Topic: Provider Relations

Blending Network Strategy and Product Strategy

Elena Martin

As more and more health systems and provider organizations successfully manage the shift from patient care to population health management, long-term health plan strategic planning should be blending network strategy with product strategy as a key indicator of the ability to achieve clinical and financial goals. The majority of providers are savvy at managing pay for performance and upside risk arrangements, and as providers have seen the margins narrow and plateau, plans have had to adapt and move beyond simple incentivizing for behavior change. We heard from the Centers for Medicare & Medicaid Services (CMS) the Accountable Care Organizations (ACOs) with upside-only risk have not performed as well or increased savings in comparison to those ACOs with downside risk and skin in the game. Systems that have ventured into managing downside risk and percent of premium arrangements and that have been successful have an appetite for more. Certainly moving up the food chain from a provider to a payer has been a topic of conversation among CEO’s of large integrated delivery systems. They have worked hard to align physician trust and referral networks, build a strong name brand in their local communities, and negotiated contracts with health plans that have met and exceeded care and cost containment goals, and the question of where do we go from here is top of mind.

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Takeaways from the Gorman Health Group 2018 Client Forum

John Gorman

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.

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CMS June Network Submission Deadline Fast Approaching

Elena Martin

In early February, there was a bit of a scramble when several plans received notices they had approximately a week to submit their Health Service Delivery (HSD) tables for a network adequacy review. Fortunately, for some, the communication should have indicated the gates were open for plans wanting to test adequacy and receive technical feedback. While it was a stressful 24 hours pending the Centers for Medicare & Medicaid Services (CMS) response on the notice, we hope the false alarm sparked the much needed jump-start to ensure a compliant network adequacy monitoring program is in place.

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CMS Reports Medicare Advantage Provider Directories Continue to be Plagued with Inaccuracies

Elena Martin

The Centers for Medicare & Medicaid Services (CMS) issued its Round Two online provider directory review, and the results were dismal. Plans reviewed showed an overall inaccuracy average higher than Year One plans. We can try to marginalize the results and say the average inaccuracy found by location was 48%. Nevertheless, the fact remains that nearly half of all directory locations reviewed were inaccurate. Breaking it down further, the inaccuracies ranged from 11% to 97.82%. We are living in an age of tech-savvy consumerism. If our GPS or Google results proved incorrect half of the time, we would not be satisfied. If results proved correct less than 3% of the time, we would be outraged.

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CMS Releases Part II of the Medicare Advantage Advance Notice & Draft Call Letter

Olga Walther

On February 1, 2018, the Centers for Medicare & Medicaid Services (CMS) released its 2019 Advance Rate Notice (Part II) and Draft Call Letter. CMS estimates an expected increase of 1.84% to payments in 2019. CMS says its estimates do not reflect underlying coding trend, which it expects to increase risk scores by 3.1% in 2019.

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CMS Announces Changes to the Network Review Process for Medicare Advantage Organizations

Elena Martin

As anticipated, the Office of Management and Budget (OMB) approved the Centers for Medicare & Medicaid Services’ (CMS’) move to network adequacy reviews on a three-year cycle, unless there is a triggering event that would reset the timing of a Medicare Advantage Organization’s triennial review.

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The Outlook for Government-Sponsored Health Programs in 2018

John Gorman

As 2018 and Year 2 of the chaotic Trump Administration kick off, trying to predict what will happen in Medicare, Medicaid, and the Affordable Care Act is as challenging as ever. It’s a midterm election year with terrible headwinds for the GOP, so the legislative calendar is abbreviated, and partisan rancor will peak. That makes it less likely Republicans will get to do much damage but also more likely they will try to serve up red meat for their base, like a return to “repeal and replace.” Congressional leaders, fresh off their billionaire bailout tax bill, are already talking about taking up “reform” (aka cuts) of Medicare and Medicaid and other social welfare programs. The only thing that is certain is 2018 will be another battleground year for government health programs.

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