量子资源网 Insights: Your source for healthcare news, ideas and analysis.
量子资源网 Insights 鈥� including our new podcast 鈥� puts the vast depth of 量子资源网鈥檚 expertise at your fingertips, helping you stay informed about the latest healthcare trends and topics. Below, you can easily search based on your topic of interest to find useful information from our podcast, blogs, webinars, case studies, reports and more.
量子资源网 (量子资源网), a leading health and human services consulting company, is pleased to announce that Matt Allen has joined the firm as Chief Growth Officer (CGO). As the firm鈥檚 first CGO, he will report to Chief Executive Officer Chuck Milligan and work out of 量子资源网鈥檚 Washington, D.C., office.
Matt brings more than 25 years of diverse experience in the healthcare sector and a proven track record of advancing growth and innovation to 量子资源网. He will shape the firm鈥檚 enterprise-wide growth initiatives, oversee strategic partnerships and help guide efforts that continue to advance innovation to meet current and emerging client needs.
鈥淢att is an excellent addition to our executive leadership team and will work closely with our business leaders to drive 量子资源网鈥檚 growth strategy,鈥� Milligan said. 鈥淗e is a proven and dynamic leader who will help unlock opportunities to serve our clients and partners now and well into the future.鈥�
Prior to joining 量子资源网, Matt was Avalere Health鈥檚 practice director and senior vice president of Client Partnerships. In this role, he led global business development, strategic growth initiatives, and marketing. During his tenure, he advanced through a series of senior leadership positions and played a pivotal role in steering the organization through major transitions.
Previously, Matt advised health system and physician practices on revenue growth and patient-acquisition strategies as part of Optum’s legacy Advisory Board Company data and analytics practices. His experience also includes having led business development at public data startup Poplicus, Inc., and serving as a vice president at healthcare policy firm Marwood Group. He began his career in Johnson & Johnson’s pharmaceutical division with various roles in finance, field sales, managed care marketing, and brand analytics.
This 10-slide presentation, Medicaid Expansion: Data-Driven Insights into Healthcare Needs, offers a focused analysis of the Medicaid Expansion population鈥攏on-disabled adults ages 19鈥�64 with incomes up to 138% of the Federal Poverty Level鈥攁cross more than 40 states. Using recent T-MSIS data, the deck highlights the high prevalence of chronic and behavioral health conditions within this group, while also detailing demographic trends among the approximately 16 million enrollees.
Developed by Matt Powers, Shreyas Ramani, Loren Anthes, and Lora Saunders, the presentation contextualizes health needs with Medicaid spending patterns, comparing the Expansion group to other eligibility categories, such as dual eligibles and children. It also breaks down pharmacy spending by therapeutic class, spotlighting common conditions like opioid use disorder. In light of recent federal legislative proposals such as H.R. 1, the deck explores how states are beginning to navigate policy changes through 1115 waiver activity鈥攑articularly around medically frail and good cause exemptions鈥攐ffering early insight into likely implementation strategies.
Today, we celebrate a significant milestone for 量子资源网 – 40 years of advancing healthcare, improving lives, and addressing the challenges that matter most.
Over the decades, we鈥檝e had the privilege of partnering with many clients across the nation to tackle healthcare鈥檚 most pressing issues, applying our deep expertise every step of the way.
As we reflect on our 40-year journey and what we have built, we refocus ourselves on what it takes to become a leading healthcare and human services consulting firm. Looking down that road ahead, we are investing in the human experiences, analytical and digital tools, and methods to deepen our value鈥攚orking with our clients and partners to create a healthier future for everyone in our country.聽
Watch our Medicaid Town Hall hosted by 量子资源网. Our experts answered your questions live on a wide range of timely and critical topics, including:
Key policies and insights about the ongoing 2025 federal budget reconciliation negotiations, including changes to Medicaid eligibility policies, financing, and cost-sharing rules.
New executive branch priorities to address program integrity and agency regulations and guidance reshaping provider tax rules and state-directed payment arrangements.
The evolving landscape of Medicaid Section 1115 demonstrations, including updated federal monitoring approaches and new state initiatives.
Medicaid managed care trends, payment innovation, and emerging strategies to address whole-person care focused on maternal health and behavioral health needs.
As Congress intensifies negotiations over budget reconciliation, including potential changes to Medicaid financing and Affordable Care Act (ACA) subsidies, new data from Wakely Consulting Group, an 量子资源网 (量子资源网) company, sheds light on how the effects of the Medicaid redetermination process continued to unfold well into 2024. Appendix A of the May 2025 white paper , provides a full-year view of enrollment and morbidity trends, showing that the influx of former Medicaid enrollees had some negative effects on risk scores. In fact, relative risk increased across all market types鈥攕tate-based exchanges (SBEs), in federally facilitated exchange (FFE) Medicaid expansion states, and FFEs in non-expansion states鈥攄espite substantial enrollment growth.
Data presented in Wakely鈥檚 and their experts鈥� findings challenge the conventional assumption that higher enrollment dilutes risk and suggest that many new enrollees may have had unmet health needs or delayed care. The data also show that states with the highest enrollment growth did not necessarily experience the greatest morbidity shifts. This decoupling of enrollment and morbidity complicates forecasting for insurers and policymakers alike, especially as Congress debates Medicaid funding and ACA subsidy structures in the ongoing budget reconciliation process.
What to Watch
As federal lawmakers consider reforms that could alter Medicaid eligibility, subsidies, and risk adjustment mechanics, these findings underscore the importance of monitoring not just how many people enroll, but who they are and the type of care they need. The individual market鈥檚 evolving risk profile will have direct implications for premium setting, subsidy design, and the financial stability of plans that serve this population.
Connect with Us
Wakely is experienced in all facets of the healthcare industry鈥攆rom carriers to providers to government agencies. Wakely鈥檚 actuarial experts and policy analysts continually monitor and analyze potential changes to inform clients鈥� strategies and propel their success.
For more questions about the analysis contact our experts below.
In this week鈥檚 In Focus section, 量子资源网 Information Services (量子资源网IS) draws on its database of monthly enrollment in Medicaid managed care programs to provide the latest quarterly analysis of Medicaid managed care enrollment, offering a snapshot of developments across 28 states.[1] The data and insights are particularly timely as stakeholders, including states, Medicaid managed care organizations (MCOs), hospitals and health systems, and providers, continue to plan for multiple possible federal policy changes and the operational realities that will follow.
量子资源网IS also compiles a more detailed quarterly Medicaid managed care enrollment report representing nearly 300 health plans in 41 states. The report provides by plan enrollment plus corporate ownership, program inclusion, and for-profit versus not-for-profit status, with breakout tabs for publicly traded plans. Table 1 shows a sampling of plans and their national market share of Medicaid managed care beneficiaries based on a total of 66 million enrollees. These data should be viewed as a broader representation of enrollment trends rather than as a comprehensive comparison.
Key Insights from Q1 2025 Data
The 28 states included in our review have released monthly Medicaid managed care enrollment data via a public website or in response to a public records request from 量子资源网 (量子资源网). This report reflects the most recent data posted or obtained. 量子资源网 has made the following observations related to the enrollment data:
Year-over-year growth. As of March 2025, across the 28 states reviewed, Medicaid managed care enrollment declined by 2.5 million members year-over-year, a 3.9 percent drop as of March 2025 (see Figure 1). This marks a continuation of the downward trend reported in late 2024, though with notable variation across states.
Figure 1. Year-over-Year Growth in Medicaid Managed Care States, 2020鈭�24, March 2025
Localized growth amid broader declines. While most states experienced enrollment reductions, Indiana and North Carolina bucked the trend with measurable gains, suggesting the influence of state-specific policy shifts or demographic factors. Oregon and Texas also saw modest growth.
Sharpest contractions. Illinois, Maryland, and South Carolina, reported double-digit percentage drops, underscoring the uneven impact of redeterminations and eligibility changes.
Difference among expansion and non-expansion states. Among the 21 states included in our analysis that expanded Medicaid, enrollment fell by 1.8 million (-3.6%) to 48.6 million. In contrast, the seven non-expansion states saw a steeper proportional decline (-5.4%), to a total of 12.2 million enrollees.
Table 1. Monthly MCO Enrollment by State, January 2025 through March 2025
Note: In Table 1 above and the state tables that follow, 鈥�+/- m/m鈥� refers to the enrollment change from the previous month, and 鈥�% y/y鈥� refers to the percentage change in enrollment from the same month in the previous year.
It is important to note the limitations of the data presented. First, states report the data at the varying times during the month. Some of these figures reflect beginning of the month totals, whereas others reflect an end of the month snapshot. Second, in some instances, the data are comprehensive in that they cover all state-sponsored health programs that offer managed care options; in other cases, the data reflect only a subset of the broader managed Medicaid population. This limitation complicates comparison of the data described above with figures reported by publicly traded Medicaid MCOs. Hence, the data in Table 1 should be viewed as a sampling of enrollment trends across these states rather than a comprehensive comparison, which cannot be established solely based on publicly available monthly enrollment data.
Market Share and Plan Dynamics
Using our data repository from 300 health plans across 41 states, 量子资源网IS鈥檚 report addresses corporate ownership, program participation, and tax status. As of March 2025, Centene continues to lead with 17.7 percent of the national Medicaid managed care market, followed by Elevance (10.8%), United (8.8%), and Molina (6.3%), as Table 2 shows.
Table 2. National Medicaid Managed Care Market Share by Number of Beneficiaries for a Sample of Publicly Traded Plans, March 2025
What to Watch
The policy backdrop remains fluid. The US House of Representatives鈥� passage of the One Big Beautiful Bill Act introduces sweeping changes to Medicaid financing, including proposed cuts of up to $715 billion. Additional federal proposals, such as mandatory work requirements, could further reshape enrollment patterns.
Stakeholders should prepare for:
Implementation of work/community engagement mandates for certain adult populations
Potential redesign of Affordable Care Act expansion programs
Retraction of federal regulations focused on streamlining of eligibility and redetermination processes to improve accuracy and efficiency
Connect with Us
量子资源网 is home to experts who know the Medicaid managed care landscape at the federal and state levels. As the Medicaid landscape continues to evolve, 量子资源网IS equips stakeholders with timely, actionable intelligence. Our subscription service includes enrollment data, financials, waiver tracking, and a robust library of public documents.
For more information about the 量子资源网IS subscription, contact our experts below.
[1] Arizona, California, Florida, Georgia, Illinois, Indiana, Kentucky, Louisiana, Maryland, Michigan, Minnesota, Mississippi, Missouri, Nevada, New Jersey, New Mexico, New York, North Carolina, Ohio, Oregon, Pennsylvania, South Carolina, Tennessee, Texas, Virginia, Washington, West Virginia, Wisconsin.
As Medicaid faces another set of policy shifts, this episode provides a look-back on the many twists and turns Medicaid has faced throughout the years. Jay Rosen, president and chairman of 量子资源网, reflects on his work with states and health plans over the past four decades in their efforts to deliver services to vulnerable populations amidst shifting federal and state priorities, innovative delivery and payment models, and increased private sector involvement. With a sharp focus on policy, equity, and system transformation, Jay offers strategic insights for leaders across healthcare, government, and investment sectors.
量子资源网 focused this paper on how states disperse Medicaid funds to certain subpopulations within the program鈥檚 categorical eligibility infrastructure. A previous companion paper centered on increasing our understanding of Medicaid managed care spending by provider, offering more detail on the relative order of magnitude of the amounts spent on inpatient and outpatient hospital care, professional services, long-term care, pharmacy, and other health services.
As the latest national Medicaid managed care enrollment data show 75% of Medicaid beneficiaries were enrolled in comprehensive managed care organizations (MCOs), these two foundational papers illustrate the importance of developing a sound methodology to reliably estimate costs associated with MCOS. These papers, which are the first to present findings related to the development of the MCO methodologies, help lay the foundation for further work that will enable us to answer relevant questions, including:
How much do we spend on Medicaid patients with chronic conditions like asthma, diabetes, and hypertension?
How much do we spend on Medicaid patients receiving long-term services and supports (LTSS) and what is the unmet need?
How is Medicaid funding spent on childbirth and a child鈥檚 first year of life?
What are the opportunities to be more efficient and effective with Medicaid resources?
We recently sat down with Medicare experts from 量子资源网 and Wakely to break down the most important and most pressing developments shaping the future of Medicare Advantage, including the latest updates from CMS on Risk Adjustment Data Validation (RADV) audits, specifically the two major announcements released on May 21st and May 30th that are sending waves through the payer and provider communities alike.
On May 21st, CMS issued new guidance related to extrapolation and how sampling methodology and medical record review standards will evolve under the updated RADV Final Rule.
Then, just nine days later, on May 30th, CMS released additional operational instructions that may tighten reporting windows, add new thresholds for error rate evaluation, and expand expectations around provider documentation compliance鈥攑articularly for retrospective reviews and risk adjustment data sourcing.
To help unpack this fast-moving landscape, we鈥檝e spoken with our Medicare experts, , and David Nater, each bringing a unique lens to the RADV conversation.
What was your first thought when you read CMS’s latest RADV update last week?
Tony – My main takeaway was that CMS was really upping the game in terms of what payers need to do to not only do the appropriate measures to optimize their risk scores but then audit claims that are coming in from providers. So this isn’t just a matter of ensuring that risk score optimization strategies are appropriate, not overstepping, but also adding a new administrative task of auditing claims that you鈥檙e getting from providers that may have errors in them.
Can you quickly summarize what CMS actually changed in this latest announcement, and what鈥檚 most significant about it compared to the previous announcement in November last year and previous RADV audits?
Ryan 鈥� The core of these changes, prior to the old way of doing RADV is, of course the extrapolation methodology that CMS will be introducing, as well as the elimination of the fee-for-service adjuster, which is going to be huge. Then we can move on to that with the announcement of enhancements of staffing and technology.
It鈥檚 going to be very interesting how CMS looks to utilize that. As well as every single contract being audited that is eligible are probably the focus points within this, and with CMS they give you a little, and then you have to look into it a lot, so I think there’s still a lot more to come related to these initial announcements that are coming through.
What exactly does this mean from a health plan perspective in the near term – especially for those already in the trenches of risk adjustment audits or pre-audit reviews?
David 鈥� Most financial teams use claims as forecasting and having concurrent risk adjustment processes is really the optimal approach to make sure that there are no surprises on the financial end for month end and quarterly reports. Making sure that plans are getting ahead of this cleanup now is imperative to mitigate those financial impacts, and then on a concurrent level, optimizing the operational processes ensures just better forecasting and overall better financial outcomes.
With the latest announcements regarding RADV, what are the current unknowns at play related to this new look RADV strategy?
Tony 鈥� On a technical level, the key things we don’t know are how CMS is going to sample claims – They’ve indicated that they’re going to move from random sampling to targeted sampling – and we don’t know how they’re going to extrapolate that. So, if you do a targeted sample, do you extrapolate that just to a targeted extrapolation, or do you extrapolate that to the whole plan? And that’s your range of low impact to high impact.
Similarly, we don’t know what confidence interval CMS is going to use. There’s been some indications of 99% in the past. That’s going to be very conservative, but 95 or 90% would be plausible confidence intervals as well, and that gets you to much more aggressive recovery rates. There are a few other small technical issues that I don’t think will have as big of an impact, but those are the three ones that we’re really looking to CMS to figure out.
What鈥檚 the one thing you think plans need to prioritize immediately in light of this update – and what鈥檚 the trap they need to avoid?
Ryan – I think plans need to very quickly understand their exposure. One of the ways to do that鈥攁nd one of the ways we are engaging our clients鈥攊s to run analytics looking at these high-risk codes. There are also certain indicators you can look at to see what needs to be reviewed and what has high error rates, based on previous OIGYG and CMS audits. From there, you need to get a quick plan in place to document and assess whether or not those codes are relevant. If they are not, submit them before the aggressive timeline CMS has put in place.
As I mentioned, there are less than two weeks to submit deletes for 2019 dates of service, and every 7 days after that thereafter for each payment year. So, the time to act is now. You need to quickly understand where your risk is and take action. And if you don鈥檛 have those capabilities, engage with strong consulting groups or partners who can support you through this.
What closing thoughts or takeaways would you like to share?
Ryan 鈥� If I put myself on the plan side, I see both a short-term, immediate plan and a long-term sustainability plan.
That short-term immediate plan is action to act NOW. Whether that is engaging with a partner, or engaging in your internal team, you need to be able to highlight where your risk areas are. Take action on this prior to CMS coming in and acting for you. What’s just as important is setting up a long-term roadmap to be able to mitigate this risk going forward.
To look at it concurrently, do you have the right analytics in place? Do you have the correct staffing in place to be able to look at these risk codes coming in? Assess them and send the necessary deletes coupled with closing the loop related to feedback. Are you pushing that information and education back to your physician groups? Because they’re the most important part to this. You need to be able to educate, communicate and meet with your providers to explain how important the act of documentation and coding is and have this at the forefront of every one of your initiatives and incentive programs going forward in value-based care.
David 鈥� 量子资源网 and Wakely are well-positioned to help in both the short-term and the long-term approach, and ideally both. Organizations need to act quickly and align their steady-state processes to ensure that they’re managing both the exposure at the health plan level and with the providers, especially those in risk-based arrangements.
Tony 鈥� Plans need to be thinking of the RADV risk here, apart from the risk that they might see from chart reviews and other add activity. You may be a plan that’s relatively unaggressive in chart reviews and adds that think 鈥渨e’re not risk here鈥�, but CMS has now assigned you risk for all the claims that providers are submitting, and you need to be ensuring that those are correct as well.
There’s a wholly separate administrative task here that plans have now assumed responsibility for, and your revenue is just as at risk for not doing the RADV as it is for being inappropriate in your chart reviews and adds and whatnot. So, you really want to be thinking of this as two separate things and acting from both fronts.
Today鈥檚 healthcare leaders are navigating an era of accelerated disruption. Traditional hospital models are under intense pressure from rising costs, workforce shortages, changing reimbursement landscapes, and shifting community expectations. Hospitals and health systems are increasingly challenged by issues that affect multiple areas of the business from strategy to fiscal management to clinical operations.
Financials & Revenue
Workforce
Improving Health Outcomes
Strategic Partnerships
Technology & Digital Innovation
OUR COMMITMENT
We empower hospitals by guiding transformational decisions 鈥� protecting legacy, stabilizing operations, and building the future of healthcare, one courageous step at a time. Our 量子资源网 Delivery Systems team works with hospitals, health systems, federally qualified health centers (FQHCs) and associations to support their strategy, clinical services, operations, finance, and value-based care needs. Let us know how we can help your organization.
Five Critical Priorities for Transformation
Financial Reinvention and New Revenue Models
Optimizing operational efficiencies, increasing price transparency, and diversifying revenue through innovations like hospital-at-home.
We offer board- and CEO-level financial, operational, and strategic assessments and tailored scenario planning to evaluate service realignment, restructuring, and sustainable growth.
Workforce Resilience and Sustainability
Investing in staff retention, interdisciplinary team redesign, leadership development, and pipeline programs to stabilize care delivery and safeguard institutional knowledge.
We support clients with strategic workforce planning, interdisciplinary team optimization, and leadership development frameworks to future-proof talent pipelines.
Expanding Access and Improving Health Outcomes
Advancing accessible, high-quality care and strengthening community loyalty.
We guide the development of community health investment strategies, trust-building frameworks, and initiatives to foster patient and stakeholder loyalty.
Strategic Partnerships and Ecosystem Building
Building alliances across systems, payers, technology firms, and community organizations is essential to expanding reach, managing risk, and accelerating innovation.
We bring expertise in strategic partnership development, merger and affiliation exploration, and collaborative ecosystem strategies.
Technology and Digital Innovation
Deploying technology and AI automation to streamline workflows, enhance patient experience, and lower costs is now a competitive imperative.
We partner with hospitals to develop tailored technology enablement roadmaps鈥攊ntegrating digital solutions aligned with operational goals and future-state visions.
Who We Help
We offer a full suite of professional health and human services consulting services to clients serving hospitals and health systems, such as:
Critical access and PPS hospitals
FQHCs, rural health clinics, & provider practice groups
Warren Brodine partners with communities, federally qualified health centers (FQHCs), and payors to deliver optimal patient and community outcomes, supporting … Read more
An experienced healthcare executive, Rob Ross is dedicated to developing solutions to provide quality, accessible, cost-effective care while ensuring the … Read more
