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The Scopewell Podcast features candid conversations with leaders transforming how organizations think, operate, and grow. Hosted by James Leuthe, CEO of Scopewell Solutions, the podcast explores leadership, AI, digital transformation, and the operational realities of turning ideas into measurable impact. Each season goes deep into a different industry and the challenges of driving meaningful change inside complex organizations.
James Leuthe: Hello, and welcome to the Scopewell Podcast. My name is James Leuthe. Today, we're going to talk about what it takes to lead finance in a public health system under historic pressure and what one leader is doing to redesign the function from the inside out. Joining me is Sham Firdausi, Deputy Chief Financial Officer of the County of Santa Clara Health System. Sham, thank you so much for joining me today.
Sham Firdausi: Thanks for having me.
James Leuthe: Sham, you have a military background, a $140 billion health plan on your resume, and now you're running finance for one of the largest public health systems in the country. Give listeners the background of how you got here.
Sham Firdausi: That's a great question. I didn't start out that way. I was born overseas in Pakistan, single mom. She always had this one thing: you see things that are broken, you fix it. She was big on education, and she decided to pursue the American dream. She brought myself and my sister here, and we grew up in the Chicagoland area. That was always the mentality growing up — you see things that are broken, you fix it. Unfortunately, she passed, and that's when I saw the broken health care system firsthand, having to deal with it, having to see the public health safety net and how disjointed the American health care system is.
I joined the military — Marines, then Army — deployed to Iraq with the 101st Airborne, unfortunately got injured, and really had to think about what was going to allow me to continue to serve people. I decided the health care system is broken and I can't just understand one area. I have to learn it all. I started my journey at UnitedHealth Group on the Optum side, learned revenue cycle systems inside and out for Optum 360. Went back to the provider side at Northwestern, continued to learn, even did the PBM work for 340B at CVS. Took it all in, and eventually became a CFO for a regional health system — a private equity, for-profit system, part of LifePoints Zion Health. But I wanted to make my way back to the public health safety net, and that brought me here to the County of Santa Clara Health System. Given the time pressure and the challenges we're in, I'm very excited, and I really chose to be here to make an impact and change the trajectory of where our health system is headed.
James Leuthe: Most CFOs at large health systems come up through accounting and corporate finance. You came up through operations and the payer side. How does that affect how you see your role?
Sham Firdausi: Both backgrounds have their ups and downs. But for me, I'm very much a person who loves to learn operations and business, because it's harder to make a decision financially that impacts others' lives when you don't know what they do day to day. I have an MBA in accounting, and I did it to learn the foundation — everyone in finance should have that foundation. But I was never the person who was just about accounting. For me, accounting tells you what happened in the past. To think about the future and the trajectory, it's really important to understand operations, financial planning, and the payer side.
Every decision I made, I liked to involve clinical leaders and operational leaders. When I was at my last health system, I would spend a week in different areas — from women's health to registration — just sitting up front, sometimes scrubbing in and watching clinicians, so I could see and understand the gaps in the processes. And then when I'm making financial decisions, I keep that in the back of my mind. That's how I'm training the future generation of finance leaders. Finance and operations are now so combined, and the future CFOs have a big challenge ahead of them — either they stick to those roots in accounting and get left behind, or they think about operations, think about strategy, and really have a seat at the table.
James Leuthe: The County of Santa Clara Health System is staring down a nearly $1 billion funding shortfall by 2028. Help listeners understand what that number actually means — not just for the balance sheet, but for the people who walk through your doors.
Sham Firdausi: It's an unfortunate situation. As we know across the country, there are close to a trillion dollars in cuts happening in health care. For a system like ours, we have four hospitals and clinics spread throughout the county. Even though we're in the heart of Silicon Valley, we are a safety net health system. Our job is to take care of every single person who walks in through the door. We don't have the luxury to pick and choose our patients. A lot of our funding comes from a heavy Medicaid and Medicare population, and a lot of our DISH funding has been impacted. So we're staring down a billion dollars. And we still cannot turn away patients. Even if patients get disenrolled from Medicaid, they're still going to come here and get care — which is needed.
We cannot turn our backs on the people, especially given the environment we're in. We're going to keep our services up and running. We're just going to have to think through where we bring in more revenue, make operational changes, drive better efficiency, and start thinking the way other health systems do. Counties have always had the reputation that we provide care to everyone who walks in the room, and that's true. But we also need to bring in revenue. We have to get creative. This is an unfortunate situation, but it doesn't mean we walk away from our mission. We double down on it.
James Leuthe: You've been in the role about eight months. What surprised you most when you walked into it — not just the federal policy headwinds, but internally as well?
Sham Firdausi: County health systems are a beast of their own. There's a lot to learn because you're part of the county, so you have to understand those dynamics too. These are taxpayer dollars, and we have to be mindful of that. But one thing that really surprised me — even having grown up using the safety net system myself, with Cook County Health in Chicago as my lifeline and my sister's lifeline — is that we are way ahead of some of the other hospitals I've worked at, including some private equity systems. Public health safety net hospitals in California are only about five or six percent of the total health system, but they train close to fifty percent of providers. We're running Stanford's residency program. When other health systems look at what they're doing, the foundation starts here. That's the image I'm looking to change — that public health safety net systems can go toe to toe with the larger health systems. I'm excited to be here to make that happen.
James Leuthe: You're doing something structurally different with how finance operates — embedding finance business partners directly into each facility and service line. Walk me through what that model looks like on the ground and what problem it's actually solving.
Sham Firdausi: It's not something novel — other health systems do it. But the goal is to embed a finance lead or a finance business partner as a partner to the executive leaders in each facility and across our ambulatory areas. We still maintain shared finance, shared accounting, and a shared revenue cycle team. But this model ensures we don't have silos between finance and operations. That's key given the financial pressures across the country right now. It also helps me develop future finance leaders. When finance understands operations, and operations sees finance as a true strategic partner, it goes a long way.
When I first came into health care after the military, people were scared to have finance in the room. When they'd see us walk in, it was like, here we go — budget cuts. But that's not what it is. The goal is to break down those silos and have the right voices at the table. Health care is the ultimate team sport, but so much of it is siloed.
James Leuthe: What has it taken to bring finance and clinical together? And has there been a moment where they were looking at the same problem and genuinely saw it differently?
Sham Firdausi: There are twenty examples. Clinical leaders and providers are some of the smartest people. But for a long time, everyone had a very narrow vision — this is my role, this is what I'm here to do. Nobody wanted to step on each other's toes. But what clinical leaders know about working with vendors, and what vendors tell them, might not be the full story. That's where we've started to realize how we can partner better.
For example, vendors come into operating rooms and tell providers their product is the best — you're going to get reimbursement for it. But when I had a finance team on the ground to go back and check, they found that yes, you'll get reimbursement, but it's going to take away reimbursement from another area because the procedure as a whole is what's being reimbursed. Adding that supply the vendor is selling might be great clinically, but it could actually chip away at the low margin you already have. These are the conversations we're having in real time. Patient safety and patient care always come first — but having that financial visibility is giving us a really good look across the system. I've had executive leaders tell me how much finance has changed in just the few short months we've been here.
James Leuthe: You're asking finance people to think more like operators and technologists. That's a different hire and a different development path. How do you actually build a team to do that?
Sham Firdausi: It's really about showing people the vision. In the age of AI and technology, what sets people apart are soft skills and the willingness to learn. I'm upskilling people, making sure they have the right skill set to have a seat at the table and ask the right questions. In the age of AI, people need to know it's okay to use technology — but how do we leverage it for the good of the people and for the health system?
When I develop people, I get them to see the big picture, think about the mission, and then give them a career path that isn't just linear. My goal for the next generation of finance leaders is for them to become the next CEOs and COOs — to think through operational service line leadership. But it all starts with asking questions, being flexible, and being willing to learn. When people hear that kind of vision, it gets them excited. As leaders, we need to maintain that excitement and that forward-thinking mission.
James Leuthe: I think in the age of AI, the things that are uniquely human are going to be more important than ever to identify and lean into. Speaking of AI — you piloted ambient AI scribing on the clinical side, and you're now moving toward AI for denial management and coding. What did that scribing pilot teach you about how to bring AI into a public health system responsibly?
Sham Firdausi: We were being very careful. The goal was really thinking through how we could help our providers. There's such a high burnout rate for providers across the country — they're leaving the field because they're burned out. Our mission was to pilot it and see how it helps. We've heard great feedback from providers on how it's reduced their documentation time and allowed them to focus on other things. That's exactly what I envision for my revenue cycle team.
Right now we're getting ready to think through how we incorporate AI into our denial management areas — just thinking through where it's going to make the most impact. We're still early on. We're doing initial demos and meeting with the right vendors. When I think about vendors and external partners, I look for long-term partnerships. The goal is to find the right people and pilot from there. I'm excited for the future of what's to come and how it's going to help our teams get the support they need and stay on par with other health systems across the country.
James Leuthe: You've seen the payer side up close — Centene, UHA, UHG, CVS. Payers have been ahead of providers on AI for years. Are payers and providers actually moving toward real AI collaboration now, or is this still aspirational?
Sham Firdausi: It's still a little bit aspirational. Payers have always been ahead in a lot of different ways — from the lobbying they do in Washington to the amount of money they spend on technology. UnitedHealth Group recently announced they're going to spend $1.5 billion specifically on AI. Payers are vocal about collaborating with providers, but I've been on the other side — that's not always the case. It's one thing to put out headlines. It's another to actually show up and take action.
I am optimistic though. These are challenging times economically, and I think large organizations are starting to realize that. I think health care costs alone might drive better collaboration. I'm always open to working with payers on data sharing, AI tools that make it easier for revenue cycle teams on both sides. But right now, there's a lot of blame. Payers are saying hospitals are using AI to game the system. Hospitals are saying payers are just denying claims with their AI. Cigna got sued a couple years back for using AI to deny claims. United is on the chopping block right now. I'm happy to have these conversations with payers. Let's truly collaborate and make our health system better. Right now, I just feel like no one's really willing to have that conversation.
James Leuthe: If you hold the mission and get this model right, what does the County of Santa Clara Health System look like in five years? And what does that mean for how public health systems think about finance leadership more broadly?
Sham Firdausi: Five years from now, our health system is going to be the model for the country. I already have other health system CFOs and CEOs reaching out, wanting to understand what we're doing differently here and how I'm getting the team excited. The model we're building — my goal is for it to be replicated across the country, because our goal is to take care of people and provide care no matter who walks through the door. But how do we do it in a financially sustainable way? How do we do right by the people and by the taxpayer? That's the goal. I've gone from consulting in West Virginia hospitals to rural Wisconsin hospitals. I know how expensive health care is. I've been on the other side of it — from payer to safety net recipient. With these challenging times, it's time to get creative, time to come together and make it happen. That's what I'm trying to model at the County of Santa Clara, and I hope to replicate it across the country in the years ahead.
James Leuthe: I think that's a great note to end on, Sham. I want to thank you for your time and for what you shared today. The work you're doing at the County of Santa Clara Health System matters, and I think a lot of our listeners are going to walk away with a different picture of what finance leadership can look like when the stakes are this high. We appreciate you joining us on the Scopewell Podcast.
Sham Firdausi: Thank you for having me. It was a pleasure.
James Leuthe: Take care.