I’d start by asking where money is leaking.

Most procurement categories emerge from the same handful of operational exposures. The names change. The vendors change. The underlying problems rarely do.

If I Were Struggling With…..

BEHA…

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What interests me most about today’s discussions on Medicaid work requirements is the realization that the healthcare system is being asked to produce information it often doesn’t have.

Claims data can tell you someone has cancer, multiple sclerosis, HIV, or a recent hospitalization. It can tell you which medications were filled, which diagnoses were documented, and how often someone used healthcare services. What it generally cannot tell you is whether those conditions significantly impair a person’s ability to work.

Yet the new rule increasingly hinges on functionality. Healthcare has encountered versions of this challenge before. Functionality shapes access to long-term care services and disability benefits. From a frontline perspective, it also sits at the center of decisions involving involuntary psychiatric hospitalization, county guardianship, and post-acute placement. The difference between what a person has and what a person can do often determines whether an inpatient stay lasts three days or three months.

That turns a policy debate into a data problem.

Healthcare organizations are being asked to generate, verify, and defend evidence about a person’s functional capacity. Some of the most useful information may not come from claims at all. It may come from social workers documenting daily functioning after discharge, care managers tracking transportation barriers and caregiver support, or social care programs capturing realities that rarely appear in a billing record.

Which raises a larger question.

If healthcare is becoming better at measuring the realities of daily life, which social care models gain the most value as those measurement systems improve?

While National Health Data Week centers on interoperability, patient matching, artificial intelligence, and data standards, many Medicaid and social care leaders are paying attention for a different reason.

Every improvement in healthcare data changes what can be measured, and every change in measurement eventually changes what gets purchased.

So, which social care models gain the most value as healthcare becomes better at measuring what happens?

Better healthcare data should benefit referral platforms, interoperability vendors, analytics companies, and the broader infrastructure layer responsible for moving information across fragmented systems.

Yet recent developments suggest something more interesting may be happening.

California now reimburses medically tailored meals, housing supports, transportation, and other community services through its In Lieu of Services framework. Massachusetts has incorporated Health-Related Social Needs services into MassHealth. Community Servings can point to published analyses linking medically tailored meals to lower utilization and lower spending. None of those developments changed the intervention itself. Meals remained meals. Transportation remained transportation. What changed was healthcare’s ability to document who received a service, connect the intervention to utilization data, and evaluate outcomes inside an accountability framework.

The largest beneficiaries of better healthcare data may not be the organizations building the newest technology. They may be some of the oldest interventions in social care.

LIVE: POLL

Which social care models get stronger as healthcare data improves?

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The Strait of Hormuz sits nearly 8,000 miles from Los Angeles. Yet a disruption there can influence whether a meal reaches a homebound senior in Riverside or whether a nurse completes six visits today instead of four.

Gas is approaching seven dollars a gallon in parts of California. Most people experience that fact in the same way: standing at a pump, staring at numbers. The conversation that follows is predictable. Family budgets. Commutes. Inflation. Whether this is temporary or permanent. Whether the Strait of Hormuz reopens. Whether the next fill-up will be worse.

Healthcare leaders are having a version of the same conversation. The difference is that their vehicles happen to be attached to some of the fastest-growing care models in America.

A nurse driving to a patient’s home. A medically tailored meal traveling across a county line. A community health worker making a home visit. A maternal-health program serving a rural family. An acute-care team dispatched to a living room instead of an emergency department. The healthcare system increasingly delivers care through movement. People, meals, supplies, services, and relationships all travel across geography before they create value.

Most discussions about social care focus on outcomes. Did the intervention reduce readmissions? Did it improve engagement? Did it save money? Those questions matter. They tell us whether something works.

They tell us less about what it costs the system to make that intervention happen repeatedly, reliably, and at scale.

A medically tailored meal delivered five miles away and one delivered seventy-five miles away may generate identical outcomes. A community health worker serving a dense neighborhood and a community health worker covering three counties may produce identical engagement rates. A maternal home visit conducted in a city and one conducted in a frontier region may create the same clinical benefit.

This sounds obvious until you realize how rarely it appears in procurement conversations. Healthcare has spent years building frameworks for evaluating clinical risk, social risk, financial risk, quality performance, compliance exposure, and return on investment. Geography often appears as context. It rarely appears as an operating variable.

Yet geography influences something every healthcare executive ultimately cares about: capacity.

Meanwhile, the Strait of Hormuz closure makes this harder to ignore.

Home-based care, meal delivery, community outreach, maternal home visiting, and transportation services have always depended on moving people, supplies, and services across physical distance. Every mile consumes time. Every hour spent driving is capacity that cannot be spent elsewhere.

When fuel costs rise, the underlying constraint becomes more visible. Service areas become harder to sustain. Routes become more important. Capacity becomes more expensive to produce.

What makes this particularly difficult to see is that the first sign rarely appears on a financial statement. Organizations adapt long before it gets that far. Routes are redesigned. Territories are adjusted. Service areas contract. Staff spend more time driving and less time delivering care.

If two organizations produce identical outcomes, but one requires substantially more geographic effort to produce those outcomes, they are not equally scalable. They are not exposed to the same operating risks. They are not necessarily equally durable.

This is where the conversation shifts from logistics to procurement.

Healthcare buyers routinely compare outcomes, utilization reductions, quality scores, audit readiness, and ROI. Increasingly, they may need to evaluate something else as well: geographic scalability.

Some organizations create value through physical movement. Others create value by coordinating, authorizing, routing, activating, documenting, and managing movement. Both can generate extraordinary outcomes. Both can be economically valuable. They operate under different constraints.

The social-care conversation has spent years asking whether these models work.

As the strait remains effectively closed, different question is becoming more widely recognized:

How efficiently can they move through geography while continuing to be effective?

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POLL | FROM THE LINKEDIN COMMUNITY

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Good morning,

I went to HCCA’s Managed Care Compliance Conference with a specific goal: to test a hypothesis I’ve been sharing with you.

It’s that regulatory and payment models are no longer tolerant of narrative proof.
If it can’t be validated in claims and encounter data, it increasingly doesn’t “exist” for audit, renewal, or financial recognition.

I went looking for enforcement posture: the parts that show up later as IDS, CARs, denials, repayment exposure, or a quiet non-renewal decision.

This edition isolates what sponsors will be expected to already have in place for 2026, and why vendor oversight tends to be where things fail first — even when everyone is acting in good faith.

The 2026 reality is a redefinition of failure conditions.

Audit exposure now hinges on whether a sponsor can produce reconciled, testable, time-stamped evidence across internal and delegated systems within compressed windows, not just whether policies exist.

This is for leaders who own outcomes but don’t always own the data:

• Medicare Advantage / Medicaid plan executives

• compliance, audit, SIU, and vendor oversight leaders

• vendors whose contracts depend on producing auditable universes under time pressure

If your world includes delegation, universes, denials, corrective actions, renewals, or PMPM negotiations, this is your operating environment.

In this edition:

• What CMS audits will require sponsors to prove in 2026

• How audit timelines now test governance, not intent

• Where delegation creates unpriced risk exposure

• Why post-discharge ROI fails financial recognition

• The evidence standards finance teams now apply

“Doing the minimum required by contract isn’t enough. If you want to pass a UPIC audit, you have to put the work in before the audit starts.”

- A director of program integrity at a large Medicaid plan

Back in November, I flagged that CMS was moving quality measurement away from self-reported assessments toward multi-payer verification using claims and Medicare Advantage encounter data. That direction and mechanism held: CMS finalized recalculation of the antipsychotic use measure using administrative data, confirming claims-grade inputs now supersede self-reported MDS-driven measures. This aligns with a broader CMS audit posture shift: intent and narrative no longer matter if workflows do not generate verifiable data artifacts.

What did not hold was timing and visibility: the shift did not produce immediate, public enforcement or market disruption, as effects are being absorbed through internal reconciliation, universe validation and recalibration cycles rather than external action. In other words, the enforcement surface has moved upstream.

Quality scores now reflect verified utilization, reducing variance driven by documentation practices. Impact accrues at rating recalculation, audit review, delegated oversight, and renewal rather than day-to-day operations. Decision relevance centers on preparation, not response.

Takeaway: treat self-reported quality metrics as provisional until reconciled against claims and encounter data; this is a baseline assumption that surfaces at renewal and audit cycles.

If this lens feels useful, that’s not an accident.

PULL exists to surface the standards that determine whether this work is recognized or excluded across audit, compliance, and finance.

If that’s relevant to how you operate, full access is where this work continues.

Upgrade to Premium.

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CMS & OIG AUDIT PRIORITIES FOR 2026 AND WHERE VENDOR OVERSIGHT BREAKS FIRST

I’ll start with what I didn’t hear: Nobody stood up and said, “We’re going to punish you for imperfect data.”

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KFF | Provider Tax Crackdown Removes $226B in Medicaid Financing
New KFF analysis estimates the reconciliation law’s provider-tax restrictions will cut $226B in Medicaid funding over ten years, part of a broader $911B (14%) federal reduction. States that rely heavily on nursing-facility and hospital taxes now face rate compression and benefit pressure. Budgets will shift toward hard-ROI social care that substitutes for cuts (ED, inpatient, and SNF avoidance) not discretionary pilots.

Congress.gov | SUPPORT Act Reauthorized Through 2030
The SUPPORT for Patients and Communities Reauthorization Act is now law, extending federal SUD, overdose-prevention, maternal behavioral-health, housing, and workforce programs through 2030. Multi-year grant authority gives systems an external funding floor to braid alongside Medicaid and MA, allowing BH-heavy, community-rooted models to scale even as state match dollars tighten.

Yahoo Finance | CMS Extends Quest Analytics Adequacy Contract (5 Years)
CMS renewed Quest Analytics’ contract to oversee MA and pharmacy network adequacy for another five years, locking in the current time/distance and directory-accuracy regime through 2030. Network adequacy remains a growth and compliance gate, not a political variable. Plans will fund partners who shore up access in rural and behavioral-health deserts or clean provider data to avoid sanctions and denied expansions.

Fierce Healthcare | Reema Raises $19M; 23% Cost Reduction Validated
Reema Health closed a $19M Series B led by LRVHealth and Optum Ventures after actuarial review showed 22% fewer ED visits and 23% lower total cost of care in a high-risk Medicaid cohort. The raise sets a benchmark for navigation and foundational-needs vendors: plans now expect 15–25% cost reduction on defined risk panels not anecdotal outcomes or engagement rates.

Medical Economics | SDOH Screening Code G0136 Survives 2026 Rule
CMS ultimately kept HCPCS G0136 in the 2026 fee schedule, preserving a billable pathway for structured SDOH conversations. The dollar value is small, but the data value is high. Screening accuracy shapes future risk, equity, and benefit-design decisions and keeps SDOH documentation embedded in clinical workflows.

CMS | CMS Expands IRF Review Choice Demonstration
CMS is widening its pre-claim / post-payment IRF Review Choice Demonstration to additional states, including California and Texas. The expansion increases audit exposure and documentation pressure for high-cost post-acute episodes driving demand for partners who can reduce readmissions, standardize medical necessity documentation, and protect IRF revenue under heightened review.

Bloomberg Law | Curative Raises $150M, Valuation Hits $1.28B
Employer-focused insurer Curative secured $150M to scale its zero-cost-sharing plan, citing 20% higher primary-care use, ~30% fewer hospitalizations, and up to 40% lower drug costs. While primarily a commercial play, the raise signals continued investor appetite for upstream models that convert preventive utilization into total-cost-of-care savings.

Reuters | CVS Settles $37.8M Insulin-Pen Case
CVS agreed to pay $37.8M to resolve allegations of over-dispensing insulin pens and receiving improper government reimbursements. The settlement underscores growing pharmacy and PBM compliance risk plans will favor vendors whose utilization improvements are matched by tight documentation and billing hygiene.

IF I HAD TO SUM UP WHAT PULL IS IN A SINGLE SENTENCE

It’s this: where frontline realities meet enterprise strategy.

Every day I write with you in mind: the ones who carry the weight, the ones responsible for outcomes, and the ones who see the system from 1,000 feet up.

That’s the standard I’ve held every edition to since the beginning because social care deserves and requires analysis with the same discipline as any other market.

And last week’s audience analytics told me something important: I was right.

1) The deep-read rate is unusually high.

If you’re here, you’re just as serious about the business of social care.

2) When the content gets more technical, you lean in.

Even the heaviest issues trigger zero churn. That confirms the need for serious, enterprise-grade SDOH analysis (and validates every time I ignored advice to water down , expand scope or “write at a 7th grade level.”)

3) You’re a tight group that keeps returning.

A smart, analytical, high-context set of readers who think hard about how this system actually works.

I don’t think of Pull as a newsletter as much as it is a place where frontline reality, payer economics, policy signals, and procurement logic get analyzed with the same discipline you’d expect from a strategy desk and not a content feed.

And if this small corner of the internet has become anything, it’s a room where people like you can think clearly without the noise.

Thanks for showing up with that level of seriousness.
It’s shaping what Pull becomes next.

PROOFCRUNCH | VENDOR

The ROI Spread in Housing

How Tenancy Supports Swing 0.4%–1.2% Margin Depending on Fidelity

👉🏽 Which housing programs actually save health plans money, and why do some deliver 3× the ROI of others?

Housing-first operators look similar from the outside: same mission, same populations, similar retention rates, yet produce dramatically different financial outcomes for Medicaid plans, ACOs, and D-SNPs. As tenancy supports become a measurable foundational-needs intervention in 2026, the spread between a high-fidelity housing operator and a complex, multi-service operator is emerging as one of the clearest ROI differentiators in the entire SDOH lane.

• Brilliant Corners (CalAIM-aligned) shows what a tightly operationalized tenancy-support model can deliver.

• Central City Concern shows what happens when outcomes are strong but attribution is more diffuse.

Both create stability.

Only high-fidelity operators reliably reduce crisis-driven medical costs at a reliably enough to make them true healthcare partners.

👉🏽 These are archetype examples used only to illustrate model structure, not evaluations on performance.

The members who churn through ED, IP, SNF, and crisis services aren’t failing clinically as much as they are failing logistically. High-fidelity tenancy supports interrupt that cycle fast enough to create meaningful, within-cycle financial impact. Modeled scenarios show that depending on fidelity, tenancy supports can swing 0.4% to 1.2% of margin in high-risk segments.

The gap is variance, fidelity, and measurement discipline.

Below, I’ll show:

• The directional PMPM math behind high- vs medium-fidelity tenancy support

• Why documentation, activation speed, and service clarity account for most of the ROI gap

• How to translate housing work into MLR-forward, Stars-adjacent, or withhold-relevant impact

Keep reading to see the ROI band executives use to evaluate tenancy-support models and why the spread between these two operators is the margin signal most plans are missing.

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CMS | CY2027 MA & Part D Proposed Rule
CMS issued a sweeping proposed rule for Contract Year 2027, rebalancing Stars, equity, and benefit design. The agency proposes eliminating 12 administrative measures with little variation, adding a new Depression Screening & Follow-Up measure for 2029 Stars, and critically rolling back previously mandated health equity requirements (equity lead, disparity analyses, public posting). Three RFIs open the door for multi-year influence: risk adjustment modernization, C-SNP vs D-SNP misalignment, and a full inquiry into nutrition, emotional well-being, and social connection. Equity carrots are out; ROI-driven social care tied to clinical + behavioral metrics becomes the new bar.

👉🏽 I reconstructed the Stars math behind the scoring changes and a pattern surfaced. Even as a hypothetical it exposed a quiet dependency that could shift portfolio performance in ways most plans won’t see until it hits their ratings. Nothing is final but it felt worth sharing now because this sensitivity exists with or without a finalized rule.

Illinois HFS | Medicaid Policy Change (Effective Nov 21)
Illinois added evidence-based home visiting as a formal Medicaid-covered service for pregnant and parenting members: BP monitoring, behavioral-health screening, IPV risk, postpartum care, and referral management delivered via nurse and non-nurse models. The move formalizes funding for programs like Changent (Prev. Nurse-Family Partnership) and Family Connects and follows last year’s doula/lactation coverage expansion. This is a direct signal: maternal-equity models must show outcomes, not press releases, because coverage is now tied to validated delivery formats, coding, and billing.

Becker’s | MA Benefit Reduction
Blue Cross Blue Shield of Minnesota will drop YMCA of the North and Life Time Fitness from its SilverSneakers network in 2026, affecting ~26,000 Medicare members. Executives cite Medicare cost pressure and a need to “adjust the network structure” to sustain the benefit at all. A visible example of MA plans quietly reducing low-ROI supplemental benefits to preserve Stars and MLR performance. Vendors not tied to measurable margin defense are first on the chopping block.

UnitedHealth Group | Prior Authorization Overhaul
Optum Rx expanded its “PreCheck Prior Authorization” automation to 45+ medications, adding hormone therapy and knee-OA injectables. Pilot systems saw approvals drop from 8.5 hours to under 30 seconds, with an 88% reduction in appeals. This is where payer capital is moving: automation that collapses admin cost and reduces provider abrasion. A ceiling is forming if a vendor can’t quantify minutes saved, appeals eliminated, or throughput increased, they won’t make the 2026 procurement lists.

Oklahoma TSET | Legacy Grants
Oklahoma’s Tobacco Settlement Endowment Trust finalized ~$150M in multimillion-dollar “Legacy Grants” across rural health, workforce, nursing expansion, data gaps, and prevention infrastructure. These investments create new delivery and partnership scaffolding in rural regions including future lanes for Medicaid SDOH contracting, CHW deployment, and hospital stabilization. A parallel funding stream is emerging: states are using settlement and alternative capital to pre-fund proof infrastructure before Medicaid picks it up.

I Was On Mic’d Up!

I hopped on Mic’d Up with Ryann Hill from Indigo Strategies to talk about why social care has quietly moved to hard infrastructure in Medicaid and MA. We got into how Pull translates 1115 waivers, Stars rules, withholds, and HRSN/ILOS into one simple question: who actually gets paid, and why, in this new audit-heavy environment?

Full episode here.

PROOF CRUNCH | The Stars Shock: The $100M Exposure Hidden in CMS’ CY2027 Proposed Rule

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Official Sources: CMS CY 2026 Physician Fee Schedule Fact Sheet | Federal Register

The CY 2026 Physician Fee Schedule (PFS) was supposed to be the moment social care became financially sustainable.

Expanded CCM and BHI codes, general supervision for team billing, and permanent behavioral telehealth.

On paper, it’s the most supportive environment care management programs have ever had. In practice, the reimbursement logic still collapses under wage inflation.

Modeling a typical care coordination pod under the new rule showed how quickly rising labor costs erase the margin gains these codes were meant to create.

The Red Bar

Each bar represents the effect of a 10 percent change in a core driver of monthly margin. While enrollment, documentation accuracy, and transitions-of-care capture all lift monthly net margin, each 1 percent rise in labor cost compresses margin by ≈ 3 percent.

The 2026 PFS expanded billing pathways but left rate logic mostly unchanged.

Beyond the paywall: Full breakdown on what the CY 2026 rule really does inside a care-coordination pod, where the dollars move, and what to do about it.

The New Standard For Care-Coordination ROI in 2026

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Scaled across units and shifts, those minutes quickly compound into margin.

Revenue-cycle firms monetize it. AI vendors automate it. CMS defends it.

Now you can measure it, too.

The Crunch

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1. Efficiency Audit Framework — Five-step method that aligns with audit and procurement standards.

2. Benchmark Dashboard — 2024–25 admin-cost and DSO benchmarks by sector.

3. Workbook | ROI Audit Model 2025 — Downloadable Excel tool for turning efficiency into auditable savings.

4. Case Lens — The $4 M Lesson (Modeled Scenario) — What this framework looks like when applied to a mid-size system.

1. The Efficiency Audit Framework

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This edition maps provider-ops efficiency metrics to SDOH programs, showing how social care can deliver identical, audit-grade savings within realistic financial constraints.

Signal

Silicon Valley Bank’s Future of Healthtech 2025 report shows $18.5 B in global health-tech funding, with provider-operations tools capturing ≈ 44 % (~ $8.25 B), the largest share on record.

The capital isn’t chasing innovation; it’s chasing shorter claim-to-cash cycles and lower administrative cost per encounter.

Typically social-care ROI lives outside the finance dashboard.

Today’s Proof Crunch shows how social-care programs can quantify the same efficiency gains—time, errors, and cost per encounter—that $8 B in provider-operations tools are built to deliver.

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Today we’re continuing the conversation:

What happens when you treat MTM like any other piece of capital equipment—run through depreciation, sensitivity, and cost-of-quality math?

Here’…

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