The Gorman Health Group 2017 Forum concluded last week in New Orleans with over 200 of our closest clients and partners. As we enter our 21st year, we returned to where it all began for us, with a little startup called Peoples Health, our first and closest client who now dominates southern Louisiana. The Forum ended the day JazzFest 2017 began, so many of us stayed to enjoy the festival and the best of New Orleans heritage and culture.
An enormous array of material was covered, as always, from the political landscape for government programs to compliance, Star Ratings, clinical and pharmacy challenges, provider relations, and health plan operations. Here are a few takeaways:
- Government programs continue to drive health plan revenues and earnings. Medicare Advantage (MA) remains the only safe game in all of health insurance, but there is deep uncertainty surrounding Medicaid and the subsidized individual markets.
- We’re sticking by our projections of over 29 million MA enrollees by 2023, driven by more positive rate trends and a plan-friendly baby boomer tsunami underway. PPOs, retiree plans, and Special Needs Plans are all growing ahead of projections. We expect major national and publicly-traded health plans to invest heavily in MA.
- Profound changes to Medicaid are developing rapidly under Trump, Health and Human Services (HHS) Secretary, and the Centers for Medicare & Medicaid Services (CMS) Administrator Seema Verma, a lifelong Medicaid reformer. Even if TrumpCare/Affordable Care Act (ACA) repeal fails, Medicaid reform to fund a tax cut could still make it to Trump’s desk. These include:
- Structural changes, including block grants and/or per-capita caps, driving a rapid move to capitation for beneficiaries who haven’t yet been enrolled in health plans.
- “Conservative principles” such as work requirements, cost-sharing, and drug testing will become the norm under Medicaid waivers inbound to CMS from some 30 red states in the next two years. Administrative complexity will grow exponentially for plans participating.
- Significant enrollment gains for dual eligibles as home and community-based services (HCBS) waivers and managed long-term services and supports (MLTSS) initiatives become the new normal. We expect Dual Eligible Special Needs Plan (D-SNP) enrollment to double and exceed 4 million by 2020.
- In the subsidized individual market, uncertainty is the new normal. The Trump administration continues to hold subsidies hostage on a monthly basis, with “Zombie TrumpCare” now making its third tour of the US House. With mixed signals from stalwarts Anthem and a management shakeup at Molina, a Health Insurance Marketplace “death spiral” could be brought about by Trump tweets. Membership reconciliation and cleanup of membership discrepancies, and hitting sales targets with a shorter Annual Election Period (AEP), remain front of mind for issuers.
- A standing-room-only crowd attended our workshop on social impact investing, a new source of $16-20 billion in capital for projects and infrastructure on addressing social determinants of health and measurable clinical improvements.
- Risk Adjustment Data Validation (RADV) audits took on new significance with the Trump administration intervening in the United whistleblower case. RADV and program audits will intensify in MA — 2017-2018 will be the first time we see plans prosecuted under the False Claims Act and hundreds of millions of dollars clawed back by CMS for unsubstantiated codes submitted for higher payments.
- I moderated a spirited lunchtime panel discussion around integrating and improving call centers to provide a better member experience and a hub for holistic, proactive service, outreach, and medication management.
- Clinical and pharmacy data integration and strong provider partnerships around person-centered care were clear priorities in medical management, Star Ratings improvement, and Pharmacy Benefit Manager (PBM) oversight.
- The Star Ratings system of performance-based payment drives the payer and provider markets. This year will bring changes to measures under Price and Verma. We expect measures that contribute to physician burden to be consigned to the “display page;” measures that affirm the role of physician like outcomes and member experience metrics will take on new significance.
- CMS will increasingly work policy changes “below the waterline” in subregulatory guidance and enforcement where politicians are less likely to intervene – that means more surprises for plans not paying attention.
- Appeals and grievances and pharmacy benefit management vendor performance remain the #1, 2, and 3 regulatory infractions in MA – and the biggest drag on Star Ratings.
- Integration of long-term care and supports and services represent the leading challenge facing Medicaid health plans.
- Provider network adequacy and accuracy of provider directories will be a key audit focus for both CMS and many state insurance commissions in 2017. Machine-readable formats and an “all hands” approach to keeping directories current were solutions discussed.
- CMS is on pace for its most aggressive enforcement year ever, with over a dozen actions taken against plans this year already. Anyone who thought there’d be a traditional easing of enforcement under a GOP Administration needs to think twice.
- GHG’s very first client, Peoples Health CEO Warren Murrell, provided a gripping and poignant keynote on his plan’s evolution in 20 years to become a regional powerhouse in MA. Their success has been driven by one thing: obsessive focus on the member and their social determinants. It’s what drives their service model, their commitment to compliance, and their proactive multidisciplinary care approach.
Government-sponsored health programs remain the focal point of Republican reforms, and the opportunities and dangers that come with this shift have never been greater. Our clients went home with a clear grasp of both, and we are thrilled so many joined us this year. We are currently locking in dates and our new venue for next year’s event. Stay tuned!
Gorman Health Group’s Summary and Analysis of the Final Rate Announcement and 2018 Call Letter for Medicare Advantage and Part D is now available. Download now >>