Mission & Margin

Katie Martin, Vice President of Quality at Wellth, runs quality with no clinical background and treats it as a data problem first. In her words, information without data is just an opinion, so before pushing a care gap to a provider, she cleans her own data house, since most misses trace to a coding or data error.

She joins Trey on why the member has to be the core, how to segment outreach to how people actually want to be reached, and how she builds provider relationships around one question, how can I help?

Topics discussed:

- Cleaning your own data house before blaming provider gaps

- Segmenting member outreach by phone, text, or portal preference

- Applying behavioral science to close gaps, not just flag them

- Building provider trust by leading with current, accurate data

- Publicly celebrating high-performing providers to drive competitive improvement

- Defending quality budgets as outcome metrics under Medicaid pressure

- Addressing behavioral and cultural needs before physical health gaps

- Turning interoperability and FHIR data into usable risk stratification

Listen to more episodes:

Apple: https://podcasts.apple.com/us/podcast/mission-margin/id1896789104

Spotify: https://open.spotify.com/show/033kCfDSdndEFcVRsPJq2J

YouTube: https://www.youtube.com/@Siftwell

Website: https://siftwell.ai/mission-margin/

Gary Jessee, Senior Vice President at Sellers Dorsey, leads the national consulting practice working across state Medicaid agencies, managed care organizations, vendors, and solution providers on readiness, policy implementation, and system transformation. In this episode, Trey Sutten and Gary walk through where vendors pitch to the wrong buyer in Medicaid, what state Medicaid directors are actually managing during HR 1 implementation, why states are pausing new vendor onboarding, and how to separate waste from fraud in program integrity.

Topics Discussed:

- Medicaid readiness and capacity under HR 1: redesignations, community engagement requirements, and what states are actually focused on

- Service delivery models matter: why pitching to a state Medicaid director doesn't work if your buyer is a managed care organization

- Why vendors miss the mark: understanding who pays for a solution before approaching a buyer

- Medicaid directors under pressure: the toughest job in state government, managing federal mandates, policy changes, and 22 new directors navigating the role

- Medical frailty definitions and policy advocacy: what constitutes medical frailty, how states define it, and where MCOs have leverage

- Vendor fatigue and consolidation: health plans with 17 vendors solving the same problem, pausing new vendor onboarding, and what solutions need to look different

- Carve-in and carve-out transitions: why unwinding benefits from managed care is complex, political pressure, and learning from pharmacy and other carved services

- Waste versus fraud in programs: distinguishing between bad actors, compliance failures, and system inefficiency; where analytics and AI change program integrity

- How work actually gets done in state government: procurement processes, demonstrating value, and why flying to meet a Medicaid director might be a waste of time

- Purpose and impact in healthcare: what motivates people to stay in Medicaid, the heart of the industry, and leaving your mark on systems of care

Listen to More Episodes:

Mission & Margin on Apple Podcasts

Mission & Margin on Spotify

Siftwell on YouTube

siftwell.ai

At Centene, the Pennsylvania plan transitioned over 450 people out of nursing homes last year with a 3 percent recidivism rate. Anna Keith, Vice President, LTSS Product & Strategy, helped build the playbook behind that result and is now carrying it across the company's other 12 markets.

Anna tells Trey why duals integration has to anchor on the LTSS member's existing services, how Centene moved risk-averse nontraditional providers into shared savings by starting with bonus-only performance models, and how a new National Falls program uses predictive analytics to catch falls that 90-day-old claims data never sees.

Topics discussed:

• Scaling a foundation-first LTSS model across 12 additional markets

• Anchoring duals integration on the LTSS member's Medicaid services

• Separating person-centered plans from clinical care plans

• Easing risk-averse nontraditional providers into shared savings models

• Paying family caregivers while keeping quality measurable

• Predictive analytics for falls beyond 90-day-old claims data

• Incentivizing home care workers to close care gaps

• NCQA LTSS distinction as table stakes for health plans

Listen to more episodes:

Apple: Mission & Margin on Apple Podcasts

Spotify: Mission & Margin on Spotify

YouTube: Siftwell on YouTube

Website: siftwell.ai

Healthcare isn't broken in one spot. Hillary Galyean, Chief Growth Officer at St. Luke's Health Plan, believes it's broken in all the spots, and the root cause is trust. After nearly 25 years in health insurance, including a co-op that was one of only two to survive, she backs the integrated model.

Hillary tells Trey why regional plans lose competing with nationals on scale, how lighthouse accounts bring like-minded employer groups with them, and how a virtual care visit led to a PCP connection and a mammogram after more than seven years.

Topics discussed:

- Competing on trust instead of scale as a regional plan

- Why integrated models fail when they lean toward delivery

- The structural failures behind ACA co-op collapses

- Cultivating a culture comfortable with payer-provider tension

- Resisting the easy button of annual premium increases

- Staffing virtual care with in-house doctors to close gaps

- Technology platforms and AI as the biggest administrative wins

- Holding retention against broker pressure to shop accounts yearly

Listen to more episodes:

Apple: https://podcasts.apple.com/us/podcast/mission-margin/id1896789104

Spotify: https://open.spotify.com/show/033kCfDSdndEFcVRsPJq2J

YouTube: https://www.youtube.com/@Siftwell

Website: https://siftwell.ai

Bradley Riley's biggest fix for his analytics team at Longevity Health wasn't a new dashboard or a better data pipeline. It was hiring someone with zero analytics background. Riley, VP of Analytics, Medical Economics, Reporting, and PMO, pulled someone from clinical operations into his data team full-time and built a role from scratch — the clinical delivery lead — to translate between analysts and the clinicians and operators they serve. He's since added a second one for market growth.

Riley also breaks down his "boring AI" approach — using AI tools to build non-AI solutions faster rather than leading exclusively with AI-forward products — the 82% healthcare AI pilot failure rate and why small wins beat large pilots, and a peer's quote on compliance risk appetite that shifted his thinking: "Your AI strategy is only as good as your compliance and IT team's risk appetite."

Topics discussed in this episode:

1. Hiring a non-analyst to sit inside the analytics team full-time as a permanent translator between data and clinical operations, and why analytics leaders keep repeating the same cycle of hiring more analysts who don't understand how the business runs.
2. Building an internal member movement alert system using facility-level communications to identify hospitalizations and transitions before claims data arrives, bypassing the 60–90 day lag that makes most health plan interventions too late.
3. Pursuing small, repeatable AI wins instead of betting resources on a single large pilot, after an industry study found 82% of healthcare AI pilots fail because the technology is outdated by the time it clears compliance and IT review.
4. Using AI tools to build non-AI solutions faster — what Riley calls "boring AI" — embedding AI into analytical workflows to increase speed and efficiency rather than leading exclusively with AI-forward products.
5. Matching your AI strategy to your compliance and IT team's risk appetite, and why a misalignment between analytics ambition and organizational readiness will stall any rollout regardless of ROI.
6. A clinical GPT study across roughly 56 practices in Kenya that showed 96% accuracy, but clinicians disproportionately adopted the 4% of bad recommendations over the good ones — raising questions about human behavior in AI-assisted clinical decisions.
7. Building a custom managed care RAG agent loaded with operational context to train analytics team members who understand data but have never been exposed to how the managed care machine works end to end.
8. Using agentic desktop automation tools like Cursor and Windsurf to replicate manual, redundant processes — file transfers, portal logins, eligibility downloads — where no API integrations exist.

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

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

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.