skip to Main Content

Of Healthcare Punditry and Crystal Balls, Part 2

Of Healthcare Punditry And Crystal Balls, Part 2

We, here at Strategic Insights, don’t see ourselves as ever rivaling Nostradamus’ prophecies, but in the shutterstock_201766217_Nostradamus.jpgspirit of the season, we will spend a few moments trying to emulate the Frenchman’s clairvoyance — not on the weighty matters of world events, natural disasters, and Armageddon, but on our more staid — really? — topic of healthcare matters.

Compliance: It does not take a crystal ball to see that compliance will continue to be the name of the game for the Centers for Medicare and Medicaid Services (CMS) in 2016. Since the new audit regime was issued in 2012, CMS has continually fine-tuned its audit approach, and health plans should be prepared for a rigorous audit season. CMS’ new expanded audit universes aimed at getting at questionable practices will come to the fore in 2016, now that the 2015 honeymoon period is over. Expect continued issuance of Civil Monetary Penalties (CMPs) and increasing suspension of enrollment and marketing. And now that CMS is the policy-maker for all lines of business, it will continue to accelerate its compliance focus in Medicaid and Exchange.

Quality: The crystal ball is quite clear when it comes to the issue of quality. As with compliance, CMS is buoyed by its record. Expect CMS to continue pushing the limits on quality and Star performance in 2016 and beyond with a strong Star program for 2017 announced and a complex roadmap for later years. The Medicaid Uber rule will bring Star performance to all Medicaid states and Exchange Star should also be just around the corner.

Exchanges: Expect some greater turmoil in the Exchanges as complete data from 2014 and 2015 is now in. The risk corridor payment shortfall could well lead small plans out of the Exchanges. Larger plans may come to the same conclusion, given impacts on growth and margin. All of this could impact premiums, network, and plan availability.

Medicaid: With the presidential torch to be handed off in early 2017 and CMS’ frustration with the half a loaf it got with Medicaid expansion, CMS may finally change its approach on Medicaid expansion under the Affordable Care Act (ACA) and consider expansions and pilots that represent eligibility levels short of 133% of the federal poverty level.

Special Needs Plans: 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.

Healthcare Mergers: Despite reservations raised by both state and federal authorities, the prominent mergers under review should be expected to go through with minor revisions. This points to increasing concentration of lives in a small number of insurers.

Fee-for-service (FFS) pilots: While the verdict is still out, expect CMS to continue pushing parallel reforms to Medicare Advantage in the traditional Medicare world. But as consolidation continues among health plans, expect that at least some of the successful and mature providers look to the health plan world as more lucrative than the FFS pilots.

Like all good prognosticators, we close this post—and this year—wishing all of our blog readers good fortune in the future. If the past few years are any indication of what lies ahead, we in the healthcare industry are in for a funfilled ride! Happy New Year!

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.

Back To Top