Last year, the U.S. Department of Health and Human Services announced a new payment model called Direct Contracting for entities that want to take on risk for fee-for-service (FFS) Medicare beneficiary expenditures. This program built upon existing Centers for Medicare and Medicaid Services (CMS) efforts to reduce healthcare expenditures while attempting to improve the quality of care for FFS Medicare beneficiaries. Although Direct Contracting is designed to appeal to a wide range of entities (including those that have not previously participated in risk programs with CMS) many current Medicare Shared Savings Program (MSSP) and Next Generation accountable care organizations (ACOs) are naturally going to want to understand the potential pros and cons of this program, and how it compares to their current ACO risk-sharing structures.
In this paper, Milliman’s Colleen Norris, Brent Jensen, and Dustin Grzeskowiak provide an in-depth technical evaluation of Direct Contracting, based on the CMS request for applications, along with comparisons to its sister programs MSSP and Next Generation ACO.
The Centers for Medicare and Medicaid Services (CMS) issued
a Quality Rating Information Bulletin in August 2019, announcing that public
display of 2019 quality rating information by all exchanges will begin during
the individual market open enrollment period for the 2020 plan year. The
initial guidance regarding this program was released in October 2018, and there
have been several deadlines for health plans to meet throughout 2019. However,
there may be some uncertainty for both plans and consumers regarding what the
quality scores represent, how they are developed, and/or how they may be used
now or in the future.
This paper by Milliman’s Dustin Grzeskowiak, Darin Muse, and Daniel Perlman provides some clarity on these topics, general background on the program, and a summary of the 2019 quality information published by CMS in the public use file.
The Prescription Drug Pricing Reduction Act (PDPRA) of 2019
proposes changes to the Medicare Part D program that could impact all
stakeholders beginning as early as 2021. The Senate Finance Committee approved
a draft of this Act on July 25, 2019. The key provisions affecting Part D
1. Redesigning the Part D benefit, including eliminating the
current coverage gap phase, establishing an out-of-pocket maximum for
beneficiary cost sharing, and splitting the cost of catastrophic phase claims
between plan sponsors, the federal government, and drug manufacturers.
2. Requiring drug manufacturers to pay a rebate directly to
the federal government if prices for certain Part D drugs increase faster than
3. Mandating public disclosure of aggregate rebates,
discounts, and other pharmacy benefit manager (PBM) contract provisions.
In this article, Milliman consultants provide an overview of these provisions and the potential effects on Part D stakeholders. The PDPRA also proposes changes to the Medicare Part B and Medicaid programs. However, the authors only focus on the proposed changes relating to Medicare Part D.
Successful Medicare Advantage organizations maximize federal revenue to provide enhanced benefits and/or reduced premiums to their members, which ultimately improves marketability with the aim of increasing membership. Organizations entering the Medicare Advantage market should be aware of the current star rating climate as well as short- and long-term star rating and revenue considerations. This report by Milliman consultants provides perspective.
The Centers for Medicare and Medicaid Services (CMS) publish star ratings to measure the quality of Medicare Advantage and Medicare Part D plans. They are also published to help beneficiaries select the best plans for them and to financially reward high-quality plans.
In this article, Milliman’s Dustin Grzeskowiak and Pat Zenner provide an overview of CMS’s methodology for calculating star ratings. Additionally, the authors discuss the financial and marketing implications of star ratings for Medicare plans and summarize best practices common to high-rated plans.