Medicare National MCO Analyzer 2011

Analysts: Paula Wade, Roy Moore, Ric Gross, Jane DuBose, Joel Payton

Report Summary
Medicare is big and getting much bigger, largely because of the aging of baby boomers, set to enter the program for the first time in 2011. The double-digit growth in Medicare beneficiary enrollment will be an underlying factor in drug and medical service utilization, provider supply and benefit design over the next decade. 2011 finds Medicare at a crossroads:policymakers are planning for a new care delivery system via accountable care organizations while Medicare Advantage plans work to maintain enrollment among new beneficiaries accustomed to managed care. Health plans, meanwhile, are concerned about bonus payments related to their Star ratings and in keeping members compliant with their drugs through medication therapy management.

Questions Answered in this Report

The federal government will likely improve MTM requirements for 2012 and 2013.How are health plans and MTM vendors working to improve their compliance systems? What changes are under way in standards?
The Obama administration has made care coordination for dual-eligibles a national priority. How many seniors could enroll? What diseases will be targeted by ACOs? How much will it cost to start one?

The Shared Savings Program for accountable care organizations is set to begin Jan. 2, 2012. Will the building boom result in new members? Is it a sign Kaiser plans to pursue new business more aggressively? How will the new construction prepare Kaiser for the new members when health reforms' coverage mandates go into effect in 2014?

Primiary Research
Interviews with the Gorman Group, Fallon Community Health Plan, Humana Inc., XL Health, WellCare, Outcomes Pharmaceutical Health Care, Mathematica Research and the American Pharmacists Association.