Rebecca Kavoussi

Breaking: CMS just opened a $50B rural health transformation fund — with a one-time state application deadline of Nov 5. . For HIEs and last-mile providers, this isn’t just another pot of federal money. It’s a chance to: ▪️ Strengthen digital infrastructure in rural communities ▪️ Expand real-time data sharing across hospitals, clinics, EMS, and behavioral health ▪️ Support flexible care models that only work when the data actually flows The risk? States could funnel the dollars into broad programs that don’t solve the interoperability gaps at the edge of care. The opportunity? HIEs can step up as the trusted backbone to make sure rural investments actually close care gaps instead of widening them. Applications are due in less than two months. Now is the moment for HIEs, state leaders, and rural partners to get aligned on what last-mile interoperability really looks like. Read our take on what this means for HIEs here: https://lnkd.in/giYD2FgW #LastMileInteroperability #RuralHealth #HIE

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Star Ratings as a Strategic Imperative and Why Alignment Sets the Benchmark   Today, star ratings in Medicare Advantage show how well plans deliver quality, build trust, and stay sustainable. CMS reviews these ratings based on clinical results, member experience, complaint handling, retention, and access to care. Managing these areas takes focus and commitment.   This is why Alignment Health Plan’s latest results stand out. For the second year in a row, 100% of members are enrolled in plans rated 4 stars or higher. Two Nevada HMO contracts earned 5 stars, and a Texas plan earned 4.5 stars. These results demonstrate that a member-first care model can be replicated and scaled, rather than being a one-time achievement.   Why This Matters   1. Sustained reliability Many plans aim for high star ratings but struggle to maintain them as CMS raises the bar. Alignment’s California HMO has held 4 or more stars for nine years in a row, which is rare. This steady performance leads to better risk management, stronger member loyalty, and more reliable bonus incentives. 2. Clear market differentiation. Medicare’s Plan Finder clearly displays star ratings, which directly impact consumers' choices. High ratings give plans a real edge over competitors, not just a mark of honor. 3. Quality as a business driver, not just compliance.   The most successful plans prioritize quality by closing care gaps, retaining valuable services, and responding promptly to members, rather than merely meeting minimum requirements.   The New Age of Medicare Advantage   New carriers are transforming the industry through flexibility, data-driven insights, digital engagement, and a focus on members. Here’s what makes them different:   * Flexible modular care models delivering individualized quality care * Bold benefit innovation that differentiates * Relentless measurement and iteration, where analytics feed continuous quality improvement * Culture-driven execution, where clinical leaders, operations, and member services act with alignment   Alignment demonstrates how these strengths can be leveraged on a large scale to consistently deliver great results across different markets.   Our Dedication to Long-Term Quality   * We invest in quality to achieve lasting results that can be replicated across different markets, yielding clear benefits from the first year. * Our benefits are tied to clear clinical and satisfaction goals, as shown by our star ratings and member feedback. * All of our members are enrolled in high-rated plans, not just a select few.   The future of Medicare Advantage will favor those who pair strong performance with new ideas that put members first. Alignment is already leading the way and setting the standard for the next generation of plans.   #AlignmentHealthPlan #AlignmentHealth #Duals #HealthcareLeadership #AdvocacyMatters #ValueBasedCare #FreedomOfChoice #LeadershipInAction #MedicareAdvantage #HealthPolicy

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The Policy Alignment Gap Healthcare’s core failure is not operational. It is structural. The current payment architecture forces providers, payers, and policymakers to operate inside misaligned incentives that guarantee cost escalation and chronic underperformance. If policymakers are serious about improving health outcomes, stabilizing rural access, and reducing long-term spending, the conversation must begin with the alignment problem. Here is the reality: • Providers are reimbursed based on downstream utilization. • Payers protect margin through friction, delay, and risk deflection. • Policymakers are evaluated on budget stability, not population health improvement. Three actors. Three incompatible incentive structures. No shared accountability for upstream health. This is why past reforms stalled. MSSP, shared savings, and incremental value-based pilots never touched the underlying payment rails. They tried to create change without changing the structure. VRM is built for policymakers who want a system that finally aligns incentives with outcomes. VRM creates a unified payment architecture where prevention, chronic disease management, and N=1 visibility are financially rewarded rather than financially punished. • Providers receive predictable funding to manage risk at the population level. • Payers gain cost stability, actuarial clarity, and real savings tied to verified outcomes. • Policymakers get a model that reduces long-term spending by addressing the drivers of cost, not the symptoms. Policy reform will not succeed without structural reform. VRM provides the architecture that allows policy, payment, and outcomes to move in the same direction. The issue is not political. The issue is the design of the system itself. JC

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Advanced Health Coordinated Care Organization, which serves Oregon’s Medicaid population, has selected 1upHealth to lead its interoperability initiative and support critical data exchange goals. Using our full suite of solutions for CMS-0057 compliance, Advanced Health will meet federal interoperability requirements while improving member care across rural and underserved communities. About the new partnership, 1upHealth CEO Andrew Boyd said, "As we look across our customer base, we’re seeing a common theme. Payers are moving from mandate to mission; finding ways to use required interoperability investments to support their broader organizational purpose. We are proud to partner with Advanced Health as they work to make a difference in the health and well-being of their members and the communities they serve.” 🗞️ Read the full press release: https://bit.ly/4pHagw6

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Good news on Friday post. Once again, Medicare #ACOs composed of relatively more primary care clinicians outperformed (generated more shared savings per beneficiary) than those with fewer primary care clinicians in the CMS 2024 results released this week. This is a consistent annual result and seems like a relatively easy change that all ACOs can make to help improve their performance. I'm curious to see if the PC average is moving up, which might suggest learning is happening across the sector and patients are benefiting from better access. #primarycare David Muhlestein Zach Davis https://lnkd.in/eJ-uxxTj

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As signals grow stronger that this administration may move forward with high-impact changes to #ACA and #MedicareAdvantage (on top of WISeR reforms in Trad #Medicare and OBBB changes to #Medicaid) every insurer is asking the same question: "What should we do while we wait?” Here are a few high-ROI moves to consider: 1️⃣ Re-separate operations by product. During the last 5-7 years, many plans consolidated operations across products to minimize cost through scale. But with financial and regulatory rigors of products now diverging at warp speed, shared infrastructure is often now a shared distraction. Consider returning to product-specific processes to reclaim strategic focus on each product's needs. 2️⃣ Appoint a Chief Change Executive for each product. No single leader or workgroup can evolve all products with the speed required. Assign an executive with detailed expertise to live in the details and rapidly adapt processes, decisions and initiatives for: ➡️ provider contracting, net ops and incentives ➡️ PBM alignment and medication optimization ➡️ Quality, #MA Stars, #CAHPS and #HEDIS ➡️ CS, A&G, CM, UM ➡️ #RiskAdjustment ➡️ #Compliance This can't be delegated to staff, and is not long-term. It is how you keep pace with the regulatory curve instead of being crushed by it. 3️⃣ Designate a Chief Silo-Buster. Silos inside health plans are stronger than ever, making organic silo-busting unrealistic in the short term. Someone must arbitrate. Assign a senior executive versed in nuances of all products to decide, quickly and definitively, who owns what and who will do what when collaboration stalls. This leader will make the hard calls: ❓ Who absorbs the expensive, painful, or unglamorous work no one wants? ❓ Who must change their operating model even if they’d prefer not to? ❓ Who must relinquish control for the sake of product-level success? ❓ Who holds other teams accountable when fragmentation requires delivery by multiple departments? Without this role, weeks (sometimes months!) are lost to internal deadlock, which is untenable right now. 4️⃣ Strengthen financial discipline. During the last few years, many large investments were charged to all products, whether they delivered value to the product or not. But MLRs are rising and many plans are trapped under outdated or low-ROI spending. Request the Chief Change Executives: ➡️ examine every budget line item, both direct and allocated ➡️ verify each expense still aligns with product needs ➡️ renegotiate or terminate spending mid-year ➡️ redesign roles and job descriptions ➡️ bring in new vendors when needed for speed or expertise Introduce monthly detailed budget reviews and real-time course correction. The next few years will reward insurers who treat financial management as a living, adaptive process, not an annual ritual. Winners will be those who re-imagine themselves now, with bold clarity, product-specific leadership. If you need help, we’d love to chat.

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As my latest OPED in RealClearHealth lays out, health care affordability is the number one problem facing American families — and what’s happening in the ACA marketplaces shows it clearly. Premiums in the individual market have climbed far faster than employer plans or inflation, with the average ACA family premium now projected above $27,000 and deductibles exceeding $5,000. The Council for Affordable Health Coverage estimates if current trends persist, the typical American family will spend 40 percent of their income just on premiums, up from 20 percent today. That's brutal. But here’s the part too many miss: this is not an accident or a temporary glitch — it is built into the incentive structure of the system. Under current law, subsidies flow to insurers based on the cost of the most expensive plans. As premiums rise, subsidies rise dollar for dollar, funneling taxpayer money into insurance company revenues rather than driving competition or meaningful cost control. These subsidies plus other policies like MLR rules, 340B expansion, and regulatory complexity, accelerated massive market consolidation. Just a few companies now wield incredible market power. The result? A concentrated marketplace dominated by a few large insurers, narrow networks that limit access, and higher costs for families and taxpayers alike. The underlying program is flawed. More subsidies and money into an expensive system will produce...a more expensive system. Congress should work to realign incentives so insurers compete on price, quality, and consumer value. 1. Break up the monopolies (Trump Administration should use the Clayton and Sherman Act, Congress should expand authority) 2. Establish meaningful transparency 3. Allow consumers to pick any plan on the market 4. Give subsidies to people, not companies Congress must restore competition, transparency, and consumer choice if we are serious about making coverage more affordable. These ideas are a starter set. We're too focused on ACA - just 7 percent of the population - and need to widen the aperture to all markets. Thoughts? https://lnkd.in/eQ7FRZkZ

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We’re pleased to launch the updated MCP-Hub Toolkit: A Resource for MCPs and CalAIM Providers, developed by DHCS, the California Health Care Foundation, and Aurrera Health Group. This resource supports Medi-Cal managed care plans (MCP) and community care hubs in building effective, compliant partnerships to address health-related social needs. The toolkit includes contracting guidance, oversight tools, and program-specific considerations for Enhanced Care Management, Community Supports, community health workers, and doula services. 📘 Explore the toolkit: https://lnkd.in/gn39sQGf. Join us for an informational webinar on January 16, from 1–2:30 p.m. PST: https://lnkd.in/gg7gj94h #CalAIM #MediCal #CommunityCare #HealthEquity #PublicHealth #DHCS

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Pretty striking analysis from KFF, to illustrate how narrow a lot of Medicare Advantage networks are. Particularly in places like Southern California and Nevada, where these networks are often delegated to IPAs and health systems that may exclude 70 - 80% of local physicians. Note of caution this AEP! If you are not sure what care you may need, there is a real risk in choosing one of these narrow network plans.

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