Melissa Newton Smith’s Post

⏰ The clock is ticking! With 25% of the measurement period for #CMS inaugural application of the #MedicareAdvantage #HealthEquityIndex already gone, many plans are still in neutral, struggling to determine where to begin and how to justify activities and investments. Remember: decision-making isn’t about finding the elusive “best” strategy. It’s about making informed, impactful choices that drive results. Too often, the #HEI has been handed off to the #StarRatings team. But here’s the truth: the #Stars value of the HEI should be the result of smart decisions across all departments, not a stand-alone task. We've been advocating for #MA plans to integrate the HEI, along with the Star measures that drive its success, to be the measurement of the organization’s broader #Compliance, Provider Network and Clinical Quality evolution needed to adhere to the #OCR May Nondiscrimination FR, CMS’s May #Medicaid FR, and the D-SNP Alignment elements of the 2025 MA FR. ❓ Will it be simple? No. ❓ Will it be the fastest way to the immediate-term HEI Math Path? Maybe. ❓ Is it essential? Absolutely. There simply isn’t enough topline revenue for MA plans to continue tackling new rules individually or in silos, especially with #RiskAdjustment V28 changes. These new regulations demand thoughtful, intentional, deep work so that strategies and tactics are sustainable and profitable. We crafted an innovative #QualityImprovement model to guide MA plan evolution and Stars success using Reality-based Leadership Principles. Our team has capacity to launch 3 more clients on this unique, year-long Stars Improvement journey in Q4. If you’re ready to transform your approach and achieve sustainable success, send me a message.  ⭐ ⭐ ⭐ ⭐ ⭐

Heart disease is the leading cause of death for women, and the gaps in care and access between women and men are substantial. Addressing these disparities could add >1.5 million quality years of life and boost the U.S. economy by $28 billion annually by 2040, according to a new report by the American Heart Association and the McKinsey Health Institute. Within #MedicareAdvantage, the #CMS #StarRatings changes underscore the urgency to understand and resolve these issues swiftly. While maternal health often takes center stage in #WomensHealth discussions, the multifaceted female aging process-encompassing mental health, childbearing, caregiving, menopause, and more-presents many more areas worthy of investment. But shockingly, only 1% of healthcare research and innovation is invested in female-specific conditions outside of oncology. As #MA plans tackle 3x-weighted #HOS measures, #HealthEquity Index, and #PartD Redesign, one size will not fit all. Nor will trying to tackle #CardiovascularHealth via MEASURES, rather than MEMBERS. Gender-focused investments can significantly drive the #TripleAim, leveraging #Stars and Risk Adjustment for guaranteed #ROI. Every plan can add some activities to their #QualityImprovement and Stars Workplans to support women in the unique ways they often need, using improved AccessToCare to drive accurately coded mental and physical healthcare and #CAHPS improvements. And insurors also offering commercial, #Medicaid and #ACA plans as strategic precursors/pipelines for MA lives have an exponential, cross-LOB ROI. In recent months, Daphne Klausner and I have been ideating in this space and are actively seeking a few innovative MA plan partners interested in taking meaningful next steps in this space, using the short-term Stars and RiskAdjustment gains as the easiest ROI to justify the investment of time/effort in this area. If you are interested in joining us as we explore early efforts to pioneer these essential changes, please DM me or email me at msmith@newtonsmithgroup.com.   Let’s reimagine the future of women's health together.  💟 ⭐

TL;DR? Navigating the rapidly-growing body of Final Rules and technical updates in #MedicareAdvantage and #Medicaid in 2024 has become increasingly challenging. New rules and rigors introduced by #CMS, #HHS, #OCR, and #NCQA redesigning areas such as #Interoperability, #ECDS, #StarRatings, #RiskAdjustment, #HealthEquity, #PartD, Sales, Marketing, #SupplementalBenefits, #MemberExperience, #HOS, Civil Rights, Nondiscrimination, cybersecurity, #QualityImprovement and more is…quite frankly….simply too much for most #MA leaders to read, let alone achieve #Compliance and earn 4+ #Stars.  Even those of us who meticulously go through every page of every new rule struggle to distill the extensive content into the type of concise, digestible summaries that can be shared at conferences or online. This issue is not new. It’s been one of the most consistent, yet unsolved, challenges since the inception of MA. But what is new? 2025 ushers in the most change we’ve ever seen in MA. Ever. And there’s just no way around the reality that success amidst change requires decision-makers to know the detailed rigors in all of the regulatory updates so their decisions and new strategies align with the totality of new program rigors. We’ve been trying to figure out how to do more, and better, to help with this. So I’m curious: how are you keeping up with the latest regulatory updates? 1️⃣ I read every Final Rule and new regulatory update in detail. 2️⃣ I rely on summaries from advisors/consultants/vendors I trust and feel good about the amount and quality of information readily available. 3️⃣ It’s TL;DR! I would be willing to pay a nominal fee to experts for a detailed, extensive summary of all new regulations as they are issued.

As another week of #TukeyGate drama wraps up in #MedicareAdvantage, I’m surprised and saddened by the number of plans not submitting revised bids to capture the newfound revenues they earned through last week's CMS adjustments. Thursday’s #HPMS memo is a stark reminder to plan leaders: any plan receiving an upward adjustment to their overall #StarRating through the June 13 #Tukey recalculations will not reap the benefit of their increased rating unless they submit a revised bid. If you ended last week thinking you'll skip submission of a revised bid, I strongly encourage you to reconsider that this weekend. Choosing not to submit a revised bid under these circumstances in order to collect the money your organization is legally entitled to is perhaps one of the highest-stakes business decisions I can recall in MA. Many plan leaders don’t realize that “Quality Bonus Payments” are not a transactional “bonus” payment paid directly by #CMS to #MA plans – rather, #QBP is ‘disbursed’ to plans through an adjustment to the benchmarked rate submitted in bids. Yes, I know. Submitting a revised bid on a super short timeline (now down to just 1 more week) is hard. Requires an all-hands on deck fire drill. Potentially using vendors or consultants who you have to ask to work “off paper” with a promise to get contracts and payment in place after submission. The sheer volume of analytical work done by #Stars teams and Stars-centric vendors in the last 10 days is enormous and hard to quantify. Every MA plan is trying to reverse engineer the math to figure out whose ratings increased. With immense effort being asked of Stars teams. But many of those plans that were impacted are choosing not to submit new bids and will forego the newfound funding. While I understand this is the easiest pathway for plan personnel (especially during the summer slowdown), it harms your members and providers, since 85% of revenue has to flow back out as MLR. Monday is the deadline to notify CMS if you plan to resubmit your bid to leverage the increased revenue associated with Tukey-related changes. If your plan was impacted and you are reading this over the weekend, please don’t miss your opportunity. There is still time to add relatively simple, yet impactful adjustments, to your bid through a rapid revision before next week’s deadline to use the incremental revenue CMS’ adjustment provided to your contract(s). Please don't miss your chance. Trust me. This IS your commitment to the best possible #MemberExperience. And since benefit erosion will hit on 1/1, this is your most critical MY2024 #CAHPS decision. Your beneficiaries will thank you. Your providers will thank you. Your Board will thank you. ⭐ ❤️

Are you a #MedicareAdvantage expert looking for your next role? We are expanding our team across the following areas this fall: #HEDIS (including #ECDS and #digitalquality), #RiskAdjustment, #StarRatings, #MA #Compliance and plan operations. Whether you're looking for a temporary role between permanent positions or long-term advisory role, we'd love to talk with you. Please email us at admin@newtonsmithgroup.com or submit your resume online.

#INDUSTRYALERT: #CMS confirms they will be recalculating 2024 #StarRatings for all #MedicareAdvantage plans. Be watching for the HPMS memo any moment! (And also be ready for a rapid reopening of the 2025 bids! It's the Summer of Surprises!) Huge kudos to my #MA and #Stars friends who studied the APA guidelines so carefully with us and filed these high-impact suits. ⭐

Strategy or Tactics? Strategy sets the vision to achieve goals, while workplans track tactics to get you there. I learned the distinction firsthand while leading the #Stars charge for a national #MedicareAdvantage plan. After presenting our detailed 4th quarter push, a C-level leader rightly pointed out: “These are great TACTICS. Now what’s our STRATEGY?” <<GULP!!>> He was right! We had become so focused on tasks - measures, programs, lists, owners, numerators, denominators – that we neglected to align them with the organization’s overarching operating strategy. We had the Money, Means, Goals, and Activities covered but had not adequately anchored with Market, Magic and Momentum. As #MA and #Stars teams embark on this vital #SummerOfStars, it’s a great time to refine both Strategy and Tactics. Strategy articulates direction and vision, focusing on the "WHAT" and "WHY," rarely changing. Workplans detail the "HOW" and "WHEN," documenting tasks, ownership and resources, with frequent updates, additions as new needs arise, and removals as tasks are completed. Here are a few key things to think about this summer as you work on your strategy and tactics for success among the #NewNeedsOfStars: 🌟 STRATEGY: Formalize whether Member, Provider or Internal are primary or secondary channels for success. Memorialize whether you’ll rely on People or Technology 🌟 TACTICS: Craft your Workplan with activities and tactics that match your vision. Resist the temptation to add activities just because others call them Best Practices if they do not align with your strategy. Delete tactics that misalign with your strategy. 🌟 WORKPLANS: Add Measure-level activities as necessary to achieve measure goals. 🌟 UPDATES: Schedule an annual Strategy update and monthly Workplan updates. Without Strategy, workplans are just lists of tactics. Without tactics, strategy is just an idea. #WhatGotYouHereWontGetYouThere #QualityImprovement is a Journey, Not a Destination   Thanks Alan (AJ) Silber and Jeroen Kraaijenbrink for the inspiration! And Katie Viehbeck the new #SOS term! Now #LetsRoll ⭐ ⭐ ⭐ ⭐ ⭐

#INDUSTRYALERT: In response to the #OCR clarification that #HIPAA Covered Entities may delegate PHI #breach notifications to UHG and Change, and with confirmation that only one party (either the Covered Entity or their Business Associate), must perform the notifications, we are inching closer to a flood of patient/member breach notifications. These notices will be fear-inducing and worrisome, especially for seniors and vulnerable people. Recognizing that the required 60 days for notifications has now passed, Senators Blackburn and Hassan have now issued an official request for notifications to be sent by June 21. What should you do right now? ✅ Every health plan, provider and member-facing vendors should examine Call Center and front desk staffing and arrange extra capacity to handle complex inbound calls and more intense F2F discussions with patients. ✅ Prepare member-facing staff with empathetic, detailed information on what they need to do next to protect themselves. Identify theft in this situation is a very real threat, and vulnerable people may struggle with the resulting fear and uncertainty. ✅ Prepare for a busier-than-normal fall in member-facing departments. As patients experience normal phishing and identity threats, we expect them to call providers and insurors more frequently than normal seeking information, reassurance and potentially identify theft protection. ✅ Help your key vendors and suppliers whose PHI vulnerabilities are impractical to remediate rapidly. Many organizations self-audited their hack-readiness and realized they were, indeed, vulnerable - but when the world went so quickly back to #BusinessAsUsual, all parties just began living with the increased awareness of existing risks. As soon as these notifications drop, we expect to need all-hands on deck interactions. Hoping my #MedicareAdvantage, #Medicaid and Commercial health plan friends are all ready (as well as your member-facing vendors too)! With #CAHPS and #MemberExperience remaining a key priority in #MA #StarRatings, this is a vital time to remind leaders that #ThisIsCAHPS. It will require incremental expense, documented adequately to serve as documentation for potential legal or financial recovery suits in the future. This means we're going to need our CFOs involved to authorize rapid budgets, and potentially more/better vendored flex support to get through what promises to be a busy summer within the #Stars world! #NotBusinessAsUsual ⭐ ⭐ ⭐ ⭐ ⭐

As #MedicareAdvantage plans continue building organizational resiliency to succeed amidst the many #StarRatings and #RiskAdjustment changes in 2024 and 2025, a #CultureOfChange is critical. While many leaders and high-performers fear the word Failure, some degree of #FastFailure is vital to finding reliable pathways to success. As executives begin working on 2025 budgets and leaders continue coping with the sweeping 2024 #Stars, #HEDIS, #HOS and #CAHPS changes which will lead into mass Product overhaul in 2025, this is a great time to #FailFast to help InnovateFaster. Here are some helpful ideas to get your organization moving: 1️⃣ Redefine Failure 2️⃣ Encourage Risk-taking 3️⃣ Activate Learning 4️⃣ Enforce Post-Failure Analysis 5️⃣ Maximize Financial Impact 6️⃣ Accelerate the Failure Cycle 7️⃣ Revamp Communications 8️⃣ Lead By Example Our team of seasoned experts have long histories of driving #QualityImprovement and #PerformanceImprovement amidst immense change. If your organization needs help bringing these principles to life as part of your end-of-year push, please reach out. We’d love to help! #WhatGotYouHereWontGetYouThere #LetsRoll ⭐ ⭐ ⭐ ⭐ ⭐