Takeaways from the Gorman Health Group 2018 Client Forum

The Gorman Health Group 2018 Client Forum concluded last week in Las Vegas with over 300 of our closest clients and partners. As we enter our 22nd (!) year, we returned to the Red Rock Resort where a great time and shared learnings were had by all.

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 50% of Medicare beneficiaries enrolled in MA by 2025, driven by more positive rate trends and a plan-friendly baby boomer tsunami underway. Preferred Provider Organizations (PPOs), retiree plans, and Special Needs Plans are all growing ahead of projections, with PPOs now representing over one-third of all MA enrollments. We expect major national and publicly-traded health plans to invest heavily in MA.
    • The 2019 MA Call Letter affirms the program remains the only safe game in health insurance. The year 2019 will usher in the most favorable rate environment in over 15 years, along with the Centers for Medicare & Medicaid Services (CMS) new supplemental benefits policy, which opens up a whole new toolbox to address social determinants of health. Starting in 2019 and accelerating in 2020, plans will be able to include in their annual bids benefits such as telehealth, transportation, food security, over-the-counter (OTC) health products, assistive devices in the home for the disabled, and much more. It’s the most exciting policy development in a decade.
    • Profound changes to Medicaid are developing rapidly under Trump and CMS Administrator Seema Verma, a lifelong Medicaid reformer.
      • “Conservative principles” such as work requirements, cost-sharing, and drug testing will become the norm under Medicaid waivers inbound to CMS from over a dozen 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 5 million by 2021.
    • In the subsidized individual market, uncertainty is the new normal. Health Insurance Marketplace plans exceeded enrollment projections in the face of near-daily sabotage and Trump’s termination of cost-sharing subsidies to plans. Membership reconciliation and cleanup of membership discrepancies, and hitting sales targets with a shorter Annual Election Period (AEP) and no enrollment outreach or assistance, remain front of mind for issuers.
    • A standing-room-only crowd attended our pre-conference workshops on Star Ratings and Risk Adjustment 101 for industry newcomers. Advanced sessions and a client panel discussion on improving the member experience, which accounts for over half a plan’s Star Rating, were heavily attended as well.
    • The transition to 25% encounter data/75% Risk Adjustment Processing System (RAPS) data for MA risk adjustment as finalized in the 2019 Call Letter was discussed at length.
    • Our incomparable Star Czar Melissa Smith and I provided a lunchtime discussion on addressing social determinants of health, a deep dive on the new CMS MA supplemental benefits policy, and social impact investing as a source of operating capital for these initiatives.
    • 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.
    • 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, as well as behavioral health 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 2018 and 2019. 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. Anyone who thought there’d be a traditional easing of enforcement under a GOP Administration needs to think twice.
    • GHG President Jeff Fox moderated our annual Practice Area Leaders panel where we heard from all 7 of our Senior VPs – all strong women, I’m proud to say – on priorities within their domains.
    • The joint GHG/Convey technology exhibit hall was busy with round-the-clock demos of our solutions in MA and Part D administration, OTC health benefits, appeals and grievances automation, and sales force management. Who knew ice cream breaks would be the big draw?


Government-sponsored health programs remain the focal point of political 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 Forum. Stay tuned!




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John Gorman
John Gorman

Under John's leadership, Gorman Health Group has become the leading professional services and solutions firm for government-sponsored health care, providing thought leadership and expert strategic, operational, and technology-based solutions. Read more

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