The plan lens
Healthcare leaders
How the money really moves: revenue, risk adjustment, medical cost, Star Ratings, distribution, and the trade-offs behind every line of a plan P&L.
Followed through Mark, a health plan executive.
A book from inside Medicare Advantage
Decoded.CareInside Medicare Advantage
A Guide for Healthcare Leaders, Clinicians, and the Members Who Trust Them
Two decades inside Medicare Advantage, as a divisional CFO, a chief Medicare officer, a plan CEO, and now an operator again, turned into a practical playbook for running a plan that works financially, clinically, and operationally.
IN PREPARATION FOR PUBLICATION
Medicare Advantage doesn't fail in dramatic explosions. It fails in small, rational decisions that no one slows down enough to question. From Decoded.Care
Why this book
Plans that work on paper. And plans that work for people.
Medicare Advantage is one of the great operating achievements in American healthcare. Running a plan well is also one of the hardest jobs in it. The same mistakes repeat at scale: plans that pencil out on paper but quietly drift toward insolvency, physicians worn down by incentives that point the wrong way, members whose experience erodes one operational shortcut at a time.
None of it comes from malice. It comes from reasonable decisions made in isolation. Decoded.Care translates what actually works into a playbook, one that treats operational excellence as moral work and holds that the people Medicare Advantage serves have earned better than cleverness.
One chapter, three lenses
Written for everyone who sits at the table.
Every chapter follows the same decision through three sets of eyes, because in Medicare Advantage a choice made in the finance office lands in the exam room and, eventually, at a member's kitchen table.
The clinical lens
Clinicians
What plan decisions look like from the exam room: networks, prior authorization, value-based contracts, and incentives that help or hurt good care.
Followed through Dr. Sarna, a practicing physician.
The member lens
Members and families
What it means to choose, use, and depend on a plan: benefits, access, care after a hospital stay, and your rights when the answer is no.
Followed through Gloria, a Medicare Advantage member.
The three-legged stool. Financial discipline, clinical trust, and member access. A plan that lets any one leg go short eventually tips over, no matter how strong the other two look.
What's inside
The operating system of a Medicare Advantage plan, decoded.
Chapter by chapter, the book works through the machinery most people only see from one side.
The economics
Where Medicare Advantage dollars come from and where they go.
The competitive landscape
How the largest carriers compete, and what scale does and doesn't buy.
Risk adjustment and coding
Accurate documentation, audit exposure, and why the middle is the only safe place.
Distribution and marketing
Brokers, commissions, and the real cost of acquiring and keeping a member.
Reading the P&L
Medical loss ratio, medical cost trend, and what the numbers are trying to tell you.
Networks and access
Adequacy, provider relationships, and networks that perform.
Care after the hospital
The fragile window when coordination matters most.
Social needs and root causes
Food, transportation, and housing, and when addressing them pays off.
Value-based care
Targeted care and accountability shared between plan and provider.
Quality and Star Ratings
How quality is measured and how performance gets rewarded.
Appeals and member rights
How denials, appeals, and grievances actually work.
Compliance and enforcement
The rules, the audits, and the lessons regulators keep teaching.
Launch updates
Be first to know when the book is out.
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