The 2017 Star Ratings: A Contrast Between Macro Versus Micro

The more things change, the more they stay the same. Despite the many, often significant, changes amidst plan-specific 2017 Star Ratings, there is a surprising amount of stability in the 2017 Star Ratings. Stable performance is evident at the macro level:

  • The 2017 average Star Rating is 4.00 (down only slightly from 4.03 in 2016).
  • Approximately 49% of Medicare Advantage Prescription Drug plans (MA-PDs) earned ≥4 stars in both 2016 and 2017.
  • Weighted by enrollment, approximately 68% of MA-PD enrollees are in contracts with ≥4 stars in 2017, down from 71% in 2016.
  • The Consumer Assessment of Healthcare Providers and Systems (CAHPS®) cut points for 7 measures again stagnated in 2017, and national average performance rates (not ratings) for 13 additional measures remain unchanged.

This stable performance seemingly contradicts the generally accepted notion that “quality is improving.” Indeed, a closer analysis of the many micro-level performance changes reveals many changes and fluctuations:

  • United delivered perhaps the strongest performance in the 2017 Star Ratings among the largest industry players, showing strong performance improvement across all plans.
  • Pending industry mega-mergers eroded Star Ratings performance of the plans being acquired while the acquiring organizations’ Star Ratings survived relatively unscathed.
  • Thirty-four plans that earned  ≥4 stars in 2016 dropped below 4 stars in 2016 and will lose their Quality Bonus Payment (QBP) revenues. Eighteen of these 34 plans earned only 1 star on both the Part D Appeals Upheld and Appeals Autoforward measures, mostly, if not entirely, due to audit results. Because many plans rely exclusively on their Pharmacy Benefit Manager (PBM) for these measures, this is an opportune time to reevaluate the Centers for Medicare & Medicaid Services’ (CMS’) somewhat utopic expectation an MA plan has enough contractual and practical leverage to influence its PBM’s operations and performance in a way that prevents audit findings and delivers consistently high Star ratings within the plan’s MA population. Particularly given CMS’ ongoing, transparent acknowledgement that audited plans are disproportionately affected by audit findings, these plans face strong headwinds as they prepare to lose QBPs, even if only temporarily. With long-term PBM contracts already in place, most of the financial impact resulting from these pharmacy audit-related penalties will be felt by beneficiaries and the provider network if CMS does not reconsider its approach to capturing audit results within Star Ratings.
  • The uncertainties associated with bell-curved Star Ratings continue to present serious challenges for health plans as they attempt to build sustainable benefits that meet member needs and expectations over the long term.
  • Five of the 6 plans receiving the Low Performance Indicator (LPI) in 2016 were not rated in 2017, and 4 of these 5 remain active at present. The long-term future of these plans appears to remain at the mercy of Congress. Despite being slated for termination by CMS due to consistently low Star Ratings performance, a “hospital improvement” bill, which has passed the House and is currently in the Senate, includes a provision to delay CMS’ authority to terminate MA contracts based on poor Star Ratings. It is unclear when Congress will take up this issue, though the bill does have noteworthy bipartisan support. As with many of the important program changes on the horizon for next year, we’ll be watching this issue closely to determine the bill’s ultimate fate and to determine its impact within the parameters of Star Ratings.

So where do we go from here? At a macro level, significant evolution and effort lies ahead to accomplish the Triple Aim foundation of the Star Ratings program. But in order to do so, the micro-view is where we must focus our energy and effort. Successfully improving health, and thus Star Ratings, requires us to carefully decide when, where, how, who, and why to work with micro-targeted groups of members in micro-targeted, person-centered ways.

For questions or inquiries about how Gorman Health Group can support your organization’s Star Ratings efforts, please contact me directly at



New Webinar! The 2017 Star Ratings are out! Join John Gorman, Gorman Health Group’s Founder & Executive Chairman, and colleagues Melissa Smith, our Vice President of Star Ratings, Lisa Erwin, our Senior Consultant of Pharmacy Solutions, and Daniel Weinrieb, our Senior Vice President of Healthcare Analytics & Risk Adjustment Solutions, on Thursday, October 27, from 1-2 pm ET, for a cross-functional review of the 2017 Star Ratings. Register now >>

New Webinar! Each year, billions of dollars are set aside by investment banks and pension managers to invest in measurable social good. Gorman Health Group (GHG) is offering a new capability to connect health plans and providers with social impact investors to obtain capital for clinical innovations of which many plans have only dreamed. Join us on Tuesday, November 1, from 2:30 to 3:30 p.m. ET, to learn how social impact investing can be used to improve health outcomes and Star Ratings and how your organization can benefit. Register now >>

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2017 Readiness Checklist – Valuable Tool or an Exercise in Redundancy?

Some people are list makers and wholeheartedly embrace the value of checklists. They utilize lists to manage tasks, stay focused, and ensure high-quality results. A publication by the Institute of Health’s Committee on Quality of Health Care in America, titled “To Err is Human: Building a Safer Health System,” lays out the value of checklists in improving patient safety. We should view the Centers for Medicare & Medicaid Services (CMS) Readiness Checklist in that same view: it is a tool to allow health plans to improve the quality and compliance of their health plan and safety of their members.

As with all checklists, the process can be a “check the box” experience or a valuable tool to make sure everything is in place and nothing was forgotten. We all know to expect a CMS Readiness Checklist on an annual basis, but do we use this amazing tool to its fullest?   Be sure you make this a serious exercise to evaluate your program and readiness for 2017.  Some sections may be redundant year after year, but health plans find broken processes year after year, sometimes through negative member experience―don’t let that be your plan.

Every item on the Readiness Checklist should be reviewed and validated. Some items are new and may take more time and effort to validate. Here are four new items on the 2017 Readiness Checklist where you may want to invest additional time:

  1. Medicare-Medicaid Dual Eligibles Non-Discrimination and Cost Share Protection – The 2017 Readiness Checklist has a new emphasis on protecting the rights of lower income members, particularly Medicare and Medicaid dual eligibles and others eligible for the Low Income Subsidy (LIS). CMS also highlighted this topic in their conference in September. Plans are required to ensure dual eligible beneficiaries are not balance billed for deductibles, coinsurance, or copayments for which they are not responsible. CMS is requiring plans to verify they have procedures in place to ensure their providers do not discriminate against beneficiaries due to their dual eligible status or balance bill those members who receive assistance with Medicare cost-sharing from a state Medicaid program. It is a health plan’s responsibility to manage their provider network to prevent this type of abuse of Medicare and Medicaid full dual eligible individuals.
  2. Best Available Evidence (BAE) – CMS included additional guidance for plans to review their BAE process. CMS expects plans to have processes in place to allow BAE to be accepted at the point of sale. If health plans do not have scripts in place to assist their member services and pharmacy help desk staff, then they must be developed and put in place to support members requesting assistance with BAE-type issues.
  3. Online Enrollment Center (OEC) Application Receipt Date – One policy change this year is the way the receipt date is calculated for OEC applications. Plans need to calculate the receipt date to 11 hours earlier than the time and date stamp provided on the CMS file.
  4. Non-Discrimination and Alternate Language Tagline Language – CMS also raises the new requirement for Non-Discrimination and Alternate Language Tagline translation language plans are now required to distribute to their members. CMS is requiring plans to verify they have processes in place to satisfy these new requirements.

This year’s release is earlier than previous years, allowing plans more time to validate and implement all actions. Similar to last year, CMS has changed the attestation process for the 2017 Readiness Checklist to a strategic conversation between plans and their CMS Account Managers. Without that formal attestation process, don’t devalue the Readiness Checklist and required actions – utilize the tool as the valuable resource it is which will ultimately make your health plan better and your members safer. To err is human, and for that reason, redundant validation is a critical step to make sure your program is ready for 2017.

Our consultants have implemented items from the 2017 Readiness Checklist for health plans just like yours. If you need assistance verifying you are ready for 2017 or have questions on your processes, we can help. You can reach us through our website or by emailing me directly at



New Webinar! Each year, billions of dollars are set aside by investment banks and pension managers to invest in measurable social good. Gorman Health Group (GHG) is offering a new capability to connect health plans and providers with social impact investors to obtain capital for clinical innovations of which many plans have only dreamed. Join us on Tuesday, November 1, from 2:30 to 3:30 p.m. ET, to learn how social impact investing can be used to improve health outcomes and Star Ratings and how your organization can benefit. Register now >>

Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG's weekly newsletter. Subscribe >>

MACRA Flexibility Proposal

As we enter the last stretch of the year, many questions remain on what to expect from the Quality Payment Program as required by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) come January 1, 2017. With the final rule due in November, much of the industry is quick to point out the difficulty in preparing for a brand new reporting program in just a month. Reporting in 2017 will affect payments in 2019.

The Centers for Medicare & Medicaid Services (CMS) recently attempted to alleviate these concerns with a new flexibility proposal, effectively allowing those who choose to do so to put off fully jumping into the Quality Payment Program for the first year. There are four options under the proposal:

  1. Quality Program "Testing" — Practices can submit some data to the Quality Payment Program, including data from after January 1, 2017, in order to avoid a negative payment adjustment. CMS is providing this as a way to test that systems are working to allow for successful participation in 2018 and 2019.
  2. Partial Year Participation — This option allows for participation for a reduced number of days. Because practices would submit quality measures, technology use, and improvement activities, they could potentially qualify for a small positive payment adjustment under this option.
  3. Full Year Participation — Practices whose systems are ready on January 1 can jump in fully in order to reap a bigger positive payment adjustment than Option 2.

Advanced Alternative Payment Model (APM) — Practices can, of course, still choose to participate in the Quality Payment Program through an APM such as Shared Savings Track Program 2 or 3. This option would qualify for a 5 percent incentive payment in 2019.

This new flexibility proposal gives some leeway and buys time for practices that are not prepared to fully comply with the Quality Payment Program, however, there is still a lot of work to be done before now, January 1st, and during the first reporting year.

This new flexibility announcement affirms CMS expects to move forward January 1, 2017. It also means we should all brace for a steep learning curve and speed bumps the first year and will likely see much more guidance and interim regulations as both the industry and CMS come across these. Despite these new flexibility options, the need to prepare for the new payment model is pressing, and those who prepare the soonest will see the greatest success under MACRA.

Gorman Health Group's experienced team is currently working with the provider, health system, and health plan communities in determining the best approach to influence more efficient care delivery models that support clinicians and hospitals as they change the way they practice medicine and adapt to new payment and risk arrangements.

Our experts can review current operations to identify risks and opportunities, increase integration within clinical and pharmacy programs, design well-coordinated activities across multiple healthcare programs, and ensure your organization's infrastructure and tools are prepared for MACRA's impact on your bottom-line. From in-depth analytics and tactical support to strategic planning and implementation. We can help >>



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Star Ratings Plan Preview #2: 2017 Trends to Improve 2018 Scores

With the Centers for Medicare & Medicaid Services (CMS) release of 2017 2nd Plan Preview Star Ratings and updated 2017 Technical Notes, the Star Ratings "busy season" is officially in high gear.

Though our clients are already reaching out to us to understand how to enhance existing programs and best leverage staff to improve their 2018 Star Ratings during the remainder of 2016, we think it's important all Medicare Advantage (MA) plans do so within the context of the trends and issues emerging from the 2017 ratings. A few highlights from the 2nd Plan Preview:

  • The triple-weighted Plan All-Cause Readmissions measure has an average (draft) Star Rating of 2.5 (down from an all-time high of 3.5 in 2014);
  • The triple-weighted Improving or Maintaining Physical Health measure has an average (draft) Star Rating of 2.6 (down from an all-time high of 4.6 in 2015);
  • The Reducing the Risk of Falls measure fell for the 3rd year in a row to 2.4 (down from an all-time high of 3.4 in 2014);
  • The MTM Program Completion Rate for CMR measure illustrates health plan struggles for a 2nd year with an average (draft) 2017 rating of 2.4.

These three Part C measures have now eclipsed the Osteoporosis Management in Women who had a Fracture measure (with a draft 2017 rating of 2.7) as the poorest performing Part C Star measure. These measures require strategic provider support to help members through well-managed transitions of care, consistent and persistent integration of medication management and pharmacy data into clinical workflows, and member education and coaching regarding non-clinical issues such as exercise and safety. In addition, the struggles with the MTM Program Completion Rate for CMR measure likely foreshadow the type of performance health plans can expect on the Medication Reconciliation Post Discharge measure, which CMS has indicated will be introduced in the 2018 Star Ratings.

With CMS' planned addition of numerous medication-related Star Ratings measures and ongoing development of measures to codify and quantify Care Coordination through new Star Ratings measures, a strategic approach to improving Star Ratings performance has never been more important. With this in mind, a plan's response to improve performance on an individual measure or group of measures must incorporate the following:

  • Care Coordination and Care Management activities that extend beyond the traditional definition of case management and integrate medication management firmly into care, case, and disease management activities;
  • High-quality care delivered throughout the provider network, with enhanced contracting, engagement, and coordination that support a patient's experiences, diagnoses, and clinical care needs across all clinical settings, including the primary care physician (PCP), specialists, pharmacies, inpatient/outpatient facilities, and emergency rooms/urgent care settings;
  • Risk Adjustment activities and interventions that simultaneously meet health plan needs across Star Ratings, Quality Improvement, and Risk Adjustment while seamlessly supporting and enhancing the care received in the clinical setting;
  • Expanded responses to address social determinants of health, such as food insecurity, unstable housing, loneliness, decreased cognitive function, etc.

Star Ratings reflect not only the effectiveness and outcomes of the policies, procedures, and business decisions made inside the plan but also the effectiveness and outcomes of external parties' performance. A strong Star Rating reflects the summative measurement of all actions and decisions of all parties involved in the healthcare experience, including the vast array of providers, vendors, pharmacies, and caregivers involved in delivering care and medications to a member and supporting that member's lifestyle choices and needs.

The 2017 ratings make it clear CMS will continue using the Star Ratings program as an important vehicle through which to test innovation experiments that will ultimately serve as the foundation for Health Insurance Marketplace care delivery and management and the Quality Payment Program.

If you achieved 4 stars this year: There is "no rest for the weary." Many of our clients are new entrants to the MA space — they understand what it takes to achieve 4 stars and are counting on the Quality Bonus Payments associated with >4 star performance. The work may feel relentless, but keep it up!

If you did not achieve 4 stars this year: Now is not the time to panic. You still have time to influence your 2018 Star Ratings. With a carefully planned 4th quarter strategy backed by data and executed to perfection, you may be able to attain (or regain) your all-important 4th star.  You'll need to carefully evaluate your current performance and use your time and resources wisely to hit 4 stars.

Whether you need help developing or finalizing your 4th quarter Star Ratings strategy or adapting to the innovations needed for longer-term Star Ratings success, Gorman Health Group (GHG) can help. For additional questions and inquiries about how GHG can support your Star Ratings efforts, please contact me directly at



There is no time to delay. Your organization needs to identify opportunities to increase your Star Rating, implement an enterprise-level strategy, and carefully monitor your progress over the next plan year.  We can help you every step of the way with our full portfolio of GHG practices, products and services. Visit our website to learn more about our Star Ratings Services >>

Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG's weekly newsletter. Subscribe >>

An "October Surprise" in Medicare Advantage Star Ratings

Each year, one of the most anticipated announcements in the Medicare Advantage (MA) industry is the Star Ratings and program technical guidance for the coming year from the Centers for Medicare & Medicaid Services (CMS). This year's includes an "October Surprise:" a little-known methodological change that could force dozens of 4- to 5-Star-rated plans to lose their hard-fought bonuses and rebates.

Roughly 370 MA plans are currently scored under the Star Ratings system, which we all know by now is graded on a curve. Plans above 4 Stars get substantial bonus payments and bid rebates from CMS and above 5 Stars can market and sell their products year-round. In this sense, plans below 4 Stars are circling the toilet bowl as there is only so long they can compete against the better benefits of 4+ Star plans. The Star Ratings for 2017 will likely knock many 4+ Star plans off their pedestals. Here's why: for 2017, for the first time, 188 new plans could be scored under Star Ratings.

  • 64 of the 188 are Medicare-Medicaid Plans (MMPs), which CMS announced in June will be moved into their own separate Star Ratings program this fall. This is a bit of bad news for most MA plans, since their inclusion in the MA Star Ratings program would likely have helped fill the lowest end of the curve.
  • The 124 that are left still represent enough mathematical volume that their performance will shift the bell curve. Most will likely earn an overall rating of 3 or 3.5 stars, which will cause rating dilution for those at 4+ Stars. If those plans have the same level of performance as the previous year, they will likely dip below 4 Stars. This is a looming disaster for those companies because they've already booked the bonus money and predicated their benefit designs and 2017 campaigns on receiving the rebate.
  • Regarding the 6 "dead men walking" plans below 3 Stars for 3+ years and slated for termination: a "hospital improvement" bill, which passed the House and is still in the Senate, includes a provision to delay CMS' authority to terminate MA contracts based on poor Star Ratings for 3 years. It's possible these 6 plans may continue to fill the very lowest end of the Star Ratings bell curve, thus helping other low-performing plans by padding the lowest end of the bell curve.

Many plans are going to get a nasty shock when they dig into CMS' latest news. It's another stark reminder Star Ratings management is a constant campaign, and plans cannot afford to get comfortable when it comes to their quality performance.



CMS recently notified plans of the first preview period for the 2017 initial Star Ratings data. It is critical for plans to begin the annual re-evaluation of Star Ratings performance now to pinpoint new problem areas, implement tactical actions, and identify improvement opportunities to raise ratings. Read full analysis >>

Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG's weekly newsletter. Subscribe >>

Star Ratings: Medication Management Is Not Just for D Ratings Anymore!

As a pharmacist and Star Ratings Senior Consultant for Gorman Health Group, whenever I am asked to provide insight on how to achieve or maintain Star Ratings success, the conversation has been limited to the "D" part of the metrics, and the folks involved with Medicare Advantage (MA) and Healthcare Effectiveness Data and Information Set (HEDIS®) kind of glaze over and mumble something like, "That's for the Pharmacy folks to deal with." That attitude has always been somewhat befuddling to me considering the historical and ever-increasing impact of appropriate clinical management of medications on many HEDIS® measures and the quality conversation in general. Equally confusing to me has been the willingness of many pharmacists to relinquish the ownership of the medication-related HEDIS® measures to Quality, Case Management, or other teams.

The team approach, with the patient at the center of the team, is vital to delivering high-quality care. At many health plans, the Star Ratings teams historically have been "siloed" into medical Care/Case Management on one team and Pharmacy on the other. While we at the health plans were all focused on Star Ratings for the past several years, something happened outside of MA that will have a huge impact on the whole spectrum of healthcare. That event was MACRA — the Medicare Access and CHIP Reauthorization Act of 2015 — the latest and most sweeping healthcare reform law from Congress. MACRA will fundamentally change how healthcare providers are paid. Under value-based payment, the foundation of the reward system will be quality. Out of this change will come huge shifts in alignments and the creation of new partnerships requiring "outside-the-box" thinking. At the center of many of these new partnerships will be the critical role of the pharmacist and medication management.

Health plan Star Ratings teams would do well to pay attention to these profound trends outside of MA and understand the huge impact on how care will be delivered in order to respond to these changing incentives. Wasn't the Star Ratings system one of the early forms of value-based payment? Certainly if metric success is not achieved, there is a huge financial impact that will be incurred. A cornerstone of value-based payment is preventing hospital admissions impacted by many aspects of care but notably including a huge focus on medication reconciliation, medication management, and medication adherence. Sound familiar?

So how do we take these shifting sands and turn them into something tangible? The first step is collaboration. Star Ratings teams need to prepare themselves for a global value-based system by no longer segregating their teams into "C" and "D." And even if teams meet in an integrated way, the pharmacy members need to take the lead on metrics that extend beyond adherence and Medication Therapy Management (MTM) Comprehensive Medication Review (CMR) rates. Pharmacists should be taking the lead on new metric challenges like medication reconciliation even though they are a HEDIS® measure. A strong medication reconciliation program not only impacts the "checking of the box" that it was done but, if done right, has been shown to actually have an impact on reducing hospital readmissions (another Star Ratings measure). So this is good for Star Ratings, good for the plan, and, most importantly, good for the patient.


Every organization in the healthcare industry will be impacted by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). Gorman Health Group's Senior Vice President of Healthcare Analytics & Risk Adjustment Solutions, Dan Weinrieb, provided insight into the various options Providers will have if the legislation moves forward in a previous blog post on the subject >>

On Tuesday, September 13, 2016, from 1:00 — 2:00 pm ET, join colleagues Diane Hollie, Senior Director of Sales & Marketing Services, and Carrie Barker-Settles, Director of Sales & Marketing Services, as they outline the keys to building an integrated member experience program that will deliver a significant and positive impact on health plan enrollment, retention, and revenue generation. Register now >>

Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG's weekly newsletter. Subscribe >>

Evolution Through Strategy: Pinpointing Growth Opportunities

My last article explained the choice of Medicare Advantage (MA) health plans to evolve or disappear. Evolution is certainly the preferable choice, so let's examine the steps needed to do so.

As with any company, you need to identify your target customer. State of the Art Membership accounting helps an existing determine strategies around expansion through a) new members (new to a company and new to Medicare) as well as b) the art of retention through pricing, quality and customer service.  Both efforts are necessary to maintain a steady growth pattern. This is more sustainable than a membership spike up or down that will cause operational havoc and financial uncertainty.

Risk adjustment Adaptation follows the member through every clinical encounter. If not fully documented, inadequate risk adjustment practices mean money left on the table, which is not an option. Diligence and good provider relations with proper analytic tools are critical to support risk adjustment.

Proactive Member Service means caring about the member experience to set the stage for high level of care and high quality ratings. It helps with retention while ensuring maximum quality of care to the member as well as enhanced revenue from CMS to reward good service. The payback is healthier members who want to stay: a win — win situation!

Collaborative Accountable Providers
represent a key partnership for the sake of the members. It is not always a natural alliance — different resources and priorities often conflict, but the health of the member through appropriate care management should be a common objective for both payer and provider. Various partnerships with providers to help with risk sharing is a new element that will offer advantages to both sides.

Make it Work Care Management focuses on the member's health as the single objective that requires proper and necessary medical care and ensures proper resources for the health plan to manage. The product design that attracts your membership base must also be managed to ensure a balance of quality for the member at the right price for the payer.

Finally, the partnership with providers is an integral part of the overall Mastery of Quality Ratings to maximize the outcomes as well as the member experience.  CMS is serious about quality — it impacts enrollment opportunities, care management and member outcomes as well as financial performance through critical revenue bonuses and rebate opportunities.

Gorman Health Group has the expertise in all aspects of health plan operations to lead you through best practices but also how to leverage these steps into financial stability. With a proprietary pro forma model designed to quantify these areas based on an in-depth knowledge of MA best practices, we are able to lead management through the different strategic decisions and analysis to customize what works in your marketplace and how to leverage your own strengths. The goal is not just to survive MA but to evolve into something that will improve the community's health.

Join us next month to discuss how analytics can help manage these levers going forward to ensure success.


On Tuesday, September 13, 2016, from 1:00 — 2:00 pm ET, join colleagues Diane Hollie, Senior Director of Sales & Marketing Services, and Carrie Barker-Settles, Director of Sales & Marketing Services, as they outline the keys to building an integrated member experience program that will deliver a significant and positive impact on health plan enrollment, retention, and revenue generation. Register now >>

In a recent case study, GHG examined a mid-sized managed care health plan who struggled with poor MLR and how a cost-efficient affordability review that utilized trend management conducted by out integrated team of experts generated targets of $4 million in expected improvements. Download the case study here >>

Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG's weekly newsletter. Subscribe >>

Evolution or Extinction

"The Theory of Evolution has two main points," said Brian Richmond, curator of human origins at the American Museum of Natural History in New York City. "All life on Earth is connected and related to each other," and this diversity of life is a product of "modifications of populations by natural selection, where some traits were favored in an environment over others," he said.

This same theory can be applied to current healthcare. A health plan is the sum of various functions that deliver and monitor the beneficiary's care. The line between payers and providers is becoming more blurred as financial risks and quality measures are critical measures for all healthcare components.

The concept of evolution vs. extinction is quite real. Providers are looking at partnering with payers and taking on more financial risk to leverage the subsequent reward and help coordinate care.  Payers are eager to have more control and visibility with providers as well as to follow beneficiaries through the continuity of care to manage shifts in income, demographics, and clinical needs over a beneficiary's lifetime.

As Medicare Advantage (MA) continues to cover almost one-third of the eligible population, new product trends are evolving.

Over the past four years, Health Maintenance Organizations (HMOs) dominate the marketplace with managed
care and tighter networks, but the recent duals demonstrations are recognizing demographic shifts as well as states moving to Medicaid expansion and better coordination.

Another predictor of the duals market is the Special Needs Plan's focus on duals as an at-risk beneficiary. A third driver is the stable Chronic Condition Special Needs Plan (C-SNP) market, which manages the clinical needs and provider partnerships. The Centers for Medicare & Medicaid Services (CMS) is expanding this concept further through the new Value-Based Insurance Design (VBID) demonstration starting in 2017.

Gorman Health Group has the tools and experience to help the healthcare community evolve and avoid extinction. Our feasibility model includes detailed financial projections and onsite strategy discussions to walk a plan through the entire process of entering MA or expanding current products and service areas with an emphasis on risks and rewards. We can then lead you through the product design and implementation phases to build a competitive and compliant organization with the proper financial and operational controls in place. Even existing plans need a new perspective to manage member retention, risk adjustment, and overall analytics to support an integrated care organization.

Let's build a more adaptable, efficient approach to healthcare! So standing still is simply not an option — the marketplace is moving due to changing competitors, regulations, and populations: evolve and adapt.


In a recent case study, GHG examined a mid-sized managed care health plan who struggled with poor MLR and how a cost-efficient affordability review that utilized trend management conducted by out integrated team of experts generated targets of $4 million in expected improvements. Download the case study here >>

Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG's weekly newsletter. Subscribe >>

Star Ratings: 10 Years, 10 Lessons

The Star Ratings program celebrates its 10th birthday this year. In honor of the first decade of quality ratings systems within managed care, and to celebrate the many lessons we've learned during these formative years of the Star Ratings program, here are 10 of our top lessons from the first 10 years of the program.

  1. Success is not easy. Not only are Star Ratings constantly evolving, but the ever-changing regulations and Centers for Medicare & Medicaid Services (CMS) guidelines surrounding Medicare Advantage and Part D prescription drug benefit plans and the increasingly competitive Star Ratings environment make Star Ratings success a continuous, often challenging battle. Evolution is difficult, and every detail matters.
  2. One size does not fit all. Every health plan has a unique culture, strategic plan, and relationship with its members and providers. And every health plan has a unique combination of vendors, analytical tools, systems, and business decisions that support its culture and strategic vision. As a result, every Star Ratings work plan is similarly unique. Customization, personalization, and tailoring is vital for success.
  3. All healthcare is local. Every provider network is unique and has a unique combination of systems, tools, programs, priorities, and business decisions through which it provides clinical services to your members. And every group of members presents its own unique prevalence of conditions, expectations of local physicians, and social and lifestyle patterns. As a result, every Star Ratings work plan is unique.
  4. Social determinants of health are a lynchpin to achieving and sustaining high quality ratings. Critical gaps between clinical care and community services exist in the current healthcare delivery system. CMS Innovation Model tests are underway to systematically identify and address the health-related social needs of beneficiaries while evaluating their impact on total healthcare costs, improved health, and quality of care. Star Ratings success on challenging triple-weighted measures is far easier accomplished when plans simultaneously support the clinical, social, and lifestyle needs of their members.
  5. Easy, understandable, and contextually-appropriate requests (of members and providers) are most successful. Systems work best if they are kept simple rather than made complicated; Star Ratings is no different. Whether we are asking our members or our providers to take action, simplicity should be a key goal and external-facing, unnecessary complexity should be avoided.
  6. Converting "big data" into "actionable intelligence" is key. Include carefully selected clinical, pharmacy, and Health Risk Assessment data elements for efficient, holistic success.
  7. Member and provider interactions and programs are most successful with carefully targeted investments. This requires data-driven strategic planning, close alignment of routine operations with Star Ratings measure needs, and consistent execution of well-planned processes.
  8. Manual workarounds and tactics likely won't sustain success over the long term. When data and reports are manually built or Star Ratings-impactful activities occur outside of system-driven workflows, Star Ratings success isn't easily scalable. As the principles and foundation built during the first 10 years of Star Ratings expands into the Health Insurance Marketplace, Medicare Fee-for-Service, and managed Medicaid, this is an excellent time to reengineer any manual activities into sustainable workflows.
  9. The physician-patient relationship is the foundation for high-quality healthcare. Support members' physician relationships wherever possible and augment where/how needed by developing personal relationships between carefully-selected members and a care coordinator.
  10. "Best Practices" are often claimed as "best" before they have been carefully evaluated for wide-scale adoption. And don't forget — a best practice is only a best practice until it becomes standard practice.

For questions or inquiries about how Gorman Health Group can support your organization's Star Ratings efforts, please contact me directly at



Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG's weekly newsletter. Subscribe >>



Health Plans Need to Start Talking About Disparities in Care

On the heels of a recent groundbreaking RAND report on racial disparities in Medicare Advantage (MA), the US Department of Health & Human Services' Office of Civil Rights (OCR) issued a regulation that requires serious attention in health plans participating in MA, Part D, Medicaid, and ObamaCare. It's a game-changer in advancing health equity and reducing disparities.

The new regs, implementing Section 1557 (the nondiscrimination provision) of the Affordable Care Act, prohibit discrimination, marketing practices, or benefit designs that discriminate on the basis of race, color, national origin, sex, age, or disability. This will escalate disparities from simply being a "quality improvement need" to being a huge compliance issue. It goes without saying that an investigation of your plan by the civil rights cops splashed across local news would be devastating. As the Centers for Medicare & Medicaid Services (CMS) has begun more aggressively using their data to identify these disparities, health plans certainly should begin doing the same.

The final rule prohibits sex discrimination in healthcare, including by:

  • Individuals cannot be denied healthcare or health coverage based on their sex, including their gender identity and sex stereotyping. These last two items are of particular importance given transgender policy enforcement is relatively new. OCR has prosecuted cases recently where transgender patients were discriminated against in hospital admissions and room assignments, denying mammograms to transgender females, denial of gender reassignment surgery as "cosmetic," and harassment by medical transport drivers.
  • Women must be treated equally with men in the healthcare they receive and the insurance they obtain. OCR has prosecuted several cases recently where hospitals assigned male guarantors when a wife obtained services but not the other way around.
  • Categorical coverage exclusions or limitations for all healthcare services related to gender transition are discriminatory.
  • Individuals must be treated consistent with their gender identity, including in access to facilities.
  • Sex-specific health programs or activities are permissible only if the entity can demonstrate an exceedingly persuasive justification.

The regs also include important protections for individuals with disabilities and those with limited English proficiency by:

  • Requiring covered entities to take appropriate steps to ensure communications with individuals with disabilities are as effective as communication with others.
  • Covered entities must post a notice of individuals' rights, providing information about communication assistance, among other information.
  • Covered entities are required to make all programs and activities provided through electronic and information technology accessible to individuals with disabilities, unless doing so would impose undue financial or administrative burdens.
  • Covered entities cannot use marketing practices or benefit designs that discriminate on the basis of disability.
  • Covered entities must make reasonable changes to policies, practices, and procedures, where necessary, to provide equal access for individuals with disabilities.
  • Requiring covered entities to make electronic information and newly constructed or altered facilities accessible to individuals with disabilities and to provide appropriate auxiliary aids and services for individuals with disabilities.
  • Requiring covered entities to take reasonable steps to provide meaningful access to individuals with limited English proficiency. Covered entities are also encouraged to develop language access plans.



CMS recently announced the release of the 2017 Medicare Marketing Guidelines for Medicare Advantage Organizations and Part D Sponsors, which include added language, clarifications, and new requirements. Join Regan Pennypacker, GHG's Senior Vice President of Compliance Solutions, and Carrie Barker-Settles, Director of Sales and Marketing Services, on Tuesday, June 28, from 1-2 pm ET, to discuss what provisions in the final guidelines will have the greatest impact on your organization and how plan sponsors can prepare for the upcoming changes. Register now >>

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