to New York you don't need to wait in the emergency room; they see you right away. Next time you have any pains you should catch a flight out there and try it.
— how my mum describes me to her friends
During my time at Anterior I made meticulous notes and maps about US healthcare as I tried to wrap my head around this monster. At every turn there is a new rabbit hole to dive deep into, and I believe so much of this industry is yet to be uncovered and solved. With the help of Claude, I have spent some of my sabbatical typing, writing and dictating my thoughts, insight and understanding into a comprehensive operator's guide. Nikhil's Out Of Pocket Health helped me a lot in the early days, so I hope my material might specifically help founders navigating this space too.
There is a better way to do healthcare out there on the horizon. Don't chase the future. Build it.
For unlocked readers
Want to go deeper? Book a 1:1.
If you've unlocked the map and want to talk through your market, your wedge, or your go-to-market in US healthcare admin, book a call with me — $1,499. After payment you'll get a link to schedule right away (or email zahid@theadminlayer.com).
Book a 1:1 — $1,499