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

Show Notes

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