‘We can do anything, we can’t do everything’: TPA switch, ACA exit, 30% growth | Mark Rakowski

Show Notes

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