Quality & Revenue Newsletter - No. 11 - Fall 2022

Key takeaways from

RISE West

MA moves closer

ratings

Tukey’s

quotes

THE LATEST NEWS

Medicare Advantage prior authorization bill passes House, heads to Senate »

CMS proposes mandatory quality measure reporting for Medicaid, CHIP »

CMS releases second plan preview of 2023 Medicare Advantage Star ratings »

KFF report: Few big differences between traditional Medicare and MA on various measures

Telehealth during the first year of COVID: OIG releases dual reports that examine dramatic increase in use, program integrity risks

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Study: MA plans fall short in coverage of mental health, substance abuse services »

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CDC: Fewer than 1 in 3 insured hepatitis C patients receive timely treatment »

CMS proposes rule to make Medicaid, CHIP enrollment easier »

Congress passes Inflation Reduction Act: What it means for health care » HHS declares monkeypox a public health emergency »

RAND study: Higher premiums not always linked to better quality in Medicare Advantage plans

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National uninsured rate reaches an all-time low »

ACOs saved Medicare $1.6B in Shared Savings Program in 2021 »

CMS final rule for inpatient, LTC hospitals: Updates payments, introduces new measures, and advances health equity

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Surprise medical bills: Feds issue final rules, guidance on arbitration process to protect consumers

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RISE Radio Episode 12: RISE West 2022 panelists on the most pressing policy issues facing health plans this year

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HHS proposes rule to reinstate, strengthen nondiscrimination protections removed by Trump administration

8 questions every health plan should ask a health care analytics & technology partner Veradigm

Working together for greater interoperability in health care: Consent and data segmentation

Change Healthcare

Navigating RA workflows for utilization reimbursement and performance outcomes GeBBS Healthcare Solutions

5 ways to set up your team for success in risk adjustment Navina

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REGULATORY ROUNDUP

MedPAC considers standardizing benefits in MA plans; CMS seeks input on health care access, provider experiences, health equity, and PHE flexibilities

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CMS invests $100M for ACA navigators ahead of 2023 open enrollment; White House issues guidance on publicly funded research; and more

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CDC to reorganize to restore public trust; FDA rule will allow hearing aids to be sold without a prescription; NCQA announces 2023 update for HEDIS®

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CMS suspends prior authorization requirements for certain orthopedic devices; HHS paves way for emergency use authorization for monkey pox vaccine; and more

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Moving to in-year HEDIS: 5 best practices to boost scores and member engagement Cotiviti

The rising importance of risk and quality in value-based contracts

Change Healthcare

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Medicare Part D premium will drop slightly in 2023; Feds issue guidance on nondiscrimination in telehealth, birth control coverage, new Medicaid health home benefit; and more

Watchdog calls for CMS to recover $226M in uncollected Medicare overpayments; CMS turns to public to help improve Medicare Advantage; and more

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Key takeaways from RISE West 2022

More than 650 participants (the biggest RISE

West summit to date) attended our three-day annual event in Los Angeles.

The live event featured four preconference workshops and two days of general and concurrent track sessions that addressed risk adjustment strategies, quality, compliance/regulatory updates, payer/provider align ment, and how to achieve health equity and address the social determinants of health (SDoH) for the aging population.

Below are seven highlights from select sessions:

WHY MEDICARE MEMBERS LEAVE YOUR PLAN – EVEN IF THEY ARE SATISFIED

• Price and provider network were factors for enrolling in their current plans

• To improve service, they recommend easy-toread websites and portals, better dental coverage that includes a network of nearby dentists, and information on how members can take advantage of their benefits

REGULATORY AND LEGISLATIVE ACTIVITY TO KEEP ON YOUR RADAR

We heard from eight seniors who shared their experiences with Medicare and Medicare Advantage (MA) and what would cause them to switch plans.

The good news: All the patient focus panelists said they were satisfied with their plans in 2022. The bad news: Half of them still plan to shop around for another plan.

The discussion, moderated by Shannon O’Connell , senior manager, Engagys, revealed that convenience is a huge factor when choosing a plan. That means a network that includes their current (and nearby) doc tors, better over-the-counter benefits, and an attractive rewards program. One panelist who is healthy and plans to travel in 2023 said he may leave his MA plan that he likes and enroll in traditional Medicare in case he gets sick when he’s away and isn’t near his network providers.

Among the panelists who will shop around for a new plan during AEP was a senior who has been with his cur rent plan for five years. But he looks at his options every year. “It’s like automobile insurance,” he said. “When it’s renewal time, I start snooping. Maybe the snooping will result in more bang for my buck and if does, the search was fruitful. And if it’s not, I stay where I’m at.”

Other revealing tidbits:

• Star ratings aren’t a factor when choosing plans as they never heard of the quality ratings

The RISE Policy Committee discussed the spill-over effects of the Inflation Reduction Act, as well as pressing policy issues that impact health plans and risk-bearing providers in the managed care, Affordable Care Act (ACA), and commercial sectors. Among the concerns:

• The fact that Medicare finally can negotiate the price of certain drugs could lead to cost-shifting from one drug to another and cost-shifting to the commercial market, said Mike Adelberg , leader of Faegre Drinker Consulting’s health care provider and plans practice

• Medicare beneficiaries may have more cash available to them since the Inflation Reduction Act caps the amount they pay out of pocket for prescription drugs. But Adelberg noted that it’s clear from the patient focus panel that while it may make members satisfied, they may only be satisfied for one year. “It’s transitory satisfaction,” he said. “After a year, it’s an expectation. What do you do for them next year?”

• Mikal Sutton , managing director, Medicaid policy, Blue Cross Blue Shield Association, said she is concerned with the Medicaid redeterminations at the end of and unwinding of the COVID-10 public health emergency (PHE). Studies indicate that 15 million people and five to seven million children could lose their coverage once the PHE ends. While the PHE is scheduled to end in October, Sutton said all signs point to it being extended

through mid-January, after the midterm elections.

The Centers for Medicare & Medicaid Services is not taking the issue lightly and has been working with multiple stakeholders, including managed care organizations, to come up with comprehensive guidance for states.

RISK ADJUSTMENT LITIGATION AND RISK AREAS FOR MA PLANS, VENDORS, AND DOWNSTREAM ENTITIES

when they try to tell you sharks are circling.

Second waves involved providers, the third wave focused on vendors and consultants, and the fourth wave was a deeper dive into Office of Inspector General audits.

Inman, Ed Baker , of counsel, Constantine Cannon, and Stephen D. Bittinger , partner, K&L Gates, LLP, said that health plans need to pay attention to future potential liability for improper denials and proper documentation, assessment/revision of chart review programs, and upstream liability. Providers also need to pay attention to proper documentation and audits and incorporate lessons into their compliance plans.

What’s next? Speakers said to expect a focus on the role of private equity, value-based contracts, upstream liability, and COVID-19 relief-related fraud.

LEADERSHIP LEARNINGS FROM 2022

Panelists explained the current state of risk adjustment litigation by describing MA as an ocean, comprised of

• Waves or the challenges, obstacles, problems in the MA risk adjustment system (including various types of government oversight and enforcement actions)

• Boats/surfers/swimmers or MAOs/providers/vendors that participate in the MA RA system

• Lifeguards or individuals, and entities that monitor the MA RA program and watch for problems

• Sharks, crabs, and other sea creates are participants in the program, some of whom present dangers

The first wave, explained Mary Inman , partner, Constantine Cannon, involved Department of Justice cases for risk adjustment fraud against MA plans. All but one of the cases came from whistleblowers. Her advice: Save a lot of heartache and listen to whistleblowers

A leadership panel, moderated by Ciox’s Tim Macken, vice president of payer growth, discussed a wide range of topics, including annual wellness visits, telehealth, revenue management strategies, and their top concerns and strategies for the year.

Panelist Margaret Paroski, M.D., president and chief executive officer, Catholic Medical Partners , said she was surprised that post-COVID, there is a lot of unhap piness in primary care practices. “What we learned is when we saw a light at the end of tunnel what they saw was headlights of an ongoing train,” she said. In addi tion to political unrest, the overturning of Roe v. Wade, and the high inflation rate, Dr. Paroski said that primary care practices are seeing their overhead increasing,

higher salary demands from staff that leads to turn over, and they are perpetually training new staff. Yet, they are under pressure to see patients every 15 minutes.

“People are anxious, irritable, and entitled. They have forgotten how to work as a team,” she said, adding that as her team works to improve the patient experience, they are also working with practices to restore positiv ity in the office so all the unhappiness doesn’t resonate with the patient.

Gretchen Shanofsky , an independent consultant, said health plans need to think about how they can influence and align member incentives with provider incentives to address inequities in the health system.

Tom Nasadosk i, vice president, risk adjustment, CDPHP, a small regional health plan, said he is focused on innovation. They recently formed a management ser vices organization and partnered with a local primary c/are group of 400 physicians. CDPHP is running the administrative piece of it. The next step is working with providers to incentivize them properly to improve doc umentation. Another consideration he is exploring is virtual scribes to help support providers.

HOW ONE PARTNERSHIP HELPED TO CLOSE HEDIS® CARE GAPS AND IMPROVE MEMBER EXPERIENCE MEASURES

percent of their MA members have been diagnosed with two more chronic conditions and the area depri vation index scores are much higher among Clover Health members compared to New Jersey as a whole. They partnered with Walgreens Health to provide dig ital and in-person wrap-around services via Health Care Corners that offer access to personalized, clin ical expertise, a tech bar where patients can receive continuing education, and one-on-one visits with a health adviser.

There are more than 25 Walgreens Health Corners available to members who live in the most populated counties. “Our goal is to make care easy and conve nient and bring care to members rather than members seeking care and travel and we want to target areas of the highest concentrations of our members,” said Eckert.

For Walgreens Health, the collaboration is a “signif icant way to build sustainable relationships with Clover members in the community where the member lives,” Mahimkar said.

The collaboration led to a return that was greater than expected:

• The Walgreens Health Corners Customer Satisfaction rate of 97.2 percent for CY2022 exceeded the 80 percent target

• In 2022, health advisors have had 54,599 conversations with members within Health Corners

• More than 6,000 of these conversations resulted in care gap closure services

• An improvement in Star ratings from 3 to 3.5

The Health Advisors at Walgreens Health became “Clover Health ambassadors,” according to Eckert. “They knew our benefits, they knew our members, and they knew how to manage them and help us identify unknown barriers to care and needs. They were able to address urgent health conditions and address with the doctor, Clover teams, or the hospital for treatment,” she said.

Julianne Eckert , senior director, clinical quality pro grams, Clover Health, and Archana Mahimkar , senior director, clinical quality improvement and safety, Walgreens Health, discussed the innovative and collab orative approach Walgreens Health and Clover Health took to improve the lives of MA members in New Jersey.

Clover Health serves a large population who live in socially disadvantaged neighborhoods. Seventy-two

The partnership has led to providing members with offerings that address prevention, treatment, and well ness. The speakers encouraged attendees to think about health care differently to make it sustainable and easier to navigate. Doctors are overwhelmed so it makes sense to have the Walgreens Health Corner staff provide screening and other basic care and alert clinicians so they can make the best clinical decisión for members.

Mahimkar said the next step is scaling the mem ber-care advisor partnership model and building a multi-modual approach to care including onsite, in-home, and whole-person care.

The talented Ryan Brolliar took us on a musical journey as he recounted his recent nine-month nation wide “Music is Medicine Tour,” where he brought music to 78 hospitals in all 50 states and visited with more than 1,500 patients. His life’s purpose, to play music for people in need, began in August 2015 when he learned that he had a tumor on his spine. After surgery, it took three months of rehabilitation until he could walk again. Following a spiritual journey to 13 countries, where he studied several religions, Brolliar began his “Music is Medicine Tour.” His motto is to see the light in every single person. “When you see the light in people, if you see the best in someone, you get the best in people.”

environment. Among his suggestions: make sure meetings focus on problem-solving, establish core “team hours” for communication but also create quiet time blocks, such as a certain day of the week free of internal meetings, or a quarterly quiet week that has no scheduled meet ings so employees can devote themselves to deep work.

“Create intentional time for interpersonal time for depth and relationship building,” he said. It’s important to ask intentionally about what is going well in your team members’ lives and what isn’t going as well as intended. “Remember, we are humans first, colleagues, second.”

WHY ATTENDEES COME YEAR AFTER YEAR

Kian Gohar , founder & CEO of Geolab, an inno vation venture lab in Los Angeles that explores impact-driven innovation moonshots to tackle grand challenges, offered insights into thriving in the new world of hybrid work. His research began in the chaos of the pandemic when he wanted to know how to innovate and compete in this hybrid world. So began a two-year project that involved interviews with 2,000 executives from across sectors and all over the world. “I wanted to understand what their teams were doing in real time to survive in a world that had turned upside down and into a life of uncertainty.”

Gohar dispelled the old myths of onsite work, such as that physical presence is required to be productive and offered tips to make the most of the new hybrid

Attendees left with new connections, a wealth of knowledge, and actionable steps to take back to their orga nizations. Here’s what a couple of attendees had to say:

“RISE West does a great job of weaving quality and SDoH together with risk adjustment,” said Anna Basevich , vice president of enterprise partnerships, Arcadia. “HCC coding is an inherently actuarial topic, but RISE highlights presenters who’ve grappled with the challenge of assembling accurate and comprehensive patient records to ensure both appropriate reimburse ments and the right information to allow care teams to support their populations effectively. I was excited to see discussion around SDoH as this area presents much promise for health care organizations to understand their patients and engage them with the interventions that account for barriers to care that have tradition ally held back progress.”

Enam Noor , CEO, and founder, Insightin Health, said that by attending the conference, health plans can better consider their role in stewarding their mem bers’ wellbeing over time and investing in a data-driven, omnichannel engagement approach that offers deeper insights into creating personalized health care journeys for members. “By understanding the health of members and the challenges they face as well as overcoming obstacles to proper communication and care coordina tion, health plans will be better positioned to address member needs and improve satisfaction,” he said. ■

6 quotes on leadership—and life— from RISE West 2022 keynotes

The keynote presentations at RISE West 2022 offered lessons on leadership as well as strategies on how to live a better life. If you were unable to attend the annual conference in Los Angeles, here are six quotes that may inspire you in your personal and professional lives.

ON DEALING WITH CONFLICTS

ON HOW TO EFFECT CHANGE

“What I like to do as a leader is surround myself with all types of people…diverse groups, high perform ers, middle of the road, intergenerational groups. It takes a democratic collaborative style to effect change. It doesn’t always work in a crisis. I did a lot of disas ter management, which is more authoritarian. My style is more democratic and reflects my core philosophy. To effect change and improve lives of others, it has to include justice and has to be about equity. I create conditions for people to have opportunities to do well. Leadership and philosophy have to be integrated in that way.”

Melanie A. Prince, MSN, BSN, RN, NE-BC, CCM, FAAN, former president, Case Management Society of America, and retired military colonel, U.S. Airforce, during her keynote address on “Learnings from Grief, Grit, and Focusing on the Light at the End of the Tunnel”

“I truly enjoy conflict management. It’s a great chal lenge because it’s an opportunity for growth… I call myself an accommodating negotiator. My Gen Z family members hate that. But I’m trying to understand the other person’s point of view. I believe in that…So when I deal with conflict, it helps other parties to walk in shoes of each other so they can experience the factors within that conflict.”

Prince during her keynote address on “Learnings from Grief, Grit, and Focusing on the Light at the End of the Tunnel”

ON GIVING BACK AND CREATING OPPORTUNITIES FOR OTHERS TO SHINE

“My why is to create conditions so that people can have an opportunity to excel and be whatever they want to be. It drives me every day. I’m grateful for my experiences. I had a lot of opportunities and a lot of people helped to make opportunities to make reality. My why is to give back.”

Prince during her keynote address on “Learnings from Grief, Grit, and Focusing on the Light at the End of the Tunnel”

ON WINNING AS A TEAM

“We were trained in corporate American not to share our personal lives but we saw in the last two years that is not real…If something is going on in individual’s life, try to solve the problem. It makes for a more powerful team. Practice thinking about how you can help your team mates so we win as a team not as individuals.”

Kian Gohar, founder & CEO of Geolab, an inno vation venture lab in Los Angeles that explores impact-driven innovation moonshots to tackle grand challenges, in his keynote address, “ Competing in the New World or Work”

ON TAKING CREDIT WHEN IT’S DUE

“I think we sometimes shy away from being our own best cheerleader. This is what I did. There is a lot of we in teamwork. Sure, but if you led it, let people know you led the team. You did and don’t make apologies about that. I was doing hard work and I was so concerned about being a team player, often the team fell apart when I was deployed. I learned the hard way I had to be loud about my accomplishments.”

Prince during a panel discussion on “Empowering Women in Health Care”

ON SEEING THE BEST IN PEOPLE

“When you see the light in people, if you see the best in someone, you get the best in someone . . . If we can be with those in need the most and see light in those people, we going to change the world.”

Ryan Brolliar, founder and author of “The Music is Medicine Tour,” about his tour which included visits to all 50 states, 78 hospitals, and more than 1,500 patients in nine months ■

STAR RATINGS AND TUKEY’S DISAPPEARING ACT

The Centers for Medicare & Medicaid Services (CMS) blames a codification error for the disappearance of the Tukey outlier deletion, a statistical method for removing outliers when calculating Star measure cut points, when the final rule for Medicare Advantage (MA) and Part D prescription drug programs was imple mented on June 28. While we watch and wait for this to be fixed, here’s why “TukeyGate” matters and what to do next.

NOW YOU SEE IT, NOW YOU DON’T

In the May 9 Final Rule that took effect on June 28, CMS quietly erased the Tukey Outer Fence Outlier Deletion statistical method from the regulatory text that describes its calculation methodology of Star ratings. You read that right. Hardly anyone noticed when it happened, not even some Stars folks at CMS. It was such a surprise that Stars and actuarial experts we consulted with were all left scratching their heads. Opinions as to what happened ranged from “nothing to see here… it’s just an error” to “someone tried to get away with something” to “CMS is trying to give itself a little more flexibility in case the timing needs to change.”

What does CMS say? They assure us they are imple menting Tukey as announced for 2024 Stars and that they will fix the “codification error in the regulatory text” during the next regulatory update. While we watch and wait for this to be fixed, here’s why “TukeyGate” matters and what to do next.

SO, WHAT’S THE BIG DEAL?

The Tukey method is expected to improve the stability of cut points and prevent cut points from being influenced by outliers beginning with the 2024 Star ratings. Through the use of the Tukey method, CMS intends to remove extreme outliers from measure scores prior to clustering to prevent these outliers from impacting cut points for all contracts. In doing so, CMS expects that it would be harder for plans to earn (or keep) their Star rating.

In the 2020 Final Rule where CMS finalized the use of Tukey, the agency explained the results of its model ing: “If Tukey outer fence outlier deletion and a 5 percent cumulative guardrail had been implemented for the 2018 Star ratings, 2 percent of MA–PD contracts would have seen their Star rating increase by half a star and 16 per cent would have decreased by half a star.”

WHAT WILL TUKEY’S IMPACT BE?

It’s hard to predict in advance of the measurement period which measures will have extreme outliers, but in prior modeling, CMS determined that extreme outliers are more common in the lower end of the score distribution. As a result, the 1- to 2-Star thresholds often increased in the simulations when outliers were removed compared to the other thresholds which were not as impacted.

Plans with measure ratings at or near the lower edges of current cut points are scrambling to get measurement year 2022 rates up and bracing for the potential loss of half to a full Star. That’s because lower Star ratings would reduce bonus payments, rebates, and supplemental ben efits offered to beneficiaries. For plans serving the most vulnerable, lower bonus and rebate dollars could make it even harder to address disparities. So, Tukey or no Tukey, plans shouldn’t rest on their laurels.

While CMS downplays the impact Tukey will have on 4- and 5- Star cut points, our math shows numerous instances where past cut points would have been higher after removal of outliers, significantly in some cases. While we await the full measurement year 2021 measure rate data, we’ve computed the impact Tukey and mean resam pling would have had on measurement year 2020 scores, and it’s clear that current year goals are going to need to be adjusted this fall on many measures. Most plans either use prior year cut points as their basis for current

year goal setting or use relatively rudimentary prediction methodologies to set goals.

Tukey’s impact on measurement year 2022 will not be inconsequential. Our advice is to take the time to create a modernized cut point governance model, and as pain ful as it will be, educate stakeholders on the mathematical technicalities they need to prepare for.

THREATS BEYOND TUKEY

There are also other significant threats to the measure scoring for Star ratings in 2023 and beyond, including:

• Rollback of the temporary expansion of E xtreme and Uncontrollable Circumstances (EUC) due to COVID: Virtually all plans met the definition of “affected” contracts in the 2020 measurement year under the EUC policy. “Affected” plans enjoyed the better of current or prior year performance in almost all measures. This led to an artificial increase in the 2022 Star Ratings for about 50 percent of contracts, relative to what their Star rating without EUC would have been if the Star rating had been calculated on 2020 measurement year performance alone. Once EUC goes away for 2023 Stars, this artificial boost goes with it.

• Guardrails go into effect: To increase the predictability of the cut points used for measurelevel ratings, CMS adopted guardrails for measures that have been in the program for more than three years. Guardrails are meant to ensure that the measure threshold-specific cut points for nonCAHPS measures don’t increase or decrease more than 5 percentage points from one year to the next. But the trade-off for the consistency provided by the bidirectional cap is the inability to keep pace with changes in achievement across the industry. While cut points that change less than the cap would be unaffected and keep pace with changes in the measure score trends, changes in the overall performance that are greater than the cap would not be reflected in the new cut points.

• Improvement measure “Hold Harmless” protection ends: The Star ratings calculation methodology includes a Hold Harmless provision that stipulates that if the inclusion of the Part C and Part D improvement measures reduced the overall Star ratings for plans with 4 or more Stars, they would be excluded from the overall rating calculation. For 2022 Stars, CMS expanded the Hold Harmless protection to all plans, not just those with 4 or more Stars. Once that protection is removed for 2023 Stars, the improvement measures can once again drag down the ratings of plans with less stellar performance.

• New measures TRC and FMC shine new light on common data challenges: The challenges associated with communication lapses between inpatient and outpatient providers must be resolved to succeed in these new measures. Transitions of Care (TRC) measures key points of transition after members leave inpatient facilities. Plans must report four separate rates for this measure:

• notification of inpatient admission

• receipt of discharge information

• patient engagement after inpatient discharge

• medication reconciliation post-discharge

Follow-Up after Emergency Department Visit for People with Multiple High-Risk Chronic Conditions (FMC) mea sures the percentage of emergency department visits for members 18 years or older with multiple high-risk chronic conditions who had a follow-up service within seven days of the visit. Plans must collaborate with inpatient and outpatient providers to achieve real-time or near-time com munication to make headway.

• Member experience measures go to 4x weight : For 2023 Stars and beyond member experience measures will make up a majority of the overall Star ratings score. Plan received their CAHPS scores earlier this week, which make up about 50 percent of the member experience measures. The big takeaway was that plans underperformed from the prior year. That was a big surprise for many, given the concerted focus on these measures. Our colleagues across the industry think this result was due to widespread resistance to evolve the workflows, processes, and “old thinking” that’s so embedded within our organizations. Change management is hard! Success with member experience measures will depend on flawless execution and being “brilliant at the basics.” Plans must look at multiple journeys, identify all member touchpoints, and understand the drivers of abrasion and satisfaction. Only then can they shift from traditional gap closure efforts to a more holistic way to serve members to drive Star ratings achievement.

THE BOTTOM LINE FOR 2023 AND BEYOND

The bottom line… 2023 Stars is just the beginning of the paradigm shift that will require incremental organi zational change management for the foreseeable future.

As we are fond of saying, don’t let the perfect be the enemy of the good. Take small steps if you can’t take big ones… and by all means, ask for help. Plans that get this right will have a very significant competitive advantage over those that don’t. It’s go time!

ABOUT THE AUTHORS

Ana Handshuh, principal at CAT5 Strategies, is a government programs executive with expertise in creating and implementing corporate pro grams for the health care industry. Her background includes quality, core measures, care management, benefit design and bid submission, accreditation, regulatory com pliance, revenue management, communications, community-based care management programs and tech nology integration. Handshuh currently serves on the board of the Resource Initiative and Society for Education (RISE) and is the chair of RISE’s Quality & Revenue Community. She is a sought after speaker on the national health care circuit in the areas of quality, Star ratings, care manage ment, member and provider engagement, and revenue management. Her recent consultancy roles have included assisting organizations create programs to address the unmet care management needs in the highest risk strata of membership, document their processes and procedures, achieve accreditation status, design and submit govern ment program bids, institute corporate-wide programs and create communications strategies and materials.

Melissa Smith is the executive vice president of consulting and pro fessional services at Healthmine, bringing over 25 years of experience in Star ratings, strategy, sales, and marketing for health plans, provid ers, pharmacy benefit managers, and industry vendors. She has extensive experience developing strategic and tactical solutions to meet client needs and a strong background of building productive partnerships across internal teams and with external vendors to improve performance on clinical, medication, patient survey, and administrative quality measures.

Most recently, Smith was senior vice president of sales, marketing, strategy, and Stars at Gorman Health Group. She is a well-known thought leader and healthcare strat egist with proven success developing enterprise-wide solutions to improve Star ratings, quality performance, health outcomes, and the member experience. Her team helps clients improve performance within quality ratings systems, evaluate market dynamics and opportunities, optimize distribution channels, and support our clients’ stra tegic planning needs. Prior to Gorman Health Group, Smith served in a leadership capacity at Cigna-HealthSpring. Before working in Medicare Advantage and quality rat ings systems, she was an associate director at Vanderbilt University Medical Center. ■

MA moves closer to becoming predominant way seniors get their health coverage and care

As Medicare Advantage (MA) continues to grow, a new Kaiser Family Foundation (KFF) analysis finds a grad ual but significant reshaping of the Medicare program is taking place.

The KFF study on MA enrollment and key trends in 2022 finds that nearly half of eligible Medicare beneficiaries—28.4 million out of 58.6 million Medicare beneficiaries overall—are now enrolled in MA plans. That represents a more than doubling of the share of the eligi ble Medicare population enrolled in such plans from 2007 to 2022 (19 percent to 48 percent).

Enrollment is projected to cross the 50 percent thresh old as soon as next year, making MA the predominant way that Medicare beneficiaries with Parts A and B get their coverage and care, KFF said in an announcement

The rise of MA signals the transformation of Medicare to a program in which most people receive benefits by enrolling in plans offered by private health insurance companies.

The new analysis is one of three released by KFF that examine various aspects of MA. In addition to the latest data on MA enrollment, a companion analysis describes MA premiums, out-of-pocket limits, cost sharing, extra benefits offered, and prior authorization requirements. A third study examines trends in bonus payments to MA plans, enrollment in plans in bonus status, and how these measures vary across plan types and firms.

Among the key findings from the reports:

• Enrollment in private plans is highly concentrated among a small number of firms, with UnitedHealthcare and Humana together accounting for 46 percent

of all MA enrollees nationwide. In nearly a third of counties across the U.S., these two firms account for at least 75 percent of MA enrollment.

• In 2022, nearly 7 in 10 MA enrollees (69 percent) are in plans with prescription drug coverage (MAPDs) that require no premium other than the Medicare Part B premium ($170.10 in 2022).

• Nearly all enrollees in individual MA plans open for general enrollment have access to some benefits not covered by traditional Medicare, including eye exams and/or glasses (99 percent), hearing exams and/or aids (98 percent), and a fitness benefit (98 percent).

• Virtually all MA enrollees (99 percent) are in plans that require prior authorization for some services. Prior authorization is most often required for relatively expensive services, such as prescription drugs administered by a physician (Part B drugs; 99 percent), skilled nursing facility stays (98 percent), and inpatient hospital stays (acute: 98 percent; psychiatric: 94 percent), but it is rarely required for preventive services (6 percent).

• Federal spending on MA bonus payments has increased every year since 2015 and will reach at least $10 billion in 2022. Payments vary across firms, with UnitedHealthcare receiving the largest total payments ($2.8 billion) and Kaiser Permanente receiving the highest payment per enrollee ($521). Recently, the Medicare Payment Advisory Commission (MedPAC) and others have raised questions about whether the bonus program includes too many measures, does not adequately account for social risk factors, and may not be a useful indicator of quality for beneficiaries.

UPCOMING EVENTS

The 12th Annual HEDIS® & Quality Improvement Summit

October 25-26, 2022

Hyatt Regency Miami. | Miami, FL

Star Ratings Reflections

Webinar

October 27, 2022 | 1:30 EST

The RISE Population Health Summit

November 15-16, 2022

A Live-Streaming Virtual Event

The 20th Risk Adjustment Forum

November 28-30, 2022

Fairmont Scottsdale Princess | Scottsdale, AZ

The 13th Annual RISE Star Ratings Master Class

December 13-15, 2022

InterContinental San Diego | San Diego, CA

The RISE Women in Health Care Leadership Summit

December 14-15, 2022

InterContinental San Diego | San Diego, CA

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QUESTIONS? REACH OUT TO OUR TEAM

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