The clinical-growth coalition: a Medicare Advantage blueprint for maximizing margin

Editor’s note: This is the second in a three-part series that explores how Medicare Advantage plans can turn the post-V28 landscape into an opportunity for growth. From capturing clinically complex members to optimizing engagement and transitioning populations into the right plans, we explore how integrated clinical and marketing strategies can drive both better outcomes and stronger margins. You can access Part 1 here.

In our first blog, “The end of absorption,” we explored why Medicare Advantage (MA) plans must move beyond the CMS V28 risk adjustment shift and toward growth in a landscape where volume is no longer king. We focused on the why. Now, let’s turn to the how.

Medicare Advantage plans have long competed to reach as many Medicare-eligible seniors as possible. That approach fueled steady growth. Enrollment grew an average of 9% per year between 2007 and 2024.¹

Today, growth is slowing and requires a more targeted strategy. Momentum is shifting toward higher-acuity members, reflected in rising enrollment in Chronic Condition Special Needs Plans (C-SNPs).

Broad-reach campaigns are no longer enough. Plans must activate a clinical-growth coalition. Marketing, care management, and data science align around a single goal: identify, engage, and retain high-need members. This is not just a growth strategy. It is how plans protect margins under V28 and turn regulatory pressure into long-term financial stability.

Turn clinical intent into revenue growth

Targeted acquisition requires a fundamental shift in prospect engagement. Traditional growth models built on mass-market age-in lists are increasingly inefficient and misaligned with margin discipline in the V28 era. To improve marketing ROI, plans must use first-party clinical search data to identify and reach high-value prospects at the moment they are actively researching specific chronic conditions.

Outreach must shift from reactive to proactive clinical identification. When a prospect searches for a clinically relevant topic (for example, “how to better control asthma”), that behavior becomes a condition-level intent signal — an indicator of active clinical complexity. By acting on these signals, plans can prioritize spend and deliver highly relevant messaging in real time. Instead of a generic appeal, prospects see tailored information about specialized benefits, including C-SNPs, aligned directly to their search intent.

With this approach, teams can move beyond demographic targeting and broad campaigns. Marketing can focus investment on individuals actively seeking information about complex health needs, accelerating enrollment into C-SNPs and supporting revenue stability. It also better aligns high-cost populations with V28 reimbursement structures, helping protect and expand margins.

Real-time intent alone is not enough. Plans should combine clinical search signals with predictive modeling based on existing member data — such as utilization patterns and supplemental benefit use — to build lookalike audiences of high-value C-SNP members. As a result, plans can proactively target individuals with complex health needs who are not yet aware of their eligibility, optimizing every dollar of marketing spend and lowering cost per acquisition for your most profitable member segment.

Finally, targeting must be supported by clinically relevant messaging rather than generic benefits. For C-SNP prospects, the value lies in a tailored clinical support model: care coordination, condition-specific drug coverage, and targeted ancillary services such as nutritional counseling. Aligning intent with message builds trust early and strengthens engagement from the first interaction.

Make retention a clinical growth engine

Retention is both a clinical and financial imperative, not simply a service metric. The first 90 days after enrollment are critical for establishing engagement and ensuring accurate risk documentation. For care management leaders, retention must focus on driving interactions that support clinical validation and close care gaps early in the member journey. Viewing retention through a clinical lens turns it from a cost center into a growth engine. Losing a high-acuity member is not just a care gap. It can mean six-figure revenue loss over time.

Automate risk capture from day one

A primary objective in the first 90 days is completing a Health Risk Assessment (HRA). Manual outreach is costly, resource-intensive, and difficult to scale. Automation is not just an efficiency gain. It directly improves financial performance. By replacing manual workflows with automated engagement, plans can increase HRA completion rates while more accurately documenting complex conditions. Aligning early engagement with risk capture protects margins. It ensures accurate documentation, stabilizes revenue, and helps capture the full allowable risk score within the first year.

Automated outreach works best when it respects member preferences. Seniors today expect personalized interactions. Honoring a member’s preferred communication channel is a key driver of engagement and ensures the initial HRA outreach connects. Studies consistently show that outreach delivered via a member’s preferred channel can significantly boost response and completion rates, directly reducing the need for costly, low-yield manual follow-up calls.

However, the HRA is not the end point. It serves as a starting point for clinical action. Effective retention strategies ensure seamless follow-through, moving members from assessment into care. Embedding an intelligent education system directly into the care manager workflow enables efficient, scalable execution.

The system surfaces recommended, condition-specific education tailored to each member’s needs, allowing care managers to assign pre-approved pathways that guide members to schedule primary care visits, complete referrals, and begin personalized education. It also supports multi-channel communication to maximize follow-through and equip care managers to deliver resources via email, chat, or SMS, using the member’s preferred channel. SMS is critical for timely engagement. Studies show 98% of messages are opened, and 90% are read within three minutes.²

Additionally, a secure, scalable message center within the platform would allow plans to maintain consistent follow-through, positioning them as an active partner in care. Real-time engagement metrics flow back into the system, giving care teams immediate visibility into what members view and complete.

Sustaining this engagement requires addressing barriers that disrupt care access. Social determinants of health (SDoH) screening, embedded within the HRA process, helps identify non-clinical factors that impact adherence. When paired with automated outreach, it enables care teams to connect members with local resources and support sustained engagement in care plans. By proactively connecting members to local resources based on SDoH data, plans mitigate future utilization risk. Each successful SDoH intervention helps prevent avoidable, high-cost events and protects margin.

SDoH screening is necessary, but insufficient. It identifies risk after it appears. The next frontier is predicting it before it surfaces.

Predict risk. Prevent costly events.

With V28 fully implemented, scale alone is no longer enough. Success now depends on a clinical-growth coalition that unites precision acquisition with clinically driven retention.

By combining real-time digital engagement, claims data, and provider feedback, predictive models can identify high-acuity members early — flagging signs of non-adherence or potential crisis, such as missed medications or searches for emergency symptoms. Automated alerts then prompt care teams to act, enabling targeted outreach that helps prevent avoidable, high-cost events like ER visits or hospitalizations. This level of targeted intervention demonstrates immediate value to the member while protecting plan margins. A single avoided inpatient stay or ER visit can offset the cost of the model, directly improving medical loss ratio and profitability.

Final thought (for now)

Targeted acquisition focuses marketing investment on prospects showing strong clinical intent, accelerating enrollment into specialized products like C-SNPs and improving revenue alignment. Retention builds on this by creating early clinical engagement and continuity. Together, automating key touchpoints, integrating SDoH screening, and applying predictive analytics transform the experience from a service interaction into a true partnership.

In the post-absorption era, clinical excellence is no longer just a differentiator. It is the engine of sustainable growth and financial performance. Winning in the V28 era requires three capabilities: identify the right members, engage them clinically from day one, and predict risk before it becomes cost. This integrated approach is how plans move from managing cost to generating margin and sustaining competitive advantage.

SOURCES

1. Medicare Advantage enrollment reaches 35 million, increasing by 1.1 million since February 2025, KFF, https://www.kff.org/medicare/medicare-advantage-enrollment-grew-by-about-1-million-people-mainly-due-to-special-needs-plans/#:~:text=Medicare%20Advantage%20enrollment%20reaches%2035,enrollment%20averaged%209%25%20a%20year
2. Mobile Text Messaging for Health: A Systematic Review of Reviews, National Library of Medicine, https://pmc.ncbi.nlm.nih.gov/articles/PMC4406229/#:~:text=As%20a%20result%2C%20it%20has,of%20being%20received%20%2822%29