Mission & Margin

Siftwell
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  • Технологии
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Mission & Margin is a show celebrating the executives, policy advisors, and turnaround specialists transforming managed care organizations from the inside out. Hosted by Trey Sutten, CEO of Siftwell and former health plan CEO and Medicaid CFO, the podcast explores how leaders are implementing AI, improving quality, uncovering revenue opportunities, and preparing plans for what’s next across Medicaid, LTSS, SNIP, behavioral health, and complex populations.

Выпуски

  1. $11M for one patient's drug: why gene therapy threatens plans more than GLP-1s | Peter Marino

    25 июн.

    $11M for one patient's drug: why gene therapy threatens plans more than GLP-1s | Peter Marino

    One member at Neighborhood Health Plan of Rhode Island carries an $11 million annual maintenance drug. For that same cost, Peter Marino says he could vaccinate the entire state for the flu. Peter tells Trey why community plan leaders should be far more worried about gene therapy than GLP-1s. Peter has run Neighborhood as CEO for 11 years and grew the plan from 92,000 to 220,000 members and $450 million to $2 billion in revenue without a healthcare background. He brought state budget and government finance experience to an industry he'd only seen from the OMB director's desk, and built an operation that holds an 8.5% administrative rate at half the competitor average. Neighborhood is one of only 10 out of 200 Medicaid plans nationally to maintain a 4.5 out of 5 NCQA rating for 22 consecutive years, with NPS scores above +70, putting it in the same range as Apple and Ritz Carlton on the back of 350+ community events a year and senior leadership embedded on local boards. Peter also breaks down how his team applied redetermination lessons to get ahead of HR1 before federal definitions were finalized, what vendors get wrong when claiming FIDE SNP readiness, and why he stopped most hiring before the financial pressure hit so he never had to do layoffs. Topics discussed: Gene therapy and $11M single-member drug costs vs. GLP-1 pressure Running an 8.5% admin rate at half the competitor average Applying redetermination lessons to proactive HR1 member outreach Vendor readiness gaps when standing up a FIDE SNP FIDE SNP consuming almost half of staff and revenue at under 10% enrollment Preemptive hiring freezes to avoid layoffs under rate pressure Growing exchange market share from under 2% to 81% Managing member churn between Medicaid and exchange lines of business

    27 мин.
  2. 'We can do anything, we can't do everything': TPA switch, ACA exit, 30% growth | Mark Rakowski

    11 июн.

    'We can do anything, we can't do everything': TPA switch, ACA exit, 30% growth | Mark Rakowski

    Chorus Community Health Plans started with 30 members inside a children's hospital system that already held 90% inpatient market share. This wasn't a bed-filling play. Mark Rakowski, President of Chorus and SVP at Children's Wisconsin, tells Trey how that origin drove the decision to exit the ACA marketplace after medical and pharmacy trends hit 40-50% in 2025, and to redirect every available dollar back to the Medicaid families the plan was built to serve. Mark walks through how 20 years of voluntarily sharing financial statements, claims data, and parent-entity payment structures with his state Medicaid agency built the kind of trust that gets rate concerns taken seriously, while other plans that show up without supporting data get ignored. His tactical advice on state relationships goes a layer deeper: build with career department staff who outlast election cycles, not just the Medicaid director. On the innovation side, after years of low-engagement member apps, the real shift came from embedding Foodsmart tele-nutrition referral prompts directly into EPIC so the provider, not the plan, makes the introduction. It was the first time a provider told them: this makes sense and I'm going to promote it. On AI, Mark draws a clear line: use it to accelerate claim approvals and free leadership time for strategy, but every denial still goes to a physician advisor, and he says that will never change. His framework for leading through a simultaneous TPA migration, 30% county expansion, and ACA line exit at the same time comes down to one principle he repeats to his senior team: "We can do anything. We can't do everything." Topics discussed: Exiting ACA marketplace after 40-50% medical and pharmacy trend Building state agency credibility through voluntary financial transparency Adopting Housing First over the traditional treat-then-house model Embedding Foodsmart referral triggers in EPIC to activate provider engagement Why closed-loop CBO referral platforms stalled without matching resources Managing concurrent TPA migration, county expansion, and line-of-business exit Funding social determinants of health from administrative budgets Drawing the AI line at claim approvals, never automated denials

    33 мин.

  3. 21 мая

    Introducing Mission & Margin: a New Podcast for Community Health Plan Operators

    We're excited to launch Mission & Margin, a podcast for the executives running today's most complex health plans. In each episode, Trey Sutten sits down with the operators doing the work to share the strategies, decisions, and lessons that don't make it into press releases. The Plans Worth Fighting For The community health plan landscape has gotten harder. Capital constraints, subscale operating costs, rate pressure, and increasingly aggressive national competition. We've all watched it play out: regional plans merging, scaling back, or closing entirely. Community plans that serve populations the rest of the system doesn't know how to serve often get lost in the narrative. Kids in foster care. Adults with severe autism and substance use disorder. People navigating serious mental illness. Elders managing complex care. These are the members behind the financials and they don't fit cleanly inside a quarterly earnings call from a thousand miles away. When a community plan goes away, it doesn't come back. The leaders who'll keep these plans alive are the ones already in the work of segmenting populations, modeling scenarios, making the hard calls before the guidance fully arrives. The Conversations We Need to Have I've been in nonstop conversations with health plan leaders working through HR1, redeterminations, and the operational reality of January 2027. The practical wisdom inside those rooms — the strategies, the frameworks, the buy-versus-build calls, the vendor friction, the member-facing reality — is the playbook the next generation of plan leaders needs. That's what Mission & Margin is built to surface. Each episode, I'll sit down with a sitting health plan executive, policy advisor, or turnaround specialist tackling the industry's hardest challenges. We won't debate whether the policy is good or bad. Talk is cheap. We'll go straight to what it actually takes to run a modern MCO. Why "Mission & Margin" Because both are real, and neither survives without the other. A plan that loses its margin loses its mission. The community plans still standing in five years will be the ones that hold both with discipline. That balance is the throughline of every conversation on this show.

    2 мин.

Трейлер

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Mission & Margin is a show celebrating the executives, policy advisors, and turnaround specialists transforming managed care organizations from the inside out. Hosted by Trey Sutten, CEO of Siftwell and former health plan CEO and Medicaid CFO, the podcast explores how leaders are implementing AI, improving quality, uncovering revenue opportunities, and preparing plans for what’s next across Medicaid, LTSS, SNIP, behavioral health, and complex populations.

Информация

  • Автор
    Siftwell
  • Годы выхода
    2 тыс.
  • Выпуски
    3
  • Ограничения
    Без ненормативной лексики
  • Авторские права
    © Siftwell
  • Сайт подкаста
    Mission & Margin

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