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Rob Lourenço shared thisSeniors receiving bad news in their ANOCs this year are going to be motivated to switch. Deft Research's Shopping and Switching Study from last year showed that reading an ANOC with worse benefits was the biggest driver for voluntary switching. And you count on seniors to be paying attention again this year. For agents and plans heading into AEP: 🔹 Know how every plan in your book is changing for 2027 🔹 Reach out first to the members facing negative changes 🔹 Explain the change before a competitor does This clip is from my talk earlier this year at LeClair Group's broker conference.
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Rob Lourenço shared thisThis should be a great conversation between Sam Melamed, Martin Graf, and George Dippel. You don't want to miss it! Check out the link in Sam's comments...Rob Lourenço shared thisPlease join us for the Medicarians "State of the Medicare Advantage in 2027" pre-AEP webinar on October 8th. Martin Graf and George Dippel will be joining me to do a deep dive on the state of the market. For those who don't know, Martin and George are two of the leading thought leaders in the Medicare Advantage space. As a Medicare nerd myself, I count them as two of my leading sources of information and insights! Martin leads the Oliver Wyman Medicare, Medicaid and ACA practices (among many other things) and consults for many MA C-suites. George founded Deft Research, where he leads the team in producing industry leading research reports and data analytics (among many other things) Join us for for a deep dive on the state of the market this AEP. We will cover new CMS regulations, shifts in star ratings, consumer expectations, carrier plan availability and market exits, supplemental benefit changes, plan headwinds, and much more. Link in the comments
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Rob Lourenço shared thisYear-over-year plan count changes can obscure the size and competitiveness of the underlying market. The 2027 Medicare Advantage Landscape files were released this week, providing an early look at where plan availability is expanding and contracting. The bubble map below highlights those YoY changes. However, looking at baseline MA plan counts is important to fully understand how each state's MA market is evolving. For example, Vermont gained 2 plans while Florida lost 51. Looking only at the YoY change can obscure the fact that these are vastly different markets. Florida went from 611 to 560 plans, while Vermont went from 3 to 5. More to come when the crosswalk files are released.
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Rob Lourenço reposted thisRob Lourenço reposted thisEnrollment Caps Are Officially “A Thing” With the release of the Landscape files yesterday, we can now see which MA carriers took CMS up on their pre-bid reminder that enrollment caps existed and that plans could apply for them. After seeing back-to-back years of 1.8 million and 2.8 million non-SNP terminations, we at Deft speculated that many regional carriers would want the downside protection of enrollment caps for some of their plans should nationals or other competitors be tempted to release too many members onto the market. When thousands and thousands of members land in the lap of an unsuspecting MA carrier ill equipped to handle such a torrent of new membership, networks become strained and prompt service becomes impossible, thus putting CAHPS performance in serious jeopardy. 15 carriers received such enrollment cap protection for 2027 (BCBSMA, BCBSNE, CareFirst, BCBSNC, Group Health Cooperative, HMSA, HAP, HealthPartners, Horizon, Independent Health, Johns Hopkins, LifeBridge, Martin’s Point, Network, and Sanford) for at least one of their products. Should the financial environment for MA remain as strained in 2027 as it has been from 2024 through 2026, look for even more carriers to seek such protection should the estimated 2.8 million terms we expect to see in 2027 continue on for 2028. It’s hard to make a case for why a smaller carrier would not seek such protection with some of their plans as long as the financial environment in MA is as challenging as it is today.
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Rob Lourenço shared thisI asked 2 LLMs for the best research and insights for the Medicare and ACA markets. In 6 of 7 prompt attempts, Deft Research was ranked #1. This was about a month ago. So, when I received an email at work yesterday from an AI company claiming they could improve Deft’s AI visibility, I laughed. Then I checked my phone to see whether I still had a screenshot saved. I did (and included it below). In our recently published ICHRA study, we found that almost half of ICHRA enrollees are using AI to look for coverage. And of those, almost 7 in 10 said they mostly/strongly/completely trust AI for plan recommendations. We asked a similar question in our Medicare Age-In Study. But with age-ins, it was less than ¼ that had similar levels of trust in AI. For Medicare sales and marketing, AI is a concern of tomorrow. For the under-65 market, it is a concern of today. But if a slick-talking AI company, founded yesterday, comes and tells you they can improve your health plan’s position within AI tools, check for yourself whether it even needs improvement. In 10 minutes, you can run a set of different prompts across different models and see how you stack up against your competitors. And in case you’re wondering what I told the sales rep who emailed me yesterday, yes, I did send her the screenshot below. 😊
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Rob Lourenço shared thisHealth plan members don’t have a problem with NPs and PAs as primary care providers; they have a problem finding out at the front desk. 22% of patients said their PCP is an advanced practice provider (APP); that is either a nurse practitioner (NP) or physician assistant (PA). This is data from Deft Research's 2026 How the U.S. Consumer Selects a Provider and Health System Study. So, are they satisfied with these APPs? Generally, yes. Seventy-seven percent of patients with a physician were very or extremely satisfied, compared with 75% of those with an APP. But there is a catch about that 2nd group. That 75% satisfaction was only true of those who KNEW their provider was an APP in advance of their appointment. Among patients who didn’t find out until the first appointment, satisfaction dropped to 54%. Low satisfaction nearly tripled from 8% to 22%. It's the mismatch in expectation that led to low satisfaction. Given that almost half of new PCP relationships come from either an auto-assignment or a patient asking for whoever is available at a location, there is a low-effort fix here for payors and providers who want to impact this metric: Carriers: when you auto-assign a PCP, explain the provider’s credential in the assignment letter (in plain English). Providers: when an appointment is booked, explain in one sentence who they will be seeing.
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Rob Lourenço shared thisPatients favor a brand-new PA with 3-star reviews over a 5-star MD with 30+ years of experience and advanced imaging on site… …when the PA is < 10 minutes away while the MD requires a 1-hour+ drive. This is data from Deft Research’s 2026 How the U.S. Consumer Selects a Provider and Health System Study. When we ran a conjoint analysis with 420 adults choosing between providers: • Nearby clinic, new 3-star PA received 47% preference share • Clinic an hour away, 5-star veteran MD received 38% preference share What does this mean? If both providers are in-network, proximity carries more weight than pedigree. So, when building a network, top providers matter. But they won’t steer members if those providers are too far away. My take: look at geography first and then work on how you can improve a provider’s performance.
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Rob Lourenço shared thisHaving worked at Tufts Health Plan, I've been enjoying Andrew Tsang's deep dives into the Boston healthcare ecosystem. In this post he highlights how a quiet arrangement between a local payer and provider led to an outsized impact to other payers(like THP), members, employers, employees and virtually the entire local healthcare market. If you work in healthcare, in Boston or anywhere else, he's worth a follow.Rob Lourenço shared thisIn 2008, the Boston Globe Spotlight Team (the one from the movie) published a story called “A Handshake That Made Healthcare History”. The handshake happened in 2000, between Partners HealthCare (now Mass General Brigham) and Blue Cross Blue Shield. BCBS of MA substantially increased what it paid Partners. The understanding, according to the Globe, was that Partners would then seek comparable increases from other insurers. Both organizations disputed that anything improper had occurred. Was that coordination? Tacit collusion? I don’t know - and neither did the Globe. But it changed the negotiating environment for everyone downstream. I traced what happened next at Tufts Health Plan. Partners threatened to leave the Tufts network. Tufts tried to hold the line on price. Then major employers told Tufts that a plan without Mass General and the Brigham couldn’t be offered to their workers, which forced Tufts back to the table. The new provider costs arrived after Tufts had already set the premiums it would collect in 2001. Tufts said it would spread the added expense across three years (hence my obsession to make a chart about an HMO’s margins from more than 20 years ago). That’s how a hospital negotiation makes its way to the rest of us. Hospital prices move first. The insurer carries the mismatch until renewal season, when the cost begins appearing in premiums, employer contributions, employee contributions, or benefits. The bars on the chart are only a few cents because health insurance is a low-margin business. But those pennies translated into real money. Tufts’s one-cent loss in 2002 represented roughly $14 million. Its two-cent loss in 2004 represented roughly $33 million. Then, in 2005, keeping just 2.37 cents of each premium dollar produced a reported $43 million underwriting gain. A movement of three or four cents was the difference between losing tens of millions of dollars and making tens of millions of dollars. The insurer could recover by getting premiums back above costs. Employers and workers had no similar escape hatch - their insurance bill simply kept climbing. The handshake is famous because it changed what Partners could charge. The Tufts fight shows how that price traveled: from a hospital contract, through an insurer’s balance sheet, into an employer’s renewal, and eventually into what workers paid for coverage. That’s what led me to write Tough Partners, Tufts Choices: the story of an insurer that tried to resist a must-have hospital system, only to be overruled by the customers it was supposedly bargaining for.
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Rob Lourenço shared thisIt’s hard to believe it has been 25 years since the 9/11 attacks. This personal account from Nate Williams is worth your time this morning. It left me reflecting on what he calls “God’s shuffle”: the idea that a series of minor details and decisions could have put you in the towers, outside as a witness, or completely out of harm’s way. Never forget.Rob Lourenço shared this💔 Tomorrow marks 25 years since September 11, 2001 (#9/11). I've thought about writing down my experience of that day for years, but I never quite could. There was nothing heroic about my experience. I was simply a young New Yorker who happened to be there; on the 4 train beneath Lower Manhattan, later watching the South Tower collapse from a JPMorganChase conference room at 4 MetroTech, and then trying to make sense of what had happened alongside millions of others. Twenty-five years later, my memories are inevitably becoming less precise. My wife and children know only pieces of the story. So I decided it was finally time to record it. This is my small piece of that history and how September 11 ultimately changed the trajectory of my life. #NeverForget #GreatestCityInTheWorld #GodBlessUSA 🇺🇸 UNION LabsThe Boy on the Badge: Recording My Experience - September 11, 2001 in New York CityThe Boy on the Badge: Recording My Experience - September 11, 2001 in New York City
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Rob Lourenço liked thisRob Lourenço liked thisParagon Turns Five In this week’s newsletter, I reflect on Paragon Health Institute’s five-year anniversary and the principles that have guided our work. Since Paragon launched in 2021, we have produced hundreds of newsletters, research papers, policy briefs, Prognoses, PICs, and congressional testimonies. Most importantly, our work has helped produce meaningful policy change. At our anniversary dinner, we were honored to welcome CMS Administrator Dr. Mehmet Oz and Texas Congressman Chip Roy, both of whom delivered remarks. We presented Dave Steffy with the Paragon Vision Award, and we remembered Grace-Marie Turner’s life and impact and unveiled a new fellowship in her name with Gabrielle Minarik as the inaugural fellow. In preparing my own remarks for the evening, I thought about the principles that make Paragon tick. Here are the five principles I identified: 🔵 First, it starts with top-notch research and analysis. We try to anticipate which issues will matter, do the research before the policy window opens, and subject our work to a demanding review process. 🔵 Second, results matter more than intentions. Health policy is filled with well-intentioned programs that do not work as their designers expected. Good policy requires looking at what programs actually produce—not simply what policymakers hoped they would produce. 🔵 Third, incentives matter. Government programs generate incentives for states, insurers, providers, brokers, patients, and other participants. Our focus is on how reforms can better align incentives, so Americans, especially the most vulnerable, can receive more value from the enormous resources we devote to health care. 🔵 Fourth, good ideas must be effectively communicated. Two phrases—“Medicaid money laundering” and “phantom Obamacare enrollees”—helped make extraordinarily complicated policy problems understandable. 🔵 Fifth, and most important, people are policy. Good policy ultimately depends on principled, talented people willing to do the hard work of turning ideas into action. I am deeply grateful to everyone who has been part of Paragon’s first five years, and that extends far beyond Paragon’s staff. Read the full newsletter here: https://lnkd.in/e2WJ_YdK
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Rob Lourenço liked thisExcited to share that my husband, Eitan Becker, has launched his own consulting business! If you work in biotech or know someone who does, I'd love for you to check out STRATALYTx Biopharma Consulting and spread the word!Rob Lourenço liked thisNot every company needs a full-time hire to answer a hard commercial question. And not every question justifies a full-service consultancy. That gap is why I am launching STRATALYTx Biopharma Consulting (pronounced "strat-a-LI-tix"), an independent biopharma-focused commercial strategy consultancy that generates insight and translates it into judgment decision-makers can act on. For more than 20 years, I held competitive intelligence, market research, and commercial strategy lead roles supporting franchises at Vertex Pharmaceuticals, Novartis Vaccines, and EMD Serono. Along the way, I facilitated cross-functional competitive war games, developed strategic forecasts, assessed opportunities, and presented recommendations to senior management. I have also been a client of consulting firms across numerous engagements, so I know what great looks like. Now I bring that experience to: • Emerging biopharma and lean commercial teams needing strategy support • Investors seeking an independent read before capital is committed • Boutique consulting firms requiring senior expertise for a specific engagement I handle every engagement personally. No bench, no junior staffing, no layers between you and the person doing the work. If you have a business issue I can help with, or simply want to reconnect, send me a message.
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Rob Lourenço liked thisRob Lourenço liked thisOur secret is out! Ever since we announced that we were partnering with Costco Wholesale to launch Medicare Advantage, the question has been when and where. Well, the cat is finally out of the bag. We are launching high-value Medicare Advantage plans in California and Nevada for THIS annual enrollment period. Most of our plans are $0 premiums for our members. Up to $500 in OTC benefits annually—which will go far with Costco’s low prices. The opportunity to earn dollars towards a membership with our Healthy Rewards program. Access to best-in-class hearing aids and vision benefits. And best of all—two organizations who operate with an unrivaled level of member obsession! Visit our website to learn more: Http://www.scanhealthplan.com
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Rob Lourenço liked thisRob Lourenço liked thisVance: "...if our argument is always that it's good for the workforce [economy], then we have made an idol out of the American corporation. And I think that is a deeply anti-Christian idea, because the economy exists to serve the human person."
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Rob Lourenço liked thisRob Lourenço liked thisThe most successful people I know brainwash themselves with positivity. They invest in: - Healthy food - Great workouts - Positive affirmations - A supportive network - A curiosity-first attitude And they literally convince themselves that anything in this world is possible. And guess what? It is. To anyone. But unfortunately, less than 10% of people will act this way. The other 90% are focused on: - Anger - Politics - Division - Unfairness - Tearing people down What a miserable way to live. Give your own ideas as much attention as you give everything that's wrong with the world. The skills you could teach. The problems you could solve. That little business you could start. Give yourself a chance! Find out what’s possible. If you want help turning what you know into a small business, I put together a short, 30-minute guide to starting: https://buff.ly/lwqZSlG
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Rob Lourenço liked thisRob Lourenço liked thisI learn something every time Brendan Keeler gives a talk - at healthcare 101 yesterday there were a few things that really made me think 1) Can AI doctors access data through the health information exchanges? what counts as an AI doctor? 2) Healthcare actually has it better than a lot of other industries because we have regulations that force data out. For example CCD-A exports, or EHRs allowing robotic process automation if an API doesn't exist. In other industries those rules may not exist which allow systems of record to box out third-party applications 3) The sheer number of places data is sent between stakeholders is just enormous, I mean look at this chart of just a small subset of networks that already exist. There's so much work to do Brendan's talk summary + hi res graphic of this is in the comments
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Rob Lourenço liked thisRob Lourenço liked thisWhat does a hospital merger actually merge? One of the most eminent mergers in healthcare history is the formation of Partners HealthCare in 1994 - consisting of Mass General and Brigham and Women's. But did you know that it almost included Beth Israel, Deaconess, and Boston Children's? Harvard Med tried to get them all to join, but alas, there was too much drama between them. So, MGH and BWH struck a deal over lunch (quite literally), formed their own agreement, got approved by the AG, and the founders promised to save $240 million a year by combining the two hospitals. But it wasn't that easy. Merging hospitals is hard! Even a well-run merger today means years of project plans, workstream charters, and incomprehensiblely huge Excel trackers. I couldn't find one for Partners, so I made my own: 45 workstreams, from payroll to surgery, and how far each one merged, year by year, from 1994 to 2026. To be fair, this isn't an official account - I had to compile all this from books (John Kastor's Mergers of Teaching Hospitals), Harvard Crimson and Boston Globe articles, state filings, and MGB's own web pages. The merger actually happens in phases: insurers were dealing with one Partners by 2000, patients got one bill in 2016, and the surgeons finally got one chair in 2025. Negotiating with insurers as one system paid off right away - but the merger inside took a lot longer. The two hospitals didn't share a medical record until 2016, more than twenty years in. By my count, 9 of the 45 integration workstreams were run by one team in 2015, and 32 are today. Most of the merging I could find came after the 2019 rename to Mass General Brigham, and it sped up once an operating loss and rising labor costs squeezed the whole system (the data from the 1990s are probably undercounted - less of that decade made it online). Partners got what it was built for: a stronger hand against the insurers. It never needed the medicine merged to get it. Revenue from a merger needs one signature, but savings need thousands of people to change how they work. Two in three American hospitals now belong to a system built by mergers. If you work in one, you've probably seen the scars: two badges, two titles for the same job, a spreadsheet kept alive because the new system can't do what the old one did. Read my opus, "Partners: A One-Word Oxymoron" in the comments below.
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Rob Lourenço liked thisRob Lourenço liked this"When you grow up, you won't have a calculator in your pocket!" So I was told in school. I came across this photo recently (taken in 1986). I found myself thinking about this pattern, this resistance to depriving people of abilities, but how quickly that tends to be followed by acceptance. Once we realized that automating the calculations themselves freed students up to focus on more complex and impactful mathematical problems, it became easier to dismiss the "threat" of calculators, but of course no one could see that in advance—it created uncertainty about what that means for people, their role in society, their relationship with technology.
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Jacob Manzoor (Miller)
⏱️ Why Submitting Claims Daily Is a Game-Changer for Your Practice One of the simplest yet most impactful habits in RCM is daily claim submission. Practices that submit claims every day see: ✔️ Faster reimbursements ✔️ Steady, predictable cash flow ✔️ Reduced backlog and fewer processing delays ✔️ Quicker identification of documentation issues ✔️ Lower denial rates due to timely filing compliance If your current VMA or Medical Billing company isn’t submitting your claims daily, you’re leaving money on the table - and slowing down your revenue cycle. At Physicians Care Services, we ensure same-day claim submission, precise clean-claim processing, and proactive follow-up that directly boosts your bottom line. 📩 If you’re looking to improve cash flow and eliminate delays, reach out — we can help. #MedicalBilling #RCMExperts #RevenueCycleManagement #MedicalClaims #HealthcareBilling #DailyClaimSubmission #CleanClaims #PracticeManagement #IncreaseCashFlow #MedicalBillingServices #VMA #HealthcareProviders #PhysiciansCareServices #BillingSolutions #RCMTips
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RVA Healthcare Consulting
https://lnkd.in/epwscdar The latest KFF Medicare Advantage 2026 Spotlight makes one thing clear: The MA market is tightening and the ripple effects will be felt most by the people who rely on it the most: our seniors. For 2026, we’re seeing: • A 9% reduction in MA plan offerings • Major insurers pulling back from entire counties • Growing disparities between urban vs. rural access • A shift toward Special Needs Plans over broad MA-PD options On the surface, it may look like routine adjustments. But beneath it, the system is signaling a deeper shift. Who Feels the Impact First? Seniors. When plans exit a county or shrink their footprint, seniors lose stable coverage, preferred networks, and predictability in costs and medications. For those with chronic conditions or limited resources, even small changes can disrupt care, access, and outcomes. This is why operational excellence is no longer just a revenue conversation, it’s a patients and practices protection strategy. What This Means for Healthcare Organizations 1) Documenting True Patient Complexity Nonspecific documentation doesn’t just lower revenue, it underrepresents what seniors actually need. 2) Strengthening Revenue Integrity Fewer plan choices often bring tighter utilization controls, more audits, and higher denial rates. Organizations without strong front-end accuracy and denial analytics will feel the financial pressure. 3) Preparing for Market Volatility Plan exits can shift patient attribution overnight. Understanding payer mix, MA profitability, and operational readiness is now essential. RVA Healthcare Consulting helps organizations build infrastructure that protects financial stability and patient care by: ✓ Improving documentation accuracy ✓ Strengthening risk adjustment workflows and provider education ✓ Reducing denials through proactive revenue cycle processes ✓ Preparing for RADV, MRA, and internal audits ✓ Analyzing payer performance and MA contracting strategies When systems break down, seniors feel it first. When systems are strong, seniors benefit from better access, consistency, and outcomes. The 2026 MA market isn’t shrinking, it’s evolving. Organizations that invest now will be best positioned to support the aging population navigating increasingly complex healthcare needs. If your group wants support navigating the next phase of Medicare Advantage, RVA is here to help. Message me to schedule a 30 minute free consultation. #MedicareAdvantage #Medicare2026 #SeniorCare #AgingPopulation #HealthcareOperations #ValueBasedCare #RiskAdjustment #RevenueIntegrity #ClinicalDocumentation #HealthEquity #HealthcareConsulting #HealthcareFinance #HealthcareLeadership #MedicarePolicy #HealthcareStrategy #PopulationHealth #MedicalCoding #HealthcareCompliance #RADV #ACO #MAPlans #PayerStrategy #HealthcareQuality #MA #VBC #RA #RAF #RCM #CDI #SDOH
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Roland Omene
In 2025, cash flow isn’t the problem, it’s the follow-up. According to HFMA and MGMA, 45% of practices lose revenue due to delayed insurance follow-ups and denied claims — not because they aren’t billing, but because no one has the time to chase results. Front-desk staff are juggling calls, managers are closing charts at midnight and collections fall through the cracks, quietly. But here’s the shift: The most resilient clinics this year aren’t hiring more billing staff. They’re delegating smarter — using Virtual Healthcare Billing Assistants trained specifically for healthcare revenue cycles. Therefore, they’re reducing A/R aging, recovering missed payments, and freeing up internal teams to focus on patient experience. At Honest Taskers, our Virtual Healthcare Billing Assistants manage claims, denials, and payment posting with precision and ensuring no dollar (or day) is wasted. Because every minute your team spends chasing claims is time not spent building care. Visit honesttaskers.com. Book your free discovery call today, and start your 14-day free trial. #RevenueCycleManagement #MedicalBilling #HealthcareOperations #ClinicManagement #VirtualHealthcareAssistant #HonestTaskers #HFMA #MGMA #HealthcareFinance
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Kevin Thoresen
Most TPA vendors pitch cost reduction. The ones winning long term are pitching something more valuable. Growth. Here's what I mean. A TPA's entire book of business runs through brokers. A broker who stops recommending a TPA can meaningfully damage their revenue overnight. A broker who sees a TPA as indispensable feeds them more employer groups every single year. So the real question for any TPA isn't just "how do I reduce costs?" It's "how do I make my brokers look so good they can't imagine working with anyone else?" The answer is data. Not generic reporting. Employer-group-level data that shows each broker exactly what their clients saved, how their members engaged, and where costs are trending before the next renewal conversation. When a TPA walks into a QBR armed with that data, something shifts. They stop being a vendor and start being a strategic partner. Brokers notice. Employer groups renew. New business follows. The flywheel turns. Most vendors don't build for this. They report on what already happened and call it account management. The TPAs pulling away from the pack are the ones treating data as a growth tool, not just a compliance requirement. Brokers control employer group distribution. The TPA that makes brokers more successful wins more of it. It's that simple. Are you seeing TPAs use data this way yet, or is most of the market still stuck in reactive reporting mode?
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