Annetta Coleman

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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Medicare Advantage unrest, Change Healthcare fallout and more big takeaways from insurers’ Q1 https://lnkd.in/eyg48k7e via Healthcare Dive #MedicareAdvantage #ChangeHealthcare #Cybersecurity #CMS #Medicaid

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Risk adjustment and quality reporting are evolving. Standard formats. Interoperability. New sources of data. AI. Result- claims-based risk capture will play less of a role. Great article for some insights into the potential future for those that have not read/seen it yet.

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While the industry is experiencing a plethora of regulatory changes, mounting litigation, new and complex coding changes, it is vital that health plans and providers are armed with everything they need to survive. Hear your peers discuss real world solutions and practical options to optimize your comprehensive risk adjustment strategies. You won’t want to miss this event. You will gain best practices for strengthening your risk adjustment strategy plan. Hear how others in your position are navigating these risk adjustment complexities. Register today,

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Feeling overwhelmed by CMS's interoperability and prior authorization rule (CMS-0057)? You're not alone. This regulation brings critical changes for payers, with new compliance deadlines and technical requirements. Ready to tackle CMS-0057? Don't go it alone. Connect with Kendra Obrist or Brian Dwyer for personalized guidance and strategies to ensure your organization has a comprehensive strategy to ensure success. Reach out today to start navigating these changes with confidence!

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🚨 Prior Authorization in Healthcare: Broken System or Necessary Control? 🚨 In episode 3 of #VHV podcast, Amar Rewari, MD, MBA, FASTRO and Anthony Paravati, MD, MBA dive deep into the financial strain, delays, and even life-threatening outcomes tied to prior authorizations and other "utilization management" techniques. Hear about eye-opening stats, the latest reforms, and the looming role of AI in claims denials. Is it time for a major overhaul, or are these policies essential? 💬 Do you think prior authorization is hurting or helping healthcare? Drop your thoughts below! Ep 3. The Games Insurers Play: Utilization Management and Prior Authorization. https://lnkd.in/d6TFDyAu

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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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Program Audit season is over. Join our webinar to hear all about what CMS is focusing on. If you haven’t done a mock audit now is a great time to do one and incorporate our lessons learned.

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📉 Elevance Health 3Q Earnings Recap: What Went Wrong? On October 17, Elevance Health reported its Q3 earnings, and the market reaction was swift—a 15% drop. The major culprit? A soaring Medical Loss Ratio (MLR) of 89.5%, up by 270 basis points from Q3 2023. The primary driver: Medicaid reimbursement misalignment, which has burdened payors across the board. The mismanagement of Medicaid redeterminations led to a per-member cost spike, which wasn’t matched by state reimbursement increases, pushing Wall Street into a broad sell-off of the “Big Six Payors.” 📉 Despite these challenges, Elevance’s revenue still grew by 5%, reaching $44.7B. Their membership remains steady at 45.8 million, with ACA and commercial gains offsetting Medicaid losses. Key Takeaways from the Earnings Call and 10-Q: • Medicare Advantage: Conservative bids for open enrollment amid CMS rate cuts. While Elevance improved Medicare Star ratings on 60% of measures, one of their 4-star plans narrowly missed CMS’s cut-off, costing them. • Medicaid: CFO Mark Kaye noted cost-per-member increases as high as 3-5x in some states, driven by a shift to sicker populations post-redeterminations. With half of the state rate adjustments set for January, there’s hope that reimbursement alignment will improve. • Carelon’s Growth: Low 20% growth anticipated as Carelon expands its specialty drug offerings, with recent acquisitions of BioPlus, Paragon, and Kroger Specialty. Their latest acquisition of Carebridge further solidifies Carelon’s role in Elevance’s growth strategy. The specialty drug assets will be driving new value for larger employers they seem to attract. • AI Investments: Elevance is pursuing AI to streamline internal operations and enhance member experiences. This investment is set to mature through 2025, aiming to improve productivity and personalization. While Wall Street’s reaction may seem like an overreaction, the strategic groundwork Elevance has laid—especially in Carelon and specialty pharmacy—positions them for a potential rebound. Expect Carelon to become a key revenue driver as Elevance navigates the current Medicaid headwinds. For a deeper dive into the Elevance Health earnings for Q3 feel free to read and subscribe to my substack! #Healthcare

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Despite recent challenges, Medicare Advantage, or MA, now accounts for more than half of all Medicare beneficiaries—a patient population that every healthcare organization must engage. In a new article Joyjit Saha Choudhury, John Poziemski and Webster Macomber explore possible scenarios for the future of MA—and the potential impact on providers and payers—amid rising uncertainty. #payerproviders #medicare #healthcaremanagement https://lnkd.in/gB_GTZU4

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Cigna Group allegedly exaggerated the health conditions of its enrollees to fraudulently obtain hundred of millions in federal funds. Read more: https://direc.to/fhHz Cigna Group significantly impacts healthcare today by expanding its pharmacy and medical customer base, as evidenced by a 25% increase in pharmacy customers and a growth in medical customers. Additionally, Cigna's involvement in healthcare trends and innovations, such as the Better Care Bulletin, showcases its role in improving health outcomes and integrating technology in healthcare. The HHS Office of Inspector General (HSS-OIG) combats healthcare fraud through rigorous oversight, investigations, and audits. It collaborates with the Department of Justice (DOJ) to enforce laws and impose penalties on fraudulent activities, as seen in actions against the Center for Medicare and Medicaid Services (CMS) fraud. #unitedseniorassociation #USA #eldercare #FDA #seniorliving #ADA #AI #NIH #patientcare #compliance #hospitals #OIG #healthcare #HHSOIG #digitalhealth #HSS #CMS #assistedliving #nursinghomes #seniorcare #medicare #seniorcitizen #homehealthcare #caregiver #dementia #inhomecare #seniorhealth #kloekorby #alzheimers #mentalhealth

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So, CMS has decided to terminate the Medicare Advantage Value-Based Insurance Design (MA VBID) model at the end of 2025 due to unsustainable costs to the Medicare Trust Funds. Introduced in 2017 to reduce healthcare costs and improve health outcomes, the model led to significant expenses, totaling $2.3 billion in 2021 and $2.2 billion in 2022, due to increased risk scores, higher rebates, and elevated Part D costs. So, how does this impact providers 🏥 💉 Providers may see modifications in supplemental benefits like transportation and reduced drug costs, which may continue under Special Supplemental Benefits for the Chronically Ill (SSBCI) but without previous flexibility. 💊 Disruptions in Part D cost-sharing could complicate patient medication adherence. 🩺 MA organizations and providers must begin adjusting workflows and care delivery strategies for 2026. 🥼 Providers serving underserved or chronically ill populations may struggle with maintaining programs that promote health equity. While CMS recognizes VBID's achievements in enhancing transparency and health outcomes, its termination emphasizes the need for more cost-effective care delivery models. Providers will need to work closely with MA plans and CMS to ensure continuity of care for patients.

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Check out the entire agenda by clicking here,

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Let's explore the critical factors shaping the landscape of MA STARs ratings in the upcoming year with a focus on quality and excellence. 🌟💊 🏥 🩺 2025 Medicare Advantage and Part D Star Ratings: Key Metrics for Providers ⭐ 💹 https://lnkd.in/e7aZkZvC Introduction to Star Ratings: -> Star Ratings measure the quality of health and prescription drug services for Medicare enrollees. -> CMS aims to improve the quality of Medicare Advantage (MA) and Part D programs. Significant Metrics for 2025: - Part C Plan All-Cause Readmissions -> Increased weight from 1 to 3, emphasizing the importance of reducing hospital readmissions for comprehensive care. - Tukey Outlier Deletion: -> Applied to improve the accuracy of measure-level cut points used to determine star ratings. -> Aims to minimize the influence of extreme outliers on performance measures. Performance Measurement: -> Contracts rated on up to 40 unique quality measures for MA-PD contracts and 12 for PDP contracts. -> Cut Points: Established thresholds to determine rating (1-5 stars) based on performance. Year-over-Year Rating Trends: -> Changes in measure-level cut points for 2025 reflect a shift towards higher performance standards. Example Metrics: -> Breast Cancer Screening (Part C) -> Average star rating decreased from 3.9 (2022) to 3.4 (2025). -> Colorectal Cancer Screening (Part C) -> Similar downward trend, indicating a need for improvement in preventive care measures. Impact of Contract Experience: -> Contracts with 10+ years in the program tend to achieve higher star ratings, highlighting the importance of experience and stability in delivering quality care. Tax Status Influence: -> Non-profit organizations typically achieve higher ratings (50% earning 4+ stars) compared to for-profit counterparts (36%). Consistency in High Performance: -> Contracts consistently rated with high performance icons (5 stars) maintain strong service delivery, with many having special needs plans (D-SNP). Conclusion: Providers should focus on improving metrics like all-cause readmissions, refining methodologies for accurate performance measurement, and maintaining consistent care quality to achieve higher star ratings in 2025 and beyond.

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Open enrollment is approaching, which means major #insurers have shared their 2025 Medicare plans. 📆 To stay in the loop, this article from Becker's Payer Issues does a nice job summarizing some of the main takeaways from big names such as: - UnitedHealthcare - Humana - Aetna - Elevance Health - Centene A common thread? Numerous new plan options and extended access for new states across the U.S. #Payers #Insurance #PharmaNews #Medicare

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