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Elissa Toder reposted thisElissa Toder reposted thisEvery health plan has a complex care management program. Almost none of them are reaching the members who drive the spend. Look at who's actually enrolled: members who answer the phone. Members who attend appointments. Members who respond to mailers. Members already connected to the system. Now look at who's generating the emergency department visits, the readmissions, the unplanned utilization. Different list. That's the engagement gap, and it isn't a strategy problem or a software problem. It's a reach problem. Phone calls, letters, and portal messages work for reachable members. They don't work for someone without stable housing, without transportation, without trust in the health system, or without the plan's primary language. These members aren't non-compliant. They're unreachable within a remote model. Check out our first article in a four-part series on closing that gap: https://lnkd.in/g8CyiKuR
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Elissa Toder shared thisHave you signed up for this webinar yet? Nick D'Ambra, Nate Lucena, Jessica Columbus and I are looking forward to hanging out together and talking about our favorite subject - STARs and what you should be doing! Quality peeps who are being asked - what can we do in Q4? We see you! Hopefully we can help just a little! Register here: https://lnkd.in/gZPcPhNnWelcome! You are invited to join a webinar: Stars Under Uncertainty: A Practical Playbook for Medicare Advantage Plans. After registering, you will receive a confirmation email about joining the webinar.Welcome! You are invited to join a webinar: Stars Under Uncertainty: A Practical Playbook for Medicare Advantage Plans. After registering, you will receive a confirmation email about joining the webinar.
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Elissa Toder posted thisMy friends in LTSS/ MLTC - Penn State needs you! Christina Daley is looking for some folks to meet with students virtually and share their experience and perspective. I know you all have a lot to share - as we grew up in this arena! I have to say meeting with students is one of the best things i've done recently! Its worth your time! Tag in if you would like to participate!
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Elissa Toder shared thisI'm excited to speak alongside my friends and colleagues Nick D'Ambra, Jessica Columbus and Nate Lucena on October 6. I’ll be leading a webinar discussion hosted by ACAP on what Medicare Advantage plans should be evaluating right now. Four things we'll cover: Modeling future-state Stars scenarios, including if affected measures don't return Reassessing Part D–based quality programs without overcorrecting Identifying which measures are likely to remain durable Building organizational capabilities that hold value across scenarios Join us for this webinar discussion on Tuesday, October 6, 2:00 p.m. ET. Register here: https://lnkd.in/gZPcPhNnWelcome! You are invited to join a webinar: Stars Under Uncertainty: A Practical Playbook for Medicare Advantage Plans. After registering, you will receive a confirmation email about joining the webinar.Welcome! You are invited to join a webinar: Stars Under Uncertainty: A Practical Playbook for Medicare Advantage Plans. After registering, you will receive a confirmation email about joining the webinar.
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Elissa Toder shared thisIt’s a great group and an important topic. Join us for some STARs funElissa Toder shared thisWebinar | October 6 | Stars Under Uncertainty: A Practical Playbook for Medicare Advantage Plans CMS has not issued definitive guidance on how measures affected by recent litigation will be treated going forward. Plans are making bid, quality investment, care management, and product decisions this quarter anyway. Waiting isn't a strategy, and neither is assuming the program looks the same in two years. Join us on October 6 for a webinar hosted by the Association for Community Affiliated Plans on what Medicare Advantage leaders should be evaluating right now. What we'll cover: → Modeling future-state Stars scenarios, including what happens if affected measures don't return → Reassessing quality programs built around Part D measures, without overcorrecting → Identifying which measures stay durable regardless of how CMS restructures the program → Building the care coordination, chronic disease management, and member engagement capabilities that hold value across regulatory outcomes 📆 October 6 🕐 2 p.m. ET 📍 Register here: https://lnkd.in/gAFG-Yip Elissa Toder - Nick D'Ambra - Rex Wallace - Jessica Columbus - Association for Community Affiliated Plans (ACAP)
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Elissa Toder reposted thisElissa Toder reposted thisMargins are tightening as rate increases lag inflation. Medicaid and marketplace enrollment are contracting. The uninsured population is growing. Health centers are absorbing all three forces at once — and proactive strategy matters more than it has in years. Here are five strategies to evaluate now: ➡️ Strategic PPS rate resetting — rates are meant to be cost-based, and depending on your state, triggering events allow a reset. Timing is everything. ➡️ 340B savings maximization — script capture, owning versus contracting your pharmacy, and a new HRSA rebate model expected January 1, 2027. ➡️ Quality, gap closure, and performance improvement — incentive dollars beyond PPS reimbursement, and why lagging data means missed targets. ➡️ Value-based care success enablement — where FQHCs are well positioned, and which lines of business fit best. ➡️ Clinic or service line expansion — when growth strengthens attribution, and when it becomes a fixed cost you can't unwind. Read the full piece: https://lnkd.in/g4hjBM9M
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Elissa Toder reposted thisElissa Toder reposted thisTwo hours. Thousands of meals. Mark your calendars for the 2nd Annual CAHP Give Back Event — a meal packing event presented by ModifyHealth in partnership with COPE Health Solutions. Kick off your week at the CAHP 40th Annual Conference doing something with lasting impact. Healthcare leaders from across California will stand shoulder to shoulder at the packing tables and put together thousands of meals for families and communities across the state. 📅 Monday, October 19 · 2:30–4:30 PM 📍 CAHP Annual Conference | JW Marriott, Desert Springs Check out highlights from last year, and if you're attending CAHP, add this event to your agenda: https://lnkd.in/gJ8H_9sh ModifyHealth California Association of Health Plans
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Elissa Toder reposted thisElissa Toder reposted thisDid you miss today’s NYSDOH stakeholder webinar? We've got you covered — here's what you need to know. New York's Rural Health Transformation Program drew twice the demand it can fund in its first round. NYSDOH received 91 applications containing 141 projects, requesting more than $156 million against roughly $76 million available for Rural Community Health Integration. Awards are expected by the end of August. Dr. Bridgette Wiefling, our Chief Medical and Transformation Officer, summarized the session. Four things stood out: 1. The timeline is the binding constraint. All Budget Period 1 funds must be obligated by October 30, 2026 and spent by September 30, 2027. Anything not obligated by October 30 is deducted from future year awards. That pressure means DOH will favor contract-ready partners — organizations with governance, fiscal, and reporting infrastructure already in place hold a real advantage. 2. This is not an operational grant. Funds cannot cover current operations, existing salaries, or overhead. Projects must be new. 3. Engagement differs by initiative. RCHI flows through county-level coalitions. Primary care, workforce, and technology funds run through statewide contractors. One strategy will not work across all four. 4. There will be no state vendor list. The published awardee list, expected at the end of August, becomes the primary market-entry document for anyone wanting to participate. Full summary and sources here: https://lnkd.in/g_TvyBQq Bridgette Wiefling
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Elissa Toder shared thisRe-posting for reach! Liz Haynes is a wonderful leader to work under!!!Elissa Toder shared thisStars friends- Come join our team! I’m looking for someone who knows and loves Medicare Advantage Stars, has a track record of driving results and improving performance, and is excited to work for an organization where Stars is a major priority. (Hiring 2 positions)
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Elissa Toder liked thisElissa Toder liked thisToday marked my final day at VNS Health Plans in NY. I want to thank the leadership for the opportunity to share my knowledge and experience while moving the organization in the right direction. I especially want to thank my Population Health Team (Utilization Management, Care Management, Pharmacy, Behavioral Health and Grievance and Appeals) for working hard to achieve our targets. Without your hard work, we could not have come as far as we did. Thank you to the support teams and others at the health plan and provider organization who work so hard to continue this 100+ year old organization and help members get the right care at the right time with dignity and quality. Your trust and hard work pays off in so many ways. As for me, I will be taking a short vacation and when I return, I will begin consulting with groups and organizations that are looking for assistance to achieve their goals. I look forward to the future and all it brings. Thank you...Jerry
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Elissa Toder liked thisElissa Toder liked thisI’m hiring! 📣 I’m looking for a Director, Quality Improvement to join my HEDIS Operations leadership team and help lead our digital quality transformation. This leader will help shape our strategy across dQMs, FHIR, ECDS, and HEDIS technology, while building a longer-term roadmap for how we use data, technology, and automation to modernize and simplify our work. I’m looking for someone who brings strong HEDIS and clinical quality experience, thinks strategically, and knows how to turn transformation into operational results. If this sounds like you, or you know someone who would be a great fit, I’d love to connect!Director, Quality Improvement, Digital Quality MeasurementDirector, Quality Improvement, Digital Quality Measurement
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Elissa Toder liked thisElissa Toder liked thisI'm #hiring! Currently hiring for a Manager, Quality Improvement to lead a team of Clinical Practice Consultants, RN-level clinicians driving population health for members and our provider network. I am also hiring for two Clinical Practice Consultants on that team, link to be shared shortly. Several other positions are in the works, so stay tuned for more opportunities. Positions coming soon include a Sr. Stars Consultant and Medicare Stars Project Manager. https://lnkd.in/gBR4pVFZ #hiring #healthcare #clinician #RN #populationhealth #medicare #starsManager Quality Improvement at Health Care Service CorporationManager Quality Improvement at Health Care Service Corporation
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Sidley Global Life Sciences
In July 2026, the Centers for Medicare & Medicaid Services published two of their annual proposed rules: the CY 2027 Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Proposed Rule and the CY 2027 Medicare Physician Fee Schedule Proposed Rule. These proposals include several significant policy and payment changes. Read more in the blog post by Meenakshi Datta, Trevor Wear, Catherine Starks, Beth Kolbe Hardcastle, Rina Mady, Kim Schroer, Taylor Andelman, George Maliha, and Allie Gilchrist: "CMS’ CY 2027 OPPS and PFS Proposed Rules Include Major Changes to Reimbursement for 340B Hospitals, Data Reporting, and Digital Health."
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