Topic: Prospective Evaluations

The 2015 Medicare Advantage Final Call Letter = Unicorn Rainbow Farts

John Gorman

The Center for Medicare and Medicaid Services’ (CMS) release of the final 2015 Call Letter for Medicare Advantage (MA) Monday after the close was a “unicorns farting rainbows” moment.  Unicorn rainbow farts bring happiness and joy to all those that observe them, and then dissipate quickly.  After a beating at the hands of the ever-more powerful insurance lobby for another draconian draft released in February, CMS reversed itself yet again and proclaimed a 0.4% increase in MA benchmarks.  Lobbyists and Wall Street analysts rejoiced…only to find after a closer look that there are some nasty hooks in the pie CMS put on the windowsill.

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Lighting the Path in the Golden Age of Government-Sponsored Health Programs: Join Us for the GHG Client Forum

John Gorman

More than 300 guests will convene on May 1-2 at the Red Rock Casino in Las Vegas for the 2014 Gorman Health Group Forum, our annual strategic retreat for leaders in government-sponsored health programs. This year’s gathering promises to be the most actionable, content-packed conference you could attend on how to succeed in this new Golden Age of government business. And when the learning and planning is done for the day, we will celebrate this unique moment in health care history as only GHG can in Vegas.  Here’s what’s happening this year and why you’ve got to join us: Read more

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The New Post-Reform Core Capability for Health Plans: Risk Adjustment

John Gorman

Medicare Advantage and Part D have for years been the world’s largest experiments in paying insurers more for the care of sick members while paying less for healthier members, or risk adjustment.  Some two dozen states now risk-adjust Medicaid payments to health plans, and the hundreds of Accountable Care Organizations (ACOs) launching this year and next are risk-adjusted as well.  Now that the election has been decided, we know that health plans operating in the insurance exchanges launching in 2014 will also be risk-adjusted based on a similar methodology to that used in MA and Part D.  It’s the new core capability for health insurers in the post-reform world, and it’s examined closely by my two top experts, Bill MacBain and Dr. Jack McCallum, in this month’s Managed Healthcare Executive magazine here.

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Insourcing: So you are thinking about internalizing risk adjustment . . .

RaeAnn Grossman.

We talk to health plans everyday that want to internalize risk adjustment.  Bottom line: It is a good idea.

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My Talk at AHIP’s Medicare Conference

John Gorman

I had the pleasure of addressing a standing-room-only crowd at the AHIP Medicare conference yesterday, sponsored by our friends at TMG Health, our 4th year together there.  That speech always keeps me on my toes, especially this year – a tough, smart audience that demands a tough, smart message on how to survive in the new Age of American Austerity.  Here are the main points of what I said: Read more

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Get your money’s worth

RaeAnn Grossman.

When I was a kid, we would jump on those tiny merry-go-arounds outside of stores or those little goofy race cars in Toys R Us and my dad would shake them. Yes, it is true.

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Using What You Know to Improve Care for Your Members

Jack McCallum.

In the current issue of the New England Journal of Medicine , a group of physicians from Harvard Medical School describe an unfortunate and instructive case.[1]  One of the system’s patients had her spleen removed after an automobile accident.  I would venture to guess that just about  every sophomore medical student knows  that people without a spleen are more likely to have infections, especially with streptococcus pneumonia, and that those infections can lead to death or, as in this poor lady’s case, severe, permanent complications.  Anyone who has had a splenectomy should be vaccinated against pneumococcus.  So far so good, but the vaccine was never given in this case because the problem list in her electronic medical record was never updated to include the fact that her spleen had been removed.

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