Amy Brown

The growth of the health insurance marketplace is picking up steam, fuelled by Medicaid disenrollment. https://ow.ly/N1vW50Tafsq MMIT’s Erin Trompeter explains what these large-scale changes mean for providers, manufacturers, payers and health IT vendors. Get the insights by clicking the link in this post. #HealthInsuranceMarketplace #HealthInsurance #Medicaid

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The era of splashing the market with flashy supplemental benefits is in the rearview as CMS, MA plans, and downstream risk-bearing providers are collectively challenged to "do more with less."   CMS' heightened data collection requirements will slowly but surely drive an emphasis on cost-saving, impact-driving supplemental benefits rather than those that simply attract members.   This shift could serve risk-bearing providers well, as overly generous and unmanageable supplemental benefit allowances have often driven MLR headwinds in recent years.

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Next year, payers will need to increase member communication on supplemental benefits, per new rules from Centers for Medicare & Medicaid Services. Find our summary of the changes and ways to reduce related operational challenges: https://lnkd.in/gz6PN7g2

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New for 2025, CMS is rolling out a geographically based targeting option for Medicare Advantage organizations based on an Area Deprivation Index. If these orgs get things right, this could mean opportunities with new enrollees (especially in Midwest and Southern states) with potential rewards, incentives, and reduced cost sharing. This is in addition to CMS’ 2025 proposal to draw from ACO REACH and its geographic adjustments (which saw some big winners). If finalized, savvy ACOs would have additional capabilities through prepaid shared savings. tl;dr, CMS continues to push geographic considerations for beneficiaries. #sdoh #healthequity #medicare #medicaid .Variate Health

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#MedicareAdvantage keeps getting more popular among seniors: #MA plans typically offer a range of supplemental benefits (like transportation/#NEMT) that can improve quality of life and health outcomes. But they are facing challenges headed into 2025, including lower star ratings, resistance from some health networks, rising healthcare costs, and a revised CMS payment model. Read our latest blog for a summary of MA changes that will impact health plans, providers, and members in the year ahead. https://hubs.li/Q02XP0700

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Basic “explainer” on Risk Adjustment and a RAF conundrum. This article from The Commonwealth Fund does a good job of providing the basics of risk adjustment. It also calls out one of the major contributors to patient outcomes that isn’t captured in traditional risk models, the Social Determinants of Health (SDoH). They do a great job on this, so I won’t summarize it here. However, I think there is another factor that isn’t captured that I wanted to discuss and would appreciate some different perspectives. I’d love to get some thoughts on the following. Maybe I am simply being pedantic. The issue not mentioned in the article that I think current methodologies of risk adjustment miss is duration and management of disease. A patient with a new diagnosis of diabetes, for example, now has an elevated risk of numerous complications over their lifetime. However, that risk in year 1 after the initial diagnosis is much lower than the risk at year 10. Current risk models don’t take that escalating risk into consideration, keeping the risk adjustment fixed regardless of duration of underlying diagnosis. In addition, there are few scenarios that will impact me differently as the provider: 1) Management of this patient’s diabetes has been poor for the prior 9 years and now my group “inherits” this patient at year 10. 2) My team has helped this patient manage their diabetes very well for the past 9 years. 3) For the past 9 years, this patient’s prior group had managed their diabetes well but they have now switched into my group. As noted above, in scenario 1, that “new” diagnosis of diabetes severely underestimates this patient’s risk of needing expensive resources this upcoming year. I will be adversely impacted from something that is clinically obvious (duration of a disease increases risks) but which is not captured in the current data. To go one step farther, in frameworks 2 and 3, there is a gap between what the patient’s risk would have been without 9 years of great care and what it likely is now. However, there is no recognition of this work. That is to say, if the patient switched to a group that did a terrible job of managing diabetes, they’d receive the same risk adjustment in year 10 as my group would receive after all of our time, effort and resources had been dedicated to keeping this patient healthy. If the patient’s healthcare needs in year 10 are low because of our efforts, shouldn’t we receive more credit than a group that simply gets attribution? And, what about the prior group? How are (were?) their efforts recognized? Please share your thoughts in the comments.

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MCRA Member, Evolve, shares insights on how Medicare Advantage Plans can improve star ratings through home modifications. Not only can it reduce hospitalizations and care costs, but it can increase member safety and quality of life. Read their insights 👉 https://loom.ly/-oRkqR4 #Evolve #HomeModifications #AginginPlace #mcra

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New CMS Rules Hope to Curb Consumer Fraud! KFF Health News reports, “Unauthorized switching of Affordable Care Act plans appears to have tapered off in recent weeks based on an almost one-third drop in casework associated with consumer complaints, say federal regulators.” CMS “credits steps taken to thwart enrollment and switching problems that triggered more than 274,000 complaints this year through August.” But “now, the annual ACA open enrollment period that began Nov. 1 poses a real-world test: Will the changes curb fraud by rogue agents or brokerages without unduly slowing the process of enrolling or reducing the total number of sign-ups for 2025 coverage?” The article says “the clampdown could add complexity to enrollment and slow the process.”

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We’re proud to announce our strategic partnership with Holzer Health System to help primary care providers in Ohio and West Virginia deliver more proactive, patient-centered care for Medicare beneficiaries. Through this partnership, Holzer providers will gain access to data insights, financial tools, provider enablement technology, and a broad range of services designed to improve patient care and drive success in value-based Medicare programs. With more than 160 providers across multiple outpatient clinics, hospitals, and post-acute services, Holzer has expanded the boundaries of care delivery in rural communities, offering unparalleled access to primary care physicians, specialists, skilled care teams, leading technology, and advanced healthcare services. We’re excited to work alongside the Holzer team to help primary care providers enhance the quality of care for their Medicare patients. Read the press release to learn more. https://lnkd.in/gjfbJEfi #valuebasedcare #medicare #healthcareinnovation #primarycare 

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Listen Here: https://lnkd.in/gMEkNNTS This episode, recorded live at the Becker’s Healthcare 2024 Fall Payer Issues Roundtable, features Krischa Winright, President of Medicare Advantage at Blue Cross Blue Shield of Michigan. Here, she discusses sustainable solutions for seniors on Medicare, focusing on providing seamless access to healthcare. Winright also examines market shifts in the post-COVID era and highlights the importance of strengthening partnerships with providers to enhance care delivery and outcomes. For more information about Becker's Healthcare, please contact Jessica Cole or Scott Becker. #podcast #healthcare #leadership

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With over 2 million members displaced by major healthcare players exiting underperforming Medicare Advantage markets, regional insurers face both a challenge and an opportunity. This influx of high-cost members demands innovative solutions to manage chronic conditions like diabetes and heart failure effectively. At Circadian Health, we’re helping regional insurers navigate this disruption with virtual-first specialty care, reducing costs and improving outcomes for the most complex members. This market shake-up isn’t just a challenge—it’s a chance to redefine care delivery. Discover how regional insurers can transform disruption into opportunity—read more on our blog. #MedicareAdvantage #HealthcareInnovation #VirtualCare #CircadianHealth #ValueBasedCare #HealthEquity

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New year, new model! CMS has announced updates to the 2024 Medicare Advantage risk adjustment model, including more Hierarchical Condition Categories (HCCs) than the previous system. Read our latest blog to learn more about the new updates: https://hubs.li/Q02wgNS10 #riskadjustment #medicareadvantage #medicare #hcc #cms

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There was a great discussion at the 2024 National Association of Medicaid Directors conference about enhancing care for individuals who qualify for both Medicare and Medicaid. CITIZ3N GM Rob Miller breaks down the insights on our blog 🔽 https://bit.ly/3OagXq4 #Medicare #Medicaid #Healthcare

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