Eric Miller, FSA, CERA, MAAA

📰 White paper release: Stars in Retrograde – Decoding the 2025 Decline The 2025 Medicare Advantage Star Ratings brought significant changes to the quality landscape, challenging health plans to rethink their strategies. Our latest Milliman white paper authored by Hayley Rogers and Matthew Smith dives into key factors affecting this year’s decline, including: ⭐ Sharp decline in Quality Bonus Payments (QBP): The member-weighted average fell below 3.5% for the first time, impacting revenue. See Figure 1 for number of contracts by change, with more contracts negatively impacted. ⭐ Rising impact of Social Risk Factors (SRFs): Plans with high SRFs saw more substantial rating drops, highlighting the need for targeted quality improvements. ⭐ Legal landscape: Multiple Medicare Advantage organizations are challenging the Star Rating methodology, including issues with transparency and data reliability. ⭐ Market restructuring: Fewer new entrants and increased contract consolidations may signal further Star Rating declines, with profound implications for future quality initiatives. Learn more about these industry-wide shifts and what they mean for healthcare policy and strategy. 📄 Read the full white paper to prepare your organization for what's next. Link in comments

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The discussion surrounding weight loss management and obesity is constantly evolving with an increased focus on prescription drugs. In this SOA podcast, Jackie Lee and I discuss GLP-1s and why actuaries and other healthcare professionals need to continuously monitor their growth.

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Price Transparency in Indiana for 2 Large Health Systems: IU Health & Parkview Focus is ER visits comparing Anthem PPO and UHC PPO contracted rates benchmarking to Medicare Adjusted Rates CPT 99283 Anthem Range % of Medicare: 366%-520% UHC Range % of Medicare: 410%-1,119% CPT 99284 Anthem Range % of Medicare: 639%-794% UHC Range % of Medicare: 631%-1,011% CPT 99285 Anthem Range % of Medicare: 440%-551% UHC Range % of Medicare: 490%-727% Additional Insight: CPT codes 99285, 99284, and 9923 generated $339,301,095 in billed charges through July 2024 YTD for IU Health System All three CPT codes were in the top 13 of utilization and generated the most in billed charges #employeebenefits #pricetransparency

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With the struggles that many health plans are facing in Medicare Advantage, understanding care management and where the best place to focus resources and hit the gas is of utmost importance. With that in mind, I'll be brushing up on this oldie but goodie from the SOA in the early 2000s and will be sharing my thoughts as I go. https://lnkd.in/eZWnVS8q #Medicare #CareManagement #Wakely

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This week's Medicare Market Insights deep dive looked at the shift in Stars, Premiums, Drug Deductibles and MOOPs. For plans that are renewing in 2025, how are these components changing? Here's a summary. -Star Rating Down -Premiums Level/Down -Drug Deductibles Up -MOOP Mixed, though largely up Go here for the full deep dive -> https://lnkd.in/gs_wURZG __ P.S.- don't forget to subscribe!

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This piece by Modern Healthcare is spot on (link in comments), and well worth the quick read for any stakeholder in the #medicareadvantage space to ensure you are considering the risks new membership may bring. 📉 We know that many of the national #medicareadvantage organizations pulled out of markets for 2025. They likely were doing so because the areas were under performing or because they didn’t see a path to profitability. 💲 In service areas where MAOs retained plans, many nationals are also not paying commissions in some form or another – and the reason for that is after seeing what competitors are offering, they are worried the membership they may attract will be “poor risks” or that they will be unable to manage these members in the long-term. 👵 For smaller, regional, health insurers who remain in these service areas, they have an unprecedented opportunity to expand market share due to the nationals plan terminations or SARs. ❓ However, smaller, regional, MAOs should stop to question – what does this really mean for us? It will be critically important to understand the new membership MAOs are taking on in 2025 – the characteristics each member brings and if your organization is prepared to manage those members. This may or may not have been something #medicareadvantage organizations planned for in their 2025 bid – but as you are going into 2026 bids, it will be especially important to measure and adjust your 2024 population baseline (used in the 2026 bids) for the new membership you have taken on. If you have any questions on better understanding this dynamic, please do not hesitate to reach out!

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GLP-1's and Medicare. This week's Medicare Market Insights deep dive by Andrew Ryba takes a look at GLP-1s. What are they? Why are they always in the news? How does Medicare currently handle them? Don't miss out. Read the deep dive here -> https://lnkd.in/gipRAVSG P.S. -> don't forget to subscribe!

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For the next installment in my review series we’re taking a look at Paper 4 of the SOA’s Care Management series which explores critical nuances in the economics of care management programs. Key insights include: 🔹 Beyond ROI: Focusing only on ROI can obscure total financial impact—look at net savings for real influence on costs. 🔹 Refining Scope: It’s important for the various stakeholders to understand how the financial outcomes are impacted in order to find the right balance of implementation. 🔹 Precision Matters: Evaluating both marginal and average savings pinpoints the most impactful approaches. Overall, this is a valuable read with great insights! https://lnkd.in/gnWdaZHF

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A case for the value of Medicare Advantage. Key takeaways from the study: 1) Low Value Services (LVS) provide little or no benefits to patients, and in some cases, may even cause harm. 2) In a study of 6M Medicare beneficiaries, it was found that Medicare Advantage enrollees experience fewer unnecessary medical services compared to traditional Medicare enrollees. https://lnkd.in/eVFZss7r As the 2025 Medicare AEP rapidly comes to a close, it's important to recognize the value of the plan you recommend to your client. At Priority Health we always focus on value-based care to ensure our members receive the best care to lead to better health outcomes. This is something you can count on when you enroll your clients with a Priority Health Medicare Advantage plan. Good luck closing out a busy AEP! #medicareadvantage

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Well, this wild ride of a year is about to get wilder! Buckle up!! Hayley Rogers and the Milliman team have been hard at work. Her analysis shows that 76 contracts, representing 44 parent organizations and almost 3.5 million members, would gain 0.5 Stars if CMS recalculates the Star Ratings using the SCAN ruling. https://lnkd.in/g4y23J6Z If you haven't read the WSJ article above yet, please make sure you do. The article is claiming that CMS "plans to redo this year’s quality ratings of private Medicare plans, according to people familiar with the matter, a move that would deliver hundreds of millions in additional bonus payments to insurers next year." That is unprecedented, especially after bids were already submitted on June 3rd. The message seems to be, be prepared - if CMS reaches out, you may only have a limited window with which to resubmit bids. Make sure your product and actuarial teams are ready to sprint. 💡 The burden of proof is on MA plans. The Elevance ruling highlighted that MAOs must provide proof at the individual MA contract level to show they deserve a higher Star Rating, requiring detailed analysis for each contract. 🏥 Impact on Low-Income Subsidy (LIS) Members: Contracts affected by guardrails to hypothetical cut points have a higher percentage of LIS members, with a 50% to 70% higher likelihood of being negatively impacted by lower 2024 Star Ratings. Lower Star Ratings can lead to reduced medical benefits for these vulnerable populations. If you are interested in exploring how these rulings may affect your organization how Milliman can assist, please reach out to schedule a call.

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Use case on cost variability within the LA market. Below is the Average PPO Rate for an MRI of your low back. This is comparing 7 LA hospitals contracted/allowed amount average PPO rates across Aetna, Anthem, Cigna, and UHC with Medicare as the benchmark. Huge variances over Medicare and displays why employers need to gain access to this information and take action to steer members away from hospitals that are not a fair market price. Unfortunately, LA is not a unique city as there is cost and quality variability by facility, by provider, by procedure code across all states and all networks. Good news is that there are proven solutions to reduce cost, improve quality of care, decrease or eliminate members out-of-pocket cost, and enhance benefit offerings. If you do what you’ve always done, you’ll get what you’ve always gotten.

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📣 📣 📣 Centers for Medicare & Medicaid Services dropped the CY 2025 landscape files! 📣 📣 📣 https://lnkd.in/gMhye24W ❓ What questions does this answer? Post below so we can share learnings!

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Im sitting in the airport on my way back home from a whirlwind of a week and reflecting more on this care management paper series. One additional takeaway that i want to add from paper 4 is that many programs and interventions may promise significant savings based on clinical research or a focus group. While these results may be valid, it’s important to consider that there are decreasing marginal returns as you expand a program to a larger population. It’s critical to understand at what point expanding the program is no longer providing the desired returns. This is something that Wakely can help with. Check out our care management practice page or reach out to me with questions - https://lnkd.in/eqkUFkeA #Wakely #CareManagement

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🌟 Medicare Advantage plans face significant challenges heading into 2025, and Julia Friedman's latest article delves into how MA-PD plans are adapting. Here are some of the challenges: 1️⃣ Cost pressures continue to grow: Rising medical costs and inflation are impacting the bottom line, pushing plans to get creative in cost management without compromising on quality. 2️⃣ Heightened regulatory scrutiny: CMS has implemented new rules for star ratings, pushing plans to boost quality measures while carefully managing costs—a fine balance that's critical to success. 3️⃣ Pharmacy benefit changes: The shifting pharmacy landscape, particularly around Part D, has been a big focus. Plans are exploring cost-effective drug management, especially with the rising cost of specialty drugs. 4️⃣ Enhanced benefits and flexibility: To stay competitive, plans are focusing on more than just healthcare, offering benefits like transportation and nutrition services to meet members' holistic needs. Whether you're working with Medicare Advantage plans or interested in healthcare policy, these insights shed light on the industry's future. Dive into the article in the comments for a closer look! #MedicareAdvantage #HealthcareTrends #MillimanInsights #Medicare

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Lots of Star Ratings changes being measured in 2024 - check out our summary linked below!

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🚀 Healthcare Consolidation: A Double-Edged Sword The consolidation of both vertical and horizontal businesses in healthcare has led to substantial profits for the largest health insurance companies and pharmacy benefit managers (PBMs). This trend has resulted in a system where a few major players wield significant power, often at the expense of the public's best interests. 💡 Rethinking the Path to Change While government intervention, like the FTC's impending lawsuit against major PBMs (Optum, CVS Caremark, & Express Scripts) and pharmaceutical manufacturers, aims to address these issues, it's not the only solution. Employers, as the largest purchasers of healthcare resources for employees and their families, hold a unique power to drive change. 📊 Employers: Catalysts for Transparency and Reform By leveraging transparency and data, employers can shift the dynamics of healthcare purchasing. Here are some strategies: Independent TPAs and PBMs: Utilizing independent third-party administrators and PBMs can help break away from the dominant players, fostering competition and potentially lowering costs. Cost-Containment Programs: Implementing initiatives like reference-based pricing or alternative funding models can reduce expenses and increase efficiency. 🌐 Empowerment Through Innovation Employers have the opportunity to reshape the healthcare landscape by making informed decisions that prioritize transparency and cost-effectiveness. It's time to rethink our approach and harness the power of data to benefit everyone. #HealthcareReform #Transparency #CostContainment #EmployeeBenefits #InnovationInHealthcare

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Since when did health insurance companies received thier “MD’s”? This is a long article but a fascinating read. We wonder why healthcare costs continue to escalate and premiums are unaffordable? Well, when you have insurance companies being able to add diagnosis’s and conditions to a members healthcare record which allows them to receive more money for treatment - oh and by the way these members don’t have these illnesses…rocket science not needed here! While this seems like its a “Medicare” problem - it’s happening everywhere. In your commercial and group health plan too. Providers trying to charge patients for negotiated discounts, millions of dollars in fake billings, pharmacy rebates being used to increase insurance company profits versus going back to the companies footing these bills or the patients using the drugs. Insurance companies and the organizations that own physician groups and hospitals have figured out how to game the system to increase profits - not deliver better health outcomes. I do believe that there are a lot of great professionals in the medical field that honestly want to improve the lives of people that they treat - they unfortunately now mostly work for companies that don’t really care much about that.

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The new ACO PC Flex program offers some potentially substantial financial upsides for MSSP ACOs. We discuss five key takeaways in a new paper: https://lnkd.in/gQeeJY8X

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