红领巾瓜报 Insights: Your source for healthcare news, ideas and analysis.
红领巾瓜报 Insights 鈥� including our new podcast 鈥� puts the vast depth of 红领巾瓜报鈥檚 expertise at your fingertips, helping you stay informed about the latest healthcare trends and topics. Below, you can easily search based on your topic of interest to find useful information from our podcast, blogs, webinars, case studies, reports and more.
红领巾瓜报 and Wakely, an 红领巾瓜报 Company, have released an updated Issue Brief to the comprehensive profile of ACA Marketplace enrollees that was based on claims data from nearly 6 million of the 24 million Marketplace enrollees.
The issue brief discusses these key questions:
Do Marketplace enrollees spend more or less out-of-pocket relative to Medicare, ESI and Medicaid enrollees?
How may the potential expiration of eAPTCs impact out-of-pocket costs?
What are some initial considerations regarding overall healthcare affordability?
Please fill out this form to receive a copy of the update and issue brief.
Contact any of the report authors with further questions, or to discuss potential applications of this work for your organization.
As Medicare Advantage and Part D plans prepare for the 2026 contract year, Wakely, an 红领巾瓜报 Company, has published two white papers that offer critical insights into the latest developments in the Centers for Medicare & Medicaid Services鈥� (CMS) Star Ratings program. These analyses follow CMS鈥檚 release of the final 2026 Star Ratings, which play a pivotal role in plan performance, member retention, and bonus payments.
Why It Matters
Star Ratings reflect plan quality, member experience, and regulatory compliance. With CMS continuing to refine its methodology and cut points, understanding the nuances of these changes is essential for plans looking to maintain or improve their ratings. Wakely鈥檚 white papers provide a clear, data-driven lens into what鈥檚 new, what鈥檚 stable, and what it means for the industry.
No Major Shifts in 2026 Ratings
In the paper, , Wakely experts report that the 2026 Star Ratings show no major systemic shifts in overall scores. Wakely鈥檚 analysis finds that:
Most plans maintained their previous ratings, with only modest movement across the board.
CMS鈥檚 methodology updates had minimal impact on overall scores, suggesting a period of relative stability.
The distribution of scores across contracts remains consistent with prior years, offering plans a chance to focus on incremental improvements rather than major overhauls.
A companion white paper, , explains the cut point adjustments that define how performance translates into Star Ratings. The analysis finds that several measures saw tightening of cut points, especially in areas like medication adherence and member experience. In addition, the paper indicates that early signals of quality improvement are emerging in certain domains, suggesting that plans are responding to CMS鈥檚 evolving expectations.
The paper offers guidance on how plans can strategically target measures most likely to influence future ratings.
With changes to ACA subsidies included in H.R. 1, the healthcare industry could face the biggest change since the passage of the ACA.
Health insurance coverage is likely to be disrupted by changes in ACA marketplace financing, particularly due to the projected reductions in ACA subsidies, as well as the impacts of eligibility and enrollment changes in Medicaid. At a recent 红领巾瓜报 webinar, our ACA marketplace experts detailed a number of challenges that health plans participating in the ACA will face in the coming months and years due to these new policies, and some of the thinking behind ways that plans can take action now while Congress debates whether to extend any of the subsidies.
The webinar touched on areas including:
How the recent policy and funding changes will affect strategic planning, longer term goals, and 2027 plan year rate setting;
Actuarial analysis/rate setting/risk adjustment insights from 红领巾瓜报鈥檚 actuaries;
Changes likely to occur in plan and marketplace operations in both state exchanges and on the healthcare.gov federal platform;
The importance of effective communications to avoid creating consumer confusion, and ideas on stakeholder engagement strategies;
And, how all of this will impact workforce/access to care, and the likelihood of changes to in-network care
The ACA marketplace is bracing for impacts for the 2026 plan year, depending upon potential Congressional actions in the remaining months of 2025. In May 2025, CMS put out a rate filing bulletin for plan year 2026 that gave technical directions for submissions and urging states and issuers to be prepared to react to Congressional action. This was a signal that the administration anticipated potential policy changes between May when they put this out and the rate filing window in the fall.
This is reminiscent of the ACA changes that happened in 2017, when there was litigation around cost-sharing reduction (CSR) subsidies that needed to be appropriated. (This was during the 鈥渞epeal and replace鈥� debate in Congress, in that same July-August timeframe.) When repeal efforts failed in Congress, the Administration decided not to pay CSRs, necessitating a bipartisan agreement to address this new financing issue. Changes to CSRs were dropped from this year鈥檚 law but could be addressed before the end of the year in upcoming appropriations bills in Congress.
鈥淎CA plan strategies need to change to ensure that they are considering different outcomes in the market composition and competitor changes to pricing strategies. Expect more policy changes and potential for market churn, making pricing difficult in 2027 given the limited information on what happens in 2026.鈥� – Michelle Anderson
A recent Wakely report analyzing the early draft of HR 1 before passage () details estimated reductions in the individual market enrollment with potential reduction anywhere from 47 to 57% or 11.2 to 13.6 million enrollment enrollees by 2028. The attrition estimates include the loss of both federally subsidized individuals, as well as the unsubsidized due to premium increases. This paper was quoted in a recent NY Times piece,
鈥淐hanges are coming for Healthcare.gov and state marketplace consumers in 2026. The (likely) expiring enhanced premium tax credits, as well as provisions within HR 1 and the Marketplace Integrity and Affordability rule will all be rolled out to marketplace consumers this coming Open Enrollment. In addition to the marketplaces, state departments of insurance, issuers, enrollment assistance professionals, and other stakeholders will play a critical role in helping consumers navigate the coming eligibility and affordability changes.鈥� – Zach Sherman
Impacted marketplace consumers need to be made aware of these coming changes. States and issuers should undertake a broad, aggressive, and coordinated communication effort around the overall rate changes. Ensuring consumers understand how their net premium is changing due to expiring enhanced premium tax credits as well as the other operational changes will be crucial to their ability to stay covered. We expect to see considerable consumer plan switching this coming open enrollment as a result. Some consumers may need to buy-down to silver or bronze plans to be able to afford to maintain their coverage. Marketplaces will need to ramp up customer service and navigation support. States with reinsurance programs or premium subsidies should consider ramping up funding to mitigate the affordability gaps that are likely to occur.
鈥淚t’s really important for folks in the ACA marketplace community to be active when it comes to policymaking and advocacy.鈥�&苍产蝉辫; 鈥� Liz Wroe
These issues are part of the government funding debates underway right now as a government shutdown looms. Depending upon the outcome with the September funding deadline, or the possibility of a supplemental funding bill this year, these ACA marketplace issues could be addressed in several sets of negotiations. Now is the time to talk to your state officials, insurance commissioners, associations and contacts in the Federal government to ensure they have a good understanding of how these ACA marketplace changes will impact coverage in your state.
To hear the full discussion, you can find the replay and materials for the ACA webinar here, and download the full Wakely paper at .
As the end of 2025 approaches, the future of enhanced premium subsidies for Affordable Care Act (ACA) Marketplace coverage remains uncertain. These subsidies, extended by the Inflation Reduction Act (IRA), are set to expire December 31, 2025. Without congressional action, millions of Americans will face a sudden and significant increase in out-of-pocket premium costs, reintroducing the 鈥渟ubsidy cliff鈥� and raising the percentage of income that they will need to direct toward health insurance premiums. More than 16 million consumers who now receive subsidies will be affected, making this a critical issue for policymakers, payers, and consumers.
A new from Wakely, an 红领巾瓜报 Company, offers a timely and detailed analysis of the potential impacts and strategic considerations for stakeholders navigating this uncertain terrain.
How ACA Subsidies Are Calculated: The Mechanics Behind Premiums
The white paper explains that advance premium tax credits (APTCs) are designed to cap a household鈥檚 health insurance premium contribution at a specific percentage of income. The calculation is based on household income, size, the cost of the benchmark Second Lowest Cost Silver Plan (SLCSP), and age. The expiration of enhanced subsidies will revert contribution percentages to higher levels, increasing costs for all income brackets.
Premium Shock: Quantifying the Impact of Subsidy Expiration
Wakely鈥檚 analysis shows that the expiration of enhanced subsidies will result in a substantial increase in monthly premium contributions. For example, a hypothetical single 40-year-old at 150 percent of the federal poverty level (FPL) will see monthly premiums jump from $0 to $81.97 in order to keep the same plan.
Mitigation Strategy: Buying Down to the Lowest Cost Silver Plan
Consumers may offset part of the premium increase by switching from the SLCSP to the Lowest Cost Silver Plan (LCSP). The difference in premiums between these two plans translates directly into monthly savings, independent of income. In Raleigh, NC, a hypothetical 40-year-old could save $53.03 per month by buying down, mitigating about two-thirds of the premium shock. For older consumers, the savings are even greater; however, in highly competitive markets like Charlotte, NC, the premium gap鈥攁nd the savings鈥攚ill be much smaller, offsetting only a modest portion of the increase.
Consumer Savings
After applying the buy-down strategy, the net premium increase for a hypothetical single 40-year-old at 150 percent of the FPL in Raleigh will be $28.94 per month rather than $81.97 without mitigation. Depending on age and location, consumers can offset 37鈥�100 percent of the premium increase in less competitive markets, but only 7鈥�28 percent in highly competitive ones.
Market Dynamics: Why Local Competition Matters
The effectiveness of mitigation strategies depends on local market dynamics and competition. In markets with fewer carriers and larger premium gaps, consumers have greater opportunities to offset premium increases. In competitive markets, options are more limited. The paper notes that the 2026 landscape may shift due to carrier exits and price changes, underscoring the need for ongoing monitoring and adaptive strategies.
Recommendations for Payers, Regulators, and Brokers
Payers聽should consider product design strategies that create meaningful premium gaps between Silver plans, where actuarially justified, to maximize consumer savings.
Regulators聽can collaborate with insurers to support these strategies and, in state-based Marketplaces, may play an active role in limiting Silver offerings that erode premium gaps.
Brokers and Carriers聽may want to market Bronze plans as a last-resort coverage option, as some consumers can access Bronze plans for free, which is preferable to going uninsured.
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Wakely is experienced in all facets of the healthcare industry鈥攆rom carriers to providers to government agencies. Wakely actuarial and policy experts continually monitor and analyze potential changes to inform healthcare organization strategies and advance effective solutions to propel their success.
For questions about this analysis or to discuss strategies for navigating the post-subsidy cliff, contact聽our expert below.
Michelle Anderson, director and senior consulting actuary at Wakely, an 红领巾瓜报 Company, joins Vital Viewpoints on Healthcare to unpack the state of the Affordable Care Act (ACA) marketplace. From the market鈥檚 volatile beginnings to today鈥檚 uncertainty around subsidies, Michelle shares how insurers, states, and consumers have adapted and what challenges lie ahead. We explore the forces shaping affordability, coverage options, and consumer behavior, as well as the critical policy decisions that could redefine the individual market in 2026 and beyond.
The Centers for Medicare & Medicaid Services (CMS) has officially opened the window for the (RHTP)鈥攁 $50 billion federal initiative designed to stabilize and transform rural health systems across the country. This one-time opportunity allows states to submit a comprehensive plan that could redefine how rural communities access care, manage chronic conditions, and sustain their healthcare infrastructure.
As outlined in our earlier In Focus article, , RHTP represents one of the most significant federal investments in rural health in decades.
Applications must be signed by governors and submitted by November 5, 2025, and awards are expected by December 31, 2025, providing states with a very narrow window to act.
The remainder of this article explains key aspects of the RHTP application, including the evaluation and scoring aspects. Notably, the structure of the scoring system will reward states that are already aligned with these , as well as those willing to implement new initiatives or make state policy changes to achieve alignment.
Program Overview and Funding Structure
Created under HR.1, the 2025 Budget Reconciliation Act, the RHTP allocates $10 billion annually from federal fiscal year (FY) 2026 to FY 2030, totaling $50 billion over five years. Funding is split into two tranches:
Tranche 1 (Baseline funding): $25 billion distributed evenly聽across all states with approved applications.
Tranche 2 (Workload funding): $25 billion distributed based on CMS scoring criteria, which include:
The percentage of the state population in rural census tracts
The proportion of rural health facilities in the state
The financial and operational status of hospitals
Other factors explained in the RHTP application notice
States must submit a single, one-time that covers the full five-year period. Stand-alone provider applications will be declined. Hence, states must coordinate across agencies, providers, and stakeholders to develop a unified transformation strategy.
Importantly, this award is not a grant; rather, it is a cooperative funding agreement, which means CMS will play an active role in oversight and collaboration. States must be prepared to meet higher standards of accountability, transparency, and performance monitoring. According to the RHTP application, continued funding requires states to demonstrate satisfactory progress toward implementing their plan.
Application Requirements and Strategic Priorities
To be eligible for funding, states must submit a Rural Transformation Plan that addresses eight core priorities as follows:
Within these core priorities, state plans must propose activities that address several specific issues.
Technical Factor Weighting for Workload Funding Reflects Federal Policy Priorities
CMS outlines the eligibility criteria for baseline funding and the scoring components for workload funding. Baseline funds will be distributed equally among states, while workload funding will be based on each state’s rural facility and population score as well as their technical score. Evaluators will score technical factors based on state policy actions and initiative-based plans for each state.
The technical factors, and the weighting of these factors, in the RHTP application are not just neutral scoring mechanisms; rather, they are closely linked to the Trump Administration鈥檚 health policy priorities.
Weighting Structure: The RHTP funding is split evenly between baseline funding (50%) and workload funding (50%). Although baseline funding ensures all states receive support, the workload funding is directly tied to technical scores that reflect how well a state鈥檚 plan aligns with federal objectives and demonstrates readiness to implement transformative change that furthers federal objectives.
Scoring Criteria: Technical factors, such as rural population share, facility density, hospital financial status, scope of proposed activities, administrative capacity, stakeholder engagement, evaluation framework, and especially alignment with federal priorities, all contribute to the overall score. States that have already adopted or are willing to adopt federal policy priorities are positioned to score higher and receive more funding.
Annual Recalculation: CMS will recalculate each state鈥檚 technical score and workload funding annually to incentivize ongoing alignment with federal priorities and measurable progress toward transformation goals.
Alignment with Federal Priorities: One of the explicit scoring factors is 鈥淎lignment with Federal Priorities,鈥� which measures the degree to which a state鈥檚 plan supports CMS goals for rural health transformation and sustainability. Under the Trump Administration, these priorities may include promoting value-based payment models, encouraging technology adoption, advancing adoption of Supplemental Nutrition Assistance Program (SNAP) food restriction waivers that prohibit the purchase of non-nutritious items, availability of integrated care plans for the Medicare-Medicare dually eligible population, reporting of full Medicaid T-MSIS data, and align policies with federal guidance on short-term limited duration insurance plans.
Preparing for What Happens Next: Implications for States, Providers, and Health Plans
The RHTP offers a rare opportunity to reshape rural healthcare. But success will require strategic coordination and a commitment to long-term change. States in the short and long term should consider include:
Identifying stakeholders who will be involved: Hospitals, rural health clinics, federally qualified health centers (FQHCs), behavioral health providers, and community organizations must be part of the planning process.
Reexamining priorities: States will need to reconcile competing needs across regions and provider types, balancing infrastructure investments with service delivery redesign.
Understanding infrastructure needs to support their project: Technology, workforce, and models of care must be strengthened to support long-term transformation.
Designing evaluation frameworks: States must include robust performance monitoring and reporting mechanisms to meet CMS expectations and secure future funding.
Providers and other stakeholders should also prepare to align with state strategies. Examples include:
Participating in regional partnerships
Adopting new care models and payment arrangements
Investing in technology and workforce development
Contributing data and insights to support evaluation efforts
The scoring structure also incentivizes states that may not yet be fully aligned to implement new initiatives or make policy changes that would improve their technical scores and secure greater funding. States and their partners will need to be united on the goals and initiatives, disciplined about implementing and evaluating the plans based on data informed reports, nimble and willing to make strategic pivots based on feedback and experiences.
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States that are already aligned with Trump Administration priorities鈥攕uch as those with established value-based payment models, short-term limited duration plan options, preferred technology infrastructure, or strong rural hospital support policies鈥攁re positioned to be rewarded in the scoring and funding process.
红领巾瓜报 (红领巾瓜报), is actively supporting states in developing compliant and compelling RHTP applications. Our advisory services include:
Strategic assessments and stakeholder engagement
Program design and grant writing
Implementation support and technical assistance
Actuarial support
Evaluation and performance monitoring
We help clients navigate the complexities of federal funding, align transformation goals with community needs, and build sustainable models for rural care delivery. For details about the RHTP, including the 红领巾瓜报IS State Action Tracker, contact 红领巾瓜报 experts below.
Hospitals and health systems are under growing pressure to succeed in new value-based models that demand both operational transformation and strategic alignment. In this webinar, advisors from 红领巾瓜报, Wakely, an 红领巾瓜报 Company and Nixon Peabody broke down the latest regulatory and contractual developments, explored lessons learned from the Comprehensive Care for Joint Replacement (CJR) model, and discussed how organizations can prepare for upcoming opportunities.
Speakers shared practical insights on:
The regulatory, operational, and actuarial considerations hospitals must navigate
Key takeaways from bundled payment initiatives like CJR
How to leverage data and design strategies to build partnerships that position organizations for success in new Medicare models
This session was designed for hospital executives, provider organizations, payers, and policy leaders seeking to better understand how emerging value-based models will shape the future of care delivery and payment.
Reference-based pricing is a tool that can help to address growing healthcare costs and ultimately improve healthcare affordability, especially for consumers with private health coverage. Two states 鈥擮regon and Montana鈥攈ave already implemented reference-based pricing (RBP), and several others have considered it or are in the process of implementation. RBP can be implemented in two ways- either through setting limitations on what insurers can reimburse for health services or by setting limitations on what providers can charge for services. The 鈥渞eference price,鈥� usually a percentage of what Medicare pays, can also function as a floor for provider payments. This is especially important to combat issues of access to behavioral health services, where payments are notoriously low, and workforce shortages and limited network participation issues are a significant barrier to patients seeking care.
since implementing caps in 2019 on what insurers can pay providers- $107.5 million over 27 months- and recently demonstrated reductions in out-of-pocket spending without unintended consequences such as hospital network disruptions or price hikes. `
In Washington, reference-based pricing was evaluated as a possible policy intervention in two reports prepared by 红领巾瓜报 (红领巾瓜报). The reports were produced for the Office of the Insurance Commissioner (OIC) to address healthcare affordability in 2023 and 2024. The included a landscape of the healthcare system in Washington as well as an overview of several policies for consideration, while the involved actuarial and economic analyses of selected policies to understand their potential impacts they might have in lowering healthcare costs and improving healthcare affordability for consumers.
红领巾瓜报 and Wakely, an 红领巾瓜报 Company, worked closely with the OIC and other partners to select and model the impact of various policies. The process for developing a model to evaluate reference-based pricing involved Wakely accessing the state鈥檚 , and included a review of claims from the state鈥檚 commercial and Medicaid health plans. To establish a baseline, Wakely compared different sets of healthcare services to what Medicare reimburses for that category of services, on average. This data showed vast differences in how much was being reimbursed by private plans relative to Medicare depending on service category- ranging from .
Recognizing the value of access to primary care services, that 12% of healthcare dollars should be spent on primary care. Ever since, the state鈥檚 has been focused on tracking progress towards this goal. There had not been a similar focus on establishing targets for behavioral health services until this analysis. The low reimbursement rate for outpatient behavioral health services was not surprising and confirmed what had long been suspected as a contributor to challenges accessing outpatient behavioral health services for those with private insurance. Poor access to behavioral health services also contributes to healthcare affordability issues for consumers with private insurance, who end up going without, or paying for care out-of-pocket when they can鈥檛 find behavioral health providers that take private insurance. An analysis by the found that privately insured adults who had a diagnosed mental health condition had twice as much out-of-pocket expense compared with those who did not have an identified mental health condition and that employers reported narrower networks for mental healthcare than their overall provider networks.
These findings, combined with the data from the APCD about low reimbursement rates, were catalysts for how Washington approached legislation to apply reference-based pricing for its public and school employee health plans in the 2025 legislative session. Recognizing that reference-based pricing could be used not only as a tool to improve affordability, but also to potentially increase access to important services, , signed into law in May 2025, sets caps on how much insurers can pay providers for specific sets of services, but establishes floors for how much insurers must reimburse for primary care and outpatient behavioral health services to 150% of Medicare. Notably, Colorado was considering , but it did not pass.
Healthcare affordability and access to behavioral health services are two persistent problems that contribute to poor health outcomes for many Americans and the relationship between the two is complex. It will be important to track how Washington鈥檚 new law impacts both of these issues to better understand and explore other questions, such as how expanded access to outpatient behavioral health services could improve overall healthcare affordability by addressing behavioral health issues before they become critical and/or emergent? Will it avoid or reduce traumatic and expensive trips to emergency room and crisis services? Washington鈥檚 new law offers an opportunity to closely evaluate and understand these types of questions and offers a potential model to address these intertwined and persistent problems.
红领巾瓜报鈥檚 work on reference-based pricing was supported in part by Arnold Ventures.
As states struggles to address healthcare costs and invest in behavioral health, reference-based pricing and supporting analytics are one tool that 红领巾瓜报 can offer to organizations. Contact us to learn more.
This week, our鈥�In Focus鈥痵ection highlights key insights from a new 红领巾瓜报 (红领巾瓜报), white paper,鈥�. Experts from 红领巾瓜报 and Wakely, an 红领巾瓜报 company, used the national Transformed Medicaid Statistical Information System (T-MSIS) database to learn more about specialty provider networks and examine the provision of specialty services across various states.
The analysis, released in January 2025 with support from the Robert Wood Johnson Foundation, focuses on three representative services that are relatively common, potentially difficult for Medicaid beneficiaries to access, significantly affect quality of life, typically accessed as elective procedures, and unlikely to be provided by other clinicians, such as primary care or mid-level practitioners.
T-MSIS Analysis Overview
T-MSIS analytic files are a comprehensive resource for Medicaid encounter, beneficiary demographics, program enrollment, service utilization, and payment data. Individual states compile their Medicaid claims data and submit monthly files to the Centers for Medicare & Medicaid Services (CMS). As each state submits data individually, numerous state-specific variations occur in data availability and quality. Currently, T-MSIS data are available for 2016鈭�2023. 红领巾瓜报 data scientists have permission to use the T-MSIS files for healthcare services research.
This paper examines services in 10 states that met a threshold of data integrity in the T-MSIS dataset for 2022. Other important design aspects of the analysis are as follows:
The three service procedures included in the analysis are total knee replacement (TKA), cataract removal, and impacted tooth extraction.聽
Selected states represented a diverse sample of geographic, socioeconomic, and other demographic factors.聽聽
The analysis includes non-dually eligible adult populations, ages 22鈭�64 years.聽聽
The data cover all services provided in 2022 for each procedure and the providers who rendered the service; facilities are excluded.聽聽
Concentration of Specialty Providers
Table 1 summarizes findings about the concentration of specialty services.
The authors further analyzed the provision of services and, building on a previous study, examined network concentration. Findings were as follows:
When looking at the same procedure across states, no consistent pattern emerged regarding which states had the highest and lowest concentration of services in the top 10/25 percentile of providers.聽
However, when looking at the same procedure across multiple states, TKA tended to have the lowest concentration of services among those studied.聽聽
Regardless of procedure and state, the 50 percent of providers with the lowest number of procedures tended to provide fewer than 10 percent of the total services combined.聽
These findings suggest that the specialty networks within each state are highly nuanced, and state policymakers need to look at individual specialty networks when considering health policy. State policymakers and managed care organizations (MCOs) need to examine each specialty individually to assess the distribution of services and access to care.
Looking Ahead
Timely access to healthcare services is critical for ensuring optimal health outcomes. The report authors鈥� analysis of T-MSIS data showed significant concentration of selected specialty services among providers, which may affect appropriate access to these services.
The analysis of concentration of specialty services among Medicaid specialty providers can guide MCOs and state policymakers in developing strategies to improve network adequacy, including clarifying the level of network adequacy and developing policies to assess and regulate access to specialty care. Addressing gaps in access to specialty care can contribute to better health outcomes for Medicaid beneficiaries and may be aligned with provisions in value-based contracts.
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Medicaid consumers, providers, MCOs, and states all have an interest in ensuring access to specialty care for Medicaid beneficiaries. The methodology applied in the analysis for the 红领巾瓜报 white paper can be applied and adapted for future analysis to monitor network stability and to compare access among various payers.
For details about this analysis, its implications for state and local policies, and additional research using T-MSIS, contact聽our experts below.
The Medicare Advantage (MA) market has had an eventful year, and the chaos is expected to continue. As plans begin their preparation for the upcoming 2026 Plan Year, what are the emerging trends in benefits, STARS, revenue optimization and the regulatory environment? Are you a Medicare Advantage health plan leader overwhelmed with all the changes in the industry? Check out this webinar for some helpful information.
Learning Objectives:
Review recent high-level challenges in the MA market.
Gain an understanding of several 鈥渉ot topics鈥� that MA plans should be thinking about as they begin planning for 2026.
Learn from 红领巾瓜报 experts on recommended actions for each of these topics
Tim Murray is a principal and senior consulting actuary of Wakely Consulting Group, an 红领巾瓜报 Company. With over two decades of experience as a health actuary, Tim illuminates the challenges and opportunities within Medicare, particularly focusing on value assessment and the pivotal role of data collection. Digging into the complexities of Medicare Advantage, he discusses predictive modeling, innovative supplemental benefits, and the need for structured data metrics to drive sustainable healthcare solutions.
红领巾瓜报 was engaged by the Washington, District of Columbia Department of Health Care Finance (DHCF) to lead their Medicaid Business Transformation D.C. Initiative, assessing the technical assistance needs of Medicaid providers and organizations in the areas of legal analysis, budgeting, and business development as they move toward value-based care arrangements. 红领巾瓜报 partnered with the D.C. Behavioral Health Association (BHA), Medical Society of the District of Columbia (MSDC), D.C. Primary Care Association (DCPCA), and DHCF to engage, recruit, and collaborate with organizations and stakeholders across the District.
The 红领巾瓜报 team implemented a mixed-methods assessment approach that included a literature review of national value-based payment (VBP) best practices, focus groups, interviews, and a technical assistance (TA) survey of District organizations, agencies, and stakeholders. This strategy identified the TA needs of District healthcare providers that informed the design of an intensive 3-month technical assistance program that included a variety of tools, webinars, and trainings. All resources and tools are available on the webpage.聽The report and other information about the program were published on the website.
Experts from 红领巾瓜报 as well as Wakely Consulting Group and Lovell Communications, both 红领巾瓜报 subsidiaries, contributed to this report. We offer our clients a wide range of deep technical, analytical, policy, and communications support to providers, state agencies, and recommendations on ways to improve value-based payment models.
Report authors include Caitlin Thomas-Henkel, Suzanne Daub, Art Jones, Hunter Schouweiler, Amanda White Kanaley, and Vicki Loner.
To learn more about this effort, contact聽our experts below.
Be sure to block off March 5-6 for 红领巾瓜报鈥檚 Spring Workshop in Chicago, IL, where our experts will be continuing the dialogue about value-based care. Early bird registration ends January 26, 2024.
