How leading plans are breaking free from the headcount-to-growth ratio
Growth is supposed to be good news. More members. New programs. Expanded service areas. But for many health plans serving complex populations, growth brings an uncomfortable reality: every 10,000 new members seems to require proportionally more care managers, more UM staff, and more administrative overhead.
It’s a paradox that keeps executives up at night. How do you pursue growth opportunities—whether that’s Medicare Advantage expansion, new MLTSS contracts, or integrated behavioral health programs—without watching your cost-per-member-per-month climb in lockstep?
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The Hidden Cost of "The Way We've Always Done It"
Most health plans have built their care and utilization management operations on a foundation of manual processes, spreadsheets, and what we call “tribal knowledge”—the clinical and operational expertise that lives in your staff’s heads rather than in your systems.
When you have 50,000 members, experienced staff can manage. They know the policies. They recognize the high-risk members. They know which prior authorization requests require scrutiny and which can be fast-tracked.
But at 150,000 members? At 500,000? The cracks start showing:
- Inconsistent decision-making as different staff interpret policies differently
- Delayed authorizations because manual review processes can’t keep pace
- Higher appeal rates from inconsistent application of clinical guidelines
- Care manager burnout from administrative tasks that crowd out member interaction
- Compliance risk when regulatory requirements depend on individual follow-through
- Quality performance gaps that slip through because tracking is reactive, not proactive
The traditional solution—hire more people—addresses capacity but amplifies the underlying problems. More staff means more variation, more training overhead, and more potential for things to fall through the cracks.
Scaling Smart: From Tribal Knowledge to Embedded Intelligence
The health plans that successfully scale for performance rather than just volume share a common approach: they transform expertise and policy from knowledge residing in people’s heads into intelligence embedded in their operational workflows.
This isn’t about replacing clinical judgment—it’s about eliminating the administrative friction that prevents your clinical staff from focusing on what matters most.
What Embedded Intelligence Looks Like in Practice
Prior Authorization at Scale: Instead of every PA request requiring manual policy lookup and clinical guideline reference, your system applies medical necessity criteria automatically. InterQual or MCG guidelines are built into the decision support, not consulted separately. Requests that meet straightforward criteria auto-approve. Complex cases route to the right clinical reviewer with all context already assembled. Providers receive real-time notifications, not phone calls after business hours.
Result: Authorization turnaround times measured in hours, not days. Clinical staff spending time on genuinely complex cases, not routine approvals. Lower provider abrasion. Fewer appeals.
Care Management Without the Busywork: Risk stratification happens automatically based on claims, assessments, and gaps in care. Care plans generate from evidence-based templates tailored to the member’s conditions. Tasks auto-trigger based on member status changes or upcoming deadlines. Care transitions from hospital to home initiate workflows without manual intervention. Community resource referrals integrate directly into the care plan.
Result: Care managers spending face time with members instead of on documentation. Consistent application of clinical protocols across your entire population. Proactive gap closure that improves Star Ratings and health outcomes.
Regulatory Compliance as a Byproduct: CMS requirements, NCQA standards, and state regulations aren’t tracked in separate checklists—they’re embedded in your workflows. Turnaround time compliance is automatic because the system won’t let tasks fall behind. Documentation requirements are enforced at point of entry. Audit trails generate automatically.
Result: Compliance becomes a natural output of operations rather than an additional burden requiring dedicated staff.
The Configurability Imperative
Here’s where many technology solutions fall short: they embed intelligence, but they also embed rigidity. When CMS publishes new SNP Model of Care requirements, when your state issues updated MLTSS service authorization rules, or when your organization decides to launch a new care transition program, you face a choice: wait months for your vendor to custom-code the changes, or work around the system with spreadsheets and manual processes.
True scalability requires configurability—the ability to adapt workflows, assessment tools, business rules, and reporting as your programs evolve. And not just IT configurability. Business-user configurability that lets your clinical operations leaders and compliance staff make changes directly without vendor dependency or development sprints.
Real-World Impact: The Numbers That Matter
Organizations that successfully embed intelligence into their operations are seeing measurable results:
- 30-50% reduction in prior authorization processing time through automated decision support and approvals
- 20-40% improvement in care manager productivity by eliminating administrative tasks
- 15-25% reduction in appeals from more consistent, guideline-based decision-making
- Improved Star Ratings through systematic gap closure and quality tracking embedded in daily workflows
- Faster time-to-market for new programs—weeks instead of months—through configurable workflows
Perhaps most importantly, they’re achieving these results while growing membership and adding new programs. The cost-per-member-per-month curve starts to flatten, then decline.
Breaking Free from the Growth Paradox
Scaling for performance requires a fundamental shift in how you think about care and utilization management technology. It’s not about a system that stores data or tracks tasks. It’s about an execution platform that embeds your policies, clinical guidelines, and regulatory requirements directly into the point of work.
When your platform enforces medical necessity criteria automatically, when care plans generate based on evidence-based protocols, when compliance tracking is a byproduct of workflow rather than an add-on burden—that’s when you can grow membership without proportionally growing headcount.
Your clinical staff focuses on clinical judgment. Your care managers focus on member engagement. Your compliance team focuses on strategy rather than firefighting. And your finance team sees operational leverage that wasn’t possible before.
The Questions to Ask
If you’re planning for growth in 2026 and beyond, consider:
- Can our current systems scale without proportional cost increases?
- How much tribal knowledge would be lost if key staff left tomorrow?
- Are we configuring workflows ourselves, or waiting on vendors for every change?
- Do our systems integrate medical, behavioral, and social determinants in a single member view?
- Is compliance something we track separately or something our workflows enforce automatically?
The health plans that answer these questions honestly—and act on what they learn—are the ones positioned to turn growth from a cost challenge into a competitive advantage.
