Ellen Brown’s Post

Congratulations Wakely Consulting Group for a superb primer on #Star Ratings. Wakely Consulting Group is a primier #MedicareAdvantage actuary and policy group. The white paper at the link below is a must read for all #Star and quality folks at MA plans. Key points made by Wakely I wanted to highlight: -- With the drop in member satisfaction measures weighting in 2026, the effective importance of clinical and medication adherence measures goes up a great deal -- especially HEDIS clinical. I note, too, the Readmissions measure (a trouble spot) is going to 3x weight in 2025. As well, there are returning HOS measures on 2026 for physical and mental health, which makes HOS more important too. -- The weighted average MA-PD Star score is expected to continue to dip and be below 4 Star for 2026 -- this is huge and a recognition of the tough new measures and statistical changes. -- The Health Equity Index (HEI) is demonstrably different than the Reward Factor and could spell even more trouble in Star 2027. While everyone can get the Reward Factor if they perform well, many plans won't be eligible or will only be partially eligible for the HEI Factor. And earning the extra up to 0.4 will be tough. This is shown in Wakely's analysis: while the Reward Factor has added 0.3 to Star scores on average, the HEI is expected to only add 0.1. This will be a $670 million aggregate revenue hit in 2028 (the payment year for 2027 Star) when HEI replaces the Reward Factor. In effect, CMS is moving Star funds from plans that have lower penetration of Dual Eligible/Low Incomed Subsidy and take the lion's share of the Reward Factor to plans with high DE/LIS but forcing them to earn it through quality performance. This is consistent with CMS' greater duals intergation strategy. The clear message here is that Star scores have been down overall and it will be even tougher to get to 4 Star in the future. Plans need to work now on an HEI strategy given the complexity of dual eligible and Low Income Subsidy (LIS) populations. Lilac Software is building a best-in-class source-of-truth Payer Stack and data analytics engine, including a #Stars analytics dashboard and best practice improvement strategies. Reach out to me here if your plan needs support with #Stars or has other data analysis needs. Lilac Software Marc S. Ryan 🇺🇦 Neetu R. Alex Schaefer

Day 2 of 2023 MSSP week - “The Big Ones”. Bet you didn't know Aledade ACO is as big as Centene MA! Keep in mind ACO REACH is excluded here. Fair warning - this is a total data geekfest. Aledade Inc had 42 separate MSSP ACOs across the country with almost 1 million aligned beneficiareis (962k to be exact) and you know what they absolutely CRUSHED it. The took home a cool $532M of the $791M they saved CMS which is almost a 7% savings rate. And it wasn't because they have mastered risk coding, their '23 PY risk score for aged non-duals was a respectable .984. Only 2 of their 42 ACOs experienced a loss that totaled ~$6M (ValleyHealth ACO over $5M). So 1.7% of all Medicare eligible beneficiaries are in an Aledade ACO. I still remember sitting in a conference room in Columbia, MD w/Farzad Mostashari when I had littles as he shared his vision back when people needed you to spell out the acronym (Accountable Care Organization). I'd say he nailed it. Next up Caravan aka Signify Health aka CVS Health is the other behemoth with 761k lives. That means CVS is responsible for the care costs for ~5M Medicare lives between ACO and MA. It won't come as a surprise that their shared savings pailed in comparison to Aledade. They saved CMS $187M (2% savings rate) and kept $91M because unlike Aledade that has gone all in with either Enhanced or Track E with downside risk, Signify still has 1/3 of their lives in upside only (A & B) tracks which made it more challenging to hit the minimum shared savings rate and therefore, they only shared savings on half of their ACOs/lives even though they achieved savings in all 6 of their ACOs. Their risk score is even lower at .961 wonder if they will be in the red by 2025 after HCC v28 is fully phased in. Next biggest? 🤑 MercyHealth with 267k lives and a noteable 6.62% savings rate with ~$150M in earned savings and all 5 of their ACOs achieving savings - hint they are nailing it on coding 1.060 😀 CommonSpirit Health (CHI/Dignity/etc) with 222k lives and ~2% savings rate taking home $32M in aggregate but paying back over $2.5M on 4 of their 9 ACOs with Arkansas Health responsible for $2M of that loss 💲 Privia Health with 180k lives took home a cool $109M (7.68% savings rate) and that's after paying back $800k for one of their ACOs and not keeping any savings on their CO ACO. But their largest ACO that isn't region specific and has 1/3 of their lives achieved a 10.6% savings rate and accounted for over half of overall savings 💰 The perennial darling Palm Beach ACO succeded again taking home $73M (9% savings rate!) on 78k lives seems reliant on their 1.118 HCC risk score if you ask me. But the other part of the story is the growing number of ACOs they have acquired or now oversee which is now 9 including themselves. 7 of those 9 entities achieved savings albeit PALING in comparison to the namesake. At first glance their approach is heavily reliant on HCC as the $PMPM savings seem to correlate with their risk scores.

Kyle Cyr is why I’m a NAIFA member. Kyle is a Medicare expert. Every time we connect, he brings insights about his world that I can’t find anywhere else. In just ten minutes, I learn more about the challenges and opportunities in the Medicare space than I could from any email, newsletter, or webinar. But here’s the thing—NAIFA is full of professionals like Kyle. He’s not that special. 😉 Take David Plumb, MBA, CLU, ChFC for example. He’ll keep you up to speed on everything happening in the DI space. Or Chris Barnthouse who’s got all the insights on LTC. And then there’s,Brad Wethington, CLU®, ChFC®, RHU®, LUTCF® who shares invaluable strategies for leveraging social media as a financial advisor while staying compliant. NAIFA is the association for insurance and financial professionals. It’s a community where members freely share what’s working, what’s not, what they need help with, and how they can help others. NAIFA is member-driven. It’s powered by people like Kyle, Dave, Brad, and Chris, who show up and make each other better. If you’re not a NAIFA member and you’re curious, let me know. I’ll even cover your first month’s dues—on me. #NAIFA #InsuranceProfessionals #FinancialPlanning #Medicare #LTC #DI #ProfessionalGrowth #Networking #InsuranceInsights #MemberDriven #Collaboration #FinancialProfessionals #CommunityMatters #JoinNAIFA #Leadership

Weekly lessons learned (is back) - Shooting (MA) STARs along with burning out. Instead of raining men it was raining STARs, '25 ratings released for Medicare Advantage. Clover shined bright hitting 4 stars for their bold AI platform based PPO flagship. In case you forgot that = 5% bump to revenue. Andrew Toy is on a well played roll - give him a congrats at HLTH next week along w/Jamie Reynoso Carl Rathjen. SCAN Health continues to soar with 98% of members in 4.5 stars or higher congrats Sachin H. Jain, MD, MBA – always love seeing the good guys win. Kaiser Permanente, Alignment Health, BCBSMN and Healthfirst were also notable winners. It wasn’t all rainbows as avg star rating dropped from 3.92 to 4.07. Humana was the biggest loser with a 54% drop in their 4 star plans which is a BIG deal for a number of providers in % of premium arrangements w/them. Florida Blue also hit a bump with 30% dropping below the 4 star revenue threshold. I don’t disagree with Eden Brownell that behavioral science is key to the future of healthcare (Marten den Haring Amy Bucher Lirio) Noah Tang Fierce Healthcare great reporting. Meanwhile MDs are cutting back on seeing Medicare patients because of low reimbursement. Stacy Mays What about MA members for '25? 60% will have a $0 premium,~80% of these will have the same or lower premium. 20% percent will see premiums decline. SNPs expected to grow to 7.2 million in SNPs to over 25% of MA. ATI Advisory published (The SCAN Foundation) great summary of nonsupplemental medical benefits being offered John Gorman. Not so happy to see in-home support services and caregiver support benefits declined. Happy to see rise of food is medicine, now let's expand beyond food insecurity and into Food Is Health lifestyle (cardiometabolic) disease reversal… Carter Williams Katie Stebbins Erin W. Martin Joni Kindwall-Moore. Even Christine Going, EdD, MPA, RD, FACHE got behind our Food As Health movement! Duke University created an uproar on LinkedIn this week reporting they employ 236 people to appeal denials Jeffrey Pfeffer David Cole pointing to United for 40% (plus failed contract negotiations). Staying true to his unicorn status Feby Abraham announced the formation of Longitude Health Paul Mango Brett Moraski - Memorial Hermann along w/Providence, Novant and BSWH as a testing ground better care delivery. You should chat with Neil M. Meltzer, MPH, MHA about lessons learned from a similar endeavor we supported for yrs in Maryland. Preston Alexander was singing my tune reminding us of the obscene cost of healthcare aka sickcare to insureds - $26k anyone? Imagine investing part of that into your actual health? Carter Williams made another brilliant analogy of the hims & hers closed loop combo of RX manufacturing, MDs and AI to when we thought of Amazon as an online bookstore. Disruption anyone? I learned Eight Sleep isn't all that after a 30-day trial but ŌURA Tom Hale you still have my heart (and $ as I ordered the next gen 4).

2023 MSSP ACO results posted by CMS. Breakdown by our data science and actuarial team. Many brokerages manage the transfer of risk, but deeply understanding that risk is the key to optimal structure and pricing. We are building the future of consultative brokerage.

Join Anthony Selm from https://lnkd.in/g2P6s-ab as he addresses a crucial question many face when transitioning to Medicare: "Can I keep seeing my current doctor with Medicare?" Discover the impact of Medicare on your choice of healthcare providers and get valuable insights on how to navigate this transition seamlessly. From understanding Medicare's coverage to exploring options if your doctor doesn't accept Medicare, this video provides essential information. Learn how to check if your doctor accepts Medicare, explore tips for transitioning to a new doctor, and understand the dynamics of Medicare Advantage plans. Whether you're new to Medicare or seeking clarity, The Modern Insurance Store has you covered. Don't miss out on key tips for a smooth transition and make informed decisions about your healthcare. Subscribe for more valuable insights, and if you have questions, reach out to The Modern Insurance Store or explore resources on the Medicare website. Your health matters, so stay informed and empowered as you navigate the world of Medicare. #Medicare #HealthcareChoices #TheModernInsuranceStore #Medicare #HealthcareChoices #InsuranceTips ::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: Contents of this video: 0:00 - Introduction 00:25 - Overview of Medicare Parts 00:43 - Medicare's Unique Structure 01:07 - Checking if Your Doctor Accepts Medicare 01:31 - Coverage Under Medicare Part B 01:42 - Options if Your Doctor Doesn’t Accept Medicare 02:23 - Medicare Advantage Plans and Doctor Networks 03:00 - Tips for Transitioning to a New Doctor 03:23 - Conclusion 03:51 - Call to Action ::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: ✅Our website: https://lnkd.in/g2P6s-ab (Secure), or call (513) 466-0209 🔔 Subscribe for more videos! https://lnkd.in/gkXadHFq 🚀 Become a channel member! https://lnkd.in/gkXadHFq ::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: ✅ Who's eligible for Medicare? https://lnkd.in/gAsbnsJy ✅ How much does Medicare cost? https://lnkd.in/g6NXsCEi ✅ How to apply for Medicare https://lnkd.in/gExNZZjb ✅ Do I need Medicare if I'm still working Past 65? https://lnkd.in/gMdeaFrX ✅ Medigap vs Medicare Advantage https://lnkd.in/gCjkqZFM ✅ Do I automatically get Medicare when I turn 65? https://lnkd.in/gcU2XfG4 ::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: Call us for FREE no-obligation quotes and assistance. Let us help you navigate the best plan (at the best price) for your needs. (513) 466-0209

For those who follow such things, I am sure that the article that I will link to below regarding Humana’s drop in MA Star ratings has already crossed your rader. This is just one example of how even well-established plans can be affected by adjustments in how CMS evaluates their performance. CMS recently updated its methodology, aiming to provide a reflection of how plans typically perform by removing outlier scores. While the goal is to ensure fairness and better judgment of ongoing care quality, the result can sometimes be a sudden drop in ratings, even for plans that have typically performed well. This adjustment process is part of a broader effort by CMS to incentivize better care, efficient use of resources, and easier access to services. The program is built to reward plans that can deliver high-quality care efficiently while also ensuring that members have access to preventive services, timely appointments, and effective treatments. But as the requirements evolve, so too must the plans—managing a Medicare Advantage plan is becoming increasingly complex as expectations for both efficiency and quality rise each year. One of the key takeaways from this shift is that success today does not guarantee success tomorrow. The program is designed to continually raise the bar. Even plans that have performed well in the past must continually adapt, investing in new technologies, improve member engagement strategies, and refine operations to meet these ever-increasing expectations. The performance measures themselves may change, and so too must the strategies for hitting the required benchmarks. While it’s crucial for CMS to ensure fairness and accuracy, Medicare Advantage plans also need to be proactive. That means investing in the technology, people, and expertise required to stay ahead of the curve. High-performing plans must be able to demonstrate not just one-off success but ongoing improvement in the areas that matter most—quality care, member experience, and efficient resource management. This is a market-wide issue, not something isolated to any one player. Medicare Advantage as a program is designed to manage costs, reduce the taxpayer burden, and improve the overall quality of care. It requires every plan to navigate a complex landscape, balance financial constraints, and ensure that care delivery remains top-notch. Staying competitive requires innovation, continuous improvement, and a willingness to adapt. Plans need to prepare not just for today’s challenges but for the future—because what works now may not be enough in the years to come. https://lnkd.in/eUvRz5XD

This morning, Humana posted their Form 8-K SEC filing. https://lnkd.in/ezWGzKHh The market is reacting to the statement they included, re-copied here: Based on preliminary 2025 Medicare Advantage (MA) Star Ratings data provided by the Centers for Medicare and Medicaid Services (CMS), which became available in CMS Plan Finder as of October 1, 2024, Humana Inc. (“the Company”) has approximately 1.6 million, or 25%, of its members currently enrolled in plans rated 4 stars and above for 2025, a reduction from 94% in 2024. A significant driver of these results was contract H5216 decreasing to a 3.5-star rating from a 4.5-star rating in 2024. H5216 contains approximately 45% of Humana’s MA membership, including greater than 90% of its employer group waiver plan (Group MA) membership. The decline in Stars performance for 2025 will impact Humana’s quality bonus payments in 2026. 2025 Star rating details are expected to be formally released by CMS on or around October 10 . Based on the Company’s review of the preliminary data provided by CMS, its reduction in Star ratings was driven by narrowly missing higher industry cut points on a small number of measures. Humana believes there may be potential errors in CMS’ calculation of certain of its results and industry threshold cut points. The Company has outstanding appeals related to certain results and has requested additional information to ensure accuracy of threshold calculations. The Company intends to continue to engage with CMS on these matters to ensure Star ratings are accurate and representative of plan quality

🔍 Dive deeper into Medicare insights with Part 2 of our AEP Reflections series! 🚀 Discover how post-enrollment data can revolutionize your AEP strategies, ensuring they're perfectly aligned with beneficiary needs. Don't miss out on unlocking the full potential of your Medicare plans. Read Now 👉 https://ow.ly/9Mjq50QylKQ #HealthAxis #Medicare #MedicareAdvantage #AEP #AnnualElectionPeriod #HealthPlans #Audit #CMS #HealthcareStrategy #HealthPlanConsulting #ClaimsProcessing #ClaimsManagement #PostEnrollment #DataDrivenDecisions #AEP2024 #AnnualElectionPeriod

Do you know what’s right for you and your family? Choosing the right healthcare plan is a significant decision and can be confusing. The two most common are HMOs and PPOs. Each one has its advantages, and here's how they differ. #work