Let’s have a conversation
The Medicaid market continues to evolve amid shifting regulatory priorities, state-level variations and economic pressures. As health plans, providers and agencies adapt to changes in funding, eligibility and oversight, the need for flexible strategies and expert execution has never been greater. In this updated Q&A, ProspHire’s Medicaid Practice Leader, Julie Evans, discusses the challenges, innovations and forward-looking strategies shaping Medicaid in 2026 and how ProspHire partners with clients to drive meaningful, measurable impact.
Section 1: Current Landscape & Pressing Challenges
What are some of the most pressing challenges that healthcare organizations face in navigating the Medicaid landscape, particularly considering recent regulatory changes?
Recent regulatory changes are most impactful with consideration to Medicaid eligibility, accessibility and sustainability. Looking ahead, as redeterminations become more frequent, work requirements become a reality and marketplace costs increase, the currently or formerly eligible Medicaid population face uncertainty. For healthcare organizations, this translates to coverage gaps, member abrasion and high administrative costs. Payors will seek to support their membership in understanding their eligibility and support in the administrative requirements to maintain coverage, but for those who temporarily lose coverage or go for an extended period without coverage, additional complications arise. The acuity of Medicaid members has increased, particularly as an outcome of the ending of the COVID-19 public health emergency redeterminations. As individuals lose or go without healthcare coverage, preventive care and health issues go unaddressed. Over time, we can expect that this will impact acuity and cost of care further, as preventive care is bypassed and members are faced with more complex health needs.
As financial pressures and administrative complexities continue to grow, how do we keep the member and care delivery at the forefront of Medicaid?
Financial and administrative burdens aren’t going anywhere as Medicaid will continue to face these challenges by nature of the program. Likewise, the pressure to drive improved health outcomes will also continue to exist and to achieve the desired health outcomes with a health plan’s wallet and administrative requirements in mind, there are several opportunities.
- Improved member engagement in preventive care and care management programs result in improved cost of care; therefore, driving a human-centered strategy will result in improved financial performance.
- Leveraging administrative data requirements to tell the human story will create added value in regulatory and quality operations.
- Removing administrative burdens on member-facing roles wherever possible through technology and operational efficiencies will allow the member and human connection to be the focus.
- Build trust and partnerships with the community and the community-based partners to engage with and improve care delivery. When members are being met where they are and their ample needs outside of medical care are being met, we will see improved engagement, outcomes and satisfaction.
As a reminder, Medicaid looks different not only across states but the needs of Medicaid members can vary down to the zip code level. The strategies are theoretically similar across health plans but execution should be deliberate with consideration to regional membership. Take care of the members to see improved outcomes and improved financial performance, allowing for reinvestment into operational efficiencies, staffing and technology to drive innovation and alleviate the “burden” of administrative and regulatory activities.
Section 2: ProspHire’s Approach & Methodology
How does ProspHire help clients drive innovation and sustainable improvement in Medicaid?
One of ProspHire’s core values is relationships. As we seek to drive innovation and sustainable improvement in Medicaid, our first step is to understand each health plan’s unique population and regional priorities through relationships with Medicaid beneficiaries, customer facing teams and community-based providers.
State regulations and region-specific needs are the foundation of Medicaid services and pose unique guardrails for our clients. While state regulations are rigid and defined, region-specific needs vary and evolve leaving room for innovation. Through a customer-centered approach, we seek to understand, rather than assume, and drive innovations that are inspired by the customer, leading to desirable and sustainable improvement.
ProspHire partners with our clients to amplify the voice of the customer through the ideation and execution of their innovations by means of strategic initiatives in alignment with organizational priorities.
Section 3: Compliance, Technology & Transformation
How does ProspHire stay on top of the evolving Medicaid regulations and policies and how do you ensure your clients remain compliant?
Read, watch, listen and react. Like many of our clients, we stay up to date on industry changes, trends and discussions to prepare ourselves and others to react to our evolving environment. This includes the ever-changing regulatory requirements and discussions at the federal and state level. Our attention to detail and quality assurance practices help us work in partnership with our clients and their legal and compliance teams to drive results and remain agile and in the case of political shifts, prepare for flexibility and adaptability in response to any sweeping or frequent policy changes.
Technology plays a crucial role in modernizing healthcare delivery. How does ProspHire integrate technology solutions into its Medicaid services to improve efficiency and outcomes?
Technology is continuously increasing in significance across healthcare delivery. Most recently our team supported the integration of a new clinical platform to enhance care management, utilization management and reporting capabilities. From requirements gathering to go-live and post go-live risk management and resolutions, our team has been in the weeds, working alongside the client to deliver a multi-state clinical solution. This tool improves efficiency of workflows, decision making and ultimately the delivery of care to the Medicaid population and those who are most vulnerable to adverse health outcomes.
Artificial Intelligence (AI) is another technological advancement that is buzzing as vendors and healthcare organizations find opportunities to integrate AI in the industry. ProspHire focuses on the business and end user when considering AI implementation, supporting health plans through business case development, user stories, vendor or system implementation and readiness and adoption activities. By preparing our clients to utilize the technology effectively, there is a greater return on investment through improved efficiency and outcomes.
Lastly, as quality improvement measurement transitions to digital quality measures (dQMs), health plans will face unique challenges in technology including application programming interfaces (APIs), coding, vendor integration and more in preparation for regulatory requirements driving this shift. The roadmap exists to embark on this transition but many health plans will require project management and subject matter expertise to drive the tactics and execution of this shift to achieve coordination across the organization, assess dQM readiness, conduct successful parallel reporting and ultimately migrate to the dQM model in a timely manner.
Plans have different technological needs depending on the current state of their operations and we partner with our clients to integrate the solutions that are prioritized in alignment with organizational goals to deliver improved member and operational outcomes.
Section 4: Data-Driven Insights and Equity
Can you talk about the importance of data analytics in Medicaid projects and how you use data-driven insights to inform decision-making and strategy development?
Social Determinants of Health (SDOH) and health equity efforts have led to a shift in the way specific care needs are identified and delivered. A challenge posed by SDOH, and ultimately health equity, is the variation in need based on environmental factors. Through partnerships with community-based organizations and our clients, mutual goals can be achieved by addressing social needs and downstream health outcomes.
To do so, data analytics is crucial. Who is our population of focus? Where do they live? What impact will our intervention have? These are all questions that data can provide insight to. Knowing this, ProspHire has supported population health assessments and data dashboards focused on marrying publicly available data and internal clinical data to support data-driven decision making. These tools support strategic development and inform the who, what and where of many Medicaid projects, specifically those focused on quality.
Section 5: Value-Based Care and Future Outlook
With the rise of Value-Based Care, how do you assist clients in transitioning from fee-for-service to value-based models within Medicaid?
Pay for performance models, shared savings programs, patient centered medical homes, Medicaid ACOs… the many value-based care models, continue to evolve and demonstrate their effectiveness. Our focus is to support the readiness and feasibility of transition followed by the monitoring and controlling of care model commitments. The continuous need to reduce costs and deliver improved quality of care poses a challenge to both providers and payors and leads to the continuous need to reevaluate and refine our reimbursement structures.
Looking ahead, what trends do you anticipate shaping the future of Medicaid consulting and how is ProspHire positioned to address these trends proactively?
As a boutique consultancy with an exclusive focus on healthcare and an emphasis on government programs, ProspHire is well positioned to be adaptive and quickly support our clients in understanding, implementing and monitoring the changes and impacts of regulatory and industry shifts.
One priority in Medicaid that will remain unchanged is the desire to reduce costs and improve quality, an effort that will continue to foundationally drive ProspHire efforts and priorities. As we evaluate the regulatory environment, industry trends and strategies, our goal remains the same – to drive positive change for our clients and the Medicaid population.
