Medicare Advantage 2020 Proposed Rule

It’s been a long wait since the passage of the Bipartisan Budget Act in February, but the 2020 Medicare Advantage (MA) proposed rule is finally here. Perhaps the biggest opportunity for plans is the shift that makes telehealth a basic benefit, which means the digital revolution that brought us things like ATMs on every corner, iPhones, and Teslas is finally seeping into Medicare. Plans can decide which benefits to provide via telemedicine in any geography. What is really exciting is the service can be delivered to the patient in the home. This is a tremendous opportunity to bring continuity to episodes of care that will really impact outcomes. It will also be possible for plans to offer telehealth services as a supplemental benefit. Additionally, it’s an opportunity for MA to offer new advantages over Original Medicare where telemedicine is still restricted to rural areas and the patient must be in a health facility to partake in the services.

Star Ratings are in for some changes, too. Measures with proposed changes will include Medicare Plan Finder price accuracy, all-cause readmission, and controlling high blood pressure.  Additional enhancements will be made to CMS’ methodology to adjustments will be made to handle unusual situations beyond a plan’s control like the fires and hurricanes that seem to be less unusual as of late.

The Centers for Medicare & Medicaid Services (CMS) gives, but, unfortunately, it also takes. On the program integrity side, the agency proposes using extrapolation in the Risk Adjustment Data Validation audits. That is a definite cloud on the horizon for plans as the regulation predicts a return to the program of $4.5 billion for the government over 10 years. Since 2012, CMS has held extrapolation from a valid sample of records was coming, and now there is an opportunity to comment on the specific methodology that might be used. Comments on the proposed rule are due 12/31. Happy New Year.



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Adjusting Star Ratings for Audits and Enforcement Actions

Within the Draft Calendar Year 2018 Call Letter, the Centers for Medicare & Medicaid Services (CMS) acknowledged the valuable comments received from the industry related to the use of audit findings and enforcement actions in the Star Ratings Program. As a result of those comments, CMS proposes a revision of the Beneficiary Access and Performance Problems (BAPP) measure.

First, what is the BAPP measure? You can find information on this Part C measure in the 2017 Star Ratings Technical Notes. As described, the agency checks each plan to see if there are problems with the plan, for example, whether members are having problems getting services and if plans are following all of Medicare’s rules. The current BAPP measure is based on CMS’ sanctions, civil monetary penalties (CMPs), and Compliance Activity Module (CAM) data. CAM data includes notices of non-compliance, warning letters, and ad hoc corrective action plans.

In the Draft Call Letter, CMS is proposing a number of revisions to the BAPP measure for the 2018 Star Ratings.

  • CMS is proposing to change the data time frame to the period from July of the measurement year to June of the following year. For example, the time frame for the 2018 Star Ratings would be July 2016 through June 2017. (Current data time frame for 2017 Star Ratings is January 1, 2015, to December 31, 2015.) This change would address feedback to use more recent data for the CMP portion of the measure.
  • In addition, CMS proposes to employ the first option outlined in the November 10, 2016, Request for Comments, that is, the agency would apply the same scaled CMP deduction to all contracts cited in the CMP notice based on a ratio of the unadjusted CMP amount to enrollment at the time of the enforcement action. So, let’s say a parent organization has five contracts cited in a CMP notice. CMS will calculate the BAPP deduction by dividing the CMP by the total enrollment of those five contracts. The resulting BAPP measure deduction would apply to all five contracts.
  • CMS also proposes the total deduction for a contract for CMPs be capped at 40 points instead of 40 points per CMP, which is what is in place today. Furthermore, CMS proposes retaining both the current BAPP measure score reduction for contracts under sanction and the current CAM deductions.

After all this work, CMS is also considering whether to implement proposed BAPP measure changes for 2018 or 2019. For more information on proposed changes to Star Ratings, refer to our expert commentary on this key aspect of the program.

It is recommended Compliance, Operations and Star Ratings professionals consider scenarios and how this would affect their Star Ratings. Ideally, a plan will keep CMPs and CAM data to a minimum, but the reality is with program audits, timeliness monitoring, an annual release of CMPs for Annual Notice of Changes/Evidence of Coverage issues, provider network accuracy reviews, and CMS’ revitalized focus on nondiscrimination and accessibility, it is expected there will be plenty of data for CMS to inform this measure.


Gorman Health Group’s Summary and Analysis of the 2018 Medicare Advantage and Part D Advance Notice and Draft Call Letter is now available. Download now >>

The Gorman Health Group 2017 Forum Conference Brochure and Preliminary Agenda Is Now Available! Download it now to see the topics we have in store for you at this year’s event. Register now for the Gorman Health Group 2017 Forum, April 26-27, 2017, at the JW Marriott New Orleans.

Our Star Ratings subject matter expert discusses several key changes for Star Ratings in the 2018 MA Draft Call Letter. Read now >>

How to Maximize Your Medicare Advantage Website Strategy

How was your Annual Election Period (AEP)? Have you evaluated your performance? Do you need to enhance your sales and marketing strategies? Now is the time to recognize and appreciate your 2017 successes as well as confront your shortcomings.

There are several moving parts to a successful sales and marketing strategy, one being your Medicare Advantage (MA) website. The internet shopping trend is ever rising and this now applies to MA. Baby Boomers are aging into Medicare and with them come a new trend in internet shopping, enrolling and communicating with not only family and friends but with organizations they receive goods and services. In the 2016 Age-In Study by Deft Research, we learn, “Internet shopping rates have surpassed the rates of all other shopping activities.” The days of only direct mail are in the rear view. In fact, we also learn that your direct mail is actually motivating your website visits. Take advantage of these trends and take control of your website strategy.[1]

Here are the top 3 items to keep in mind when evaluating, developing and implementing your MA website strategy.

  1. Think Easy: Your website mantra shall be: “clear and easy to navigate.” Not only is this the top requirement given to us from the Centers for Medicare & Medicaid Services (CMS) – in fact, this is the first requirement listed in section 100 of the 2018 draft Medicare Marketing Guidelines (MMG) – but this approach will ensure your website is user friendly and an effective marketing tool. Shoppers want the facts about your plan offerings and most importantly, they want them now. And if they are ready to enroll – the online enrollment process should just as easy as the shopping.Helpful tip: Organize your website around 3 general focus areas:
    1. Prospective member information – Here are your sales and marketing web pages, including the online enrollment tool.
    2. Current member information – These web pages focus on required content that is mostly geared towards your current members.
    3. Member Experience –Enhance your website with tools and a member portal that help drive your retention efforts.
  1. Follow the Rules: Make your list and check it twice. Compliance is key and whether you are developing, revising or monitoring your website, it is critical that you and your team have an understanding of all the CMS requirements as they apply to your MA website.Helpful tip: GHG recommends creating a website checklist that includes all CMS requirements. Are you developing a new website? List these requirements out as they would impact each of your proposed web pages or section of the website (prospective, current, retention). This is your content development driver. Are you revising or monitoring your website? This checklist is your tool to ensure compliance and it documents where each requirement is met by URL tracking.
  1. Member Perspective: It’s all about that member portal. As the Deft study highlights, web is worth it. Ensure an easy transition from prospect to member by providing your membership with an online, password protected member portal. Here the possibilities are endless – think newsletters, healthcare/health service reminders, provider/pharmacy look-up, drug search, claims check.Helpful hint: Collaborate with Stars! The experience of your members directly impacts your Star Rating. Collaborate with your Stars and care management teams to develop a member portal that truly supports member needs while simultaneously moving the numerator of your Stars measures.

Finally – don’t forget about your third-party websites. You may not have much control over the look and feel of your third-party websites but you must ensure they are compliant. Take note that one of the major changes proposed by CMS in the 2018 draft MMG is the addition of section 100.7 on third-party websites. CMS expects plans to be monitoring these sites in addition to their own.

All in all, enhancing our sales and marketing strategies is found in understanding our successes and failures. Take advantage of the rise in internet shopping and develop or revise your MA websites to go beyond the compliance requirements but to sell your products and retain your members. We are here to help!

[1] Deft Research, LLC. (n.d.) Marketing to Medicare Age-Ins: Internet and Direct Mail Trends. Retrieved from



On Thursday, February 9, from 2-3 pm ET, join John Gorman and colleagues Olga Walther, Senior Legislative & Policy Advisor, and Leslie Mullins, Senior Consultant, as they provide a hard-hitting analysis of critical areas addressed in the document, including CMS’ changes to risk adjustment and encounter data, Star Ratings, Benefit Parameters and Bid Requirements, Part D Utilization Review, and more. Register now >>

The Medicare Advantage marketplace is evolving – are you prepared? Gorman Health Group’s marketing experts have developed strategic plans for hundreds of Medicare Advantage Plans, Prescription Drug Plans, Special Needs Plans and Exchange participants. We will work with you to understand your market, mining demographic data for opportunity and finding the gaps in the competitive field into which your plan can fit. Visit our website to learn more >>

The Gorman Health Group 2017 Forum Conference Brochure and Preliminary Agenda Is Now Available! Download it now to see the topics we have in store for you at this year’s event. Register now for the Gorman Health Group 2017 Forum, April 26-27, 2017, at the JW Marriott New Orleans.

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

PBM-Supported Part D Measures Impact Quality Bonus Payment Revenues

Regulatory time frames around coverage determinations and appeals have existed since the inception of the Part D benefit. Timely access to medications has been a hallmark of the “member protective” stance the Centers for Medicare & Medicaid Services (CMS) has taken since Day 1. So how is it, even 10+ years into the delivery of the program, compliance with these time frames continues to be the bane of health plan Compliance and Star Ratings teams?

When CMS posted the 2017 ratings in October, the Medicare Advantage Prescription Drug (MA-PD) plan averages actually fell from 4.5 and 3.3, respectively, in 2016 to 3.9 and 2.9 in 2017. How can this trend be accounted for in the wake of ongoing CMS pronouncements regarding its dismay at the large number of auto-forwards sent for external review and that it would closely watch outliers and take vigorous enforcement actions against plans?

Even with all of the prodromal warnings by CMS, we have started to see the impact of low scores in these two measures in the newly released 2017 Star Ratings.  Thirty-four plans that earned ≥4 stars in 2016 dropped below 4 stars in 2016 and will lose their Quality Bonus Payment (QBP) revenues. Of these, 53% earned only 1 star on both the Part D Appeals Upheld and Appeals Auto-forward measures, which, even if “artificially” reduced via unsatisfactory performance in CMS audits, were found to have substandard performance in this area.

Are Pharmacy Benefit Managers (PBMs) the culprit? Minimally, it must be restated the origin of these Star Ratings stemmed from compliance and member protection concerns, and if they were performing adequately, would have gone the way of, say…. call center hold times (by the same PBMs), which improved enough to be dispatched to the display measure list. Even with performance guarantees, intensive oversight by plans, onsite inspections, and internal audits, these misadventures continue to occur, and dire consequences follow. In general, PBM performance guarantees cannot begin to compensate for the potential lost bonus revenue, and plans are re-evaluating performance criteria, degree of health plan oversight required, and, in some cases, pondering the insourcing of all coverage determination-related activities. It may be time for “zero tolerance” in the health plan stance toward vendor-provided coverage determination services, as even one missed time frame may be a harbinger of more to come.

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



GHG anticipates that CMS will continue adjusting thresholds, curving the Star Ratings year after year in an effort to separate the remarkable from the ordinary.  Now is a critical time – MA Plans must examine not just this year’s score and what contributed to it, but their Plan’s score history in the Stars program and what it says about the enterprise’s overall approach to key issues. Visit our website to learn more about how we can help your organization >>

New Webinar: During this webinar on November 9 at 1:30 pm ET, Regan Pennypacker, GHG’s Senior Vice President of Compliance Solutions, and Cynthia Pawley-Martin, our Senior Clinical Consultant, join Melissa Smith and Jordan Luke, the Director of Program Alignment and Partner Engagement Group at the CMS Office of Minority Health, to provide perspectives on how to implement CMS-recommended best practices in the real world within a health plan in support of Quality Improvement and Star Ratings activities as we continue focusing on providing person-centered, holistic care coordination to our members. Register now >>

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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 >>

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

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 >>

First Plan Preview of 2017 Star Ratings Data

It's official — the Star Ratings busy season is officially underway. The Centers for Medicare & Medicaid Services (CMS) recently notified plans of the first preview period for the 2017 Star Ratings data.

Although CMS did not introduce any surprises or unexpected measure changes as part of the first plan preview, plans have only a very short window to review their data for accuracy, with feedback due to CMS by August 18, 2016. Inevitably, some plans identify data issues or inaccuracies during this plan preview, so great care should be taken to validate each measure score and data element provided for review.

While the Healthcare Effectiveness Data and Information Set (HEDIS®), prescription drug event (PDE), and administrative measure scores likely contained no surprises for health plan leaders, the first plan preview data for the Consumer Assessment of Healthcare Providers and Systems (CAHPS®) and Health Outcomes Survey (HOS) measures may contain some surprises.  Improving performance on CAHPS® and HOS measures generally requires carefully planned engagement with both providers and members over a sustained period of time. With almost half of the annual member survey cycle already behind us, it is critical for plans to re-evaluate their current Star Ratings status to pinpoint high-risk CAHPS® and HOS problem areas in order to ensure the right activities are in place with the right members and providers to achieve desired improvements.

During the first plan preview, particular attention should also be paid to validating the Categorical Adjustment Index factor data, which will be used for the first time this year to account for the impact of socio-economic factors and disability status on quality measure performance.

Need assistance making sure your fourth quarter action plan is aligned with your highest risks or interested in assistance preparing for 2017? We can help. For questions or inquiries about how Gorman Health Group can support your Star Ratings program, please contact me directly at



GHG's Star Rating team has been working on the critical factors that drive your Stars score for more than 15 years.  Since the inception of the Star Bonus Program, we have supported dozens of clients, including small regional plans, multi-market players, and multiple Special Needs Plans (SNPs).  We know what works and what doesn't, and we see where MA health plans continue to miss real opportunities to greatly impact their Star score. Visit our website to learn how we can help you with your Star Ratings program >>

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