Topic: Star Ratings

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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Aetna Offers a Playbook for Evolution in the Golden Age of Government Programs

John Gorman

Ralph Giacobbe of Credit Suisse got another terrific “get” hosting Aetna’s management team for an insightful discussion last week.  I found the takeaways offer a playbook for how to adapt and evolve in the new Golden Age of government-sponsored health programs:

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Follow the Leader: United Health Group’s Outlook on Government Health Programs

John Gorman

Ralph Giacobbe at Credit Suisse is a leading health industry analyst and is doing the best work of his career.  Today he produced a fantastic recap of his discussion with United Health Group CEO Steve Hemsley and several of his top executives.  It included some fascinating insights into the market leader’s strategy for government health programs:

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Member Engagement and Experience are the New Risk Adjustment

John Gorman

In this new era of Star Ratings in Medicare Advantage and Part D, where a 4+ score is now do-or-die, health plan survival comes down to two things: member engagement and the member experience.  They’re the new risk adjustment when rates in 2014-2015 will be at their lowest levels in more than a decade, and a low-quality rating is a kiss of death in government programs.  Plans that can’t evolve into kinder, gentler, more coordinated and Member-Centric service providers are already beginning to disappear.

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