Speaker Presentation
Tuesday, January 29, 2019

Registration & Continental Breakfast


Chairperson Welcome, Introduction & Keynote Address

Mastering the Member Experience

This session will explore member experience measures in Star Ratings, and identify key operations that impact them, including:

  • Call center processes and personnel
  • Broker and sales agent conduct
  • Product design and member education
  • Provider network design and management
  • The critical role of the PBM and retail pharmacy

John Gorman,Founder and Executive Chairman,Gorman Health Group


Panel Discussion: Balancing CMS Regulation with the Needs of Running Your Business for the Best Outcomes & Least Cost

What's keeping you up at night?

  • Will provider focus on outcomes measures diminish as providers increase investments in Medicare FFS quality?
  • How might reductions in federal funding (Medicaid aid, grant programs, etc.) reduce services offered by providers and erode their ability to meet our needs?
  • Can/will providers and payers begin coordinating efforts to eliminate variations/redundancy to allow providers to improve patient care/outreach?
  • How will CMS' Meaningful Measures and Patients Over Paperwork initiatives impact Stars and/or MIPS/QPP?
  • How will providers and payers better leverage data to efficiently and collaboratively support patients' needs?
  • Are value-based, capitated and at-risk contracts adequately aligning incentives beyond financial goals?
  • How will M&A change the game?
  • What do you tell your members if providers stop taking Medicare/Medicaid?
  • Should you be thinking differently about what you pay for, ie, scholarshipping Medical School costs?
  • Focusing on substance vs. form: Rethinking the Health Outcomes Survey, ie: reducing risks of falls, adult BMI assessment, bladder control


Melissa Smith,Vice President, Star Ratings,Gorman Health Group, LLC


Nita Firestone, Director of Program Oversight & Communication,Blue Cross Blue Shield Blue Care Network of Michigan

Daniel Weaver, Director of Programs, Government Quality, Highmark

Jonathan Harding, Senior Medical Director for Senior Products, Tufts Health Plan


How Benefit Design, Cost Shares and Pricing Can Drive Star Ratings, Quality, Risk Revenue, Retention & Sales

  • Aggregating Information Across all Medicare Functional Areas; Stars, Quality, Risk Revenue, Retention and More

Christine Leo, Vice President, Senior Products, Cigna


Networking Refreshment Break

Sponsored by:

Payment Accountability: A look at how Burgess solutions have drastically reduced the cost of payment operations for large payers

This case study will explore how Burgess solutions help payers improve relationships with their providers while also improving their bottom line. During the study, we will address how process automation, CMS and Medicare data integration, payment accuracy, and practical business intelligence can help payers easily achieve these goals.

  • Learn about leveraging integrated systems
  • Discover more about process transformation and embracing a culture of design thinking
  • Understand the importance of finding the right business partner

Jared Lorinsky, Chief Experience Officer, Burgess

Michelle Puente,Senior Director Operations, HealthNet, a subsidiary of Centene


Creating & Building Culture & Processes for a High Performing Plan

Rebekah Dube, Vice President, Health Plan Clinical Programs, Martin's Point Health Plan


Panel Discussion: Where to Focus Your MA Time, Energy & Resources in the Changing Healthcare Environment


John GormanFounder and Executive Chairman Gorman Health Group


John Halsey, Vice President, Payer Development,Turn-Key Health

Catherine Macpherson, MS, RDNVice President Product Strategy and Development, Chief Nutrition Officer Mom's Meals Nourish Care

Piyush GuptaRegional Medical Officer, CareMore Health

Jonathan HardingSenior Medical Director for Senior Products,Tufts Health Plan


How to Implement Engagement Strategies on HEDIS and Star Adherence Measures While Managing Budgetary Impact

  • Define critical strategies to engage members, increase compliance and improve star ratings
  • Raising medication adherence scores by focusing on members most likely to improve their adherence
  • Tracking budgetary line of sight and impact across all Part D and Part C/HEDIS measures

Kent HoldcroftChief Revenue OfficerPharmMD


Bridging the Gap Between Payer and Provider

Frank Vo, Business Development Manager, healow Insights


Networking Lunch

Sponsored by:

Panel Discussion: Alternative Payment Models: Value-Based Product Design and Service Delivery -- - Transitioning to Value-Based Payments from Fee-for- Service

This provocative panel will focus on payment model innovations, from contract to implementation, during times of rapid health system changes. Find out how to improve physician engagement and assess readiness for success with pay for value contracts. Learn techniques that can be applied to health systems of all sizes and in tandem with current merger trends impacting the market. Key focus areas include tools and strategies to help providers use quality and finance data to produce better outcomes; comparisons between primary care models and specialty care models; and constructing a dynamic alternative payment model strategy alongside evolving MACRA regulations.


Michael Parkinson, Senior Medical Director, UPMC Health Plan


Lawrence Kuk, Director, Network Engagement, Priority Health

Kathleen Faulk, General Manager,Government Programs, Cambia Health Solutions

Kurt Waltenbaugh, CEO & Founder, Carrot Health


Case Study: Cleveland Clinic & Humana MA Partnership - Moving Towards Population Health

Integration between insurers and providers is critical for long term success in the MA space. The Humana/Cleveland Clinic partnership has been designed to drive quality outcomes for members/patients, effectively manage costs and provide a high level of member satisfaction. Find out the reasons behind the partnership, how both parties arrived at a successful arrangement, and their plans for sustaining and growing the relationship:

  • Joint goal setting around product design, care delivery and marketing
  • Integrating data exchange and flow in both directions
  • Ensuring timely, actionable data to effectively interact with patients and members
  • In support of Population Health goals

James McMahon, Senior Director, Product Development, Market and Network Services,Cleveland Clinic


Networking Refreshment Break


Creating Customized Provider Engagement Models

Meeting the needs of large multi-specialty provider groups is significantly different than reaching a smaller group of PCPs. Varying risk models also necessitate different approaches. In some cases, the health plan provides all the data, and in others it is a shared function. Standardization just doesn't work. Find out how Tufts Health Plan works with different providers with varying risk adjustment profiles, infrastructures, capabilities and personalities to ensure providers' financial success while achieving quality goals. Plus, learn how Tufts has coordinated internally to achieve multiple objectives, including utilization, risk adjustment, quality, member satisfaction, growing membership, and coordinating other payor/provider functions, while ensuring a consistent message with no contradictions, so that the limited time spent with providers has maximum impact.

Jonathan Harding, Senior Medical Director for Senior Products, Tufts Health Plan


Maximize Opportunities to Expand Medicare and Dual Medicare Memberships With Innovative Marketing, Direct Mail, and Community Partnerships

Adam Mintz, Vice President Sales & Marketing, Gateway Health Plan


How Plans Can Use Intelligent Member Engagement to Drive Incremental, Value-Based Performance and Improve Member Health

CMS has been driving an agenda to improve plan quality and member health through policy progression and increased competition, pressuring plans to breakdown organizational silos and broaden their definitions of success-all while increasing their focus on improving member health. This presentation will reveal how an objective-based framework centered on consumer engagement is a powerful strategy to drive risk adjustment, quality, satisfaction and overall plan performance in today's value-based performance environment.

Jordan Mauer, Executive Vice President of Marketing & Engagement NovuHealth


UPMC RX for Wellness: Addressing the Quadruple Aim Through Improved Patient and Physician Engagement

The leading causes of morbidity, premature mortality and excessive medical costs due to chronic diseases are related to unhealthy lifestyles, non-adherence to evidence-based care practices and lack of patient-clinical shared decision-making. Prescription for Wellness, a UPMC Health Plan EMR-integrated physician and practice engagement system has been deployed throughout Western PA and has demonstrated higher engagement and better outcomes than traditional medical and health plan models of care. This session will review the use of the Six Sigma process to design the model as well as patient and physician/staff outcomes observed over the past 3 years experience.

  • Understand application of Six Sigma QI process to development of an integrated physician and staff model to improve patient engagement
  • Review lessons learned for clinical transformation to engage multiple stakeholders to address root cause of disease and non-adherence
  • Share current and future directions for further increasing impact of the RX for Wellness model.
  • Review the education, competency training, marketing and communications plan for patients, medical staff, physicians and health coaches

Michael Parkinson, Senior Medical Director, UPMC Health Plan


Addressable Media Marketing - Breakthrough Targeting and Media Delivery Technology to Deliver TV, Digital, Social and Mobile to ONLY Your Best Medicare Prospects

  • What is Addressable Media Marketing (AMM) and how does it work?
  • Delivery of TV, Digital, Social Mobile to ONLY your best direct mail prospects.
  • True integration, known attribution greater ROI
  • The technology behind the platform.
  • What are the benefits for Medicare Marketers?
  • Economics behind AMM
  • AMM in action: A case study from 2018 AEP.

Leah Smith Director Digital StrategyAnderson Direct & Digital


Listening to the Voice of the Customer: Integrating Empathy into All Communication Channels

Jenny Graham Partner Zelus Consulting Group


Networking Reception

Thursday, January 31, 2019

Continental Breakfast


Chairman's Remarks

John Gorman,Founder and Executive Chairman,Gorman Health Group


Growing and Expanding Your Medicare Business

Aging Baby Boomers make Medicare the fastest growing segment of healthcare in the US. Yet many health plans find themselves behind in critical preparations for this burgeoning market. New enrollees bring technology savvy, consumer consciousness and an expectation to be wooed by vendors providing essential services. In this session, Harry Merkin, Vice President of Marketing at HealthEdge, will provide the critical requirements that health plans need to successfully grow their Medicare and Medicare Advantage businesses. Findings from industry studies as well as real-life examples of payers with thriving Medicare businesses will be included in the presentation.

Harry Merkin,Vice President of Marketing,HealthEdge


2018 and Beyond: What Products and Services will be Most Influential In Boosting Outcomes and Cutting Costs

The Right Solutions - How can we filter through all the noise?

The Medicare ecosystem is one that's constantly evolving and requires the right set of partners and product solutions to achieve goals. But it's a large and complex landscape of potential partners, so how do you get your arms around it? During this discussion, we'll attempt to better understand how to make the right partnerships for both strategic needs and execution of initiatives? How can you find the right partners and toolsets efficiently and effectively and increase ROI on your spend?


Stuart Rosenblum,Strategic Alliances Director,Anthem


Daniel Weaver, Director of Programs, Government Quality, Highmark

Nicole Williams,Director-Business Development,RRD Healthcare Solutions

Christine Leo,Vice President, Senior Products,Cigna

Mike Reha, CEBS , Director of Sales and Marketing,EPIC Hearing Healthcare


Key Components of an Effective Company-wide Star Ratings Training Program

  • Develop department specific presentations to ensure a global understanding of Stars across your organization.
  • Empower key staff & functional leaders with information to direct measure focus and intervention development.
  • Incorporate overall program goals and individual measure goal setting into your training agenda.
  • Provide ongoing support to key stakeholders throughout the year to maintain momentum and keep the organization on track.

Jessica Assefa, Medicare Stars Program Manager, UCare


Networking Refreshment Break


Building a 5-star Organization - What Works AND What Doesn't

  • Building a 5 Star Quality Structure
  • Value of Continuous Improvement
  • Managing Quality Improvement projects
  • Incorporating Six Sigma methods

Donna Sutton, Healthcare Informatics, Director of Medicare Star Quality Programs, SCAN Health Plan


Integrating Stars and Risk Adjustment-Tools, Incentives and Engagement Strategies

Explore how Cambia Health Solutions redefined its provider engagement strategy by integrating Risk Adjustment and Stars opportunities into its tools, data and incentives. Leveraging a dynamic platform, Cambia can deliver real time, actionable performance data which has proven to boost engagement, facilitate holistic member health management, and reduce cost & abrasion related to chart retrieval activities.

Kristine Walhof, Program Director, Medicare Star Ratings, Cambia Health Solutions


Population Health - Data Driven Analytics to Care for the High Risk Members that Drive Clinical Variability and Costs

Using an algorithmic, data driven methodology to identify those highest risk and highest cost members, Florida Blue has developed tailored clinical programs that combine disease management, utilization management, and case management that act at a local level to meet the needs of this vulnerable population in the most effective and efficient manner. While the data is analyzed at the regional and state level, the interventions are tailored locally to better meet the needs of the consumer whether he is transitioning through the care continuum or she is having difficulty managing chronic illnesses.

  • Identify your high risk populations using data-driven methodologies
  • Provide custom services to prevent readmissions and provide interventions among high risk populations
  • Meet patient expectations with tailored consumer-centric programs

Sam Young, Senior Medical Director, Florida Blue


Investing in High-Touch Care to Achieve Quality Outcomes

Investing in cost up front for prevention and early intervention, supplemental programs, and hiring the right people - CareMore Health achieves improved outcomes and overall reduced healthcare spend.

Piyush Gupta, Regional Medical Officer, CareMore Health


Readmission Prevention: Care Transitions and Discharge Planning - More than a Warm Handover, Securing a Firm Handshake!

  • Care Management - telephonic, in facilities and in homes
  • Multidisciplinary Team Collaboration
  • Care Coordination - connecting members, families and caregivers to providers, needed care and services
  • Social Determinates and Integrated Behavioral Health
  • Education - prevention, self-management, chronic condition management, advocacy for person centered goals and long term support and services
  • Building Partnerships - develop trusting relationships for long term gains across the continuum
  • Driving for member centric results that benefit the triple aim.

Sallie Prins, Director, Care Management, Medicare, Priority Health


Networking Lunch


Reducing Costs of Treating Chronic Conditions

Behavioral - dementia, mood disorders
Coronary Artery Disease, Hypertension, CHF
Diabetes, COPD, RA

Linda S. Ellis, MD, MJ, MA, VP, Chief Medical Officer, iCare-Independent Care Health Plan


Medication Adherence Measures & MTM Completion Rates Impact on Star Ratings

In general, plans have increased their performance on the CMS Stars, triple-weighted, adherence measures. What has CMS done with the cut points and what should be expected for Stars 2019? More importantly, what can health plans do to position themselves for success today for Stars 2020?

Donovan Lemelin, Director of Operations, Medicare Pharmacy, Molina Healthcare


Networking Refreshment Break


Aetna Compassionate Care-- Advance Care, Palliative Care and End of Life Support When It's Needed Most

This session will discuss a health plan's strategies to support members, families and caregivers as they face the difficult challenges of advanced illness including opportunities to collaborate between health plans and hospice and palliative care providers to help Medicare Advantage members, Faculty will provide an update on Aetna's Compassionate Care Program including its case management and advance care planning tools. Participants also will learn about the data and quality indicators health plans look at when considering program outcomes.

  • Identify opportunities for collaboration between health plans and hospice and palliative care providers
  • Discuss the data and quality indicators health plans consider when assessing program outcomes

Alena Baquet-Simpson,M.D., Senior Medical Director, Aetna


Developing a Quality/Compliance Program Under Risk Adjustment

  • Risk Adjustment Compliance quality program 101
  • How to maximize effectiveness of a quality program
  • Navigate outsourcing and oversight of a quality program
  • Outline tactics and strategies to implement a quality program while optimizing risk-adjusted revenue
  • Importance of a quality program protecting against RADV audits
  • Discuss lessons learned and best practices that can be applied

Dennis Mihale, Medical Director, Freedom Health & Optimum HealthCare


Audit Preparedness & Compliance Best Practices from a 5-Star Plan Perspective

  • Best Practices
  • Internal Auditing
  • Internal Monitoring
  • Audit Universes - how, when and why
  • FWA/SIU Preparedness
  • Delegation Oversight Program - what works, what doesn't work
  • Annual Compliance Cycle

Keri Steege, Medicare Compliance Officer/Director of Medicare Compliance, Providence Health Assurance

Lisa Jensen, Director of Payment Integrity, Providence Health Assurance & Providence Health Plan


Actuarial and Analytical Perspectives on Paving the Road to Higher Medicare Advantage STARS ratings

  • Gain a deeper Understanding of the actuarial aspects of STARS measures and its impact on sensitivity to plan revenue
  • Foster a culture of continuous improvement in the world of cut points based on relative distribution
  • Monitor performance trends and determine targets for ensuing years

Plans will gain an appreciation for the level of risk exposure due to variance in STARS measures, the use of analytics in optimizing improvement effort, the implementation of an actuarial control cycle as it relates to risk management within the STARS context.

Puneet Budhiraja ASA MAAA, Medicare / V.P., Chief Actuary, Capital District Physicians' Health Plan, Inc.

Rajesh Munjuluri ASA MAAA, Medicare Actuary, Capital District Physicians' Health Plan, Inc.


Close of Conference