Topic: Star Ratings

The Medicare ACO Demos Are a Mess. Here’s What it Means for Health Plans.

John Gorman

This week, another Medicare Pioneer Accountable Care Organization Demonstration site, longtime GHG client Sharp Healthcare in San Diego announced it was dropping out.  It was the tenth Pioneer to quit the trail, and not for lack of trying.  Many of the Pioneers did great on improving quality and reducing costs — the issue is not the performance of Pioneers.  It’s CMS’ methodology, with its requirement for Pioneers to bear risk in the third year, and benchmarks calculated to make any gainsharing impossible.

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Health Plan Strategists: Fish Where the Fishes Is — in LTSS

John Gorman

One of the best pieces of advice I ever got in business was to “fish where the fishes is”, and for health plan strategists it holds up.  In this Golden Age of Government-sponsored Health Programs, one of the biggest fishing holes is Long-Term Services and Supports, and a new primer from KFF lays out the opportunity beautifully.  And the hazards: patients who require LTSS are of course the most vulnerable and complex patients in the entire US health system, literally the final frontier for health plans and coordinated care.  Huge risk, huge rewards.

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American Action Network Promotes Government Subsidies

William MacBain

The American Action Network (AAN), a 501(c)(4) conservative think tank, has published a report that purports to show that Medicare Advantage (MA) payments will be about 13% less in 2015 than they would have been had the Affordable Care Act not interfered. To get the attention of members of Congress, the report shows the reductions by Congressional district.

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Part D and Hospice Rules Mucking Up Beneficiaries’ Last Days

John Gorman

Last week the Centers for Medicare and Medicaid Services (CMS) met with 30 hospice & healthcare organizations about suspending a new rule intended to avoid duplicate payments for hospice medications. This is a very big deal and the new rule is mucking up many beneficiaries’ last days. The National Hospice and Palliative Care Organization described the meeting as “an important first step at righting the wrongs being faced by dying Medicare patients.”

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Further Evidence That PBMs are Failing on Government Programs

John Gorman

At CMS’ oversight and enforcement conference last week Jonathan Blanar, the agency’s Deputy Director of Compliance Enforcement, presented the following slide. In this slide, you will see actions CMS has imposed against Medicare health plans in the last two years, and for what reasons. It’s further evidence that pharmacy benefit managers (PBMs) are failing Medicare beneficiaries and the plans enrolling them.

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PBMs are the Health Plan Industry’s Achilles Heel

John Gorman

In this Golden Age of government programs, the health plan industry has never had more exposure to the generally poor performance of pharmacy benefit managers (PBMs).  Performance metrics in Medicare, Medicaid and ObamaCare are directly tied to PBM execution, and the recent track record of these companies means they are the Achille’s Heel of insurers.

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Tuesday Night’s Primary Elections Were Huge. Here’s What They Mean for Our Industry.

John Gorman

House Majority Leader, Eric Cantor (R-VA) is toast.  Trounced in his Richmond district by a nobody Tea Bagger Tuesday night. Cantor gave up his leadership position yesterday. Depending on where you sit politically, either the unthinkable or the inevitable happened.  In fact, a Majority Leader hasn’t lost incumbency since the office was created in 1899.   “The defeat of the second-ranking Republican in the House by an ill-funded, little-known tea party-backed candidate ranks as the biggest congressional upset in modern memory and will immediately generate a series of political and policy-related shock waves in Washington,” wrote Chris Cilizza of WaPo.

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