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Of Healthcare Punditry and Crystal Balls: First Anniversary Edition – Part 1

Of Healthcare Punditry And Crystal Balls: First Anniversary Edition – Part 1

With this first edition review of our annual prognostications, we boldly say that our best guesses about what would happen in 2016 may rival Nostradamus’ prophecies (with a few misses) – although we admit the Frenchman had to be clairvoyant into future centuries! Below, we summarize what we said would occur in 2016 with our self-evaluated (and, perhaps, highly inflated) grades.shutterstock_201766217_Nostradamus-7-12-22-16-edited-463643-edited.jpg

Compliance Rigor Prediction – A

We predicted compliance would continue to be the name of the game for the Centers for Medicare and Medicaid Services (CMS) in 2016 and health plans should be prepared for a rigorous audit season. We said continued issuance of Civil Monetary Penalties (CMPs) and increasing suspension of enrollment and marketing would occur.

The prediction, admittedly, did not take great prescience. Nonetheless, CMPs and suspensions did continue in a major way with the following:

  • Announcement of the new timeliness monitoring program
  • Emergence of a new provider network focus
  • Release of strict new outreach requirements, and
  • Finalization of the far-reaching Medicaid Über rule (which will remake that program into a compliance machine as well) occurred.

Quality Focus Prediction – A

Perhaps another no-brainer, we predicted CMS would continue pushing the limits on quality and Star performance in 2016 and beyond. We said a strong Star program for 2017 would be announced, with a complex roadmap for later years. We also said the Medicaid Über rule would bring Star performance to all Medicaid states and Exchange Star should also be just around the corner.

The Star roadmap announcement for the outyears is indeed complex but pretty much mimicked the previous announcement in 2016. The Medicaid Über rule was aggressive when it came to Star, telling states to fashion their own or follow one from CMS that would likely look like Medicare Star. Exchange Star was piloted in five states for the 2017 welcome season, with implementation slated for 2018.

As a side note, achievement in Medicare Star pretty much leveled off for 2017 ratings, perhaps due to the stellar achievement over the past few years.

Exchanges Fallout Prediction – A

We told you to expect some greater turmoil in the Exchanges as complete data from 2014 and 2015 is now in. We said the risk corridor payment shortfall could well lead small plans out of the Exchanges and larger plans may come to the same conclusion. We said all of this could impact premiums, network, and plan availability.

How right we were. Non-profit co-ops and smaller plans left the Exchange in droves because CMS funded the risk corridor program at about 13 cents on the dollar for the first plan year. Plans financial losses in the Exchange proved huge, leading large insurers and regional Blues to exit or considerably contract as well. There is no question, the financial stability of the program is in jeopardy and consumer access is becoming a huge issue.

Medicaid Expansion Prediction – D

We predicted CMS would finally come to its senses and change its approach on Medicaid expansion under the Affordable Care Act (ACA). We said it would allow expansions and pilots that represent eligibility levels short of 133% of the federal poverty level.

We failed miserably – it was perhaps a hope and dream. There are still 19 states that have not expanded Medicaid under the ACA, down from 21 before. We give us partial credit here for Montana going live with a waiver scheme that includes premiums and co-pays, and Louisiana expanding with a change from a Republican to Democratic Governor. But none of this was due to a shift in CMS policy on the issue.

Special Needs Plan (SNP) Reforms – A+

We said these darlings of CMS will finally get some changes when it comes to how dual eligibles get reimbursed in Medicare Advantage and how plans serving these individuals get rated.

Sure enough, the 2017 Call Letter made huge changes for SNPs. The community rating segment of the Hierarchical Condition Categories (HCC) risk adjustment system will be broken out into subcategories to better recognize costs and set premiums for these segments that generally impact SNPs more. And the Star measures for 2017 adjust some measures to account for the socio-economic and related barriers that SNP and dual eligible members face. This should boost SNP Star scores.

Big Health Plan Mergers – Incomplete

We said despite reservations raised by both state and federal authorities, the Aetna-Humana and Anthem-Cigna mergers under review should be expected to go through with minor revisions.

The Obama administration took a hard stand on the mergers and they are now in two separate court cases for the judges to decide. Decisions on one or both will be in in the next few weeks. Earlier in the year, both mergers were thought to be near dead, but fortunes appear to be moving in the right direction for one or both of them. There is a 50-50 shot right now that at least one of them wins in court or settles with the feds with additional concessions.

Fee-for-service (FFS) pilot expansions – A

These, too, were the darlings of CMS and we said CMS would continue pushing these parallel reforms to Medicare Advantage in the traditional Medicare world.

Sure enough, both the Comprehensive Primary Care Physician pilot and Accountable Care Organizations expanded and the bundled payment program went into effect. The Medicare Advantage Value Based Insurance Design was also slated for expansion in 2018.

Marc Ryan

Marc S. Ryan serves as MedHOK’s Chief Strategy and Compliance Officer. During his career, Marc has served a number of health plans in executive-level regulatory, compliance, business development, and operations roles. He has launched and operated plans with Medicare, Medicaid, Commercial and Exchange lines of business. Marc was the Secretary of Policy and Management and State Budget Director of Connecticut, where he oversaw all aspects of state budgeting and management. In this role, Marc created the state’s Medicaid and SCHIP managed care programs and oversaw its state employee and retiree health plans. He also created the state’s long-term care continuum program. Marc was nominated by then HHS Secretary Tommy Thompson to serve on a panel of state program experts to advise CMS on aspects of Medicare Part D implementation. He also was nominated by Florida’s Medicaid Secretary to serve on the state’s Medicaid Reform advisory panel.

Marc graduated cum laude from the Edmund A. Walsh School of Foreign Service at Georgetown University with a Bachelor of Science in Foreign Service. He received a Master of Public Administration, specializing in local government management and managed healthcare, from the University of New Haven. He was inducted into Sigma Beta Delta, a national honor society for business, management, and administration.

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