Mission + Quality Goals
"Creating the health system that works for you — instead of you working for it."
- Tech-enabled services, not SaaS tools (7wire thesis)
- Operator-not-vendor: own the P&L, license the stack
- Three moats: Technology + Operations + Ownership
The 7wire Thesis (External Validation)
Alyssa Jaffee at 7wire Ventures: "Tech-enabled services companies will experience major lifts from AI enablement." NOCD saved therapists 2-12 hours/week. SolvingHealth captures $80K+/surgeon/year in net-new revenue. We don't sell tools to health systems — we ARE the health system.
Why This Wins
Insight Health raised $11M to optimize the waiting room under fee-for-service. SolvingHealth captures $300-500/patient/month in net-new VBC codes under mandatory TEAM capitation. They treat the symptom of overhead. We build the valuation engine.
- OIG audit defensibility (structural, not policy)
- PHI boundary integrity (never outside audit trail)
- Attestation immutability (no UPDATE, no DELETE)
- CMS VBC alignment (TEAM, ACCESS, LEAD native)
- Physician authority preservation (AI drafts, Josh attests)
Exhaustible Authority Model
Authority activates at execution and exhausts immediately after. No standing permission. The physician's swipe IS the moment authority is consumed. The immutable attestation IS the exhaustion artifact. Authority cannot accumulate, cannot replay, cannot drift.
External Actors + Entities
- The Conductor — Alpha Daughter, 45-60, managing aging parent care
- Josh Emdur DO — NPI 1649218389, 50-state, all attestations
- Worker-Owner — carries the relationship, W-2 + equity
Authorization Matrix
| Level | Actions | Example |
|---|
autonomous | Surface info, draft comms, flag thresholds | RPM alert, CCM threshold |
conductor_required | Send comms, log billing activity, schedule | Care plan update, ACP |
josh_required | Billable judgment, LMN, CMS submission | Every claim, every attestation |
prohibited | CMS without attestation_id, RLS changes | NEVER |
- SolvingHealth LLC — MSO/IP holder (Blaine 100%). NOT YET FILED.
- Solving Health Inc — DE C-Corp (SurgeonValue). EIN 41-5139576.
- co-op.care LCA — Colorado worker-owned cooperative. Forms with first hire.
- Josh's PC — Colorado PLLC. Forms when clinical billing starts.
IP Protection
All IP in SolvingHealth LLC. SA Inc gets perpetual irrevocable license at fixed FMV. Auto-transfer if SH dissolves. SA has ROFR. Related-party disclosed. AKS clean: flat per-encounter fee (NOT percentage). OIG AO 25-03 blueprint.
Key Personnel Boundaries
Josh has NO role in SolvingHealth. Levonti/Bryan are SA Inc only. SolvingHealth builds technology. Operating entities operate.
Building Blocks
15 tools. Physician attestation infrastructure for healthcare AI.
| # | Tool | Module |
|---|
| 1-6 | Core attestation (submit, status, result, specialties, LMN, ACCESS) | index.ts |
| 7 | claim_lock | claim-tools.ts |
| 8 | claim_release + review_metrics enforcement | claim-tools.ts |
| 9 | claim_status | claim-tools.ts |
| 10 | generate_election_addendum | election-addendum.ts |
| 11 | deliver_and_capture_addendum | election-addendum.ts |
| 12 | get_addendum_compliance_report | election-addendum.ts |
| 13 | get_ssvi_score | ssvi-module.ts |
| 14 | get_ssvi_network_scan | ssvi-module.ts |
| 15 | get_ssvi_market_intelligence | ssvi-module.ts |
Plus: execute_review_payout (billing) and vbc_previsit_intake (VBC pipeline).
- SurgeonValue — 10 agents, $962 to $1,820/patient
- ClinicalSwipe — physician attestation marketplace
- co-op.care — worker-owned cooperative care, $59/mo
- CareGoals — story preservation + ACP
- ComfortCard — digital care wallet, QR + Apple Wallet
- Altru.care — Josh's physician practice
Revenue by Product
| Product | Revenue Model | Year 1 |
|---|
| SurgeonValue | $199-299/mo + $15/encounter | $360K+ |
| ClinicalSwipe (hospice) | Addendum + SSVI | $1.6M ARR |
| co-op.care | $59/mo + companion care | $142K (200 families) |
| CareGoals | 99497/99498 via practices | $69K/practice |
| LMN | $199 flat | $520K+ |
5 jobs. Every 15 minutes. Independent.
| Job | Description | Auth |
|---|
| 1 | TCM Window Monitor (day 5-6, 12-13) | autonomous |
| 2 | CCM + PCM Threshold (15+/55+ min, 99424/99426) | autonomous |
| 3 | RPM Staleness (>24hr, >48hr) | autonomous |
| 4 | Billing Queue Drain to Stedi EDI | josh verified |
| 5 | Care Gap Detection (>14 days) | conductor |
Job 4 HARD CONSTRAINT: decision_ledger_id + attestation_id + attesting_npi = '1649218389' verified before every Stedi submission.
Architecture Decisions + Data
- Vercel (6 static sites, auto-deploy from GitHub)
- Railway (CareOS backend, scheduler, AI models)
- Supabase (PostgreSQL + RLS + Auth)
- Cloudflare R2 (WORM anchor, 7-year retention)
- Stedi (EDI 837P claim submission)
- Anthropic Claude API (agent calls via governance constitution)
- Stripe Connect (surgeon billing)
7-Model Self-Hosted AI (Fastify Gateway)
| Tier | Model | Use |
|---|
| 1 | BiomedBERT (CPU, <50ms) | PHI classification, pre-flight |
| 2 | Qwen2.5 / Phi-3.5 | Mid-tier reasoning, drafts |
| 3 | MedGemma 27B (GPU) | Clinical reasoning, billing review |
| Agent | Claude Sonnet 4.6 | All CareOS agent calls |
Cost: $170-$1,250/mo vs $15K-$40K API. Hybrid inference routes by PHI/latency/complexity.
- Decision ledger: append-only, content-hashed, chain-linked
- Attestations: immutable, CHECK constraints, NPI-locked
- WORM anchors: daily R2 digest, 7-year COMPLIANCE lock
- SSVI scores: public CMS data, no PHI
4 Migrations (Built Today)
| # | Migration | Purpose |
|---|
| 001 | clinicalswipe_attestations | OIG anti-rubber-stamp + propagation trigger |
| 002 | ledger_anchors | WORM anchor index + oig_audit_evidence view |
| 003 | election_addendum_deliveries | Hospice addendum compliance + HQRP view |
| 004 | ssvi_provider_scores | Public hospice scoring + market summary view |
All rates verified April 4, 2026 against CMS-1832-F.
| Code | Description | 2026 Rate |
|---|
| 99490 | CCM first 20 min | $66 |
| 99491 | CCM physician 30 min | $89 |
| 99487 | Complex CCM 60 min | $144 |
| 99495 | TCM moderate 14-day | $220 |
| 99496 | TCM high 7-day | $298 |
| 99453 | RPM setup | $21.71 |
| 99454 | RPM device 30 days | $52.11 |
| 99457 | RPM mgmt 20 min | $51.77 |
| 99497 | ACP first 30 min | $87 |
| 99498 | ACP add-on 30 min | $78 |
| 99424 | PCM physician 30 min | $88 |
| 99426 | PCM staff 30 min | $68 |
| G0019 | CHI 60 min/month | $83 |
| G0023 | PIN 60 min/month | $78 |
| G0438 | Initial AWV | $174 |
| 99484 | BHI 20 min/month | $57 |
Cross-Cutting Concerns
- Fix 1: Anti-rubber-stamp — 30s review, 20s viewport, 80% scroll (DB CHECK)
- Fix 2: WORM anchor — daily SHA-256 digest to R2 with 7-year compliance lock
- Fix 3: PCM scan — 99424/99426 eligibility for single-condition ortho patients
Fix 1: ReviewTracker
Frontend class captures viewport visibility, scroll depth, interaction count. Server-side validateReviewMetrics() rejects before DB does. Database CHECK constraints are the final defense — attestation physically cannot exist without evidence of review.
Fix 2: WORM Anchor Chain
Daily cron (23:59 MT): query day's ledger entries, concatenate content_hash values, SHA-256 digest, write to R2 with COMPLIANCE object lock. Next day: read back, verify. oig_audit_evidence view joins attestations + ledger + anchors for auditor presentation.
Fix 3: PCM Revenue Capture
At 200 families: 60 PCM-eligible x $156/month = $9,360/month = $112,320/year incremental.
The moat. No framework ships this.
Governance Constitution (Mandatory Import)
Every file calling Claude API imports governance-constitution.ts. System prompt injected before any user message. Authorization matrix enforced at the prompt layer, not just the database layer.
Decision Ledger Requirement
Every agent output writes to decision_ledger BEFORE it reaches any human. The record is created before the action is taken. The attestation_id is attached before any claim is submitted. The audit trail is not retroactive.
WorkOS MCP Auth (Planned)
Session-scoped OAuth via WorkOS AuthKit. Tools are role-gated: attest_claim only visible to medical_director. When session ends, access ends. Human must explicitly approve new session.
Risks + Technical Debt
- Ryan owes 6 legal documents (CRITICAL PATH)
- SolvingHealth LLC not yet filed
- Railway HIPAA BAA
- Stripe HIPAA BAA + identity + bank account
- Medicare Part B enrollment (EIN 41-5139576)
- Org NPI via NPPES
- Josh PECOS reassignment
Ryan's 6 Documents
Operating Agreement, IP Assignments x2, License Agreements x2, Entity List memo. These gate the MSO-PC structure. Without them, SolvingHealth LLC cannot be filed, IP cannot be assigned, and the related-party relationship cannot be properly disclosed to investors.
- Cloudflare R2 not yet enabled (WORM anchor blocked)
- TCM rates need PFS lookup verification ($178 vs $220)
- ClinicalSwipe MCP: 15 of 60 tools built
- CareOS tests not running (Jacob's Railway access blocked)
- No TypeScript compilation on current repo structure
R2 Status
Cloudflare Enterprise contact form submitted April 4, 2026. Waiting for enablement call. Once R2 is active: create solvinghealth-ledger-worm bucket with object lock, generate API keys, set Railway env vars.
Jacob Dependency
Paid $5K for CMS ACCESS code. co-op.care Railway stuck after force-push incident. Don't block SA launch on Jacob. Blaine ships SA features solo via Claude Code + MCP connectors.
- Insight Health $11M validates category but creates EHR lock-in risk
- Competitive landscape: Hinge, Sword, Kaia in MSK digital health
- HSA/FSA via LMN is a legal gray area (need attorney opinion)
- Single-partner dependency on BCH (parallel-path required)
Insight Health Counter-Strategy
Their agents end at the clinic visit. Under TEAM capitation, the practice wins by controlling 30-day episode cost — not by seeing patients faster. vbc_previsit_intake captures PIN G0019, ACP 99497, PCM 99424 from the SAME pre-visit interaction. Revenue capture vs cost reduction.
Fitness Functions (Evolutionary Architecture)
5 fitness functions. 3 enforced at database level. The system either passes or it doesn't — these can't drift.
30s
review_duration_seconds >= 30
DB CHECK on clinicalswipe_attestations
20s
viewport_active_seconds >= 20
DB CHECK on clinicalswipe_attestations
80%
scroll_depth_pct >= 80
DB CHECK on clinicalswipe_attestations
100%
governance-constitution.ts import
Enforced by settings.json hook
100%
decision_ledger_id + attestation_id
Required before any Stedi submission
Why These Are Fitness Functions, Not Policies
A policy says "you should review for 30 seconds." A fitness function says "the database physically rejects the record if you didn't." The three DB CHECK constraints are structural — they cannot be overridden by any application code, any deployment, any credential. The governance import hook fires on every TypeScript write. The Stedi submission gate is enforced in Job 4's handler. These are the measurable thresholds the arc42 framework calls for — and they're the reason this architecture is evolutionary, not static.